Friday, November 30, 2007
So, I arrived to the RE's office in a somewhat bedraggled, soggy state. Immediately, I was called back to the ultrasound room. The nurse asked me if it would be OK if a resident watched, although Dr. A would be the one doing the scan. "Um, sure..." As a fellow (and resident as recently as 2004), I certainly understand the need for medical education. I honestly wouldn't have cared if the resident had wanted to do the scan, either, as long as Dr. A was watching to make sure that he doesn't missing anything. I can't say that I'd want a resident to do anything more invasive, though. Also, I know that I do not personally know any of the OB/GYN housestaff, so I'm not worried about the guy recognizing me. I guess I'll meet a few of them during my Gynecological Oncology rotation in January, but so far, I don't. Anyway, the resident came in, watched the ultrasound monitor, and really didn't say a word the entire time.
This was my first time meeting Dr. A, and I liked him quite a bit! Probably because of the good news that he delivered...
3 follicles are growing! They are 10 mm, 15 mm, and 16 mm. Dr. A thinks that I will most likely ovulate 2, which in my mind is perfect!! I am really excited about this! He said that Clomid usually doesn't make many more than 1 or 2 good eggs, and that it's the injectables that have the potential to produce a lot.
He then asked, "Can you come back tomorrow for another ultrasound?" Er, no. He was thinking that I was going to be getting serial ultrasounds followed by an HCG trigger shot. I told him that the original plan was for me to use OPKs to detect my LH surge, and then to come in the next day (O day) for an IUI. He said, "Actually, that's fine as long as OPKs work for you. I have actually done a study comparing spontaneous versus triggered ovulation and the pregnancy rate is equivalent."
He then made me really happy by saying that the follicles look great and that I have a good chance with IUI. I know he is not really familiar with my case (as we have never met before), so I said, "Yeah, but we have sperm issues... 1% morphology..." To this he said that no one really knows about whether morphology is relevant, except in the IVF setting. He said that they go forward with IUI no matter what the sperm count is on the day of the procedure. And then he quoted Wayne Gretzky (hockey player), something about "You will miss 100% of the shots you never take." (I love how google can help me look up that quote in less than 15 seconds!) Of course, I was liking him more and more by the minute as I'm hearing him say all of this.
I teared up for a minute as he left the room. I guess I'm daring to hope again... (Fingers crossed, knocking on wood, and jumping over all cracks...)
Thursday, November 29, 2007
Dr. G reassured me that he didn't expect them to go away. I'm not clear whether he meant "ever" or "not this soon." I actually asked people on the "Dealing with PCOS" forum on Ovusoft whether anyone had any experience with cysts resolving or not resolving on metformin, but only one person replied. Hers had disappeared, but her ultrasound had been done after many months on metformin.
Anyway, I left that appointment with a prescription for 5 days of Clomid (50 mg, CD3-7) and an appointment to return on CD12 for another ultrasound. I tried to question Dr. W about the purpose of this ultrasound. Is it to make sure that I don't have too many large follicles? She said, basically yes, and that they sometimes cancel cycles if the person has 4 or 5.
So now I am of course on pins and needles wondering how many big follicles that I'll have tomorrow. I want more than one, certainly, because of our sperm issues. They need more egg targets! And obviously, I don't want to have 4 or 5, because they'll probably cancel the cycle.
So, I'm hoping for 2 or 3 eggies. However, I truly hope that we don't have multiples, though. I feel like pregnancies with multiples are pretty scary. I worry about all the freaky medical stuff like twin-twin transfusion, cord accidents, prematurity, etc... Not to mention the extra stress of dealing with two babies at a time. Unfortunately, one friend of ours lost one of her (IVF) twins at term due to a cord accident. Such a devastating loss! I guess there is no way of knowing whether the same thing might have happened with a singleton pregnancy. That all being said, I also have two friends who have had successful ("spontaneous") twin pregnancies. Both sets of babies were early, but don't seem to have any long term problems that I have heard about. I'm sure that if I ever do get pregnant with twins, I will grow to love the idea and get over my fears. But if we had more than 2... I think we would probably make a very difficult decision and reduce. I think I would be too afraid of the consequences of prematurity to go forward. Wah. I pray that I never have to face this kind of situation.
One other fear has been on my mind. I took CD3's Clomid with no problems. I took it at night because my appointment was in the later morning and I didn't have a chance to pick up the prescription until that evening. CD4 was Thanksgiving Day, and again, I took the pill in the evening.... after that gigantic meal. TMI alert: Afterwards, I was kinda burping up/regurgitating a bit of the food (this happens to me sometimes when I'm really really full) and I spit some of it out. Of course, the next day I started worrying that maybe that tiny Clomid pill came up instead of getting absorbed. I certainly hope not!
I prepared myself for a few days of vaginal dryness, night sweats, and bitchy moods, but actually none of these things occurred beyond a tiny bit of warmness at night that I wouldn't have even noticed if I wasn't looking for it. The lack of symptoms is another reason that I'm kinda scared that the dose wasn't high enough, or that I didn't absorb it all.
I guess I'll find out tomorrow, CD12. My ultrasound is at 9:30 AM. I'll be starting OPKs tonight, as we'll be using the results to time the IUI. I already had some eggwhite CF today, so I'm betting on Monday or Tuesday (CD15-CD16) for the IUI. (fingers and toes all crossed!)
And now I'm officially all caught up!
On CD8, I went for my saline sonohystogram. Dr. W, who is a new (female) partner in the RE's office, performed the ultrasound. I was kinda hoping that my cysts had disappeared, but there were still lots and lots on each ovary. My endometrium looked good, and there was no sign of any endometrial polyps. This lovely experience last about 3 minutes and cost $450.
We had pretty good timing, and I ovulated on CD16. (Which was pretty good, but I had ovulated on my own on CD15 the month before without metformin). I had a little bit of hope (which I kept trying to squash lest I be disappointed) that maybe metformin alone would do the trick and I would finally end up with the elusive two lines. I tried not to get obsessed, but I did anyway.
During this cycle, S had his urology appointment with Dr. B. Apparently, Dr. B specializes in male fertility and vasectomy reversals. The entire experience of was really disappointing. S has a very tight schedule in the afternoons, and he only had between 1 PM and 3 PM free from work. His appointment was at 1:30 PM. (I came along for moral support and because I wanted to hear what the urologist would say.) Luckily, the medical office building is only a few minutes from his workplace. Right away, the receptionist told us that Dr. B was in surgery and she didn't know when he would be back. Well, the doctor didn't arrive in the building until after 2 PM, and there was another patient in front of us.
At about 2:23, we went to the receptionist and told her that we would need to reschedule. At that moment, Dr. B came out and said, "Let's go!" Of course, at this point we have less than 20 minutes until S would need to leave to get back to work. Dr B spent way too much time asking questions that were already answered on the questionnaire, and going over the semen analysis out loud. At the same time, he didn't offer any theories as to why S might have the morphology problems and borderline counts. He examined S for just a moment. I even went into the exam room for this part, and commented on the orchiometer (the set of "balls on a rope" of various sizes, that the doctor can use to estimate testicle volume). Then, during the exam, Dr. B made these comments about how S's testicles were really great in size, definitely on the top of the end of the range. Afterwards, S and I both thought that he probably says this to lots of guys... to try to make them feel better even despite their lowish sperm counts!
Well, Dr. B didn't feel much except "maybe" a varicocele on the left side. He recommended an ultrasound ($300), bloodwork (I haven't priced that yet), and then a followup appointment. Have I mentioned yet that the appointment itself was $300 for about 15 minutes? If we end up doing varicocele surgery, that usually runs about $3000. Argh. I have done the research and it seems like varicocele surgery has iffy results at best, especially if the varicocele is small. We have several couples as friends who have dealt with infertility stuff. Two of the men have undergone varicocele surgery, and both said that nothing improved afterwards. Finally, Dr. B recommended that S consider trying some supplements. He gave us a bottle with 6 or 8 sample pills in it. S did end up ordering it... and it's almost $300 for just a few months' supply. That is OK with me, but I wonder if Dr. B is getting a kickback.
Dr. B also made some comment that he was "impressed" that Dr. G was recommending that we do Clomid/IUI instead of proceeding to IVF with ICSI. It wasn't clear whether he meant "WTF is Dr. G thinking?...your morphology is bad!" or "Wow, I'm surprised that Dr. G is potentially giving up over $10,000 in case these two get lucky with the IUI."
Well, by the end of the cycle I tested twice (10DPO and 13DPO, I think) and I had two BFNs. By 16DPO, my temperature dropped and a new cycle began! And now I am almost caught up to the here and now...
Wednesday, November 28, 2007
The waiting room of the RE's office is kinda fancy with full length glass panels and doors, instead of a plain door like all the other offices in the building have. It looks nice, but doesn't exactly feel discreet. Not that we need to be discreet, though...right?? The office is located just off the elevator, on an upper floor of a medical professional building. S had already described it to me as he had been there twice already to give samples for semen analyses. As we walked through the door, I was really surprised to see a familiar face sitting behind the receptionist desk. "Is your name T___?" I asked. When she answered in the affirmative, I reminded her that we had worked together at Dr J's office way back in 1994. I was 19 years old, summer after freshman year of college, and had worked as a receptionist. T__ was a transcriptionist. She is a lot older, more like my mother's age, but I had always liked her. I reminded her of my old last name and we started reminscing about some of our other co-workers as well as Dr. J, our old boss. T___ looks great; she literally has not aged a bit in the 13 years since I last saw her.
I gave T___ my basal body temperature charts to give to Dr. G. When we were called into the consult room about 20 minutes later, I was happy to note that he had reviewed them in detail. Right away, he didn't like the fact that my ovulation day has been variable from CD15 to CD26. He also saw that I had made notations for "acne" on the days when my skin flares up with a pimple or too. So he was immediately suspicious for PCOS. He asked me about the excessive hair growth thing. The truth is that I do have a few coarse hairs that crop up under my belly button and chin, and even a couple dark (but not really coarse) ones around my areolae. At the same time, I feel like almost every woman that I know (or see) has something similar (or plucks/waxes to get rid of them). So, I have never been 100% certain about what is normal and what is not. Meanwhile, S and I answered lots of other questions about our medical histories, etc.
Right in the middle of the consultation, Dr. G wanted to do an ultrasound on me. I was glad that this was included since we were paying out of pocket. Sure enough, I had lots and LOTS of cysts. Like...over 20 on each ovary, in the typical "strand of pearls" configuration. I apparently also had increased ovarian stroma which is also typical. Dr. G thought that my endometrium looked unusually thick, too. (What did he expect at 14DPO???) Because of this, he wanted me to get a saline sonohystogram at some point in the near future.
Next, we reviewed the results of S's second semen analysis. We were really disappointed that there had been no improvement; in fact, things looked quite a bit worse:
- Concentration: only 9 million/mL (!!) (down from 25 million/mL in June)
- Volume 2.8 mL (down from 4 mL in June)
- Total count: 25 million (this is down from 100 million in June)
- The motility was OK...
- But unfortunately the morphology was unchanged at only 1% by Kruger strict criteria.
Based on my apparent polycystic ovaries, Dr. G wanted to start me on metformin. I kinda questioned him on this since I obviously ovulate every month even despite polycystic ovaries. How then would metformin help? He didn't have a specific answer but implied that perhaps my ovulation would be "better." He also said that studies have shown that women who are undergoing stimulation for IVF actually have higher rates of pregnancy if they are on metformin. This isn't due to better ovulation (as these women are getting other meds for stim anyway), but seemed to be an indepedent effect.
His overall strategy is for me to start with metformin alone for 1 cycle. During that cycle, he wanted me to get a saline sonohystogram on CD7-10 to re-evaluate my endometrial lining and rule out any endometrial polyps. After that cycle, I would start with Clomid IUI. Meanwhile, he would refer S to Dr. B, a urologist who specializes in MFI.
I was surprised to hear him recommended IUI instead of IVF with S's morphology issues. I had previously been pretty sure that our counts and morphology put us into the "immediate IVF with ICSI" category. Dr. G said that it might come to that, but he wants to try IUI for 1 to 3 cycles first since it is so much less invasive (and less expensive).
I left the appointment armed with a prescription for metformin and a renewed sense of optimism...
Monday, November 26, 2007
The woman (let's call her Dr. S) is about my age. She listened to my TTC complaints and told me that I probably needed to relax. She looked at my temperature curves for literally less than 1 second before setting them down. I bet if I weren't a doctor too (at the same institution), she probably wouldn't have ordered anything. However, she did agree to order a semen analysis for S, and basic bloodwork for me. I was not impressed when she told me that I could get the blood drawn that very day. Ummmm....it was cycle day 30 or so, and my temperature was plummeting. I said, "Don't you want me to get that drawn on cycle day 3 since you are testing my FSH?" She said, "Uh... do whatever you want." I literally think that even with that reminder, she had no clue what I was talking about.
Unforunately, 6 months later, I am still trying to get the bill for these blood tests paid (it's over $500) because she coded the visit as "Pap smear" and didn't put down anything about my irregular cycles to justify the check of FSH, TSH, prolactin, and estradiol. I have been in frequent communication with the billing department since early October, but it still is not resolved. On the other hand, I was greatful to have normal TSH, normal prolactin, normal FSH (5.2) and normal estradiol (18).
S scheduled his semen analysis for late June. Dr. S asked for him to get it done at the offices of Dr. G, a local reproductive endocrinologist. So, he did that. It took almost a week to get the results, because Dr. G's office refused to release them to me directly. They wanted to give the results to Dr. S. Unfortunately, Dr. S had no idea how to interpret the results and she had to call Dr. G's office to speak to one of the reproductive endocrinologists to get an interpretation. (I actually appreciate that she did this). So, anyway, she finally called and the results were not good. They were:
Concentration: 25 million/mL ... OK, not great but in the low/normal range
Volume: 4 mL
Total count: 100 million
Motility: 44% rapid forward (OK, maybe a little low)
Morphology: 1% normal by Kruger strict criteria.... this is really bad. "Severe teratozoospermia."
Dr. S said that Dr. G's RE colleague said, "We like to see the morphology at 4% or so. Tell them to keep trying, and if they don't get pregnant in 4 more months, get a hysterosalpingogram (HSG) and make an appointment with us. "
I started researching everything I could about morphology, and finding very few answers. S doesn't smoke, drinks only socially, and doesn't have a habit of using jacuzzis, laptop computers, or riding a bike. He didn't have any recent illnesses, and he's actually really healthy and fit. He did have an STD during college but was treated right away. He did switch over to 100% boxers when we found out. I was hoping that maybe the poor morphology was a fluke, and that the problems would resolve. I was terrified of the notion that we might have to undergo IVF someday.
I found other people with MFI on ovusoft and clung to the stories of men with 1% morphology who had fathered children in the past or present. I found at least one blog (http://infertilityblog.blogspot.com/) in which the author (a reproductive endocrinologist) maintains that morphology is not a real problem! I hoped and prayed for a summertime pregnancy. Still, when my period showed up yet again, I scheduled my HSG... this would be completed in late August, after 1 more full cycle.
Well, my period sure enough came around again, and it was time for the HSG. The HSG itself hurt like hell (for about 1-2 minutes), but I didn't have any blockages. The radiologist blithely told me that she was reviewing HSGs with a medical student, and "a huge proportion of the women had OB first trimester ultrasounds within a few months of their HSG." I thought this was encouraging at first and clung to the hope that maybe some invisible debris was now gone, thus opening my tubes. Although, in retrospect, I wonder how many of those women had actually gone to an RE soon after their HSGs. Maybe those are all IUI and IVF babies that she is seeing.
Well, we tried another cycle and then scheduled S's second semen analysis, with a reproductive endocrinology appointment to come a few days later. I still clung to the hope that maybe, just maybe, I would get pregnant with Cycle 10 and cancel the appointment at the last minute. But... no such luck. On October 18th, we had our appointment with Dr. G, the RE.
To be continued...
Sunday, November 25, 2007
In the course of hanging out with S on a regular basis, I no longer ate Lean Cuisine and other ultra-low cal fare every day and I gradually gained back about 12 lbs. I now have settled into the 132-134 lbs range, size 8 or possibly 10, and I'm fine with that. Although, honestly, my body looks best at 125 lbs.
Backup for some info on my periods. I got my period in sixth grade, a few weeks before I turned 12 years old. My cycles have usually been about every 33 days or so, although they have occasionally been 28-29 days and sometimes up to about 45 days. I must admit that they were getting really irregular right before I met S, at my lowest weight. I figured that it must be my hypothalamus screaming in hunger. Meanwhile, I did notice that my skin was kinda annoying. Instead of the forehead/hairline type pimples that I got as a teenager, I started getting occasional pimples at the far lateral cheeks, along my jawline, and sometimes on my chin and around my mouth. Ugh!! When S and I started dating, I did get onto the pill (Yasmin) for probably about 18 months or so and my skin did clear up.
By the time that we got married, I was 31 and S was 39. Career-wise, it seemed like third year of fellowship would be the ideal time to have a baby. So, I went off the pill after just about 1.5 months of wedded bliss. ;) And, yes, we do move fast. About 3 weeks after getting married we also found a house proceeded to buy it!
I remember the very first time that we had post-pill, no birth control sex. I really believed that we might possibly get pregnant from that very first encounter, but I knew that I probably ovulate later (based on previous cycle lengths). I knew about Taking Charge of Your Fertility (TCOYF) from my mom (more on that later), so I bought the book immediately and started charting my daily temperature. Cycle day 14, 15... 18, 19.... 22, 23 passed, but no temp rise and therefore no ovulation. It was really frustrating as S and I were trying to have sex either every day or every other day, but my temperature stayed stubbornly low. My first ovulation was on CD26! I was elated to know that my body seemed to be working. I blamed the delayed ovulation on having just come off the pill.
I became pretty active on forums.ovusoft.com, participating in various TTC forums, etc. I remember thinking that it was probably going to annoy people (namely, people who had been trying for a long time) when I got pregnant after just a few cycles. I thought that I would definitely be pregnant in just a few months, if not immediately.
I also remember my very first pregnancy test. I took it on Christmas Day, 12DPO of that first cycle, and I was so excited that I could barely sleep the night before. It was negative, of course, and we walked on the beach that afternoon. I remember telling S, "it's OK, we'll probably have a baby or I'll at least be very pregnant by this time next year." My temperature dropped a few days later and I got my period.
Cycle 2 was a bit of a bust because I noticed some egg white CF but we didn't have sex on the best day or two because we had a bit of a stupid argument and it just didn't happen. The egg came on CD15 that time. My body seemed to be back on track! I knew it was a longshot, but I tested on my 32nd birthday anyway. Another Big Fat Negative (BFN, to use the lingo of most TTC boards out there).
Cycle 3, I ovulated on CD20. Our timing was decent but we got another BFN. The stress of trying to time sex to ovulation was starting to get to us. S noticed that the volume of his ejaculate seemed to be less with multiple subsequent days of sex, too. So, we decided to go ahead and try some Ovulation Predictor Kits (OPKs) for Cycle 4. I was actually a bit reluctant because it seemed to make it feel a bit more like a science project, and less "natural", somehow. Ha! If I knew then what I know now...
The OPKs were frustrating at first (negatives for 10 days in a row), but they finally correctly predicted my ovulation on CD25. We again had good timing, and I had a beautiful temperature chart, but alas... another BFN. We tried again for Cycle 5, and another BFN. At this point, mid- May 2007, I began to suspect something might be wrong, so I made an appointment with my OB/GYN.
To be continued...
When it became clear that the mid/late-20s baby plan wasn't going to happen (I wasn't married, or even in a serious relationship), I started thinking that if I wasn't married, or at least in a very serious relationship by age 35, I would become a single parent by choice. I wasn't sure who my sperm donor would be (friend or banked), but the idea was pretty real to me. I searched some internet sites and read as much as I could about it. I told family and friends about the plan, just so that they wouldn't be shocked when the time came. However, I was still in my late 20s, so I didn't go much farther than that.
Meanwhile, the stresses of medical school and residency began to take a toll on my body. By the middle of residency (age 28), I was about 25 lbs above my ideal weight. At 5'5", I was up to 155 lbs and wearing a size 12. My BMI was 26, which falls into the lower end of the overweight category. And I was really beginning to suspect that my weight was affecting ability to find a good relationship.
I began reading a livejournal group based on Weight Watchers and the success stories really impressed me. On October 23, 2003, I started to seriously decrease the amount of food that I put into my body. I also started trying to run again. (I'm an ex-cross country and track runner, so I consider that "my sport.")
By December 2003, the first person (an ER attending) asked me if I had lost weight. "Yes, 7 lbs, THANKS!!" I completed my residency in June 2004, and started working as a per diem/urgent care physician for a year before starting my fellowship in hematology/oncology. By September 2004, I reached my goal weight of 125 lbs, which was a loss of 30 lbs! My appearance was drastically changed. Instead of size 12, I was wearing a 6. I then became kinda obsessed with it all and proceeded to lose even more weight. Quite honestly, I was reading a lot of unhealthy blogs on the internet, and while I never went to extremes myself, I found them kinda inspirational. Or, using the lingo of those blogs, "thinspirational." When I hit size 4 and 118-121 lbs, I was starting to notice worrisome signs like being cold all of the time, and having a resting pulse rate in the low 40s, and even a few times in the high 30s... Soon thereafter, I celebrated my 30th birthday.
Just about 5 weeks later, I met S...
I'll write more later... I'm getting to the infertility stuff, I swear!