Friday, 28 March 2014

For the record, I called it.

I had a much easier time slipping out of the office for my second FET prep visit. My lining is at 12.4, which I think is thicker than it was last time and with an undetectable progesterone level, we're cleared for take-off. Let's just hope our embie survives the thaw, as my RE explained that he is obligated to remind me that if we don't have any reserves if this one doesn't make it. Husband inquired and learned that we would only recuperate the costs for the transfer procedure that wouldn't happen, which is only a few hundred dollars, thus declaring such an event a total waste of time and money. Anyway... later that afternoon, I was walking back to my desk and I took at glance at that the computer screen of my colleague's medical assistant. She was in the chart of one of our primary care doctors. I didn't seen any other details other than her name, but I had a certain feeling... "She's pregnant." I said to myself (and for some reason it was in the voice of Mrs Krabappel). I recently saw a clip from an old episode of The Simpsons where Bart's class was watching a Troy Mc Clure sex-ed video and Ms Krabappel was standing in the back of the room smoking a cigarette and observed, "she's faking." As I was only 13 or 14 when I saw the original airing; it went completely over my head.

Sure enough, the voice of my inner Edna Krabappel was confirmed about 15 minutes later. "Did you hear that the doctor in primary care is going to be a mother?" a newer medical assistant who is training in our department asked me in a very excited tone. Apparently, she sent her announcement though an Outlook mass email. I read her message and then deleted all responses. Sheesh people, just send your congratulations to the mother-to-be, you don't need to hit 'reply-all'! (In fairness, it really irks me when the 'reply-all' response is used in non pregnancy announcement emails as well) Both my Lead Physician and her medical assistant approached me later to see how I was handling the news.

I wasn't surprised. For the record, I called it. She hinted that she was going to start trying after her marathon in October and I'm truly happy for her that she was able to make such short work of it. I don't know why I am gleaning such satisfaction over the fact that I predicted that she would conceive spontaneously while I was doing my first IVF cycle. I opened up a bit more to Co-worker. "I hate myself for being so jealous, but how can I not feel this way? It took her just two months to achieve something I haven't been able to achieve in over two years!" I brought up our 2014 Expense Requests that we both completed last summer. Under the question 'do you  anticipate taking any FMLA time in 2014', she answered 'maybe' with a little smiley face. I became so envious when I saw that response just for the fact that she could be so optimistic. Even though I was actively pursuing infertility treatments, I replied with 'no.' The full stop was added for extra emphasis. Mostly, I thought the question was a bit invasive and I did not want to invite any suspicion. Now my self fulfilling prophecy has become a reality. I will not be taking any FMLA time in 2014.

Since removing my IUD, five other women in my office have become pregnant. Three of those women approached me first to disclose their positive pregnancy test. For two of them, I performed their scans after hours and kept the records locked in my desk until they made the big announcement. Perhaps I was feeling a little bent out of shape as she didn't confide in me. Then again, we're not that close beyond exchanging pleasantries when we pass each other in the break room and recently we had an awkward clash after I confronted her as she wasn't appropriately managing a mutual patient's diabetes. Maybe once again, I'm not so surprised.

Co-worker admitted, "hey, I'm jealous too!" Since the birth of her twins, just over eight months ago, she and her husband have resumed coital relations without any prophylactic measures. "I wish I could become pregnant on my first or second attempt." She described that they are hoping for a freebie, but her Husband isn't ready to start infertility treatments just yet, as he'd like to wait a little longer before having another baby. She doesn't want to bother with IUIs and is thinking of going straight to IVF with an intention to do a FET at a later point in time. Although she has an AMH of 2.22, her FSH was borderline and she had a relatively poor response to stimulation. During the IUI cycle that produced her twins, her ovaries were prodded with a high dose of Follistim and Clomid. It's a logical approach and maybe even reveals a certain advantage to infertility and assisted reproduction. Of course, I couldn't help to think that things may not go according to her plans. She may have to consider a day 3 transfer of two embryos. Maybe she would have twins again. OMG, that would seriously push her sister-in-law over the edge. Anyway, I offered to accompany to her consultation as her Husband would be, ironically, taking care of their kids during her appointment.

I also discovered that my clairvoyant powers are not absolute. On the morning of my WTF appointment, one of our phlebotomists approached me while I was sitting at my desk. "Can you order me an HCG?" she asked softly, but loud enough that others in the vicinity could hear. I nodded and she walked away with a big smile on her face. I figured she must have had a positive home or in office test. As I had recently seen her for an annual visit, I looked back at my notes when I went to placed her orders. She was currently using condoms for birth control and was content with that method, and didn't want to discuss other options. As she was in a new relationship, she wanted STD testing. She also divulged that they would be going to Monterey for a romantic getaway over the upcoming long holiday weekend. I glanced at her last menstrual period and correlated it with trip. Ba-da bing, ba-da boom... this is how it happens! I thought to myself. Except it didn't. When I looked up her result, there was no red flag alerting me of a positive test. I figured she probably knew her own result before I did as she processes lab reports, but I sent her an email, "your test was negative. I'm not sure how you feel about that, but I'm available if you want to talk about it."

The following Monday, we started a new six week session of swimming, which always brings a few new swimmers into the mix. I recognised one woman as I swam in her lane a few weeks ago when I joined the noon group for a few days. After we greeted each other, she explained that her work situation had changed and she needed to switch to swimming at 6 AM. As we were warming up, another former nooner asked her if she was planning to run in an upcoming marathon. "Oh, no. Not this year. I'm 16 weeks pregnant!" Cue the chorus of 'Congratulations!'  Cue me swimming a few more laps. Did I mention that is her second baby and she's 16 weeks pregnant without a hint of a bump and she looks amazing in a two piece swimsuit?  I just have to say it to get it out of my system: bitch. No, I'm not proud of myself.

Ya down with OPP? [Other People's Pregnancy] ...yeah, you know me...

Tuesday, 25 March 2014

A Day in the Life

As soon as my RE's office was open on the Monday morning after my BFN, I called to schedule my WTF appointment. I knew that AF would be arriving soon, and I wanted to make sure I could start stimming or FET prep with this cycle. I looked through my schedule and found two blocks of time where I could leave the office without having to move any patients. Unfortunately, my RE wasn't available during either of those options. "How about tomorrow at 11:45?" the practice manger offered. I would have to take it. That was the best I was going to get. I looked at my own schedule. I would have to move three OB patients. The reason I needed to leave? How about we have some statements from our international bank accounts that need to be notarised for our tax return. Do such documents need to be notarised? Sure, why not? Oh, shit. I forgot that our practice manager's husband is a CPA and could expose my cover up. One of my swim teammates took an afternoon off from her job to compete in our championship event and cited that she needed to meet with her divorce lawyer. Hmmm. I need to consider that one. That would really conceal our intentions.

Two of those patients were 38 plus weeks, so hopefully they would be flexible about rescheduling as they're not currently working; maybe one would even deliver overnight. The last patient of my morning was only 12 weeks. Earlier, she sent a message to Co-worker asked if I could do an ultrasound at that visit and if so, she was going to have both sets of grandparents accompany her. The provider in me felt so guilty as I heard my medical assistant reschedule her, "I am so sorry...I understand that you and your family arranged to take time off work..oh, you were planning to go out for lunch afterward as well?...once again, I'm so sorry..." I was ruining their family event to celebrate their upcoming arrival so that I can figure out why I can't have a baby...

It is a 25 minute drive between my office and my RE. As the traffic can be unpredictable, I try to allow 30 minutes for travel time. Although New Girl once told me that my RE almost always runs 10-15 minutes behind, I don't intend to take advantage of that window. I needed to be in my car ready to leave by 11:15 -11:20 at the latest. "So guess who is pregnant again?" one of my medical assistants greeted me as I walked in on Tuesday morning. It was a patient who delivered in May of 2013, she has no idea of her last period. She was just seen in primary care and had a positive test. I looked at my schedule, one of my term OB patients had delivered (although not one of the ones I had moved). I offered that I could see her just to do a dating scan and then she could schedule a new OB visit for another day.

Her uterus felt about 18-20 weeks on exam. Now it would take longer to do her scan. Sure enough, her composite measurements put her at 19 weeks 6 days. "Did you have a period after your delivery?" I asked "I stopped breastfeeding in August, and I think I had one in September and one around the end of October..." she answered. Hmmm those dates line up exactly... As she was already half way through her pregnancy, I felt obligated to coordinate her care at this time. She needs her prenatal labs, as she barely passed her glucose test last time, I should have her do it now. She has chronic hypertension, but stopped her Labetalol when her prescription ran out and needs a refill. I needed to give her the requisition for her anatomy ultrasound. "Your only option for genetic screening is a Quad marker" I informed her "You have until the phlebotomist arrives to decide if you want to do it." Man, I sounded like a bitch. This has become a 25 minute visit in a 10 minute slot. Not the way I want to start a day when I need to leave at a precise time. I remembered that one of my mentors once told me, "there's no such thing as a quick dating scan..."

Later that morning I had a new patient who was scheduled for an annual visit and she wanted to discuss fertility. They had been together for three years and never used birth control. Initially they just took an 'if it happens, it happens' approach but in the last year she tried using ovulation predictor tests, although she admitted that she wasn't consistent with using them every day. Friends told her that she should have sex one week after her period and one week before her period starts. It wasn't clear if they were optimising her fertile window. It's tough to explain to a patient that while I can appreciate the duration of three years, it's not quite the same as if you've actively been pursuing pregnancy by taking advantage of every monthly ovulatory episode. While she was getting dressed, I organised her orders for her lab work, HSG and her partner's semen analysis. Her cycle started over a week ago, she would need to do her testing next month. "Oh, my insurance switches to Kaiser next month. Actually we're effective with Kaiser right now, but I still have this insurance until the end of the month. After three years, we're just so anxious to get our family started..." I suppressed a sigh. Selfishly, I thought about how she just wasted much of my time, but she probably didn't know that the work up requires a series of tests that are coordinated with her menstrual cycle. Perhaps she was hoping that I had a single easy answer for her. Nonetheless, she would have to start anew with a Kaiser provider.

I managed to leave the office in time to be prompt for my own appointment when it was my turn to be a patient. "You can go on back to his office" the office manager instructed me as I walked into the waiting room. Apparently, he was also running on time. The door was ajar, but I knocked before entering. Dr Somebody that I Used to Know briefly stood up and motioned for me to sit down. He expressed his disappointment over our failed transfer and then led with "so, um...we'll proceed with your next transfer once your cycle starts..." Oh, surely someone so brilliant who possesses dual Ivy League degrees would be smart enough to determine that I wouldn't come all this way to discuss a plan that could be conveyed over the phone. I quickly informed him of my intentions, "So, what was your analysis of my IVF cycle...?"

Ah, he probably thought this would be a quick and easy visit just before lunch. Instead, we reviewed my stimulation cycle and ran through my questions as I tried to take diligent notes. Although I didn't say it out loud, I was acknowledging to myself that he wasn't quite saying what I wanted to hear. The experience from my first cycle offers some suggestions for modifications, but we may only see a marginal improvement. He noted that he discourages patients from entering into a treatment with the view that this will be the last or final option, as it places a heavier emotional burden on the process. "I am aware that there are winners and losers in the game of infertility treatments, and it's starting to resonate that we may be on the losers side." He replied by sharing his observations on how much I have evolved during this time. "You've responded as situations have changed -this is a good thing." While I was thinking that he was subtly raising the issue of donor gametes or embryos, he commented, "you've progressed from someone who never wanted to do IVF to wanting to start another cycle before you completed your last one!" He then offered to do my baseline scan in the event that we wanted to pursue the FET. "That would be great, as I wouldn't have to schedule another appointment." I accepted with genuine appreciation.

It was 12:30 by the time I got back into my car. I had just enough time to make it back to my office. My afternoon session starts at 1:30, but I had agreed to see the 12 week patient and her family at 1:00, after they finished their lunch date. I had become that patient visit who was not so quick and easy and after spending so much time discussing a second IVF cycle, I elected to follow the original suggestion of transferring our remaining embryo. Sigh...

Sunday, 23 March 2014

Breaking Up is Hard to Do

As a note in her Christmas card, as well as in her thank you card, Myrtle expressed that we needed to communicate by speaking on the phone more often, and not just through texting. I thought she had a fair point, and I wondered if perhaps her nonchalant response to my second miscarriage reflected the fact that I informed her via text. Inspired by Body Shop Girl's suggestion to make realistic New Year's resolutions, I affirmed that I would make an effort to talk with Myrtle on a regular basis. I also resolved to assemble a proper earthquake emergency kit with provisions beyond beer. There hasn't been too much progress with that task, but it is only March.

While we were getting ready for our first transfer, Husband was assigned to umpire some top level collegiate field hockey matches on the east coast. This is a great accomplishment for him, as a few of these matches feature recent national champions, and this trip could help him work toward his goal of being selected to officiate games in the championship tourney.  He spoke with me before accepting the assignment. I reminded him that we are not basing any future plans on a contingent if I become pregnant, but I quickly did the math; if FET#1 were to be successful, I would be between 34 and 36 weeks during his trip. Myrtle texted me when she heard that he would be staying with my parents during that time and asked I would be joining him. "It depends :)" I replied.

I was due to talk to Myrtle over the weekend after my BFN. I probably should have deferred, as I fully acknowledge I was in a much more sensitive state, but perhaps against my better judgement, I decided to face the music. "Oh, I'm so sorry..." she responded after I told her about my negative beta. "What's next?" she asked. I brought her up to date with our dilemma to transfer the final fro-yo versus starting a fresh IVF cycle.
"So, that's when you take shots to make lots of eggs..."
Well, you're not really making eggs, it's recruiting follicles, but she's got the idea...
"And you do that for how long -a month?"
"About 9 to 12 days. It mimics a normal follicular phase." Damn it! I used a technical term!
"Then the eggs are sperm are mixed and put back into your uterus..?"
OMG! She's finally grasped the concept!
"So, how many of these are you going to do?"

Earlier during that week, it occurred to me that if we do conceive and come out as recipients of infertility treatments, inevitably someone will ask just how much we spent to put a bun in my oven. My money was on Myrtle's father as being the one to ask that question. Tact is not exactly his forte, and Myrtle seemed to be reminding me that the apple doesn't fall from the tree. In my more delicate state, her innocuous question translated to: so how much time and money are you going to waste chasing this non-existent rainbow?

I informed her that our intention is to only do one more fresh cycle, and I expressed my concerns about coming to a point where we would transfer two or more embryos. "I resent the fact that I have to chose between having none or twins." I explained to her that beyond the health risks of a twin pregnancy, I feel we would really struggle with two as we don't have family close by to provide any help. "Well, can't you go to your parents and say, look we went through all this to give you a grandchild, can't you help us out to get a night nurse?"

I felt irritated as she seemed to be portraying me as some petulant spoilt little brat. I replied that I alone earn more than both my parents combined, so it feels a bit inappropriate to ask them for money. Fair enough, we do have a higher mortgage payment and reside in an area with a higher cost of living, but I also know my parents ended up owing the Feds when they filed their tax return and my Dad just learned he needs extensive dental work. Mostly, I resented the implication that I would be entitled to receive help from my parents. My grandfather used to say, "the world doesn't owe you a living" and I don't feel my parents owe us anything for giving them a grandchild. I know how much it would mean to them, but we're not trying to procreate for the purpose of producing a grandchild, so it doesn't seem right to expect anything in return.

Hoping to switch topics, I pointed out that I now would able to fly out to Connecticut in October, as I won't be 34 to 36 weeks pregnant at that time. Now, one would think Myrtle might say something such as, 'oh, yeah. I wouldn't want to fly cross country at that time in my pregnancy.' You know, like a normal person might offer.  Nope. "Well, I flew to Vegas [for a work trip] when I was 28 weeks pregnant." she pointed out. (Actually she was only 25 weeks -yes I looked it up after we got off the phone!) Myrtle didn't stop there. "I worked until the day I delivered. I even did a show when I was eight months pregnant and everyone offered to get me a golf cart, but I insisted that I could walk around the venue." Yes Myrtle, we all remember what a fucking rock star you were during your pregnancy...

I often remind my patients that pregnancy and breastfeeding are not competitive sports. It pains me when I hear women create a hierarchy for motherhood. "Well I'm better because I had an all natural delivery while you wimped out and opted for an epidural, but we're both superior to those lazy women who took the easy route with a Caesarean." Erroneous notion as recovery from a C/section is much harder. "I'm more of a woman as I actually nursed my baby while you merely pumped milk, but we both outrank mothers who don't love their babies and poison them with blasphemous formula!" Yet, I feel my own emulous instincts take effect. I will not gain fifteen pounds in my first trimester. O-oh Myrtle walked a 5K while pregnant! I'll see that and raise her running a 10K! It seemed that Myrtle had moved beyond being subtle and was throwing down the gauntlet.

As I started to remind myself that it could all be a moot point as I many never be pregnant beyond six weeks, and hopefully if I ever am, I'll be wise enough not to doing anything stupid, perhaps Myrtle senses my doubts. "I still think that you have a crying mess of a baby in your future" was her creative wording to proclaim that it will happen! My initial instinct was to go with sarcasm, Oh yes Myrtle, your predictions have been so accurate to date. Please tell me what you see in your crystal ball... Yet I was struck by the way she emphaised the negative aspects of parenting. It took me many years to look beyond the negative aspects and appreciate the positive benefits. Then as the blessings felt more elusive, I placed less emphasis on the challenges. I thought I would take the opportunity to educate Myrtle that pregnancy and a baby do not necessarily heal all the scars created by infertility. "That's a sensitive issue, Myrtle. Many women who become parents after infertility treatment feel that they can't complain about the difficult aspects. You are still affected by infertility even if you have a baby. It's also harder when motherhood doesn't seem to live up to all your expectations. These women may be more vulnerable to postpartum depression" I actually couldn't find any evidence that cites infertility as a risk factor for postpartum depression, but it seems plausible.

Myrtle wasn't listening anyway. "Oh, you'll be calling me for advice when your baby won't stop crying and you're at your wit's end..." I'm actually the first to admit if I do have a baby I won't have a fucking clue what to do, but my reaction was: Wow, thanks for forecasting that I am going to be an absolute failure at parenting before I ever have the opportunity. The vote of confidence is appreciated! "I could send you videos of little Myrtle throwing a tantrum. That might serve as birth control! (light laughter)" Bitch, you did not just say that to an infertile woman with recurrent pregnancy loss who just failed an FET... "Myrtle... NOT HELPING!" Note to self: merely telling Myrtle when she's not not helping.

Although I didn't share any of this dialogue with her, the next day my local friend H sent me a link to an article entitled 'I'm so glad we're not friends anymore', which discussed when to break up with a long term friend. I didn't find that all the criteria applied, but it is time to consider that maybe Myrtle and I need to take a break for a while. I know Myrtle doesn't mean to be malicious; she's just truly clueless. After we became best friends in kindergarden, Myrtle and I were inseparable until we reached the eight grade and we got into a huge fight that ended our friendship. To this day, neither of us can remember what instigated the fight, but it led to us branching into two different paths as we entered high school. I became involved in sports and politics. Myrtle was in the school play and was editor of our senior yearbook. I excelled in science and maths; her strengths were arts and literature. By the time we graduated, years of personal growth led us to rekindle our friendship as two very distinct individuals.

Perhaps, once again we need to part as we both navigate through procreation, pregnancy and parenthood. I know Myrtle and I will always be in each other's lives, but I may need to redefine her role for the time being. I hope someday we'll find our way back.

Thursday, 20 March 2014

Sometimes you have to roll a hard six...

While I still have moments of subspecialty resentment toward REIs, there are also times when I wouldn't want to have their job. In addition to being repetitive and redundant, I imagine it must also seem intellectually frustrating. One can apply the most sound rationale based on evidence supported data as well as his or her own personal experience and still experience a disappointing outcome. An RE may also witness cases where patients go against his or her recommendations and manage to conceive spontaneously or with less likely to succeed treatments. In such a situation, it must seem personally satisfying to know that your patient reached her goal; but I can imagine that professionally, it may go beyond bruising one's ego and may even shake one's confidence. Additionally, an REI is only as good as the team around him or her. My RE described the importance of the skills in the embryology lab. One can be effective in creating optimal protocols for oocyte retrieval, but may have low success rates if the lab is poor; while another RE may be lazy during a stimming cycle, but if the talent in the lab is able to work magic with limited gametes, he or she may be credited for their achievements.

I wonder if I have become one of my RE's more irksome cases. He initially suspected that I may have a septum based on my office ultrasound, but personally reviewed the films from my hystosalpingogram (HSG) and noted if there was one present, it was unlikely to be signifiant.  I saw the live fluoroscopy during my procedure and mentioned the possibility of a septum to the radiologist, but we both concurred that it looked like a normal cavity. One month later, I attended a conference where a renowned REI reported that an HSG has about a 37% false negative rate for diagnosing a cavity defect, and he advocates performing a hysteroscopy prior to starting IVF. Around that time, we received Husband's post Clomid semen analysis. As there was only minimal improvement, my RE was abrupt with his recommendation; IVF with ICSI is our best option for getting pregnant. We could try IUI for 2-3 cycles at most. While we were digesting that news, I didn't get around to ask about re-evaluating my cavity, because we somehow managed to conceive spontaneously the next month.

My RE admitted that he wasn't surprised by our seemingly miraculous pregnancy, even though it contradicted his previous prognosis. He also described that it may have been a fluke, and while those words may sound harsh, I appreciated his candor. I'm glad he didn't dismiss us, 'well, it looks like you're fertile after all! Go be fruitful and multiply!' In the end, he was accurate about IVF and ICSI being our best option, and now it seems that it may not even work. Those of you who are long time followers know the rest of the details. After miscarrying, a sonohystogram revealed that I did have a septum present. When we started IVF, I raised the issue of PGD as I wanted to avoid a miscarriage due to a chromosomal abnormality, which is exactly what happened after a hasty day 3 transfer. A transfer of an allegedly perfect blastocyst failed to implant. I know I'm not one of the most challenging nor unfortunate patients in my RE's practice, but I sometimes wonder if he, Misery and New Girl ever speculate, 'of course this would happen to Jane -look at what she does!' On the obstetrics side, many of my colleagues have described that they perceive any patients who are medical providers to have an inherent higher risk.

At the end of my WTF appointment, my RE offered to do a baseline scan in the event that we wanted to pursue FET#2. New Girl led me into an exam room, "so you're going to go ahead with this transfer?" she asked. "Well...I'm still not sure.."I admitted. "What does your instinct tell you?" she inquired. "Forget what [the shared first name between Husband and my RE] says. It's your body, you're the one who has to go through this." My first instinct was to ask to whom she was referring, but that missed her point; what was my gut telling me to do?

Well, my intuition senses that we will need to do a second cycle. I also fear that it may yield very similar results as last time. A relatively small number that make it to the blastocyst stage. Maybe PGD testing will find that none are normal. Or maybe we would transfer a normal embryo and it still wouldn't implant. It is also possible that I could achieve a pregnancy with a euploid embryo and still have an early miscarriage. There is also the potential that we could have a completely unsuccessful second cycle, transfer the remaining fro-yo from IVF#1 and have it result in a successful pregnancy and baby. If that were to happen, I would be pissed. Thrilled and happy, of course, but still pissed. It just seems that whatever decision we make is really just a throw of dice.

So, if there really isn't any method to this madness, I decided against applying any rational thought to this selection. Here is how we elected to proceed with FET#2.

Could I still swim in our championship meet?
I know I'm not enough of an accomplished swimmer to make this such a priority, but I enjoy this meet so much, and I am on the fast girls 35 and older relay team. Additionally, as my coach takes this meet so seriously, coming up with an excuse on why I couldn't swim would be harder than thinking up a reason for being out of work. Not a problem, according to New Girl, as she asked me when I wanted to do my transfer. Whoa. I actually have some input into the timetable? Now, that is mind blowing.

Potential fresh cycle conflicts
After recommending an agonist protocol instituted in the luteal phase, my RE and I started looking at the calendar to determine day 21 of my cycle. I couldn't resist mocking him for counting each individual day rather than counting ahead three weeks and subtracting one day. "I'm really bad at math..." he explained. Such a flaw earned adoration from Husband "That's exactly the type of mad scientist you want... someone who can solve complex equations, but is stumped by basic times tables..." Anyway, I am digressing... If my day 21 progesterone level confirmed ovulation had occurred, then I would start the lupron. There are only two problems with that scenario. Firstly, it requires my ovaries to cooperate. Post D+C, it took just over two weeks to have a withdrawal bleed and then I didn't have an LH surge until day 21. Who knows what they would do after being suppressed for a month. Additionally, the timing of my blood draw comes close to when I'll be in Memphis for a few days. Oh, that is just too much temptation for the mischievous Si and Am (my ovaries have officially been named after the evil Siamese cats from Lady and the Tramp). If there is an opportunity for inconvenience; they will find it. "We could just keep you on lupron for another day or so," my RE theorised. Nope. If we are doing a second fresh cycle, we compromise nothing.

The Orange Light
“Gatsby believed in the green light, the orgiastic future that year by year recedes before us. It eluded us then, but that's no matter--tomorrow we will run faster, stretch out our arms farther.... And one fine morning-- So we beat on, boats against the current, borne back ceaselessly into the past.”

In the end, it was the little orange light on my dashboard that would serve as our beacon. I waited a few days before confessing to Husband, as I was hoping it would spontaneously resolve. While we were recapping the WTF assessment and my RE's recommendation, I introduced the potential game-changer. "So, I noticed this morning that my check engine light was on..." Technically, that was not a lie. I noticed this morning that the light had been on for four days. I'm pretty sure Husband knows me well enough to add at least more three days on the time I was reporting. The look on his face was a mixture of anguish and disgust, and I could tell he was trying to determine what is the maximum value we would justify paying to repair my 11 year old Jetta with 142,000 miles. "So, I guess we'll go ahead with the FET" he replied.

The next morning I called my clinic to inform them of our intention, while Husband took my car to a mechanics shop that investigates your check engine light for free. Sigh. Infertility has made us chavs. He stopped by my office later that morning with a peculiar smirk on his face. "You didn't tighten the gas cap tight enough that last time you fueled. The pressure in the tank decreases and sets off the check engine light..."

Our die had already been cast.
We are proceeding with FET#2.

Tuesday, 18 March 2014

What if any Thing, did we learn From this?

The hardest part after receiving the news of our BFN was not processing my own feelings, but seeing the look of disappointment in Husband's eyes. I felt that I was to blame. I was entrusted with the responsibility of producing a viable pregnancy after the transfer of our embryo, and my shitty uterus failed. At least with my other two miscarriages, we had an explanation. Now we were in unexplained territory. I couldn't stop myself from rehashing everything I did post transfer. I was complaint with the no exercise, no swimming and no sex/orgasm rules for the first five days. I never missed a prenatal vitamin. We tried some new meals from a Paleo cookbook in an effort to eat healthful foods. I didn't have a drop of alcohol. Okay, that's a lie. I had a sip of Husband's glass of wine when he wasn't looking. Okay... it was two sips... I set an alarm on my phone and I never missed a single dose of my TID vaginal progesterone or my QOD PIO injections. When two extra strength Tylenol failed to ablate my headache, I yielded to temptation and downed two Advil Liqui-gels...Maybe it wasn't such a good idea to swim double sessions before my test day...

I know none of these factors had any influence. It just would be nice to have an answer. Last year, I saw a patient who miscarried twice within a six month time period. She was in her mid thirties and had two healthy pregnancies in her twenties. Oddly, she never came in for prenatal care, she just came in after the miscarriage was complete for a follow up, which made it difficult to do an adequate evaluation. We went around in circles, she kept suggesting multiple theories with innocuous events in her daily routine, but I had the same response; nothing she did or didn't do contributed to her miscarriage, but I could appreciate her desire to pinpoint a specific activity. If a causative behaviour is identified, then the formula for success is simply to avoid that action.

In my case, I needed to know what when wrong from the start and could it be fixed. It was time to meet with my RE and to discuss the postmortem of our first IVF attempt. He took a look through my chart and described it as a solid cycle by the numbers. My retrieval was within his expectations for my ovaries, the ratio of mature to immature eggs was acceptable (I read that if there are no immature eggs upon collection, it may indicate that the oocytes were over-ripe) and our fertilisation was consistent with the statistics for the lab. Unfortunately, it just doesn't seem to be enough to produce a viable and sustainable pregnancy. It feels reminiscent of when I would fault while my tennis instructor was adjusting the mechanics of my serve. "The motion looks good! ... the ball just didn't go in..."

My RE began by exposing the unfortunate reality, it's rare for IVF to succeed on the first transfer or even within the first cycle. Hearing those words fueled my resentment for those who conceive spontaneously. "You can go ahead and say 'I told you so'" I gave him latitude, "It would have been more efficient if I transferred both embryos." He laughed lightly and pointed out that if such a transfer resulted in a twin pregnancy, I would either be upset at myself or him; probably both. For what it's worth, this guy gets me. His observation from my stimulation is that my ovaries are brittle. Funny, I use a different 'b' word to describe them. Like a brittle diabetic who experiences dramatic swings in glucose levels with the slightest change in insulin regime, my ovaries over-responded in terms of estrogen production with a relatively low dose of meds (Menopur 150/Gonadal-F 150). My SD4 estradiol was over 300, he wanted to see it around 150. He doesn't feel that follicle recruitment was hindered too much by my withheld and decreased doses. Perhaps that was most disappointing to hear; I may still come up short of a dozen. However, he feels there is room to improve the quality of my oocytes by using an agonist protocol. We would start low dose lupron during the luteal phase of a natural cycle, to prime my ovaries and get them to CTFD. Then my stims would be started an an even lower dose and increased gradually.

I didn't ask, well what if that doesn't work and I'm still faced with a potentially low yield, nor did I admit that I had thoughts about wishing we had cancelled my prior retrieval. He offered that if at minimum we could get at least three embryos to the blastocyst stage, then it would be reasonable to pursue PGD testing. "I know that is important to you, although I can't claim that it is cost effective" He may have passed earlier, but I wasn't going to miss an opportunity to be wise-ass. "Well, I can claim that my instincts were correct, and if we had biopsied the embryos, we wouldn't have transferred one with a lethal anomaly." He repeated that there isn't data to demonstrate that testing is cost effective, which I think was his defense. We discussed my first transfer. I admitted that I was enticed by the promise of higher quality with a day 5 embryo and felt that I was forced to settle for less with my day 3 transfer. "I know you disagreed with my characterisation of a desperate measure, but I stand by my adjective." Once again, he laughed lightly. "A day 2 transfer would have been desperation, Jane." Okay, fair enough. He replied that he advocated so strongly for that transfer as he felt there was a good chance to result in a pregnancy with a low potential for twins. Technically, he was right. After all, if it weren't for that pesky extra chromosome, I could be in my second trimester right now. However, I was quite certain that an untested embryo would be abnormal, so I was also right.

He concluded that he still feels optimistic about our prospects, but he discouraged me from viewing our second cycle as a final cycle. Interestingly, and a bit to my surprise, he began and closed our visit by suggesting that we transfer our remaining fro-yo. We reviewed the assessment from the hottie embryologist, who seems to think it has potential. He  also noted that he prefers to complete one cycle before starting another. Who knows? Maybe this will be the one, but if not, we've only lost one month's time for a relatively small investment. So, I'm still faced with the same dilemma I was debating last week. A BFN and a WTF later, and yet I don't feel any wiser...

Sunday, 16 March 2014

I Can't Cry Any More

Hours after receiving the disappointing news of our beta results, Husband and I sprawled on our sofas and started watching Real Time with Bill Maher. As per usual, we were both fast asleep before the end of the opening monologue. I felt a bit disoriented when I woke up in the living room, and as I made my way to my bed, I had a fleeting thought that my negative test might have been a dream. Except I knew that it wasn't. The magnitude of the failed transfer was really starting to settle. In someways, it was more disappointing than my recent miscarriage. I had such little faith that my first transfer would produce a viable pregnancy. This embryo was perceived to be superior. This transfer was supposed to work! Yet, it seems harder to mourn an embryo that never resulted in a pregnancy. In some ways, I feel relieved to have a decisive BFN rather than a chemical pregnancy or third miscarriage.

Thanks to all these heavy thoughts running through my head, I was now wide awake and felt I was due for a good cry. Not wanting to wake Husband, who was sleeping by my side, I returned to the living room. It felt as if I were giving myself permission to break down. I started to sob, but I couldn't produce any tears. I just couldn't bring myself to cry.

I was up early the next morning to make my way to the pool for our first meet of the season. As we were waiting for the warm-up pool to open, I overheard two men in their mid-forties talking about their children. I knew that one of these Dads had triplets, but of course, I never wanted to ask any of the nosy questions that we all are thinking. I had been considering sharing some of my experience with infertility and perhaps gain some insight as to how they resulted with triplets. Without needing any prompting, he told his teammate, "We needed a little help and we got a lot of help. There was a 1% risk for triplets and we hit it." Ah, it was probably Clomid... I thought to myself. Not quite the same process as going through IVF and making a decision about the number of embryos to transfer. Maybe our infertility experience wasn't such a common thread. Feeling more alone and sad about our unsuccessful conception to date, I felt the urge to cry. I quickly excused myself and headed to the women's locker room. Locked in the last stall, I leaned against the wall and put my hands over my face. Yet, no tears fell.

After only five weeks of training, I still feel very unfit for competition, but somehow I managed to swim rather fast. I heard my time after my 100 yd Free and asked, "how?" I saw what I had seeded myself for my 100 IM and thought, what the fuck was I thinking? Yet, I managed to beat that time. I'm not too far off from my best times, and with all things considered; I'm really happy with that. As our team gathered at a local microbrewery for a celebratory post meet drink, I spotted a woman with a very small baby at the next table. I guess others noticed the infant as well, as the conversation shifted to Amanda and her pregnancy. I left the table to use the restroom, but I acknowledged that it was more of a reflexive action. Somehow, I had managed to make myself so numb that I just can feel anything any more. Disappointment has become my norm and I just can't cry any more.

As I walked back to my car, I went through my all too familiar routine of embracing all the things I can enjoy in my non-pregnant state. Moments after I turned over the ignition in my car, I noticed that the 'check engine' light was illuminated; and I burst into tears.

Friday, 14 March 2014

The Thin Envelope Theory

I'll admit I am a bit of a deviant; I've never seen the original Star Wars movies (episodes 4-6). I'm familiar with the characters and basic plot summary. Classic tale of Good triumphing over Evil as the main character, Luke Skywalker, discovers his family roots. Princess Leia, who is stunning in a gold bikini, turns out to be his twin sister, but that revelation pales in comparison to the shocker that his arch-nemesis lord Darth Vader is actually his father. I'm not sure how Han Solo factors into the storyline, except that the role catapulted Harrison Ford from a carpenter who installed cabinets for George Lucas to a silver screen superstar. There are really cool special effects, various robots, an actual dog who serves as a co-pilot, and a green little gremlin who keeps talking about this mysterious force.  Oh, additionally John Williams composed a killer musical score. The End.

During my elementary school years, I observed that Star Wars was a major obsession among my male classmates. I figured it would be something they would grow out of when they became older. Oh, I was wrong. Quite wrong. While we were dating, Husband and I queued for nearly two hours to watch Star Wars Episode I: The Phantom Menace on the night of it's premiere. He also dragged me to Episode 2, but I don't remember it's title, and I think I feel asleep during the movie. We were engaged by the time Revenge of the Sith debuted in our local cinema. I had accepted that watching Star Wars films would be part of my marital obligation. However, I was actually enjoying the movie, and as we approached the dramatic fight sequence between Anakin Skywalker and Obi-Wan Kenobi, Husband leaned over toward me and whispered "I've been waiting twenty-five years for this!" Seriously? Was I really planning to marry this dork?

As you can probably gather, I did go ahead with our wedding, and I think I actually gave him a DVD set of the Star Wars series as a present. Although we have a copy of Revenge of the Sith for our upgraded Blu-ray player and Husband can watch it whenever he wants; whenever he finds it on regular TV, all activity must stop so that he can watch it again for the millionth time. I think I've  actually seen it enough times that I can quote particular lines. In particular, I'm feeling the same sense of betrayal and disappointment as Obi-Wan Kenobi.

"You were the chosen one!"
"You were to bring balance to the force, not leave it in darkness!"

My Embryo turned to the dark side...

In the words of Master Yoda: *Failed* I have.

I am manifesting my regret over only transferring one embryo by projecting the conversation between Misery and New Girl as they discovered my results.

"Aww, Jane's beta is negative"
"Silly girl, so concerned about the risk of twins. She should have transferred both."
"Doesn't she know she has shit for embryos?"
"No one ever wants to hear the truth. Shall we do rock/paper/scissors to decide who calls her?"
"She instructed us to leave a message on her voicemail. I wish they all would do that; it makes it so much easier when you don't have to speak to them in person..."

I was in a lecture on chronic pelvic pain when I checked my phone and saw a missed call and voicemail. I should have waited until the end of the lecture to do this, but I looked at the length of the message. Twelve seconds.  I still had her voicemail with the beta results from my last transfer. Not that I was saving it for nostalgia, I just never get around to deleting my old voice mail messages. I found the previous message -it was thirty seconds long. I started applying the Thin Envelope Theory. Remember when you were applying to University or Graduate programs? A thin envelope was an ominous sign of a single page rejection letter. A thicker envelope held the promise of acceptance.

Twelve seconds. That is how long it took for Misery to break my heart with the words, "I'm sorry Jane, your test was negative. Stop your meds and call us when your cycle starts. Hope you have a good weekend." Husband and I sat in our kitchen and slowly sipped beer straight from the bottle. It was really just a formality as we were already felt pretty numb from the news and we were figuratively banging our heads against the wall. I know this is so naive, but to a certain extent, once you accept that you need to proceed with IVF, you perceive that it will work. Yes, there are more treatments and transfers that don't work, but there are many that are successful. This was our stellar embryo! After our day 3 desperation transfer, I was yearning for an elusive higher quality day 5 embryo. How is it that an embryo with a lethal trisomy resulted in a pregnancy, but an excellent blastocyst couldn't make it off the ground? The further I fall down this rabbit hole, the less it all makes sense to me..

The emotional side of my brain is forbidden to engage in any optimistic thinking, but the rational side of my brain was forced to acknowledge that this could actually work. Pregnancy (not birth rates) are 65% when a high quality blastocyst is transferred into a woman my age. The statistics were in our favour! The emotional side of my brain is consoling the rational side by reminding her that this failure does not mean I will never become pregnant, it just wasn't meant to be at this time, even though it really seemed like it could have been.

At this point, my plan is to finish my beer, throw myself in the pool (literally, as I have a swim meet this weekend and I want to push myself to swim fast) and schedule a WTF appointment with my RE to discuss our best course of action in terms of the next steps. I'll close with the (modified) words of Obi-Wan;

You could have been my son or daughter. I loved you.

Wednesday, 12 March 2014

Self Imposed Deadlines

As the calendar draws closer to my beta day, I gave myself a deadline to finalise my decision about cleaning out the freezer with FET#2 or trying for a better crop of embryos with a second stimming cycle. I figured my brain would be in a more rational state prior to the emotional letdown after a BFN. I go for my beta in less than 48 hours and I still haven't made up my mind.

I think almost everyone knows a friend who gave her boyfriend the ultimatum: propose by a certain date or she'll end the relationship. I think we all remember that the date came and went without a ring. Many of us also observed that the friend failed to carry out her threat of breaking up. In general, ultimatums don't work, as I am finding that to be the case with trying to conceive.

I thought I'd take a look back at some of the self-imposed deadlines I've issued myself over time. When my IUD was still in place, my plan was to start TTC at age 35, and if it didn't happen in two years, then I'd get a new IUD and close up the shop. After all, I would never do IVF. When we started meeting with Dr Somebody I Used to Know, my intention was that we would only do IUIs. Of course, my strategy was for an IUI to work, and therefore we wouldn't need to do IVF. When I first recognised that we would need to do IVF, I was against doing ICSI. Thanks to my savvy bloggers, I accepted we would need ICSI long before my disappointing retrieval.

As I write this, it really resonates that I never anticipated that we would have any problems conceiving. Like most women, I never envisioned that Husband would have any male factor infertility issues. Interestingly, in the final three months before I removed my IUD, I became Mary Perfect with a 28 day cycle. I contributed my regular cycles to the fact that I did a three month triathlon series, and AF liked to show up on race days. I couldn't forecast that my cycles would become unpredictable and unreliable. I didn't know that I'd become that example of why REIs proclaim that you don't know how you'll respond to stimulation until you go through a cycle. Despite my low FSH/ E2 and high AMH numbers, I produced a very low yield of mature oocytes.

I can also accuse my former self of not being very specific with this deadline. The plan was to start TTC at age 35, but I postponed my IUDectomy for 6 months due to Myrtle's wedding -do I get a 6 month extension? The year 2014 was supposed to be a cut off point, but I never clarified exactly when. January 1st or December 31st? By the month of May when I turn 38? I feel like I can place a few particular limitations. We will only do one more fresh cycle, and it will not be after January 1, 2015. I will stop trying to become pregnant at the age of 40.

As another reminder about the length of we've been trying to conceive, which I know is relatively short compared to some others. I'm writing as I listen to lectures during an educational symposium on contraceptive technology. Although there is a lot of redundancy from year to year, it is one of my favourite conferences and I try to attend annually. In addition to the great speakers who deliver excellent lectures, I can hop on the train and take a quick trip back across the bay to swim in the noon class.

When I attended two year ago, I was in a two week wait from my first Clomid cycle and thought my BFP was only a few days away. It seemed so ironic to be learning about preventing pregnancies whilst I could possibly be pregnant. It was during that meeting when I scheduled a lunch date with my cousin, and felt upstaged after she announced her surprise pregnancy. "It happened in Hawaii, as we were just so relaxed..." she explained. At that time, I just interpreted 'relaxed' to mean tipsy, but as I wandered deeper into infertility territory, the 'relaxed' comment really started to irritate me, as she experienced infertility and conceived her older son as a first time IVF success.  I feel a little guilty as I realise that I've been opting to swim during these breaks and I haven't made any overtures to meet up with her again. However, during our last encounter, I discovered that we don't have much in common.

A year later, I attended this annual forum deeply entrenched in infertility. I sat at the back of the room and inconspicuously tried to write some blog posts, just as I am doing now. I was recovering from the hysteroscopy which corrected my uterine septum, and I was excited to be starting IUIs. I knew IUI success rates were low, but I figured we were appropriate candidates as we had a spontaneous conception, but the reality of needing to do IVF was starting to loom. Yet, I never could have anticipated that I'd be post FET in one year's time.

So far, focusing on strategies to address unintended fertility and unplanned pregnancies has made for a nice distraction to prevent me from thinking about what may or many not be going on in my own uterus. Or at least it was until I noticed that there were two very pregnant women sitting in my row. I sent a witty text to both Husband and Co-worker. She replied first, "Maybe you'll be among them!" She added extra exclamation points for enthusiasm, which I won't duplicate. Yeah, I've played that game before and I know the end result. Husband would know how to make me smile, "Are they Smug?" he asked.

Even including the preggos, I love being among my reproductive health peeps. Despite my personal experience with infertility and even after examining the ways my perspective has changed in past two years, I haven't been altered professionally. I still love discussing contraception. I am committed to the goals of making every pregnancy a wanted pregnancy. This remains my passion.

Looking back on what I've learned in the past two years, what stands out to me, is that one cannot make a decision based on a hypothetical; one needs to be faced with the situation. Thus, I've decided to relieve myself of the burden of deciding our next step before my beta draw. We'll just wait to see what happens.

Sunday, 9 March 2014

Not where I want to be...

I tend to get annoyed at the way 'hormones' seem to be blamed for everything. It seems to have become such a catch all cover-up. Mostly, I find it irritating that those who are accusing 'hormones' of being the culprit don't even know which hormones they are referencing... Anyway, I'm finding myself jumping on that bandwagon, as I found myself a bit more emotional and irrational while I was wearing three estrogen patches at a time. In particular, I had two near-crying episodes over my weight. I know it is something I should let go, but for some reason; I can't. Somehow, while limiting activity, I managed to lose a little weight during my stimming and early pregnancy. I was back to 150 just after my D+C. After running three 10Ks, two half marathons, going to cross-fit three times a week and playing tennis, my weight ballooned to 156. I know what many of you reading (if you are still reading this) are thinking, but Jane, it's muscle! I had myself evaluated with the hydraulic body fat test. I'm at 23% fat.

It's just not where I want to be, which is adding another layer of frustration to this process. We've been trying to have a baby for just over two years. I've had two entire years to lose weight and get my figure into top shape before embarking on a pregnancy, and I couldn't do it. More so, I am starting to fear that if I do become pregnant; how will I ever manage to lose the baby weight? I vowed that I will not gain as much weight as Myrtle did during her pregnancy. Not just because I am petty and pathetic and feel I need to do something better than her, although all that is true; because she did gain an excessive amount of weight.

I know I should be focusing on metrics other than the scale. To prepare for my half marathons, I did three training runs and ran three 10 K trail runs. My times for the 10Ks weren't quite where I wanted them to be, but I found that I felt really good while running, which I attribute to Cross-fit. During my first half marathon, I had a slow start as it was quite cold and raining hard, but I found my stride after mile 6 and finished strong. My time actually reflected a negative split, but it wasn't where I wanted it to be. Two weeks later, I was signed up to do another half marathon. I had been struggling with a cold and Husband encouraged me to switch my distance to the 10K. As the location of the race was on one of my training courses, and because I am too stubborn, I proceeded to run the half. This time, I got off to a good start and at the half-way point, I was way ahead of the volunteer 2.20 pacers. Maybe I could actually pull off a sub or near 2.15 time! I stopped at the aide station by mile 10 to remove my jacket. When I attempted to return to the course, I stumbled and placed all my weight on the side of my food whist trying to keep my balance. It wasn't a serious injury, but it was enough to slow me down. Slow down enough to watch the 2.20 runners pass me. I finished at 2.21:18. Not where I want to be, but I would take it.

Switching to another arena, I ended up taking a bit of a hiatus from swimming. When I first learned that the embryo's growth was delayed, I stopped exercising as I feared I would spontaneously miscarry and for some reason, I was really concerned it could happen at the pool. Okay, perhaps not getting up at 5:30 and swimming outdoors when it was subfreezing temperatures was also a way to console myself about the miscarriage... I was so happy to be back in the pool after the Christmas break, I almost didn't mind that the water was bone chilling cold. Later that day we learned that the heater and pump were both broken and it would take a over a month to fix. January would become the second month without swimming.

I knew our coach would be all-business when we returned in February, but I didn't realise how serious she was until she has us do timed sprints that week.  The 4 x 100 timed sprints is one of the most dreaded workouts. Any time she's counting swimmers as they arrive, and gets out her clipboard to re-arrange lane assignments; it's not a good sign. I had only swam a few times since Thanksgiving, I had no fitness for sprinting! My best time during these trials was a 1:15. I told myself to be happy with anything in the 1:20s. I went 1:23/1:25/1:27/1:22. To my surprise, my coach was actually pleased with that. "I know it's not where you can be, but given the little time you've spent in the pool, I'll take that!"

 On the morning of my transfer, I actually arrived to the pool early enough to get in some warm up laps. As I grabbed my board to do some kicking, I saw someone using the ladder to enter the pool. Use of the ladder is strongly frowned upon by our coach. We're expected to jump into our lanes (using the diving blocks is preferred) and get out "like a champion" which means you push yourself up on the side of the pool. There are only a few exceptions when using the ladder is permitted; if you're injured, if you're Lou, the oldest swimmer in the pool at the ripe age of 78, ... or if you're pregnant.

It was Amanda. I hadn't seen her since we returned to the pool after the broken pump. I remember feeling envy when I learned about her pregnancy while I was stimming. She was 14 weeks then, I would be about 18 weeks by now, so she must be 33 weeks or more. Damn! Good for her! There it was; the ultimate reminder that I'm not where I want to be. I recall in the days of my beta draws we were once in the same lane, and I was giddy over the fact that there were two pregnant swimmers in that lane. I'm ashamed to admit this, but I couldn't even look at her. As I was able to go straight home that day, I left the pool a little early to avoid seeing her on the deck.

At times I just feel that I should have more to show for myself. As I haven't been able to produce a sustainable pregnancy in the past two years, I should at least weigh less, swim better and run faster. I'm halfway through my 2WW, which is actually only a 9 day wait, thanks to my RE who likes to test early. Husband notes this is perhaps the only advantage of IVF. It's funny how certain aspects can sneak up on you. I can work with pregnant women all day long and not think about the fact that I could be a little bit sort of pregnant right now, but checking the expiration date on a carton of milk reminds me that I'll know one way or the other by the time the milk sours.

No, it's not where I want to be, but I'll take it. Actually, I'll do more than that, I'll embrace it as I know I'm fortunate to be in this position. Eventually I'll get over my other issues... someday...

Wednesday, 5 March 2014

Embryo on Board

A few years ago, I was doing my household cleaning when I flipped on the TV and started searching for something mindless to serve as background noise. I stumbled upon a marathon of I didn't know I was Pregnant! Like driving past a car crash, I soon found that I couldn't look away. I was drawn into watching episode after episode while the hoover remained in the closet. Props to the mostly unknown actresses who deserve Academy Awards for portraying someone going through the pains of labour, without realising that it is labour. I know it always gets asked; how can one seriously not notice any changes of pregnancy? In the sketches that I saw, many women had been diagnosed with PCOS and were told they could not get pregnant. A few others were in their mid-40s and figured they were too old. One very thin college age girl, I suspect was really in denial. Her pre-med roommate delivered her baby in their dorm room, thus nailing her admissions essay and interview. It was interesting to see the follow up with the real women and their surprises. Without any prenatal care or pregnancy precautions, they delivered healthy babies. My work seemed so obsolete.

In contrast, if this FET works, I'll be aware of my pregnancy from the moment it started. I'll remember that I went swimming that morning. It was raining and I love swimming in the rain. The sky may be throwing it down, but it feels so peaceful in the pool. California has been in a serious drought and we really need this rain. I'll recall that it was a (6) 1-2-3-4 and (4) 4-3-2-1 Individual Medley set. Man, she is pushing the yardage! I'll remember what I had for breakfast. Gluten free Rice Chex with almond milk, thanks to a great suggestion from Amanda at Beloved Burnt Toast.

I'll look back and recall that my transfer was postponed. We had just crossed the Bay Bridge when I received a call from New Girl explaining that my RE had a complication with a surgical case. (There was a possible perforation during a hysteroscopy and he needed to perform a laparoscopy. All was okay and he was hopeful that the surgery corrected her Asherman's syndrome.) We went to a nice spot for lunch and enjoyed the opportunity to walkabout like tourists in San Francisco. I was really glad that I decided to take the day off, especially as I have been fitting so much of this process around my work schedule. I had a really busy morning on the day of my D+C and I was almost late for my procedure. It felt good to be prioritizing my family, at least for the day.

There was more than one way that I benefited from this delay. At the time I received the call from New Girl, it was 30 minutes before my appointment and my bladder already felt as if it were about to burst. Husband has always complains about my small bladder capacity, and I may have a bit of an overactive bladder. In particular, if I know I can't go to the bathroom for a while, it really seems to drive the urge to void. The second time around, I waited until 45 minutes before my transfer to start drinking water. I only drank about half of the required amount, but it adequately filled my bladder and I was much more comfortable.

The embryologist reported that our embryo thawed well and was hatching spontaneously, which apparently is good. The transfer procedure itself went very smoothly, although the tech wasn't too proficient with the abdominal ultrasound. I could tell my RE was a touch frustrated, but I resisted the temptation to maneuver the wand myself. I've noticed that there is so much variation in the protocols between different clinics. XYZ is very no frills. They employ a non-sterile set up, and they don't offer  Valium or any other pre-meds. During my first transfer, I was so upset about the embryo report and I left a mess of loose ends as I rushed out of the office. I could have used the Valium for those reasons alone, but especially as I was so tense that it was hard to keep still during the procedure. Perhaps I was fatigued from so many laps of butterfly during our morning set, but I felt much more relaxed during this transfer. Not that I'm subscribing to the 'just relax' theory, as I know it won't make a difference... I once had a patient who described that she and her husband had been trying to get pregnant for 3 or 4 months without success, but then "we relaxed and it happened." I informed her that she was within timeframe for normal fertility, but I was really tempted to ask, "So, how exactly did you 'relax' and can you teach it to me?"

I'll remember what I was wearing on the day I may have been impregnanted; it was a shirt that read 'Swim Hard or Go Home'. It caught my RE's attention, and although we commented that it seemed more figurative for our IUI treatments; such a sentiment is my mantra for this FET. Either go the distance and produce our take home baby; or forever hold your peace with a BFN. I don't want to take another trip through the in-between territory with another miscarriage. I'm not sure we could go through this again if I were to miscarry for a third time. I also wore the It's a Marathon, not a Sprint necklace that my mother gave me. Someday when I recount these stories to her, I'll want her to know how her spirit was with me during my treatments.

How will I remember what I felt on the day I may have become pregnant? I wish I could say that I was consumed with more excitement than fear. I still can't shake the notion that my crappy stimulation yielded a tainted batch of embryos. We had the same embryologist as we did for our previous transfer. (Much to Husband's delight as he thinks she's hot....) It was nice to feel that we had some continuity, as she claimed to remember us. She reported that the selected embryo received top grades, and the other was still considered good; it just didn't score as high as the transferred one. Although my RE's description was that it barely met criteria, she acknowledged that they don't keep any embryos if they don't think they have the potential to produce a baby.

As I always like to plan my next steps in the event of a failure, this information is making me revisit the options of FET#2 versus a fresh cycle. I can appreciate why my RE recommended transferring both fro-yos. It would have been much more efficient in terms of time and money to see if none, one or both would stick. Yet, this time I was determined to hold my ground and insisted on a single embryo transfer. Neither my RE or the embryologist tried to change my mind. There is a lot to consider. Another FET is a walk in the park as it merely involves two monitoring visits, one blood draw and one scheduled transfer with a price tag of a few thousand dollars. A second fresh cycle would be much more consuming, as it involves every other day monitoring with an unpredictable retrieval date at a projected cost of twenty grand, plus meds. I feel as if I'm revisiting our decision to pursue so many IUIs, when we were hoping that spending $3K would save us from spending five times that amount. The difference now is that we would only be delaying another fresh cycle by only a month or two, and the cost of a second fresh cycle seems really steep whilst we are still paying off the first one.

Then again, maybe I won't have to make this decision. Can the fact that I am engaging in potential retrograde thinking be considered optimism?

Monday, 3 March 2014

Not so hidden Infertility

Hypertension is often referred to as the silent killer, as many affected are unaware of the condition until the damaging effects are apparent. In many ways infertility is also a hidden entity.

The sound of silence is quite literal for the woman who shies away and retreats when her co-workers talk about babies. Isolation is another presenting symptom for the woman who dreads a family gathering or avoids a friend's baby shower. Insomnia and depression may also be associated effects. Infertility can compromise one's character; as it often requires her to lie about her intentions and situation and to invent excuses for absences. Infertiles must work so hard to keep their family planning as a private manner, something that others expect without exception. Thus in some ways, the covert status of infertility affords a woman some dignity. If no one can tell from looking, her secret is protected.

Then there are times when infertility is not so hidden. Many women develop bruises as they master administering injections. Although I am adapt with a syringe, I feared the cumulative effects from multiple shots would leave some marks during my stimming and early pregnancy. My swim teammates might take note of bruises on my abdomen and ass and wonder if I had become a victim of intimate partner abuse.  I did start wearing long sleeves as my arms were black and blue from the near daily blood draws. The phlebotomist joked that I looked like a regular IV drug abuser.

Recently, I've become that girl from the Crash Test Dummies song. You know, the one who wouldn't change with the girls in the locker room, as I fear they'll find estrogen patches all over my body.  Although the patches are clear, the adhesive material frames them with a gummy residue. One of my teammates was recently diagnosed with early menopause at the age of 42, and is currently using the same patches. She has consulted me a few times about her treatment, and as she is not too socially savvy, I know she wouldn't be discreet if she saw them on me.  Therefore, it has become my routine to walk to the locker room very slowly, maybe hang back and chat with our coach for a few minutes, or accidentally on purpose leave my water bottle by the pool so I'll need to go back and retrieve it. All to consume time, so that I get into the showers once everyone is done. Thus preserving my secret.