Fertilization Report

Recall that yesterday, I had 17 eggs: 8 mature, 6 intermediate, and 3 immature. The embryologist told me that the intermediates might mature enough in vitro to undergo ICSI.

I got the call at about 11:20 this morning. As it turns out, the embryologist said that 15 ended up being mature enough for ICSI. (This means that all of the intermediates plus one of the immatures "made it"). Of these, 11 fertilized, 1 abnormally. Therefore, as of today, S and I have 10 little embryos!

Phew! I think I'm happy...but still anxious, of course. I think I'm greedy if I had hoped for anything more.

She told me that I will be scheduled for a day 5 transfer (Sunday at 9:45 AM, by Dr G). She said that we won't get any more updates between now and then, because sometimes people who have "average" embryos on day 3, end up with great appearing embryos on day 5, and vice versa. She thinks it causes too much stress. She said that we will normally hear their recommendations about the number of embryos to transfer on the day of transfer. I think that S and I are going to need to go in there with our minds already made up as to what to do if we are given the choice. That's a huge decision.

I also asked whether we would be given pictures of the embryos (like I have seen from some of you on here). She said that they "don't have a good camera," so no. She said that S would be able to view the embryos just prior to transfer, but that I would already be groggy from Valium and probably wouldn't be able to view them. (Jeeesh, they must be planning to give me a lot of Valium! I don't really know why Valium is needed if ET is sorta like an IUI or my "trial transfer.")

Now, as for me, my abdomen feels pretty terrible today. Yesterday's pelvic cramps and spotting are gone, but now I feel bloated/distended all the way up to my upper abdomen. TMI: In addition, I haven't been able to, um, have a bowel movement at all. I am really prone to this problem anyway, and I'm sure that the medications yesterday did not help. It is so bad that I don't feel hungry at all, but I've been trying to keep eating in hopes of stimulating some peristalsis (waves of intestinal motility)... but so far, nothing is happening. I gave in a couple of hours ago and took some milk of magnesia, but so far nothing but gurgling in my belly. Arggh. I swear I already look about 4 months pg today. And, oh yeah, my weight is up a whopping 5.2 lbs (!) since last week due to all of this. UGH!

I'm wondering if I do have some degree of OHSS as well (although the info sheet that they gave me says that it causes diarrhea...) My biggest fear at this point is that it'll get worse, I'll have to call the RE about it, it will be called moderate OHSS, and that my transfer will get cancelled.

I still need to find out about acupuncture, too...

Egg Retrieval Day!

I have a lot to write, so I better get started.

I decided to dress in soft black drawstring cotton pants, a sports bra, and a pink athletic shirt. I also wore no makeup, according to their instructions, and my glasses rather than contacts. I was forbidden to eat or drink anything after midnight.

S dropped me off at the RE's office at about 7:25 AM so that he could be at work by 7:45 AM. I was supposed to check in at 8:45 AM. Originally, my mom was going to drive me, but she has to drop off my sister at her elementary school at 7:45AM, and I knew that she would hit traffic coming to my house. Thus, since I wanted to avoid the "we're going to be late" anxiety, I had S drop me off. In the end, my mom made it to the office by 8:35AM or so, but we would have been late if she had picked me up on the way there. So, I'm glad that S dropped me off.

When I arrived at 7:25, I immediately went upstairs to the RE's office to talk to them about S's specimen collection time. It just so happened that the embryologist was sitting at the front desk, checking people in before the regular receptionists arrived. She said that they would want him to come in at about 12:15 PM. I then called him so that he could move a client to accomodate that. Afterwards, I decided to wait in the main lobby of the building because I was feeling a bit nervous and I wanted to keep an eye out for my mom to arrive. I passed the hour reading two "Marie Claire" magazines... fun fluffy stuff.

During that time, Dr. W came out of the elevator and happened to notice me sitting there and reading. She called out, "HI Sarah!!" and waved enthusiastically across the lobby. She was headed for the coffee cart. I stood up and asked loudly, "Oh, will you be doing my 'thing' today?" (I didn't feel like informing the entire lobby that I was scheduled for egg retrieval.) She said yes, and then joked that the coffee she was buying was going to help her do a good job.

Soon thereafter, my mom arrived and we went upstairs to the office. Within a few minutes, they took us back to one of two recovery rooms. There were two beds and two chairs, but they said that the room could be all ours for the day since the day's other patient would be in the other recovery room. C, for sure now my favorite nurse, gave me a gown and surgical cap. I changed into it, leaving only my sports bra and socks on. I settled onto the recovery bed with its nice eggcrate mattress, reading a Vogue magazine from the lobby while waiting for my turn. C told us that I would be in the OR/procedure area for over an hour, but that the actual procedure would be about 15-25 minutes.

It turns out the OR nurse is the one nurse that I had a bad experience with, way back in December. I don't know if she remembered that incident, but if she did, she didn't show it. She was quite nice today and walked me across the hall and made sure that I had warm blankets around me as I settled onto the procedure bed. The nurse anesthetist then came and I asked her what kind of anesthesia I would be getting. "Fentanyl, Versed, and Propofol.... Do you have a medical background?" I told her that I'm a hematology/oncology fellow, but that I don't have much knowledge of anesthesia beyond the basics. She then placed an IV into my left antecubital (front of elbow) area. I was surprised to see that she infiltrated my skin with lidocaine before inserting the IV. I have never actually seen that done before. Well, hey, it didn't hurt in the least, so I'm not complaining.

She didn't tell me that she was starting the fentanyl and Versed, and I pretty much fell asleep at that point. I remember just a few things after that. One is that my heart rate was in the 40s and that she was going to give me something. I remember saying that it was normal for me and asked what she was going to give me. She said the name, but it wasn't familiar. (Much later, in recovery, I asked that question a couple more times, but I couldn't retain the info due to my drugged up state. My mom remembered that it was "rob..something" and a little googling leads me to Robinul (glycopyrrolate) which is apparently an anti-cholinergic drug. Interesting.) Luckily I slept through the insertion of the Foley (bladder) catheter. I do remember them cleaning out my vagina with antiseptic. It felt like a really giant tampon/swab going in a few times. I think I saw Dr. W, but I honestly don't remember another minute. The next thing I knew, I was opening my eyes back in the recovery room. My mom said that I was already awake when they brought me over, talking, and that my chin was shaking uncontrollably (shivering). I don't remember that part.

My first priority when I woke up was "get this Foley catheter out of me!" I felt really crampy and I couldn't tell if it was due to the Foley, the procedure itself, or what. Nurse C wanted me to wait for a while. She brought me a box of apple juice (which I downed in about 3 sips) and goldfish crackers (which I couldn't even come close to swallowing eat due to my parched mouth). With one bite, I ended up with literally a mouthful of orange crumbs that I couldn't either swallow or spit out.* I ended up begging for water and got some of that, too. I had some groggy conversation with my mom, telling her what I remembered, etc. Finally C took my Foley out and let me go to the bathroom. However, when I got there, my bladder was empty (which made sense, since the Foley had been removed about 1 minute earlier). While I was sitting there in the bathroom, my chin started shaking almost uncontrollably again. Also, there was a small amount of bright red blood on my toilet paper, which they said was normal.

I went back to recovery and got two extra-strength Tylenol at that point. It feels like menstrual cramps, but maybe 3-5x worse. Post-Tylenol, it is about the level of my worst menstrual cramps. In other words, it is not horrible, but if these were normal cramps I would take Tylenol, but I can't take any more since I already had some. I thought about asking for a prescription for something stronger, but decided against it. Meanwhile, I should mention that my heart rate was hanging out in the high 40s/low 50s, but no one seemed to mind anymore.

At some point I made a groggy phone call to S, and a while later he called to say that he was on his way over. He stopped in and visited both before and after his collection, but then had to go back to work. This entire time my mom was sitting in the chair in the room with me, and we were both reading magazines and chatting. I eventually managed to get dressed, and then we waited for the embryologist's report.

Finally, at about 1:00, the embryologist came in and told us the statistics. I had 17 eggs retrieved. Of these, 8 were mature, and 6 were "intermediate." 3 were immature. This sounded fine but not stellar. However, she explained that the 6 intermediates may mature over several hours in vitro and become mature and thus able to be ICSI'd. S's semen was 19 million/mL (a little low), but his volume was 4.7 mL and motility was fine. The embryologist will call me tomorrow and let me know how many eggs were fertilized. At that time, they will probably also tell me whether I will have ET on day 3 or day 5.

C gave me some additional info about OHSS and what to look out for. She also mentioned that she would be doing IVF sometime soon, too! I was surprised and touched that she shared this info with us. Of course I am curious to hear more details, but I didn't want to pry.

I "refused" the wheelchair as I felt too silly to ride at that point and I wanted to stop at the pharmacy anyway. I turned in package of Follistim 300 units that I had obtained last Friday (prior to my E2 shooting up). I got back $199; they kept 15% as a "restocking fee."

We stopped for a little lunch and then my mom drove me home and I've been here on my computer (reading a bit, then doing a bit of work that I needed to email before 5PM, and now composing this message) ever since. I started taking my Medrol (a steroid) and doxycycline, and I'll be on both for a few days. I'm still pretty crampy feeling, but I should be able to take Tylenol again in a few minutes.... phew!

S wants to make me dinner, watch whatever I choose (probably "Sex and the City"), and generally pamper me tonight. He is so good to me!

Speaking of "Sex and the City", over the weekend TBS played the really touching episode in which Miranda has an unintentional pregnancy while Charlotte is dealing with infertility. I find that show so funny in general, but many of the longer story arcs touch on a lot of powerful themes, and the acting and character development is generally very good. I love it!

*The geek in me decided to read a little bit about Robinul, the medication that they gave me for my slow heart rate. I forgot that medications in this class (anticholinergics) also are known to dry up saliva! No wonder I was so thirsty!

(Non)-Stim Day 10 / Ultrasound / Triggering!

I think that title says it all!

Luckily I had a pretty full schedule yesterday afternoon and evening (beachside party with a co-worker, and then my parents and sister came over for a while while S went to his month "poker night"). That kept my mind busy and kept me off the internet. I was concerned both about our overall chances of success (mainly), but I was also annoyed that I would potentially have to take another clinic day off of work on Wednesday, May 7th (undoubtedly raising questions for some of my future bosses). In addition, I am also scheduled to give an hour-long conference presentation on Friday, May 9th, so it would not have worked out well to be out on bedrest on that date!

S was concerned that I was getting too stressed so he came with me to today's ultrasound. As soon as we arrived, the nurse, C -- the same one who gave me the pep talk yesterday -- drew my blood and meanwhile reassured me that coasting is not at all unusual and that everything would almost certainly be fine!

Next, Dr A did my ultrasound. This was the first time that S had met him; our two consults have been with Dr G. I started asking a bunch of questions right away and he said, "let's meet in my office afterwards to discuss these things." I do wonder whether he would have met in the office if it were just me there for the appointment, but whatever.

My lining today measured at 16 mm. Strange that it's lower than yesterday (and better, because yesterday sounded WAY too thick), but I'm assuming that there is variability in the measurement itself, where they measure it, etc. Anyway, that made me happy.

Dr A was kind of in a joking mood -- again, maybe because S was there, too. He said, "Let's measure your follicles. What size do you want?" (Sort of teasing me because I'm there in stirrups, pen and paper in hand, jotting this info down.) I said, "Um, I don't know, 20?" And then he measured and sure enough, that follicle was 20. Again, he only measured a few in the 19 to 21 mm range, and didn't count the many others. I tried to joke around, too, saying, "I'm not trying to be high maintenance, but I just can't help it!"

We went to the office and he said that as long as my E2 was acceptable today, the trigger would be tonight. I tried to get a little more specific info. Like, did it need to go DOWN from 3141, or did it need to just not double again? He said that some increase would be OK, but not much, and wouldn't get more specific than that. He then told us that he thinks that I should do acupuncture on the day of my embryo transfer to help with anxiety, etc. I am actually thinking that I might go for it. It seems interesting to me, and I don't think it could hurt and might help. The only barrier might be that if I happen to do a day 5 transfer, I don't know if their office would be open (that's next Sunday).

Next, C taught us about doing the IM injection (yikes!!) and had me sign additional consents for anesthesia. I also got some clarification on the bedrest issue. I am apparently supposed to remain horizontal for 2 days after the transfer. Ummm, I had a vision of myself blogging that day and working on that conference presentation. How will I deal with bedrest?? I think I'll borrow our workplace laptop and somehow work in a very recumbent position. I must say I think this entire bedrest thing seems non-sensical from a physiological standpoint, but I am pretty much willing to play along and do whatever they say.

As we were leaving the RE's office, I saw a familiar face. It was M, my hair stylist! I am sort of friends with her, too, as our moms used to be co-workers, but I really only see or talk to her when I get my hair cut.

As background info: M got married 6 days after me and has been TTC for the same amount of time. She is about 38, I think, and she originally assumed that the problem was on her end. After many months of trying and eventual testing, it turned out that her husband has a sperm count of zero on semen analysis and has CBAVD (congenital bilateral absence of the vas deferens, the tube that carries sperm from testicle to urethra). He is a carrier of cystic fibrosis. Luckily, they can aspirate sperm (via a TESE procedure, I think it's called) and in theory M and S will be able to have children via IVF with ICSI. (M is not a carrier of CF.)]

Anyway, they are just getting started with the RE. This was their second visit, I'm not sure for what, but probably for CD3 bloodwork or something. M seemed really nervous and a little teary-eyed. I tried to reassure her that the office is great, and that injections are not that bad!! Her husband said that it was good to meet someone else going through this, as none of their friends have had any problems with getting pregnant. I'll maybe call M and offer to lend an ear if she wants to talk. Meanwhile, I'll have to get my hair cut again soon anyway.

Afterwards, S and I went for a bagel followed by a nice walk in the hills and then along the beach in Del Mar. We came back home, and finally, around 1:00, the RE's office called. My E2 is 3655 (still rising, but not crazy), and YES -- I will be triggering tonight!! My dose is 10,000 units of HCG. Tomorrow, no shots at all, and no bloodwork. The retrieval will be Tuesday at 9:30 AM. My mom is going to be my driver as S has a full day. (She is really excited to do it, actually). S will have to make time to come over the office anyway for his "deposit," hopefully in the early afternoon.

One last thing. When my parents and 9 year old sister J were over here last night, we decided to play the boardgame "Life." (I bought it for J for Christmas, but this was the first time I've played it with them.) Anyway, it was kinda funny because I ended up with not one, but TWO sets of twins. My mom knows that I have been pondering the 1 vs 2 question, so she was pretty amused by that funny coincidence.

Stim Day 9 / Ultrasound / Coasting

I was about as happy as can be after my appointment today. But now I'm a bundle of nerves and anxiety.

Dr A did my ultrasound this morning. My endometrium was 19mm, "a little thick" but still OK. He reassured me that they only worry when the lining is too thin. Now I'm googling and finding some studies that say that "too thick" (> 14 mm) is bad, and others that say that it doesn't matter. I feel like I can deal with this.

During the ultrasound, even I could see that the follicles had grown quite a bit since yesterday. On the right, the largest were 18 and 16 mm. On the left, the largest was 17 mm. He didn't measure any others, but there were lots more and he said that I would have "plenty" of eggs.

Afterwards, I was asking one of the nurses a few questions about the logistics of retrieval day. Then, I asked about day 3 versus day 5 transfer, and which is more common. She lowered her voice and said, "Honestly, Sarah, your cycle is going so perfectly. I honestly think that you will have a day 5 transfer."

So I left there as happy as can be and shared the news with S and my mom. I then did a brisk walk up the hill from La Joll.a Shores. It was one of the most beautiful days that I can remember - warm air, blue cloudless sky and ocean, and tons of flowering trees everywhere. This is the same route that I jog/walked last Sunday, but today I was chatting happily on the phone and was deciding to give my ovaries a little TLC by skipping the running part. Next, I went to Target to pick up some household stuff and toiletries. As I was pulling out of the driveway, the RE's office called.

My E2 level is now up to 3141 (more than double from yesterday... how did that happen?) and I need to STOP both Follistim and Menopur. I will continue Lupron. This is called coasting, and it is supposed to help prevent OHSS. Basically, they wait until your E2 starts decreasing and then give you the HCG shot at that point. Of course I googled it, and while pregnancy is still possible, the rates are lower than with non-coasting cycles. The worst case scenario is that ER gets cancelled altogether (because the HCG shot itself can make OHSS worse). They didn't mention that scenario on the phone, but I'm worried that this could happen.

Writing about this here is making me even more scared. I might even call them back to discuss. I think my chances of getting Dr A himself on the phone are near zero, but maybe a nurse can reassure me. Of course, this being Saturday, I'm afraid that they may already be gone for the day.

Stim Day 8 / Ultrasound

(This post refers to Friday, April 25).

I saw the couple with the needle-phobic wife in the RE's office yesterday. They looked kinda happy, so I'm wondering if maybe she's pregnant now. Or maybe it was beta day for her. In my imagination, I think they are ultra-wealthy people from Tijuana, but that's purely a guess on my part. Anyway, good luck to them.

One of the blogs I was reading recently referred to the wrongness of bringing a toddler to the RE's office. I'm not sure whether I agree or not. On one hand, I can see that it could be really painful to see young children right after getting bad news. On the other hand, I am usually pretty hopeful and optimistic on the days of my RE appointments. (When I get bad news, it's usually at home with a negative HPT). On the few times that I have seen a mom with a toddler in the office, I think, "well, it obviously worked for her the first time, and now she is back for baby #2... I hope that's me someday."

I had my bloodwork and ultrasound at 10AM. Dr. W performed the ultrasound. She said my lining look very good at 14.5 mm. I said, "Isn't that too thick?" and she told me that it sometimes can be, but in my case it looks great with a very nice organized pattern. Of course, now I'm wondering if it's going to be way too thick by ER and transfer day next week... ack!

On the right side, I had 3 14 mm follicles and 1 13 mm follicle and many others just a bit smaller. On the left, I had a 16 mm follicle, a 13 mm, a 12 mm, and also may others just a bit smaller. Dr. W reassured me that I will likely have more eggs retrieved than the 7 follicles that she measured. Echoing Dr A's comments from Wednesday, she said that she just measures the largest ones to make sure that none of them were really getting ahead of the others. She made me feel really good by basically saying that she couldn't ask for anything different in the way that I'm responding so far. She said that if she had to guess, she'd bet on my trigger being on Sunday night, with ER on Tuesday. It's still up in the air, though.

After my appointment, I had to go down to the pharmacy to pick up another 300 units of Follistim. That's another $234, which seems like small change at this point in the game. I'm wondering if I should have asked for a 75 unit and a 150 unit vial instead, but it's too late to second guess... If I don't trigger on Sunday night, I will also need to buy more Menopur for use on Monday morning. The pharmacy is closed on the weekend, but apparently my clinic has a "weekend/emergency supply" that you can buy from if needed.

A few hours later I learned that my E2 level was 1282. So much for the doubling pattern that I was so worried about a few days ago. My medication doses are still the same.

We went out to dinner with some friends, M and Sc, and their 8 year old son. It's funny because my S is a work colleague of M (the wife), and I happen to work with Sc, who is a nephrologist and about 6-7 years ahead of me in terms of his career. Anyway, while I was busy chatting away with Sc about workplace stuff, my S told M that we are going through IVF right now. M then confided that they had gone through a few Clomid/IUI's and then were about to embark on injectibles when she was suddenly pregnant on a natural cycle. Good for them!!

I just had about 2 hours worth of dreams in which I kept missing my RE appointments and calling them and saying, "I'll be there in half an hour," and then forgetting again. It was stressful! Then, in a related dream, I was suddenly in the RE's office and ran into a pharmacist that I know from the hospital. In the dream she told me that her husband had morphology issues also, but that my REs had helped her overcome them (she has two cute little kids).

S and I talked last night about what we will do if the RE leaves the 1 vs 2 embryo transfer decision up to us. (Assuming that we have embryos...please God!) We both agree that if the embryos' quality is fair and we are advised to transfer 2, we'll do so. Also, if the quality is absolutely perfect and we are advised to transfer 1, we'll do that too. However, if the quality is good/very good and we are left with the choice of 1 or 2, it's going to be a tough decision. More than anything, I'm worried about the health dangers of a twin pregnancy, mainly prematurity. There are a LOT of things to consider, and I think the topic deserves its own post at some point.

Well, I have bloodwork and ultrasounds both today (Saturday) and tomorrow, so I'll update again later. I have to go get ready for my appointment now. (Fingers crossed!)

Stim Day 7

I told the nurses this morning about my anxiety about how the E2 has more than doubled every day. They took a look at my file and said that my numbers actually look "perfect." I wanted to hug them for using that word! I also told them how I had been worried that my E2 would be over 10,000 within just a few days. They said that it was likely going to slow down, and that if I did get too high, I would likely just "coast" until the numbers settled down. I did appreciate their reassurances.

So, I was pretty happy with today's E2 level: 984. That was less than doubling, so they were right! Phew!!

I was definitely feeling my ovaries this morning, but they seem less noticeable right now. TMI #1: It's sometimes difficult for me to distinguish between the ovary growth feeling, and maybe the sense that I might be constipated. (sorry!) I was trying to think of a way to describe it to S, and I came up with: it kinda feels like how you might feel if you had 2 cue balls (the kind you play pool with) tucked into your pelvis along with all the intestines, bladder, uterus, and stuff that is supposed to be there. It's not painful, but kinda full and heavy. Meanwhile, I made plans for S and I to go hiking with P (a guy friend from work) and his wife, L, on Sunday. I have mentioned P&L before; they too have struggled with IF but apparently have made the decision to not do IVF. They will consider adoption in the future. It's not a strenuous hike, but I did warn P that we may need to cancel the hike if my ovaries get too enlarged such that it hurts to walk.

TMI #2: Oh, just for curiosity's sake, I checked my cervical fluid today. Tons of the stretchy egg-white stuff. I guess it really is related to high estrogen. One bittersweet aspect to IF: I really do like having a better understanding of the female reproductive system! I joked to one of my friends that I want to get quadruple board-certified: Internal Medicine (done), Oncology (Fall 2008), Hematology (Spring 2009), and Reproductive Endocrinology (anytime now...ha)!

I am joking about that, but I actually could get a little bit involved with Reproductive Endocrinology in the professional sense. There is a group at my workplace called the Oncofert.ility Consortium. This group apparently works to enable fertility preservation options for young cancer patients. Last winter, a mentor of mine (Dr P) forwarded an email to me, asking me if I wanted to be get involved, too. Dr P is too busy, but she wants someone from medical oncology to get involved. After all, we oncologists are the ones who give these young men and women the chemotherapy that may save their life...but kill their eggs and sperm forever. It would be good to have someone on our end to help facilitate the referral for a young person with cancer who wants to preserve fertility.

The ironic thing is, Dr A and Dr W (two of my REs) were also listed as recipients of that original email, meaning that they are already part of the Oncofert.ility Consortium. Well, I would *love* to join this group, but not yet!! It would be too weird to be on a bunch of emails and committees with Dr A and Dr W at this point. Someday, though... I think it sounds fascinating!

Stim Day 6 / Ultrasound

The good news:
Dr. A did my ultrasound this morning and he seemed pleased with the results. My lining was 8.2 mm, which he said was "great." The largest follicles were a 10 mm follicle on the right side, and an 11 mm follicle on the left side. There were many follicles on both sides that were near that size, but he didn't measure them. He also didn't bother to count exactly how many were there, but said, "about 12" on each side. He said that they might not all continue to develop, so there is no reason to count them now. He explained that the purpose of today's ultrasound was to make sure that I wasn't developing a lead follicle. (My interpretation is that a lead follicle might lead to suppression of the growth of other follicles, which would be bad). Since I had many follicles, all about the same size, this was considered to be good.

I asked the nurse when she thought ER would be, and she said that it looks like we're on track for Tuesday (the original estimated date). It's still too early to know for sure, though.

The anxiety-provoking news:
Today my E2 level was up to 575, and it's making me nervous. My results for the last few days are: 47 -> 110 -> 255 -> 575. This is more than doubling each day. If this trend continues, I would think that my E2 will be (more than) 1100 tomorrow, 2200 Friday, 4400 Saturday, 8800 Sunday, 17600 Monday....ummm...HELP! Damn, I hate exponential numbers. I've read (pubmed and google) that high E2 levels (above 4000) are highly associated with OHSS and cancelled cycles. I've been instructed to continue my current dose of meds, but I'm definitely going to ask them about this tomorrow. I don't want them to feel like I'm a demanding/pushy patient, and I don't want to be my own doctor, but I just want to make sure that they have noticed that my numbers are more than doubling every day. I don't want to be cancelled! nor do I want OHSS! I just want my E2 to keep going up, but a little bit slower maybe (?), and for me to have nice mature eggs by next week.

On the other hand, my ovaries are not really bothering me today, and that seems like a good thing. Bloodwork again tomorrow (and every day), and my next ultrasound is on Friday.

I am so glad that I have a lot of work to do right now. It's the only thing that is keeping me sane.

Stim Day 5

Sorry that this is turning into the most boring journal ever written. I'm recording every detail so that I'll have them all for future reference.

My E2 today was up to 255. Still low (I think) but more than doubling. They apparently think it's OK now because I'm supposed to continue with my current doses of meds (Follistim 125 IU each evening, along with Lupron 5 units and Menopur 75 IU every morning.)

I have my first ultrasound tomorrow, so that should tell the tale about what is really going on. I think I'm starting to feel my ovaries just a little bit, mostly on the left side. I wonder what it will feel like in a few days.

Stim Day 4

I ran into Dr. W in the elevator on the way into the RE's office this AM. (Dr. W the junior-most of the 3 RE's in the group's office. She's probably 2-3 years older than I am, and I find her the most approachable of the three in the group. ) I hadn't seen her since my last IUI, so I said, "Oh, hey, I'm doing IVF now." I was surprised when she said, "Yes, I know. You're on stim day 4, right?"

Wow! She keeping closer track of this cycle than I am! Good job, Dr. W. She never fails to impress me.

My E2 level was 110 today. That's more than double from Day 3 (47), so I'm thinking it's a good rise, even if the number is still lower than most people's at this point. I don't want to go too fast given the significant risk of OHSS with all those follicles! I will be staying on the Follistim 125 IU dose for tonight, along with 75 IU Menopur and 5 units Lupron in the morning.

I did get the nurse's approval to move my injections around to wherever I want. I used my upper right hip for Follistim tonight. It didn't hurt any more than my abdomen, and didn't leave a bruise or bleed. I will probably still use my abdomen from time to time, but for now it's nice to have options while my other bruises are fading.

I almost forgot this lovely detail. I'm getting a lovely pimple on the side of my neck under my jawline. I also have some attractive bumps around my mouth! Argh...damn hormones.

Happy Monday, everyone.

Follistim Dose Increase

I went in for my first E2 level at the RE's office this morning. A few hours later, they called me and told me to increase my Follistim dose from 100 IU to 125 IU each night. I then asked what my E2 level was... it was 47. I don't know what it's "supposed" to be at this point, however. I guess I can ask that question tomorrow morning. I will be at the RE every day from now on until after the egg retrieval. I wonder if my slow start means that my ER will be a few days later than expected.

My stomach is getting a few more bruises, and after tonight's Follistim dose, I can literally feel the lump of fluid just sitting in the tissue. I wonder what it would feel like to inject a volume that was 2 or 3 times greater. Yowza. I think I might also ask if I can start giving some of my doses into other locations like the upper hips or something like that.

I remembered to ask about my cystic fibrosis carrier test results today. I was negative for the 32 most common mutations, which was good to hear. (I had suspected as much since they never told me otherwise, but I had never heard the official results.)

I also inquired about whether it was still OK for me to go running at this point. The nurse said yes for now, but that I might not feel up to it in a week or so when my ovaries are really huge. They'll also let me know based on the ultrasounds if I should stop. (I'm assuming this is to try to prevent ovarian torsion). In the meantime, I'm going to keep going. After all, I run, but I'm not setting any speed records. Since the daily early morning blood drawing appointments are going to impact my usual Tuesday/Thursday morning runs, I might ask my friend A, a nurse practicioner from work, if she wants to go on some jog/walks around campus or up the hill from La Jolla Sh.ores (a local beach) in the late afternoons. That's the run that I did after my appointment today, and it was really beautiful.

S and I rented Ju.no last night. I had been reluctant to see it in the theater because of the whole premise of watching a movie about someone who was pregnant but didn't want to be. I have to admit that I liked it, though. I was also relieved with the way that it turned out in the end. I have been crying at almost every movie I've seen lately, and this was no exception. :) I like getting emotionally involved enough in the stories to do that.

Obligatory Medication Photo

I swear that the collection of meds (and especially the number of needles and syringes) looked even more impressive in person. S was literally shocked to see this pile! Personally, I like the fact that I have my very own sharps container. Just what I always wanted!! :)

My first doses of Menopur (75 IU this morning, along with Lupron 5 units) and Follistim (100 IU this evening) went fine. Menopur was a little tricky because they included a lot of instructions about using a needleless system for drawing up the saline and transferring into the vial with the powder. However, this seemed more confusing than just using a needle, so I did it the old-fashioned way. I was also confused about the fact that the saline vial contained 2 cc of normal saline, but it seems that you are only supposed to use 1 cc to dilute the Menopur powder, and you can presumably discard the rest. Not to mention that I was chatting on the phone (hi K!) and trying to get ready for work as I was doing this, so it was a little bit overwhelming. I took my time and gave my full concentration to using the Follistim pen this evening, so that one went smoothly. I have no symptoms of any kind yet, except for the fact that my period is coming to a rapid halt. I'm somehow afraid that I'm going to forget a dose of something at some point. Yikes!

Since I'm always complaining about the cost of IVF, I'll take this moment to complain about the cost of something else -- gas! I set a new record today: I have now paid over $40 to fill up the tank on my little Honda Civic!! It used to cost me about $13 for a fillup, but at this point it was 10+ gallons, and $3.82 per gallon for the cheapest available gas. Luckily, I get pretty good mileage and don't drive more than 10-15 miles per day, so it should last me for a couple of weeks. However, I fail to see how suspending the gasoline tax over the summer (McCain's proposal) will really help the economy. I don't think that saving a couple of cents or a dollar here and there will affect the budget of the majority of people, but decreasing gas taxes (which generally fund transportation projects, as far as I understand) may just make road maintenance and new road construction come to a halt.

OK, I'm starting to fall asleep sitting here (I guess I'm even boring myself by talking politics for a minute), so I'm probably better off going to bed now. Good night, everybody!

Suppressed!

My E2 is indeed < 20 today. Suppressed as planned. Yippeee!

Of course, after writing the post earlier today, I started googling "high antral follicle count" etc and managed to freak myself out. Higher counts can be associated with poor quality eggs. And I found the scary IVF tale of a woman with 66 antral follicles who like me, googled high antral follicle count, suspected that she was going to develop severe OHSS, and then did just that. She has twins now, but the original IVF cycle was cancelled due to the OHSS, and then she had a miscarriage after her FET, and then she finally got pg with her second IVF. Yikes!

I just need to trust that my RE knows what he is doing. He always projects himself as so calm and confident. I sometimes want him to commisserate and admit that my case is difficult and that these decisions are tricky, etc, but he never does. They tend to just rush out of the ultrasound room as quickly as possible so that I can't quite voice all my anxieties to them. Maybe that's a good thing.

Ultrasound Report

Today I had my suppression ultrasound and bloodwork. I'll have to wait until this afternoon for the E2 result, but if it's less than 20 (indicating "suppression"), I'll be good to go. Dr. G did my ultrasound this morning. As Ms. Polycystic Ovaries (without full-blown PCOS), I had a whopping 26 follicles on the R side, and 17 on the left. Yes, that is 43 antral follicles. It's really an approximation because he was counting them really quickly. He could see that there were plenty.

So, my initial doses -- starting tomorrow -- will be 5 units Lupron and 75 IU Menopur every AM, and 100 IU Follistim every PM. I get the sense that the Follistim dose is really small, probably because they don't want to overstimulate my ovaries. At the same time, I am a bit concerned because they kept me on a small dose of Clomid (50 mg x 5 days) through 3 IUI's and I only got 1-2 follicles each time. I'm worried that I'm less easy to stimulate than they seem to think.

I expressed these concerns to the nurse, C. (Dr G was in and out of the room so fast that I really didn't have a chance to ask my questions. Grrr.) She tried to reassure me that this is the reason that I will have bloodwork literally EVERY DAY starting on Sunday (4/20/08), and ultrasounds almost EVERY DAY starting on Wednesday (4/23/08). They will adjust the dose every day to try to get a good result. She then taught me about reconstituting the Menopur from it's powder, and how to use the Follistim pen, etc.

My bill at the pharmacy today was $1450.66. My insurance covered part of the doxycycline, Medrol, and Vivelle patches. I had to pay full price for the Follistim ($$$), Menopur ($$$), HCG ($), and progesterone ($). This is a small (non-chain) pharmacy on the first floor of my RE's medical office building, and they are very used to dealing with my RE's patients, so that part is good. There was an older man in the line next to me who gasped when my total bill was announced. His cashier said to him, "See, doesn't that make you feel better about yours?" I smiled over at him and thought about telling him that it was for IVF (since I am sure that he was curious!), but I decided against it. I may need to buy more Follistim later, depending on whether my dose goes up. So far, I have a 900 IU cartridge.

Overall, I'm feeling cautiously optimistic...

Hurry UP Period!!

I took my last birth control pill on Saturday, and now I'm waiting for my period to arrive. I had some promising cramps on my jog this morning, but I'm not feeling anything now. I don't think I've ever been so eager for my period to start. It's bizarre how I took the pill for several years, most recently in November 2006, and yet I cannot remember how long it generally took between stopping the pill and starting the flow! Weird, huh? Anyway, if my period does not start by tomorrow, I will not have my suppression bloodwork and ultrasound on Thursday, and then everything will be delayed. I asked about it, and it sounds like it only delays things by a day or two (until Aunt Flo appears), but it's making me a bit antsy.

I now have two ugly bruises on my abdomen. I don't know why 2 of my 8 injections (the two most recent) have resulted in bruises. I think I was sort of injecting as I was withdrawing the needle, instead of injecting all of the solution while the needle was completely buried. Maybe it also has something to do with the fact that I've been on aspirin for a couple of weeks now. Well, I guess there is plenty of more time for self-experimentation. I never thought that I would look forward to starting 3 injections per day, but I am really eager to get to that part.

Sorry for the utter boringness of this update. I hope you all are doing OK!

Edit to add: My period finally arrived a few hours after I posted this. Onward ho!

Gorgeous Weekend

I have been pretty surprised by the utter lack of side effects with Lupron. I guess I might have had a tiny bit of night sweats last night (dampness on my chest), but it was less than I have experienced previously with either Clomid or with the end of every cycle when my temperature drops.

I took my last birth control pill yesterday, so now I'm just waiting for a withdrawal bleed in the next couple of days. Assuming that that happens, I'm supposed to have another ultrasound with the dildo-cam and an estrogen level on Thursday. Then, on Friday, I'm supposed to start the Big Guns (Follistim and Menopur). Lupron will continue, too, although the dose drops to 5 units at that point.

It has been kinda relaxing, these several weeks of TTC without having to monitor anything, have sex on demand, or worry about symptoms or lack thereof. However, I'm eager to move onto the next phase of this process.

I'm really excited to report that S and I are going to take a 10 day trip to France in mid/late May. The ironic thing is, assuming that everything goes well, we are leaving on the day of what is supposed to be my pregnancy test! (I didn't realize that IVF would take over 6 weeks when we scheduled the trip back in early March!) Of course, I am going to need to have them move the test up by a couple of days. Waiting til 16DPER seems ridiculous, anyway. I guess that if I am lucky enough to be pregnant, I would miss some of that fun stuff like seeing if my beta numbers double, etc... but in a way I think it will be good to get away. I hope that a negative won't ruin the whole thing, though.

We had a good weekend, overall. I did work overnight at my moonlighting job on Friday night. I make these shifts more palatable by thinking that they pay for the extras in life, like IVF and our trip to France. That was my 3rd Friday in a row (ugh!), and my 2nd to last shift ever (probably), so I am thrilled to have it behind me. After I slept away half the day Saturday, I woke up to one of the most beautiful weekends (weather-wise) in recent memory. S and I went to Home Depot and picked up a bunch of plants to plant in our new planter boxes in the back yard. Hopefully in a few months we will have a crop of 6 different types of tomatoes, bell peppers (yellow and green), jalapenos, and maybe even some basil, cilantro, and a giant watermelon. We also got a bunch of new impatiens and coleus for our front entryway along with several other plants for various spots. We had a lot of fun planting it all.

Afterwards, we went for a "date night" to our local barbeque joint (yum!) and then saw the new movie "Sm.art People." Thumbs up! I did cry a little... somewhere in the middle and then at the end. If you see it, you'll understand why. You must stay and watch the credits, by the way. I'm picky, so I did notice a few gaffs, though. For one, we see a paper that Sar.ah Jess.ica Par.ker wrote for her college freshman English class. It was dated 1992. Well, I was a college freshman in 1993-94, and SJP is quite a bit more than 1 year older than I am. There were also a few medical professional things that didn't ring true. SJP is an emergency medicine physician, and she 1) administered a tetanus shot (sorry, but I have never yet given a shot... nurses do that!), and 2) gave the shot to the guy in his butt (as a patient, I've always had tetanus shots in my arm), and 3) took call (I have NEVER heard of an ER doctor being on call). Also, a neurologist did a slit lamp exam, which is usually the domain of the ophthalmologists and wasn't really indicated for a patient who was being seen to follow up a seizure. Since these things bother me, you can probably see why I haven't watched the TV show ER since my intern year (2001-2002). But besides all these nitpicky details, it was a good movie. But ANYWAY...since SJP was in "Smart People", they had a preview for the Sex and the City movie. It looks really cute and I've now started taping Sex and the City so that I can refresh my memory and be ready for it.

Today, we drove up to Laguna Beach just to do something a little different. It's about a 1.5 hour drive. We went on a 5.5 mile hike in Crystal Cove State Park (beautiful, but hot!), and then had a nice lunch on a shady patio, and then went shopping and people watching for a while. Came home and drank a margarita on the patio. Summertime... and the living is easy...

First Shot

I asked S to be with me for "moral support" during my first Lupron shot. While pulling (too hard) to remove the cap from the needle, it recoiled and I managed to stab myself in the palm. OWW! I swear, I think it is a miracle sometimes that I have only had one occupational needlestick, and that was a clean needle that I hadn't yet used during a bone marrow biopsy. Lucky lucky...knock on wood...fingers crossed.

Anyway, I finally managed to draw up the 10 units, cleaned and pinched an inch on the side of my belly, and then I just took a deep breath and stabbed myself with the needle. I have to admit, the shot itself actually hurt less than I expected. I think I'll be able to do this entire part without much problem, even when it increases to 3 shots per day next week. So now I'll just have to start worrying about the trigger shot and the PIO shots. I have to admit that those DO scare me. I've seen those needles. Yikes.

This reminds me... last week, when I was at the RE's office for my trial transfer, there was a woman there who was having an absolute fit while her blood was being drawn. I mean, both her husband and the nurse were literally holding her down to restrain her arm while she flailed her entire body and was screaming and moaning really loudly. Certainly all of her movement couldn't have made it any easier to find a vein. The whole situation was pretty unbelievable and it was hard not to stare at them. I'm assuming that she is an IVF patient and I really hope that she is almost finished with the daily blood draw part of the cycle.

9 Pills Per Day

After months of searching, I finally found a stock market graph that looks exactly like a normal temperature curve in an ovulatory (non-pregnant) cycle! Tee hee hee. Too bad I'm on the pill (pre-IVF) and that I'm no longer tracking my temp. Well, anyway, that's kinda what it usually looks like.

One day after my last entry (Wednesday, 3/26/08), I went to my RE's office. They did an ultrasound to confirm no cysts (and none were seen), and then they drew Cycle 3 blood work. I got the results a few days later, and got a bit paranoid about the fact that my FSH was up to 6.7 with an estradiol of 42. Both of these are normal (they want the FSH < 10 and estradiol < 50), but both are higher than before. In June 2007, my FSH was 5.2 with an estradiol which was actually below the normal range at 18. The RE's nurse told me that "normal is normal" and that I shouldn't worry about the exact numbers. So I am trying to do that. I have also read that FSH can be higher after Clomid, but I tend to doubt that the effect would last for 2 months. As for the estradiol, I can perhaps speculate that the metformin has changed the ratio of my sex hormones? My weight is stable at 130-132 lbs, but it is possible that I have a bit more fat and less muscle than last June... who knows?

Also, my DHEA-S was measured at 142, with normal being less than 200. This is apparently a measure of my adrenal androgens. I have never had any other androgen testing, and I'm wondering what it would have been pre-metformin.

Last Friday (3/25), I started birth control pills (Ortho-Evra, I think). Ugh, since dealing with IF, I never thought I'd need to take the pill again in my entire life. Oh well, at least insurance is paying for that one. They are also paying for doxycycline, which S and I are both taking. Neither one of us have any active infections. It's voodoo, I swear. I feel that way about the aspirin, too. Of course, I'm completing willing to do any voodoo that they recommend at this point.

A couple of days ago, I was shocked to realize that I am currently swallowing 9 pills per day. 1 prenatal vitamin, 4 metformin, 2 doxycyline, 1 baby aspirin, and 1 birth control pill.)

I also went for a "trial transfer" a few days ago (on Tuesday, 4/1). As usual, I forgot to come with a full bladder, so their transabdominal view of my uterus wasn't that great, but hopefully that won't interfere with the results. Anyway, the trial transfer was exactly like an IUI, except that they made note of the fact that they used a small speculum (I could have told them that!), and they said, "6 at 6 o'clock" which is some sort of mysterious measurement that they will use during the upcoming embryo transfer.

On the trial transfer day, I had to pay the $10,525 (gulp!) IVF fee. This does not include meds. Please GOD let it work! I am starting to get more an more comfortable with the idea of transferring two embryos. (Oh, please please PLEASE let me have good embryos to transfer).

I start Lupron 10 units per day on Tuesday, 4/8/08. I take both Lupron and the pill for 5 days, then I stop the pill and wait for a bleed. Soon thereafter, I have another ultrasound and start injectibles (Lupron 5 units, Follistim, and Menopur)...

The only other related events have been:
1) finding out that one of my co-workers' wives is pregnant, and
2) while I was at the drugstore pondering why aspirin 81 mg is more expensive than 325 mg, I had to listen to a loud one-sided conversation (a young woman chatting on her cell phone) about her OOPS! pregnancy, just confirmed by blood test, with the father who she almost just broke up with just last month, and how all of their fighting made her lose track of the days of her cycle (OOPS!), and how she was about to go and apply for WIC, and how her neighbor already gave her "What to Expect when You're Expecting," and how something must be in the water because EVERYONE is getting pregnant. The only good thing about hearing this conversation was that the woman did at least seem happy to be pregnant.

Oh, wow. I promise I'm really not as bitter as I sound right there. But if this doesn't work, I probably will be. :)