Baby Bud Round Up

When last we spoke, I was mid-cycle on my IVF stimulation process.  All-in, the process lasted 12 days culminating in a nice dose of IV sedation (I do so love IV sedation) and the harvesting of my little egglets.

By my last ultrasound pre-retrieval they counted 10-12 follicles on each ovary.  Each follicle was about 20mm, give or take, and being the visual thinker I am I drew 12 20mm circles on a piece of paper and cut them out.

 Since I have two ovaries, I thought you should see it twice ;)

On the same day, they drew a blood sample as usual.  With IVF, there are generally two options for a trigger, Low-dose HCG and Lupron.  I had expected to be using the Lupron trigger because it is a good option under two conditions: when you are not planning a fresh transfer and when there's a risk of developing OHSS.  Since I have PCOS (a factor that increases the risk of OHSS) and planned to do PGS (preimplantation genetic screening), this made sense.  However when they got the blood results back and called me, they instructed me to use the more traditional HCG trigger.  I couldn't tell you the exact medical reason but as they explained it to me it had to do with my particular set of hormone levels which indicated I might not respond effectively to the Lupron trigger and a lack of warning signs for OHSS.  That's all fine and good, except that the Lupron would have been administered with more of the tiny needles I'd been sticking in my belly (and was now used to) whereas this is the needle used for the HCG trigger:

This is an IM (intramuscular) injection - yes, my husband had to stick this in my backside.  Yay.

As you can see, the HCG trigger shot needle is quite a bit longer, and thicker, than the subcutaneous ones.  On the other hand, that's a lot smaller than the needle that was going to be placed in a much more disturbing location two days later...but we'll come back to that.

Fun Fact:
The point of the trigger shot is not to rupture the follicles containing the eggs, it is to get the egg to release from the wall of the follicle - where it had been hanging out during development - and float freely in the follicular fluid.  How cool is that?!

Between the trigger shot and retrieval you get a day "off" from injections.  It's a nice little reprieve.  For retrieval I was going to be placed under IV sedation so I was going to need a day or two off from work, and with the effects of the meds and retrieval process affecting my ovaries I was encouraged to take a few days.  So in true sickie form, I took several vacation days to have this done.  On the up side, my husband was also able to take a few days so in addition to making sure I was taken care of we got to spend a little time together and do some day trips.  Gotta incorporate a little levity, right?

On the day of my retrieval, I arrived at the office and was placed under sedation.  While I was out, the doctor used a long needle placed through the vaginal wall to drain each follicle of its fluid, hopefully containing an egg.  Thank God I fall asleep from the sedation, I'm told some people don't.  I can't even imagine.

Anyway, one of the reasons I love IV sedation is how quickly and easily I recover from it, though apparently this time I did argue with my husband a little that I wanted to go back to sleep rather than really rouse myself.  I think this both annoyed and entertained him.  By the time I was with it, the embryologists had identified the eggs retrieved and within a few minutes more, knew how many were fully mature!  For some reason I thought it would take a couple hours to do that.  Even though there was a frozen sperm sample on hand for use as a back-up supply, my husband was asked to provide a fresh sample that morning, which he did.  This was also analyzed quickly and fresh sperm were selected for the ICSI fertilization process, where an individual sperm is selected and injected into an egg.  The day after retrieval you are told how many fertilized (this is day 1).  On day 3 we got an update on how many were still growing, and again on day 5 (my practice grows all embryos at least to day 5 hoping they reach blastocyst stage, and sometimes they are left for an additional 1-2 days).  At that point, we had to decide how many we would biopsy and send for testing.

As a point of order, not all follicles that are drained will necessarily contain and egg, not all eggs retrieved will be mature, and not all mature eggs will fertilize.  Additionally, the fertilization rate with ICSI is generally 75-85% and the proportion of fertilized eggs that will actually reach blastocyst is usually 60% or less.  With my age and stats we were pulling for the high end of those ranges.

That being said, I had 27 eggs retrieved, 21 of which were mature (this is considered an excellent response, and even moreso when you recall that I had used a low-dose stimulation protocol).  We gave the go-ahead to perform ICSI on all 21...and 19 fertilized.  On day 3, all 19 were still growing.  On day 5, ALL 19 WERE STILL GROWING.  A few didn't end up reaching blastocyst, but in the end we had 15 embryos eligible for biopsy!  Once we got past the initial shock of such high numbers we had to decide how many to biopsy.  For financial reasons we only sent 8 biopsies out for testing, but we did have the remaining 7 biopsied and the samples frozen for future testing.  I guess I have fairly hardy little eggs if they were only able to get through my damaged fallopian tubes!

For a woman my age, they expect 20-30% of the embyos to be chromosomally abnormal (non-viable), and this time I was right on target.  25% of my baby buds we tested (or 2 out of 8) were abnormal, leaving 6 chromosomally viable buggars to work with for now.  We chose to find out the genders, but this is a choice each couple can make.

The next step is generally to prepare for an FET (frozen embryo transfer).  In my case, they had identified one or more polyps hanging out in my uterus and it's best to remove them before transferring - which is where we can pick this up another day.

And that, dear future child, is the story of how you were made!

There's How Many Ways to Do This? (Repost from UII)

Image of ICSI found here.

Let's take a poll, shall we?

Raise your hand if you know someone who has struggled with infertility.

(If you actually have your hand up, good - it helps when you play along:))

Keep your hand up if you know someone who went through infertility treatments of any kind.

How about anyone who's been through IVF?

(I'm guessing a few hands have gone down but several are still up...let's keep going.)

Keep your hand in the air if that person you know who did IVF had a baby from the treatment.

(You're such good sports!  You can put your hands down.)

If I were the betting type, I'd have money on the chance that almost every hand that was up for "I know someone who did IVF" was still up for "they had a baby".  Is that because IVF always works?  HELL no. In fact, most women who go through IVF have only a 20-35% chance of success in a given cycle - anything over 40% is considered terrific. No, it's because in our society, we don't talk about IVF that doesn't work, let alone the things involved in the IVF process.  Unless the person doing IVF was you, a sibling, or your absolutely closest friend, I'd be surprised if you even know they were doing it until the baby was at least visibly on his or her way.  I'd bet you have no idea how many rounds that couple may have failed before having a successful transfer and pregnancy.  It's likely not your fault, they just didn't feel comfortable telling everyone.  But we all know I am not encumbered by such social norms :D

I am just beginning my journey through IVFland.  This week marks two years my husband and I have been TTC (trying to conceive), and we've been through quite a bit of testing, medications, surgery, and several different types of treatments.  We've done the classic Clomid, tried IUI.  We did, one time, get pregnant but as you know the baby had a trisomy (third copy of a chromosome) and resulted in a miscarriage right before Christmas.  We finally took a step back after that to consider if we wanted to continue treatments, and explored the adoption scenario.  After checking out three agencies, we determined that adoption may be in our future but right now we are better prepared to try some more treatments.

However, we also decided we were not satisfied with the fertility specialist we had been seeing and realized it was time for a second opinion and a new approach.  Fortunately, through the infertility support group I joined, we were aware of a few local alternatives and one in particular which seemed to have a very passionate following, and who offered a free 2nd opinion consultation option!  We took our records from the three previous doctors, went through our entire medical histories, discussed our concerns, and sat down with the new doctor.  I'll dedicate another post to why I'm liking this new place so much, but suffice it to say she has the approach we need not only to treatment but also to patient care.  Her advice is try a "mini-stimulation" cycle of IVF which uses a significantly lower quantity of medications than traditional IVF, as my tests indicate I'm likely to be a good responder.  This is important to us with all my medical issues, as we are concerned about what the process could do to my body and overall health.

And so here we are, going through the steps to get ready for our first IVF cycle.  Oh, and by the way, the terms "IVF cycle" itself is confusing, so let's break it down:

1. The first phase of IVF is egg retrieval.  This is where they stimulate the woman's ovaries to produce a higher number of eggs than are usually developed during a natural ovulation cycle.  When ultrasounds and blood tests show the follicles are mature, a needle is inserted through the wall of the vagina (while under anesthesia) to draw out the liquid in each follicle which should contain the eggs.  
2. The eggs are then fertilized (this can be with the male partner's sperm or donor sperm, and the sample may be provided the same day or in advance and frozen).  This can be done old school with many sperm in a petri dish or via ICSI (Intra-Cytoplasmic Sperm Injection) where one sperm is selected and injected into the egg.  My clinic performs ICSI.
3. The fertilized eggs are then incubated for a period of 3 - 7 days (this depends on your doctor, personal preferences, specific medical scenarios, etc).  With my clinic they usually grow for 5 days.  It is important to note that it's unlikely all embryos will make it the full length of time.
4. At this point one of two things will happen.  You can have a fresh transfer which involves placing an embryo in your uterus with a catheter on that 5 day mark (my clinic will only transfer one at a time, and I'm ok with that - with all my medical issues we don't need the added risks of carrying twins).  This will depend on how retrieval went along with your health at the time.  There are several things that could preclude a fresh transfer, including your own preferences.
5. If you don't have a fresh transfer, all embryos will be frozen.  If you do a fresh transfer, any remaining embryos will be frozen.  Oh, and you have another decision to make - PGS.
6. PGS is Preimplantation Genetic Screening, which is a NON-DESTRUCTIVE test that can be performed on embryos (and which even the best insurances don't cover).  Prior to freezing, a small biopsy is taken from the outer ring of cells which will eventually form the placenta (thereby leaving the cells that become the baby itself untouched).  The sample is then examined to determine if the embryo is chromosomally normal.  The test will determine if the embryo has the right number of chromosomes, which chromosomes may be missing, and which may have an extra copy.  It will also identify the sex of the embryo but you can ask your doctor not to tell you that.  So yes, this test will tell you if your baby has Down Syndrome or another chromosomal condition - whether compatible with life or not.  It will NOT tell you traits such as eye color, genetic risk factors, and so on.  How you use this information is a personal choice.
7. Once you have a fresh or frozen embryo transfer, you enter the infamous "Two Week Wait" where time seems to stand still and your stress level reaches new heights.  There's a lot of discussion around how to survive the time you wait to find out if the embryo implanted, and most tips center around how to keep your mind busy.  A lot of women stock pile books or binge-watch TV series.  Part of the challenge is that most forms of exercise (a stress-relief tool used by so many people) will be off limits during this time adding both to your physical discomfort and your anxiety.  During this time, it's common to continue a hormone protocol, depending on your specific case.

These are just the basic steps.  When someone says they are having an IVF cycle, it could mean that they're having a transfer, or a whole new egg retrieval being done.  And this process involves so many decisions and choices I never, ever contemplated before being in this boat.  What do I need / want to do to prepare my eggs for retrieval?  This could mean medication, supplements, acupuncture (which is incidentally something my peers SWEAR by), clean eating or other special diets, specific exercises, massage, even special heat compresses.  The medications you might take during stimulation, while preparing for a transfer, or following a transfer will mostly be directed by your doctor but you do have some input, again including diets, supplements (ALWAYS clear them with your doctor - "natural" doesn't mean it won't interact with meds), exercise (if permitted), and so on.  It's overwhelming.

So this is where I am.  I am preparing for my first egg retrieval which for me means going through several more tests since I am new to this clinic, and panicking because I'm well within the 90 day window prior to retrieval when studies indicate you can most impact the quality of your developing follicles and I have NO IDEA what if anything I should be doing differently.  Next week I will meet with my doctor again to review everything and hopefully get the green light for the retrieval, after which my husband and I will have to go for informational sessions and to be trained on administering the injections at home to encourage egg development.  I'm attending support groups twice a month (one led by a therapist and one peer-led group organized under the awesome national organization RESOLVE), and we are also in touch between meetings as we're all in a high-activity state right now.

So, if your'e still with me after all this discussion, I'll ask you one last question - how many of you had any idea what's involved in IVF?

Because I sure as hell didn't.