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!

One Little, Two Little, Three Little Follicles... (Repost from UII)

I fear I'm becoming a produce stand.

That's right, I'm basically walking around with two little bunches of grapes in my pelvis.

Today is Treatment Day 10, and I thought we would all enjoy a mid-stimulation check in.

I've been encouraging the growth of my ovarian follicles with injectable hormones for a week and a half.  My drug protocol is actually a little light, as I only have to do injections once each day (happy dance).  My regimen started with two medications to encourage many follicles to grow and a few days ago we added a third which prevents me from ovulating too soon.  Most days this past week I've headed down to my doctor's office before work (51 miles round trip - the things we do for quality healthcare) for monitoring consisting of blood draws to check hormone levels and transvaginal ultrasounds to measure and count my follicles, which I call "potential baby bud roll-call".  This means I've been stuck 32 times so far - 12 times for Follistim, 10 times for low-dose HCG, 4 times for Ganirelix, and 6 times for blood draws.

I am happy to report that at this point, things are going quite well :)  Yes, that's right, this little Sjoggie actually has something going right!  These moments are few and far between so when I get one, I like to celebrate by high-fiving myself.  But that's besides the point.

What do I mean "things are going right", you ask?  Good question!  Here are some things that are on target or even better than average at this point:

• I'm developing a delightful number of follicles - one of the clinicians told me she sees on average about a dozen follicles total for a patient, and I have 10-12 on each ovary right now.  They won't all yield a mature egg, but in this case more is basically better, and I don't have so many as to pose any significantly increased risk of OHSS (ovarian hyperstimulation syndrome).
• My follicles are generally growing at a consistent rate - sometimes a couple overachievers will get plump very quickly, leaving the rest to play catch up trying to grow mature eggs, but mine have mostly grown at around the same pace which is great because it means it's easier to tell when we should trigger to maximize results.
• My uterine lining is on target - I'm not doing a fresh transfer so this isn't particularly important right now, but I am relieved to know that my lining is thickening to a good level.  This will be important when we do transfer in a few months, because you need a plush lining to give a little embryo or embryette a good chance of implanting happily.

At this morning's visit, my potential baby buds were measuring around 17mm (give or take, there's a range of course), which means we're getting close to retrieval.

In addition to these objective ways of seeing that the cycle is going well, I am also happy (if a bit shocked) to report that I'm generally feeling pretty solid.  I'm only slightly uncomfortable from the feeling of my plumped up ovaries, which do resemble small bunches of grapes.  For me, it's this general sensation like full kidneys, and I'm more aware of it during the movements to sit down or stand up.  Of course, it's pretty likely I'll feel increasingly uncomfortable in the next few days but so far, so good!

I have had one problem crop up in all of this.  The day after my first round of shots, I had a full blown migraine.  Never having had one before, I didn't know what was going on but after talking to the doctor and reviewing all the symptoms that occurred, that's clearly what it was.  It started with a visual aura - I describe it as being like when you look at a camera flash, except the perimeter of the "blur" almost looked like tinsel, sparkly and irregular.  The "blur" began to expand and before it was over (about 20 minutes or so) it did obscure a good section of my field of vision.  While this was going on, the headache hit (I have a history of cluster or "suicide" headaches so this wasn't the worst part to me, the aura scared me the most), and eventually I had some nausea.  These "sudden onset migraines" are not uncommon with all the hormones and medications, but no one warned me about them either.  On the upside, except for a lingering headache the next day I only had one more migraine begin a few days later, without aura, and taking an excedrin when I felt it begin did help keep it from progressing.  Again, I'm not out of the woods yet but I am hoping that it was more of an adjustment issue and the worst is behind me in this respect.

So what happens next?  Another excellent question!

Each day that I go in, the office calls me a few hours later once the labs come back to tell me if there are any changes to my medicine protocol (there haven't been so far, which I think is a nice indication that my doctors did a good job figure out where to start, but for the record tweaks are absolutely normal because no two people respond exactly the same way).  One of these days that call will also tell me to take my trigger shot that night.  36 hours later, I'll go under IV sedation for retrieval.  The clinicians (and I) suspect they'll tell me trigger tomorrow (for Wednesday retrieval) or the next day (for - you got it - Thursday retrieval).  The day between the trigger shot and when we go egg hunting I get a short reprieve with no more shots.  That will be nice, considering my belly is starting to look like one of those tomato pincushions everyone's grandmother had after it's been stabbed a few hundred too many times.  And did I mention Ganirelix burns for a little after it's injected?

Granny's pincushion or my abdomen?

This is where we're at in the IVF leg of our infertility journey.  The day we have egg retrieval (and incidentally, every time we discuss that I feel like a giant chicken on a farm) we will find out how many follicles were drained and how many mature eggs were actually retrieved.  They'll inject each one with one of my husband's sperm overnight and the next day we'll know how many successfully fertilized, then we begin the highly distracting phase of waiting to see how many grow to blastocyst stage over the following 5-7 days.  Better buckle up, kids, we're just getting started!

Get It Together (Repost from UII)

Today's the big day (well, the first of several big days) - tonight I start the stimulation drugs.  These injectables will hopefully encourage many follicles on my ovaries to develop mature eggs for retrieval in roughly a week and a half.

Fun Fact:
Apparently in a "normal" ovulation cycle, many follicles are ready to develop but due to the level of chemicals produced by the body, only one or two will reach maturity.  The other follicles that started to develop are 'lost' anyway.  With IVF, enough hormones are given to encourage many more of those follicles to develop - which is why IVF does not cause a woman to "use up" her eggs any faster than her body would have on it's own!  Therefore, IVF will not cause early menopause or shorten a woman's childbearing years.  Pretty cool!

But returning to the topic at hand...
My full arsenal of meds arrived the other day from the specialty pharmacy.  To be fair, some of these meds are for use when we do a transfer (more on that another day) but even so, if I'm being totally honest, getting this package was a little overwhelming even to a seasoned sickie like me.

Let me remind you that I'm only taking doses a fraction of the quantity that women usually take in IVF.  On one hand, I have a few stats actually in my favor, which indicate I should be a good responder (produce a good number of eggs).  In addition, due to my PCOS I'm actually at increased risk for OHSS - Ovarian Hyperstimulation Syndrome.  Therefore, my doctor and I decided to go with a reduced dosage protocol which is awesome because it also helps address my concerns over the physical strain IVF could place on my already over-taxed system.  Women usually take their meds twice a day, but I'm only taking once daily doses.

It's important to understand that the protocol for an IVF cycle isn't set in stone.  You're given instructions for dosing to start out, but beginning a few days in you go for daily monitoring (bloodwork and ultrasound) and they will adjust things as you go to maximize results.

To begin my cycle, I'm taking two injectable medications every evening - Follistim and low-dose HCG.  My dear, highly skilled nurse of a husband was, of course, working this evening so I had to give myself the shots right out of the gate.  First, I got my supplies together:

(See what I did there?  "Get It Together"?  Oh come on, that's clever.)

Follistim is injected using a dial-a-dose pen, which is rather convenient and didn't cause me too much stress.  You know, relatively speaking.  The low-dose HCG was another story.  This is old school stuff.  Using what I understand to be the kind of needle used for traditional insulin injections, I have to manually draw down the dose I need from a glass vial, just like every TV show I've ever seen, then stick a legit NEEDLE INTO MY FLESH, and with a "slow and steady motion" press in the plunger.  Dear Lord.

(Sorry it's blurry, my hand was shaking a bit trying to hold the camera while remember to BREATHE WITH A NEEDLE STUCK IN MY STOMACH.)

I have blood drawn all the time, no problem - I watch the blood spurt into the vial.  I've given my mother injections of her diabetes medicine, not an issue.  As you know I recently got a tattoo, didn't bat an eye.  And yet it would seem I do have a bit of a concern with needles.  At least, needles containing a liquid that I have to force into my flesh.  And these are small needles given in my abdomen.  I can't wait for the progesterone shots to start with a transfer - IM (intramuscular) injections given in the backside with 2 inch needles.

Between you and me?  I don't want to do this.  I don't want it.  I don't want to give myself injections, to worry about checking for blood in the needle in case I hit a vein, to have pinprick marks all over, to risk major complications like OHSS.  Of course, I'm going to do it anyway, because I want a child.  I said it before, "I don't like the alternative", so I'll cry and pray and probably yell a little, and I'll get myself together and continue to do it.  But I really don't want to.