Monday, 24 November 2014

See You Tonight

Maybe I'll see you tonight,
Maybe I'll see you tonight

Wherever the night takes you,
Maybe you'll see me too, 

The colder it gets, you won't see me anymore,
but there's still a chance I might walk to your door

Maybe the time is not right,
I won't be seeing you tonight,

Maybe I'll see you tonight,
maybe I'll see you tonight...
-Green Day 

Just a month or so before I removed my IUD to let this adventure begin, I was talking with a close friend and fellow gynae about how our profession would affect our pregnancy experience. "There won't be the same sense of awe and amazement during the first ultrasound, as I know what to expect..." Of course when I said those words I thought it would only take a few months to get knocked up and the initial scan would reveal a perfect viable pregnancy...

You all know the rest of the story, three years of infertility treatments, yada, yada, yada... here we were again, wondering what could be going on inside my uterus. As Dr STIUTK was away, his partner would be performing my scan.  "So did you transfer one or two?" he asked while prepping the ultrasound probe. Fantastic. He hadn't read my chart. It's usually a good idea when you're seeing a patient not familiar to you. This means he also didn't know that I've had two miscarriages, three failed transfers, and yes this was a single transfer with a euploid embryo.

As I answered, I thought about reminding him of what I do for a living, but I decided just to lie back and to remember that I was a patient. Yet, I couldn't silence the clinician inside my brain as he started to scan. Gestational sac is inside the uterus -phew, no ectopic. There's a perfect sized yolk sac with a fetal pole right next to it. Yes, there is the blinking flutter to indicate cardiac activity. I can only see one, the little bugger didn't split! I was also doing a little backseat ultrasounding. Pause it there! That's a perfect view for the CRL measurement! 

It was both the most overwhelming and yet underwhelming moment of my life. My aforementioned friend had told me that my experience during this ultrasound would be observing Husband's reaction. I looked over at him and he just looked puzzled and confused. He wasn't sure what was happening while the doctor was auscultating the heartbeat, while I thought that even at 130 beats per minute, it could have very well been mine.

As I had previously anticipated, Husband kept his stiff upper lip intact until the other RE and New Girl left the room, and then shed a few tears once the door was shut. At last, he had reached his quest of seeing a beating fetal heart on an ultrasound. Even better -it was ours! We shared a collective sigh of relief, while we also acknowledged that we still have a long way to go. We've never made it to this point before. The embryo's measurement was right on track. The word viable is being used to describe it. This was a significant milestone. Yet, at the same time, I can't help to look at that tiny spec and think that's really it?

I know that I sound like a spoilt brat, but the picture from the RE was really anti-climatic.

So I'm embarrassed to say, that I self-scanned for a better one...

Meet our little grain of rice! 

Monday, 17 November 2014

Keep Calm and Carry On

I think we told almost all of our close friends about our most recent FET, as well as the rest of our sorted reproductive past. It was touching to see how many infertility novices quickly learned the drill of beta doubling times and it was interesting to note that many seemed more anxious about receiving my numbers than I was. For record, my RE had me do a third draw, which came back at 2136. "I know you've probably already done this," said New Girl "I looked back at your prior betas and these are way higher." I knew they were, but I didn't make any direct comparisons, as there are so many differences between this FET and my first fresh transfer. I held this unusual sense of confidence as I casually waited for my results. After receiving the first and most critical one, I just knew that my betas would rise accordingly. Wow. I thought on a few occasions, this must be what it feels like for normal women... Then I remembered that most normal fertile women don't go through beta testing. I had to explain to Myrtle what it meant to have a beta of 175. I am not kidding.

Of all the money we have spent on this procreation pursuit, and it has been a lot, the $1875 for CCS testing has been worth every penny and more. Yet, it doesn't offer any guarantees. It only means that if my heart is broken with another miscarriage, a chromosomal abnormality will not be the cause. I keep reminding myself that my embryo is not infallible. My RE recently mentioned that he has been seeing more miscarriages in women over 40 who are found to have normal chromosomes on their pathology reports. "You're not over 40" Husband countered. True, but I'm not that far away. I had two patients of my own, both are in their early 30s, whose POC analysis did not implicate a chromosomal abnormality. One was found to have a large uterine fibroid and the other was found to have the triad of a high FSH, low AMH and low AFC, leading to the craptastic DOR diagnosis. Embryos can still be shitty even if they're genetically normal.

I'm in the ignorance is bliss phase. While I was a University student, I attended a lecture by a psychology PhD candidate whose research observed that people cannot disregard information presented to them, particularly if it is very emotional in nature. Well, I seem to be proving her wrong, as I often forget that I am pregnant. For three years, I've become obsessed with pregnancy and now it's expunged from my mind? I don't know how many weeks and days I am. I refuse to calculate a potential due date. I saw a pregnant woman in Tar.get and instantly filled with disdain, until the little voice reminded me, oh yeah... I'm technically pregnant too... 

Myrtle, who apparently is an expert in obstetrics after her textbook perfect pregnancy, had some advice for me, "just cuddle with your kitties or think of Angus if you feel anxious..." Thanks, but I don't actually don't feel anxious. I know whatever will be, will be. The die has already been cast. Nothing I can do can influence this outcome, and as mind blowingly frustrating as that is, there is really no point in stressing over it.  I'm not even meticulously inspecting the toilet tissue. I tried to find an explanation that Myrtle might understand. "Imaging as a child, you really wanted a certain toy for Christmas. It was the last gift you opened and you were absolutely elated as soon as you tore off the paper. But then you were told that you couldn't play with it. You couldn't look at it; actually, you weren't allowed to even think about it."

Maybe that analogy hit a little close to home for me. If I receive a gift from an out of state relative, my mother would hold it hostage on top of our refrigerator until I wrote a thank you note. To this day, that discipline has stayed with me, with the one exception that I once needed to cash my grandmother's ten dollar cheque in order to buy a card and stamp for my thank you note. Maybe it's why I have managed to keep thoughts about this pregnancy out of sight and out of mind. "So, are we ever going to be able to enjoy this pregnancy?" asked Husband with words that stabbed me right in the gut. "Hopefully..." was all I could answer.

This past weekend I ran into an old friend at the Farmer's Market. After we chatted for a few minutes, she cut right to the chase, "so, any news?" I immediately felt shitty as I forgot that she was in the loop and I realised that I didn't tell her earlier. "Oh, I'm pregnant again." I informed, suddenly acknowledging that it was the first time I said 'I'm [the p-word]' out loud, and I sounded like an asshole. I'm sure to anyone who overheard our conversation, I came across as one of those super fertile women, we were just talking about if we wanted to have a third baby, and I realised my period was late, so I took a test and it was positive! It's so easy for us, all we have to do is talk about getting pregnant and I'm knocked up! "Three pregnancies, nothing yet to show for it." I quickly added for the benefit of any eavesdroppers. No one looked up from selecting their desired produce. They were calmly carrying on with their day, and I should too.

Monday, 10 November 2014

The Only Thing We Have to Fear... is Fear Itself

A week ago, I woke up about half an hour before my alarm rang. It was another Monday, another start to the work week. Yet, this wasn't any other week. By quitting time on Friday, I would have my beta results, and my two week wait, which has really been a three year wait, would be over. As I tried to fall back asleep, I found myself thinking about The Monster at the End of the Book.

*Spoiler Alert: Although if you haven't read this book, you must add it to your reading list!* 

Grover, the most beloved Sesame Street character until Elmo was introduced, had received some inside information that there is a Monster at the end of the book you are reading. He begs and pleads with the reader not to turn any pages, which will bring them face to face with the Monster. When that fails, he attempts to tie the pages together and even builds a brick wall to thwart any further page turning. It was one of my favourite books as a child, perhaps because my mother could do a pretty good imitation of Grover freaking out.

I've previously noted that it's the final 48 hours of the two week wait that seem to be the hardest. When I hit 8dp5dt, I started contemplating testing. I researched my fellow bloggers and while there were a few exceptions; for the most part, women with a successful implantation had a positive result by this time, and women with negative results, often had a BFN or chemical pregnancy confirmed. Why drag it out any longer? I could pee on a stick and end the suspense.

Suddenly it made sense why I was randomly thinking about that book from my childhood. I didn't actually want the two week wait to end. Each passing day was like turning a page, and would bring me closer to the BFN Monster at the end of the week. I wanted to prolong not being not pregnant as long as possible.

For the record, I did hold out on testing. Husband reminded me that even when I was pregnant, my second line was so faint you had to squint as if you were looking at those 3-D posters that were all the rave in our college days. I also came across the episode of Seinfeld where George contemplates telling his girlfriend that he loves her. "Are you confident in the 'I love you' return?" Jerry inquires. "Otherwise, that's a pretty big Matzah Ball you've left hanging." As soon as I knew that I was most likely guaranteed a second line, I broke out my lone First Response Early Result test (a gift that accompanied the Endometrin, which I was also saving for when/if I became pregnant again). I didn't break Aramis's record of twenty seconds, but the colour in the test line came through before the control line. That had never happened to me before.

Obligatory FRER Picture
I had promised myself that I would break my POAS habit, but even after replaying Misery's voice mail three times, I needed something tangible to show that I was actually pregnant. I needed to erase any doubt that the lab had switched my blood sample, or perhaps Misery intended to leave that message for another patient. My second beta came back at 839. The Monster at the end of the book was none other than furry, lovable Grover himself. Thirty-five years later, I now understood the message to that story. You must face your fears; and sometimes, they may not be as scary as you thought.

Friday, 7 November 2014

The Writing in the Tablets

Although I am scientific minded and evidence based, I exhibit a bit of a contradiction; I am superstitious. After each transfer, I have made sure that I had just enough progesterone on hand to make it through to beta day, as I refused to order anymore until I received my results. Obviously, I feared that procuring an advanced provision of extra progesterone would some how jinx the outcome. Even thought I knew such actions exerted no influence, and wouldn't even be wasteful as I would need the supplies for my next transfer, I still kept to this ritual. A few days after my transfer, I started to count the number of tablets in the bottle in my bathroom, as well as the one I keep in my purse for on-the-go dosing. It turned out, I had exactly enough Prometrium capsules to get past my afternoon dose on beta day. Right to the point in time where Misery would be telling me to stop all my meds if my test results were negative.

My stomach twisted into knots. This was definitely a bad omen. Not a good prognostic indicator at all. I shared this news with my friend Isabelle, who asked if I were using Endometrin. No, I replied. I've been prescribed Prometrium, or whatever micronised progesterone the compounding pharmacy whips up for me. Suddenly, I remembered that I had received a box of Endometrin from a fellow blogger earlier this year. I used it for a few days during FET#2 and I found that I liked it much better than the Prometrium capsules. Endometrin comes with its own applicator, so I don't have to use the Pre-Seed Lubricant applicators. (Top Tip: Pap smear cytobrushes are the perfect tool for cleaning these applicators. They work well for cleaning the straw and spout of your water bottle too. Steal some at your next visit!) Best of all, I found that the Endometrin didn't muck up my underwear nearly as much as the Prometrium.  I didn't have too much hope with that transfer. It was a Hail Mary Grade 2 Blast to possibly avoid a second fresh stimming cycle. After a few days, I switched back to the Prometrium, as I decided that I would save the preferred Endometrin as a reward when/if I ever became pregnant again. What can I say? This girl knows how to pamper herself.

Now I had to acknowledge; was there something to be said for the fact that my preference for progesterone tablets and planned use in the event of a pregnancy aligned perfectly with the timing of my results? It sounds absolutely ridiculous as I type those words. Yet, these kinds of things appeal to the meticulous nature of my mind. I always try to look for patterns. I love palindromes. I get excited when I see a sequence of numbers. Why was something so silly giving me more confidence than the top grades assigned to my euploid beautifully expanding blast, which was placed perfectly by the skilled hands of my RE?

I can't explain it either. I went into the lab for my beta test with a surprising sense of calm, that I haven't had with my previous situations. After my first fresh transfer 'The Day 3 Desparation' I truly had no expectations. I felt over-confident with FET#1 'The Chosen One' as I was mentally clearing my schedule to return for beta#2 and my ultrasounds while waiting for the phlebotomist to call my name. I had an impending sense of doom with FET#2 'The Leftovers' and with FET#3 'Haven't Named It Yet'. I was merely going through the motions of having my vein poked in order to wait for a phone call to tell me something I already knew. This time, I didn't have that same intuition that forcasted failure. It's not the same thing as believing that I might have a positive result, but hey; I'll take it.

The call came in around 2 PM. I quickly cleared the alert from my phone and I refused to look at the length of the message to avoid applying the Thin Envelope Theory. Fortunately, I had a pretty busy day, which included dealing with possible treatment failure for a patient with an ectopic pregnancy. I was more preoccupied dealing with her beta results than my own. At last, after a long day at the office, Cross-Fit and waiting for Husband to come home from his hockey match, we played the message just after 8PM.

"Hi Jane, It's Misery from Dr Somebody That I Used to Know's Office." I've told both her and New Girl that I don't have any other contacts with their names, so they don't need the full identification when they call, yet I was trying to determine if I could pick anything up from the tone in her voice. "I'm calling with your test results, your HCG..." oh fuck, she's struggling to get the words out... "Congratulations. It was 175. You are pregnant."

All I will ever remember from that moment is the smile on Husband's face. I don't think he has ever looked more beautiful to me. As we've been through two loses, we know that beta results don't always mean baby, and I once tried to dismiss their importance completely. It has taken three failed transfers to resonate their significance. We got our break. We're still in this game.

Saturday, 1 November 2014

Lady in Waiting

I was scheduled to teach a contraceptive methods course in Sacramento on the day after my transfer, which meant I got to sleep in that morning. I rolled over and found Husband was already scrolling through his phone. As I rubbed my eyes, he presented a picture of Mrs Robinson and her twins. After a month in the NICU, everyone was finally home. "That will be you in nine months." he declared, "expect with only one baby" he added. When he delivers lines like these, I find myself loving him a little more, yet hating him at the same time.

After waiting for AF's arrival and hoping it would permit my baseline scan, laminaria placement and removal and follow up scan to coordinate with my trip back east, there was one more logistical hurdle. I had signed up to run a half marathon. When New Girl handed me my tentative schedule, my transfer was planned for a Monday, and the race was on Sunday. Six days post transfer and a day past the five day rest period. Of course, I should have been suspect that anything could align so perfectly. When I went back for my final lining check, Dr STIUTK asked if we could move the transfer to Tuesday, as he had a surgical case on Monday and as XYZ tends to be busier, they may not provide a time that would work for him. As I always do, I had snapped some pictures of my own schedule and it was actually easier to move my Tuesday patients. No problem, I agreed. I actually forgot about the half, until I received an email update later that day, and also noted that it was on Saturday, not Sunday.

So that would be on my fourth post transfer day... As the race location was a ninety minute drive away, I wouldn't have minded not getting up at 0430 on a Saturday, but the complicating factor is that one of my friends heard I was planning to do this half, and she signed up with me. Additionally, she took care of the cats while we were away and her requested payment was that I drive us to the event and pick up the tab at our post race breakfast. Just to hear what he would say, I asked my RE if I could run. "I'll leave that up to you to decide..." was his non-committal answer. Husband pointed out that he did not say 'yes', while I interpreted it as he did not say 'no'.

I just wanted an evidence based answer. Of course, I doubt there are any published papers about patients running half marathons and long distances after a transfer. There isn't any evidence to support that bed rest offers any benefit. In fact, one article I read performed a comparative analysis and noted similar pregnancy rates between bed rest and non bed resters, but the women who were on strict bed rest had a lower implantation per embryo rate. I've even heard some REIs wonder outloud if bed rest may have a harmful effect, that it's better for uterine blood flow to be up and moving. Just maybe not moving 13.1 miles.

I dug up my post transfer instruction that I received from my first cycle. As a five-time guest to the XYZ Embryology Suite, they no longer give me the hand out. I have been compliant with these instructions with all my previous transfers, and it didn't make a difference. "No strenuous exercise for five days". Strenuous is the key word. My ego wants to say that running 13.1 miles isn't strenuous for me. It only take me abut 4 weeks to train for a half. Yet, I've done this course before and found it to be tough, especially if it happens to be a hot day. Plus I haven't ran much in that last few weeks. And I'm recovering from a cold. Also, are you aware that this is your fifth transfer after three consecutive failures? "Jane, you and I both know that whether or not you run won't make a distance, but I don't want to see you blaming yourself if you run and it doesn't work." Husband offered.

The logical side of my brain agreed, as she tried to tell my ego that if it were an easier course, cooler temperatures and if I had been able to squeeze in a few more practice runs, then I could have done it. Then I received another email from the race organisers announcing that they decided to add a 5K distance to the event. It would follow the last three miles of the half marathon course. Now, that was something I could do!

They offered a shuttle service from the start of the half to the 5K start. While walking to the meeting point, I ran into a woman who I'm guessing is about 28 weeks pregnant. "I signed up for the half, but I obviously can't run it now." she explained. I decided to try being open about my situation "We're doing IVF and I had a transfer done earlier this week." "Oh. I had a friend who did IVF." she replied as she pulled out her phone and quickly became engrossed by it. Sometimes you can tell how fertile someone is by how uncomfortable they are discussing infertility.

I overheard two or three conversations on the shuttle to the 5K start, "so I was planning to run the half, but then I found out I'm pregnant!" I also caught a group of guys who had intended to run the half under the team name 'Sweating for the Wedding'. The Groom (I'm presuming) had written on his bib 'Hoping she'll love me the way I am'. Apparently they didn't realise how long 13.1 miles was and didn't train appropriately. So, this 5K distance would be composed of pregnant women and people who aren't fit enough to run the half marathon. I'm neither; but I'm feeling more closely aligned with the didn't properly train group.

After the shuttle dropped us at our start, we had to wait about 45 minutes for all the elite runners to pass. Those who keep a less than 7 minute mile pace and would clear the ten mile maker in less than one hour and fifteen minutes. We were able to hang out at a winery, receive shelter from the pouring rain, enjoy hot coffee and tea as well as indoor plumbing. It was starting to resonate that switching distances was a very smart decision.

I ran the 3.1 miles rather gingerly. I disabled my timing chip so that there would be no official record on how slowly I ran the course, but it was very slow. As I was waiting for the race to start, I received a text from Robin asking how we were doing. "You two are going to be amazing parents, whether it's in nine months or a little longer." Suddenly, I had a new perspective on the two week wait. I am merely waiting to see how long I will be waiting...