Friday, December 27, 2013

Break, Breaking, Broken

It started off so well. Five mature follicles. The first time a medicine regimen has worked since I began trying. Five great opportunities for a fantastic Christmas present.

When that fell through, I pulled myself off the floor. Instead, my Christmas present was a lovely period with cramps and vomiting. I focused on this being a fresh start and new beginning in time for the new year.

Today was my baseline ultrasound for that new beginning. Today I learned that I have two large "leftover" follicles measuring over 25mm a piece, one in each ovary, each looking half deflated and described as entirely useless at this point. I held my breath until 2pm when they finally called to tell me the verdict. My fate for the next month, decided by a doctor.

I'm out.

I am to call them in 28 days if when I don't get my period, in which case they'll prescribe 7-10 days of Provera and then I will hopefully, but never consistently, get my period and begin again. So for the next 28 - 45 days, I am back to waiting without hope.

I don't know how to end this. I don't have anything prolific to say. I keep oscillating between drowning in my own misery and pulling myself back up, moving forward, and staying positive. Frankly, both of these options are exhausting and unappealing.

Thursday, December 26, 2013

Merry Christmas

For this Christmas, I received the beginning of my menstrual cycle, complete with an extra large dose of cramps that actually made me vomit.

I now vividly remember why I went on birth control pills as a teenager, and it had nothing to do with my non-existent sex life. At the age of 15, two years after I began menstruating, I was still having only 4-5 periods per year and it would completely incapacitate me when it did occur. I'm still a little annoyed that no one considered testing me for PCOS at this point.

Merry Christmas to me. If there was ever a shred of hope that the tests were inaccurate, it is now clear as day. I am choosing to look at it as a new beginning, a new chance. Here we go again!

Tuesday, December 24, 2013

Categorization of Christmasyness of Christmas Movies

Moving back in with my parents (i.e. no house to decorate), without kids, and with my sister and her husband visiting for three days, makes it difficult to partake in any holiday traditions that are just for C and I.

If I were to decide on a theme for this year, I would say it would be movies. C surprised me last week with a trip to the cinema for a showing of It's A Wonderful Life. I paid him back by agreeing to watch Die Hard. This spawned a lively debate on whether or not either of these movies are technically Christmas movies, and then a categorization of other so-called Christmas movies. The pivotal question to ask yourself is, "Can you maintain the plot of the movie by taking out (or changing) the Christmas aspects?" (i.e. is Christmas really fundamental to the story line)

Here are my findings...

Most Christmasy Christmas Movies 

  • Miracle on 34th Street
  • Elf
  • Rudolf the Red Nosed Reindeer
  • Charlie Brown Christmas Special
  • Santa Clause
  • How the Grinch Stole Christmas

Moderately Christmasy Christmas Movies

  • Home Alone: I would have put this one lower, but when I considered all of the adaptions that would be required, this one really does rely on the holiday. It just can't be most-Christmasy because it's not really about Christmas so much as this is a necessary component to the movie
  • A Christmas Story: This might be slightly biased and in this category because I don't really like this movie. Yes, it's very much about Christmas and couldn't work without the holiday. On the other hand, it does not capture the Christmas spirit or send a positive message whatsoever. And for that, I deem it not most-Christmasy. 

Least Christmasy Christmas Movies 

  • It's a Wonderful Life: It's a lovely message and my personal favorite Christmas movie, but it could take place at any point in winter and you'd just need to substitute the tree decoration bell with a different bell (cow bell maybe?)
  • Love Actually: Slightly tricky because of the Christmas play that brings the whole country together, but maybe this could be substituted with a rugby match or national cricket championship. 
  • Die Hard: This is not a Christmas movie. Plain and simple. It's a decent action movie. You could very easily substitute the Christmas party for a retirement party and the wrapping tape used to tape the gun to his back at the end (C's biggest argument) could be any office supply take easily found in an office building. PLUS, it doesn't send any positive Christmas messages at all. Frankly, it shouldn't be on this list at all, but I'm including for the sake of argument. 
There you have it. My very biased categorization of Christmasyness of Christmas movies. Am I missing any movies? Would re-categorize any of these?

Monday, December 23, 2013

Scholarly Series No. 3: IUI is Valuable and Cost Effective

Continuing on with the medical community's debate on whether or not IUI is worthwhile, I now take on the counter-argument. For previous articles that initially sparked my interest in this topic, check HERE and HERE. In my last Scholarly Series post, I discussed the first of two chapters debating the merits of IUI and, frankly, it made a very strong argument against this approach. Now I take a look at the other side.

Moolenaar, L.B., Van Voorhis, B.J., van der Veen, F. (2013). IUI is a Valuable and Cost-Effective Therapy for Most Couples. in Biennial Review of Infertility: Volume 3. Eds Schlegal et. al., 185 - 188. 


Compared with the last article, these authors take a more moderate approach and begin by acknowledging that IUI is not the best approach for some diagnoses. They state that, unfortunately, many fertility decisions are made based purely on financial considerations rather than cost-effectiveness, a subtle but distinct difference. The authors do discuss a randomized control trial that compared 6 months of "expectant management" versus hMG and IUI that showed no difference in pregnancy rates and argued that that expectant management should be the "first line" treatment approach for most couples. 

They also discuss several studies comparing the cost-effectiveness of IUI to IVF. While some of these studies did conclude that jumping straight to IVF was more cost-favorable overall, the authors argue some key problems with the research methods in each of the studies. As for the FAST trial, that the previous article I reviewed spent a lot of time discussing, these authors point out that while the median time difference to pregnancy between the two groups was approximately 3 months, there was an equivalent rate of multiple pregnancies and that, ultimately, by 1 year, the pregnancy rate in both groups was equal. The other interesting finding that the authors point out is that, in each of these studies, 14-32% of the pregnancies were "treatment independent", meaning the pregnancies occurred during a break cycle. 

The authors conclude that current evidence show that expectant management for 6 months, followed by IUI is still more cost-effective, but that the duration of treatment with IUI before proceeding to IVF and the additional value of ovarian stimulation to IUI are still unclear. There is an upcoming study that compares IUI to IVF eSET to modified natural IVF, which the authors are hopeful will further clarify this issue. 


The writing style of this article was definitely less compelling than the last article. To be honest, I found some of their arguments more confusing and harder to follow. But I think that might just be the point. Infertility is not a one-size-fits-all diagnosis and it is likely impossible that one, or even a handful, of studies can adequately capture each of the nuances that affect healthy conception and ultimately a healthy birth. There are too many different factors that cannot all possibly be controlled in a research lab, and if they were, would definitely not be generalizable to real-life.

The take-home point from this article that I gathered is that IUI can definitely be valuable to some couples, but trying this approach over and over will begin likely offset its value. Which is probably true with most other approaches/treatments if you think about it. So in other words, for many couples, it is definitely worth a try but not something to spend an excessive amount of time/money on.  

Sunday, December 22, 2013

Questions Without Answers

Day 14. I took a digital HPT to see the words clearly: "not pregnant". I also needed C to see the words, because he was a little dismissive of the early testing.

I feel angry with my body that it didn't pull through. I feel angry with myself that I let myself get too optimistic and hopeful, even cocky at times. Mostly, though, the feelings of anger are masking the more fundamental emotion of fear.

If five mature follicles, a "beautiful" lining, and correctly timed intercourse with normal sperm quality doesn't result in a pregnancy, are we missing something?

How was this possible? What went wrong?

How can we be worrying about the possibility of too many possible embryos and selective reduction in one week, only to find out that not a single egg was fertilized/implanted the next?

Aside from mature follicles, uterine lining, sperm quality, and timing; what other factors can we improve or control (without going on to IVF)?

I think it would have been easier if there was only one follicle. I could tell myself that the egg was just a dud. That happens to everyone. It's normal. But 5 dud eggs?!? I don't get it.

I think the biggest problem is that, in the effort of coping adequately with the impossibly hard time I've had to get my body to ovulate, I've convinced myself of something. I believed that our only problem was anovulation related to the PCOS.

Tubes were checked and cleared. I had a lot of little follicles, ready to mature. Sperm quality/count/motility was not an issue. Everything else appeared to be functioning optimally. The only issue was that my follicles would not grow and then ovulate. Or so I've told myself.

Once we solved this problem, that should be it. That should be our answer. Easy as that. With 5 possible mature eggs and no other issues, this should be a near guarantee. I ignored the stories I heard of others with PCOS that required IVF, that had been trying for 9 years without luck, that ended up adopting. This didn't apply to us, I convinced myself, we only have one small issue.

Now, these creeping thoughts keep finding its way into my conscious. What if it is more than that? What if this isn't going be as easy as fixing one thing? What if this isn't that simple.  What if missing something?

Saturday, December 21, 2013

Read this next CD11

Dear future Katie,

Do NOT test early. One day of dissapointment is plenty, why do you torture yourself?

Progesterone effects are the EXACT SAME as early pregnancy signs. It does not matter that your temperatures keep rising. DO NOT BE FOOLED! It is simply the Mirror of Erised (HP style), but in a pill form that you shove up your vagina daily. Just because some people can tell at 11 DPO or 12 DPO does not mean you will be that lucky. Why on earth would you assume you could be that lucky? Have you ever been lucky when it comes to fertility?

So I'll say it again - Put down the test! Walk out of the bathroom! Wait just a few more days and then you can be justifiably dissapointed and move on.

Your Previous Tortured Self

Thursday, December 19, 2013

Two week crazy... a recap

As I near the end of these two weeks, I get more anxious and crazy. Like any test, the closer you get, the less sure of yourself you become.

My body is not helping matters.

Almost immediately after ovulating, I had very bad pains and bloating that felt like I was constipated and holding onto a full bladder all at once. For days. It would wake me up at night. I convinced myself that I had OHSS, and then the pain subsided.

This symptom was promptly replaced by several days of heartburn. I do not typically get heartburn/reflux symptoms, but this was constant for several days.

The heartburn got more bearable, and now comes and goes. When I don’t have heartburn, I will typically have some mild cramping.

My breasts may be slightly sore and swollen, or I’m just a huge psychosomatic. My nipples do seem to be more erect and sensitive.

Then, two days ago (9dpo), I had an orgasm which was followed the most severe cramping and pain that I may have ever felt. It lasted for about minutes and was severe enough to make me want to vomit.

I have been temping and they seem to be continuing to rise, especially over the past three days. I always question if I’m doing this correctly though.

I am not sleeping through the night. I’m sure this is in no way related to my anxiety over the above…

Some of these symptoms are definitely legitimate. Some may be entirely in my head. None of them do any good in differentiating symptoms caused by the Prometrium (200mg vaginally, 2x/day) versus early pregnancy symptoms. All of them are making me go insane.

All I know is that any envy I had of the two week wait before (when I wasn’t ovulating), I take it back. I am only hoping that, if I do have to go through this again, that I’ll be better at it next time. Please, tell me it gets easier!

Wednesday, December 18, 2013

Knock on Wood

I don't consider myself a superstitious person, but I am a strong believer in not jinxing something. I've been known to "knock on wood" when needed, which usually curbs my anxiety.

Today there was a book signing at my hospital by Michael Roizen, MD, one of the co-authors of the YOU series. I immediately thought of having him sign the book You: Having a Baby to give as gifts or for myself. I thought long and hard about how many books to purchase and ultimately decided not to get one for myself. Better not jinx it, right? I had him sign three copies; one for my friend who recently announced to me that she was pregnant and very nervous about it given a history of chemical pregnancies, and two for friends who are desperately trying to be.

He signed, "So-and-so, Katie hopes that you have a wonderful and healthy journey. (Me too). Michael Roizen."

It was fitting. And I may have told him a small white lie, that these friends recently announced a pregnancy, so he was not even aware of the infertility struggles.

Telling him that I was buying books for people that aren't pregnant yet seemed like I would come across as a nutcase. But secretly, my plan is to write a note for the two not-yet-pregnant friends about how I am sure that they will be soon and have it dated now. So when they finally are, I can give them the book and they'll know I held the faith all along. It doesn't jinx it if someone else does it for you, I've convinced myself.

So, no, I still do not own any pregnancy books. I do not have any baby items. Our future nursery is still in full use as an office and spare bedroom.

My therapist had said that this wasn't necessarily a good thing and that, instead, I should be preparing myself and my surroundings to carry a child. She convinced me to crochet a baby blanket, which I technically did. In reality, I made it extra big so it's not limited to babies, I've told myself that it's not my baby's blanket (maybe I'll gift it or give it to charity), and have gotten it 90% complete over a month ago but have yet to actually finish the damn thing.

Because if it's finished and doesn't have a recipient, then that would been a mess. Because I can't let the recipient be my future baby that doesn't yet exist. Because I don't want to jinx it.

Where do you stand on buying/making baby items ahead of pregnancy: emotional preparation or a big jinx?

Monday, December 16, 2013

Scholarly Series No. 2: IUI - An Ineffective Treatment

In continuation of my nerdy pursuit of professional articles addressing topics related to infertility, I will be running a small section on the current debate over the whether or not IUI is worthwhile. This spawned from C and I needed to make a decision between Time Intercourse or IUI and me happening on the article I reviewed in my initial Scholarly Series post. In this book, two back-back-back chapters discuss each side of the argument and will be topics for my next two posts in this series.  

Johnstone, E.B. & Dorias, J. (2013). Intrauterine Insemination: An Ineffective Treatment. Biennial Review of Infertility: Volume 3. Eds Schlegal et. al., 173-183


These authors take a very pointed stance by clearly stating at the end of the first page that "IUI should no longer be a standard part of infertility treatment" based on several compelling arguments. The article begins by explaining how IUI performed and a little bit about its history (first published article on this was in 1962!) and the rationale for treatment, but then quickly veers into the arguments against its continued use. 

The first argument is that IUI is not significantly more effective than timed intercourse and/or controlled ovarian hyperstimulation (i.e. use of Clomid, Letrozole, Gonadotropins, etc.) and much less effective than IVF. They cited numerous studies, including many meta-analysis studies that analyze aggregated data from all previously published studies, finding that IUI was not more effective than these other approaches in both unexplained infertility and male factor infertility. Compared with IVF, IUI is becoming less beneficial over time as IVF success rates are continuing to increase but IUI success rates have remained stagnant. 

The second argument was made regarding cost effectiveness. They discussed two studies that compared the costs of "expectant management" (e.g. using OPKs, CM checks, etc.), Clomid, and IUI and found that the costs of IUI were significantly greater than the other two treatment options but without a significant increase in chance of live births. One really interesting study they discussed (which I may have to review separately at a later date), called that FASTT trial, compared unexplained infertility couples randomized to either three cycles of CC/IUI followed by three cycles of FSH/IUI followed by IVF (as necessary) to an accelerated track of three cycles of CC/IUI followed by IVF. The study found that not only were pregnancy rates increased with the "accelerated track" but there was also a cost savings of $2624 on average! They discussed several other studies that have concluded that cost-effectiveness data favors immediate IVF over IUI. 

The third argument proposed by the authors is that IUI is much riskier than other procedures and has more adverse events (e.g. discomfort of the patient and potential risk for infection). Infections were found in 1.83/1,000 women undergoing IUI. The biggest "adverse event" discussed was the risk for multiples. While most of the blame for multiples falls on ovarian stimulation (either oral or injectable meds), the issue with IUI over IVF is that you have much less control over how many eggs are mature, fertilized, and implanted. Multifetal gestations carry increased risk of numerous complications for both the mother (e.g. anemia, diabetes, preecplampsia, etc.) and the children (e.g. prematurity, cerebral palsy, visual and hearing deficits, learning difficulties, etc.). These risks are often minimized with IVF, especially with a single embryo transfer.


This was clearly an argumentative style paper. I was surprised by how strongly worded the article was but I am also surprised that this was one of my first times coming across any negative thoughts or opinions on IUI. With both REs that I've consulted with with others that I have talked to, it seems like it is still the standard protocol to go through IUIs before moving on to IVF, especially in those "milder" cases. The idea that this was even up for debate in the medical community was a complete surprise to me. This makes me wonder if either A) the general medical community is slow to change their thinking with new scientific advances or B) these authors are a little extremist and making the mistake of throwing the baby out with the bathwater.

I do have to say that the arguments were very compelling. I would definitely recommend people read the whole article if you're trying to make related decisions. What I took away from it is that, for many couples, IUI does not add much and puts additional cost and time in the fertility journey so that it can be advantageous to just jump straight to IVF. For some couples, taking the gamble of trying IUIs first will pay off and you won't need to move to IVF, but this does't seem to be a statistical norm. I'm sure that there are some psychology studies related to the gambling mentality with all of this.

I purposely did not read the next chapter, the counter-argument that IUI is an affordable and effective treatment, but now I can't wait to see what the others are saying. Until then, I leave you in suspense.

Saturday, December 14, 2013

Two Week Bore

I've noticed that I really haven't had a lot to say lately. There haven't been any new revelations, exciting thoughts, great introspections. Life is mostly boring and it feels like things are in limbo. Is this how the two-week-wait is supposed to feel?

Work has been moving along grudgingly. I find that I am (mostly) able to concentrate fully on my patients when they're actually sitting in my office, giving people my full and undivided attention. This is only what they deserve. My biggest problem has been with the documentation/billing afterwords. It's always been the least liked aspect of my job and I notice that whenever I am preoccupied or otherwise consumed with my own emotions, this is the first thing to go. Oh how I hate the paperwork. I set a goal for myself to get all of 2013 documentation complete before the end of the year, so that I can start the new year fresh. Somehow, just stating this as a goal has not actually made it happen. Dammit.

The pain that I was feeling in my lower pelvic region continued to get worse through Thursday, at which point I was absolutely convinced it was due to Ovarian Hyper-stimulation Syndrome (OHSS) and planning to call the doctor the next day. It woke me up out of sleep for three days in a row! Then, of course, on Friday it got substantially better and today it is hardly noticeable. Better enough that I decided not to call the doctor. Everything I've read about OHSS says that it will continue to get worse until you have a period, or into the first trimester if you're pregnant, and now that I seem to have improved, I'm left wondering WTF?!?!

Christmas is beginning to stress me out, but not for the obvious infertility reasons. There are still several people that I have not gotten gifts for. What's worse, I have no idea what to get these people. It's like I've been so wrapped up in myself lately that I stopped thinking about what others would like. C told me to give myself more credit, because I have bought 7 of the 9 niece/nephew gifts and do have ideas for the other two. Kid gifts are so much easier than grown-up gifts.

I have also made a conscious effort to stop worrying about my weight and getting in the best shape of my life. No, I am not going crazy with brownies and a side of streusel for dinner. I'm just eating what I want, when I am hungry. This decision came shortly after beginning the Follistim and realizing that I am fighting a losing battle, at least while I'm injecting and ingesting medications that are known for bloat and weight gain. And the stress of worrying over this can't be any better then the weight itself when if comes to fertility and overall health. Much to my amazement, this past Thursday, I stepped on the scale that I had been successfully avoiding for the past two weeks (mostly to prove to prove to myself that I had OHSS and was gaining a ton of weight from bloat) and found that I was actually a pound less than when I last weighed myself. Go figure.

C and I are dog sitting his sister's pets this weekend. We bought a new futon mattress for the comfort of our bottoms. And there is a huge snow storm that is absolutely beautiful if you don't have to travel. That's really as exciting as our life is right now. Oh, yeah, and I may be implanting some embryos as we speak, but I won't be able to figure that our for at least another week.

Marv enjoying the snow storm. 

Wednesday, December 11, 2013


Sure enough, I ovulated one time in the past two years and I've turned into that girl. You know, the one who notices every twinge and analyzes it with a fine toothed comb. The one who fantasizes about how to announce the pregnancy and daydreams about baby names on the way home from work. And it's only been three days! I'm in big trouble.

We ended up choosing the Timed Intercourse route, almost at the last minute, based on several factors. Primarily, the research of IUI wasn't particularly compelling and the RE didn't make a strong case for it one way of the other. It was also a financial decision, but whenever I remind myself of how much of this is decided by money I get angry.

The major benefit of IUI would have been the precision that we weren't necessarily guaranteed when you take the do-it-yourself approach. Especially when C's finals week is now, his dad is still hospitalized, and we are living with my parents...oh yeah, and my younger sister decided that this was the perfect weekend to bring over her new boyfriend for us all to meet all weekend! Someday, this will make a great story. ...Son/daughter, your father and I paid money to get your aunt Em and weird new boyfriend out of the house so that we could make you...and your grandmother ended up finding out and helping us coordinate the whole shebang...

It wasn't perfect. We're not machines, after all. But I do think it was good enough from everything I know about how long sperm can live and timing of ovulation based trigger shot timing. And C and I agreed that this was the best part of baby-making so far ;), especially since up to this point our primary moments of intimacy revolved around needles and vaginal u/s wands, so I am glad that we were able to keep that part of things natural.

I started the progesterone suppositories today, but this is not eventful. My only other update is that I legitimately have had a lot of pressure/mild cramping in my lower pelvic area. Sometimes it's concentrated on the right side (where my biggest follicles were) but often it's on both sides or more central. Usually it is relatively dull but last night it did wake me up and I had a hard time getting comfortable and falling back to sleep. Not quite sure what this is about. Too early for implantation cramping? A symptom of Ovarian Hyper-stimulation Syndrome? Is this what it feels for the eggs to travel down the fallopian tubes? Am I just a hypochondriac?

Monday, December 9, 2013

Scholarly Series No.1: Timed Intercourse vs IUI in PCOS Patients

Over the past several infertility decisions we've have to make recently, my nerdy side has kicked in full-force and I have found myself turning to primary-source research articles. It's been very helpful to read the same scholarly journals that the professionals are reading and, given my background in research and statistics, I can actually understand most of it.

Because nerdism should be shared, I've decided to start a new series of posts, hereby known as the Scholarly Series, in which I will discuss an original journal articles. I will try to choose recent papers, likely ones that are relevant to my current situation or ones that I just find interesting. I may include some of the classics as well. In preparation for this, I've actually found several papers that I can't wait to share with people! So without further delay, here is the inaugural Scholarly Series:

Wisner, A., Shalom-Paz, E., Reinblatt, S.L., Holzer, H., and Tulandi, T. (2012). Controlled Ovarian Hyperstimulation in Women With Polycystic Ovarian Syndrome With or Without Intrauterine InseminationGynecological Endocrinology, 28 (7), 502 - 504.


This study evaluated the value of IUI among couples with PCOS and a normal semen analysis. It was a retrospective design, utilizing medical records review. The authors evaluated records of 156 women with PCOS treated with either Clomid, Letrozole, or gonadotropins in 2009 and 2010 and only looked at cycles that resulted in actual ovulation.  Women were given oral medications for three months and then moved on to injectables if not conceiving after this time. IUI was decided based on the physicians preference and was performed 36 hours after the HCG injection. If the couples used Time Intercourse (TIC) instead, they were instructed to perform TIC on the day of the HCG shot and then the following two days. The primary outcome was pregnancy, defines as having a gestation sac and fetal heart activity.

Of the total participants, 86 patients underwent a total of 145 cycles of IUI and the other 70 patients underwent 114 cycles of timed intercourse. Each couple was included in only group. The two groups were relatively similar in regards to the woman's age, BMI, number of dominant follicles, endometrial thickness, and semen concentration/motility/morphology. The results found that there were no significant differences between the Timed Intercourse group (17.5%) and the IUI group (16.6%) overall. In fact, the only variable that appeared to make a difference in pregnancy rates were whether patients used gonadotropins (38.8% for TIC couples and 25.7% for IUI couples) versus oral medications (14.1% for TIC couples and 7.5% for IUI couples). The authors concluded that IUI does not increase pregnancy rates compared with timed intercourse for this population (i.e. normal SA and PCOS).


The study utiized a retrospective design, which isn't as strong as a prospective, randomized control trial because you are unable to control any of the variables or randomly assign participants, which could indicate that there is selection bias in the sample. Also, the study was based out of only site in Quebec, so it's not necessarily generalizable to other locations or populations. It also rubbed me the wrong way that the decision of IUI vs TIC was based on physician preference and did not mention patient preference, but I supposed you also have to consider the audience.

Despite this, the sample size was large and the results were very interesting to me. I previously assumed that IUI automatically added to your chances of success, but then with this article and a few others I came across, I realized that this is not always the case. In fact, one of the current hot topics in reproductive endocrinology is whether IUIs are a valuable tool at all. Based on this research and some others, C and I decided to forgo IUI for this cycle and instead go the Timed Intercourse route. The decision was made easier by the fact that we're still pretty early in the game, as I know it will become much more complicated when/if the decision shifts to trying IUI vs jumping straight to IVF. But alas, that will be the topic for the next Scholarly Series post.

Sunday, December 8, 2013

Some Thoughts on Selective Reduction

"What are you thoughts on selective reduction?" our nurse asked during the final ultrasound on Friday. My initial thought was: thanks a lot, Ms. Debbie Downer, for putting a huge negative slant on one of our first potentially positive monitoring appointments. 

The good and bad news is that, in the two days since my last ultrasound, I have 5 follicles that measure at least 14mm. By the time I take the Ovidrel and actually ovulate, this could possibly result in as many mature eggs. Given that I am still relatively young in the land of fertility, and we have no other known factors, the likelihood of multiple embryos implanting is quite possible.

This is a touchy subject. It can raise a lot of potential moral, ethical, and religious issues. Please know that these are my beliefs and opinions and are not meant to offend anyone and are not meant to start a debate.

I was very glad that C was with me for this appointment and he was able to express his opinions and ask questions I didn't think of. I was also very glad that we had previously discussed this possibility, as the message of having too many follicles was beat down our throats since we began monitoring with the past RE. I am glad that we were generally on the same page.

These are my thoughts: I do not want multiples. I do not want to jeopardize the health and safety of myself and my future child(ren) by risking carrying too many at one time. I do not want the risk and I do not want to subject my body to that. I am also pretty terrified of the idea of raising multiples, as if one isn't going to rock our world enough. This last argument is pretty weak and I'm sure it would be good in its own way, but it's still a terrifying prospect.

From a moral standpoint, I believe that the dichotomous view of life vs death/non-living is limiting. I believe that there is more than just being alive versus not-alive and that having a beating heart doesn't mean full life, either in the womb or on life support at the end of life. I believe that there are actually multiple levels of living and that, at some point, the the rights and health of the mother takes priority over an embryo. As never having had to suffer through a miscarriage, I know that this is my current bias.

The nurse did explain some aspects that were unfortunate surprises. First, from a practical standpoint,  she said that not many centers will readily perform selective reduction procedures and that she knows of only two main facilities in all of US that they trust, the closest being about 2.5 hours away and in the next state.

Secondly, and more importantly, C asked about the timing and when the procedure would occur. She said that they would only recommend this after determining that the embryos were viable, meaning at least 6-8 weeks, after heartbeats were heard. I have to admit that when C and I had discussed this before, we did it thinking about removing a few cells, not actually stopping a beating heart. This fact definitely caused us pause, but ultimately did not change our opinions. I told C later that, if it came to this, I will insist that I do not hear the heartbeats until we are sure that they will all be given a fair shot of developing. Maybe this is unfairly distancing myself to make our decision easier, but it will help me to emotionally cope with this challenging situation.

The nurse was not able to tell us at what point this would be recommended or two what extent (e.g. 3 to 1, 4 to 2, 3 to 2, etc.) and said the the Dr. would discuss this with us in more detail if/when necessary.

They did give us the go ahead. We are moving forward. This is probably the most excited I've been since we began this process. This is literally our first opportunity to experience the "two week wait," to pee on a stick with actual hope. Yet I can't help but feeling a gray cloud leering overhead, far above our happiness, ready to rain on our parade.

Friday, December 6, 2013

A Good Day

I'm not feeling very inspired from a writing perspective, but I should share that today was good.

First,  we had a monitoring appointment this morning and were told that I actually responded to the medication and that we were a go! (more on this later)

Then, C's dad had surgery to remove a tumor near his kidney. His mom was a wreck and everyone was very nervous that this was the tip of the iceberg. The surgery went very well, without complications, and there were no additional tumors to be found! They are still running a biopsy on the tumor but the Dr was optimistic about this.

Finally, I get home to relax and read some blogs to find out that I've been given a shout-out on Stirrup-Queen's 471st Blog Roundup! Silly, I know, but it felt vaguely like in middle-school when the pretty, smart, popular girl compliments your trapper-keeper. I started this blog as a way to journal my feelings and maybe develop some connections with others in similar situations but what I've gotten out of this after a few short months has far exceeded my expectations. Thank you all.

Wednesday, December 4, 2013

Out Of The Closet

My boss just passed by my office, popped his head in, and asked if I was "feeling strong". Sometimes he can be so vague and hard to read, but I think he may have been asking if I was doing well emotionally, handling the infertility stuff OK. See, I finally broke down and told him last week.

I've spent a lot of time writing about how open I should be with people and much more time thinking about it. Over the past several weeks, the positive aspects of keeping silent began to be overshadowed by the complications. First there were the awkward conversations. Then there was me being less reliable than my usual-worker-bee-self. Finally, with the advent of injectable medications, was the need to change around my work schedule to accommodate the vastly increased medical appointments.

My concerns were many. I didn't want people to look at be different or pitty me. I didn't want to seem broken or damaged or somehow less capable as a psychologist because I'm going through a personal issue. I am not invincible, despite how much I try to convince myself of this. I didn't want awkward conversations and inappropriate questions. I surely didn't want advice. Once you get past all this fortune telling, the pragmatic issue of "how" and "when" were also concerns. This isn't usually something that just comes up in conversation. When people ask how I'm doing, my initial response is the obligatory "good, and you?" rather than seizing that moment to explain how I really am. I still remember in my Russian class in high school, the teacher told us that in Russia, when people ask how you are, they are not just doing it as a form of greeting but are truly interested in the response. But we're not in Russia.

First I told two co-workers. It happened during a day that I was trying to figure out how to rearrange my patients to fit in an appointment of my own. They asked how I was doing, really asked, and I told them I was exasperated. Then I told them why. I talked about it in a matter-of-fact, scheduling issue, sort of way. They asked about which doctor I was seeing and this lead to insurance coverage. Then they both said they hoped for the best and we changed the subject. Very nonchalant.

Then I told a different co-worker and one of my mentors at work. This happened on the day of a very stressful patient issue. I was emotional anyways because of the medicine and then this catalyst resulted in a complete emotional breakdown, the kind that hurts your chest and makes it hard to breathe. My co-worker "caught" me in the middle of this and I explained that my emotions were probably heightened because of the medicine but also that something very upsetting was happening. She gave me a lot of guidance and support on the work situation and then she asked about the medicine. Her first response was, "But you're so young!" to which I replied, "Yeah, but my body still doesn't work." After that, she asked about what medications I was on and who I was seeing for care and if I was happy with him*. She was pretty knowledgeable about different medications and the process overall, which was nice. I think this conversation ended by returning to talk about the patient issue again.

So that leads up to the boss. Personally, I love him as a boss but it's sometimes difficult to imagine him as a fellow psychologist. He's very abrupt and goal-oriented and not-warm-and-fuzzy. The first two years I worked here I was downright terrified of him, but less so now. We just don't have many heart-to-hearts. I knew that I would have to have some type of "excuse" to bring it up, and needing to change around my schedule provided just that. Now the silly thing is that I've changed my schedule around for other reasons on numerous occasions and have never gotten his permission. He's basically said not to waste his time with these types of things as long as I continue to have the same level of productivity. But this was the best excuse I could come up with so it took it. He called me into his office to give me support for the patient issue that he heard about from my other colleagues and I told him there was something else I wanted to talk to him about. I fumbled with my words. It was awkward. In the end I said something to the effect that due to increasing infertility treatments and appointments I will need to change around my schedule and maybe cancel an occasionally patient, but I will try to have make a minimal impact on work and patient care.

He responded, "No worries. Take care of yourself. That's the first priority. If you're not healthy then you're no good to the patients anyway."

On the one hand, this was his way of being supportive. I don't have to worry about infertility impacting my job anymore. Despite this, I left his office wondering if he actually heard the word infertility or if he thought I was getting treatment for some other, life-threatening disease. It was definitely an odd response in my opinion, but probably what I should have expected from him. At least now it's over. I'm outed and it feels good. At this point, there is no one else that I feel a burning need to open up to, no one that I feel like I'm hiding anything from. I haven't shouted it from the rooftops (or more realistically, FaceBook) but that's not my thing. Then again, I feel more confident that the next time someone genuinely asks how I am, how life is going, that I will be able to answer honestly.

Coming Out of Your Closet: Ash Beckman at TEDxBoulder

*I think this is a common question because I work at a hospital so everyone assumes they know everyone. 

Tuesday, December 3, 2013

Fertility Status Updates

Apparently 'tis the season to announce your pregnancy...

1. An old friend from graduate school and sister-in-law to my also infertile friend, we'll call her E. This one is much harder for E of course, because the friend/SIL already has a 18 month old and tried for a month or two. In fairness to friend/SIL, she does have PCOS and did take a little longer with the first one, requiring a few rounds of Clomid, so anticipated that the second might be as arduous.

2. My friend from graduate school, who happens to be 42, got pregnant within a few months of moving to the same state as her boyfriend.

3. An old colleague, aged 35, who got married 14 months ago.

4. C's high-school friend/brother-in-law to his sister, due in April, less than 20 months after their first child was born, which was less than a year after they got married. I remember feeling mildly irritated with their first pregnancy and now here comes number two.

All within the past two weeks. This doesn't the count the peripheral FaceBook announcements of people I hardly know or care about. Happy Holidays to you!

I'm not at all bitter.

My updates are much less exciting. So far I've have three ultrasounds, and my Follistim has been upped from 50iu to 75iu to 150iu. Still no eggs bigger than 10mm. On the bright side, my lining was described as "beautiful": 7mm and Trilaminar. I go back tomorrow morning for another monitoring appointment and then will likely need to pick up a third vial of the medication.

As suspected, the fantastic price of the first vial ($0!) was just a fluke. When I went to pick up the refill, I was charged $65, which is still fantastic that my insurance was willing cover a majority of it, but I have a feeling this will begin adding up quickly. I'm trying to stay grateful that my insurance is covering as much as it is (at least until the end of the year) and that I got a bonus round of medications free.

Getting the shots has gotten a little easier as we've developed a routine. I've figured out that it is better if C is talking to me, preferably telling me a good story about his day, and doesn't announce when he's about to insert the needle. So far, the major side effects have been a little hard to determine. I am definitely getting more migraines, which really sucks, but I also got these with the Femera. I did have some IBS-type symptoms over the weekend, which is something I haven't had is a very long time. I've also felt bloated and constipated. These last two, though, I'm not ready to fully blame on the medication considering I've also had two full Thanksgiving dinners/desserts and leftovers around the time I was beginning the medication. As I've gotten back to eating healthier, the case for the medication side effects is definitely growing stronger.

Sunday, December 1, 2013

Thankful for Family

We had two Thanksgivings this year: one with my family on Thursday and then one with C's family on Saturday. Whenever you have over 18 people in a house, for multiple hours, all trying to cook and eat, and with a lot of pre-determined expectations about what the holidays should entail; there is bound to be some emotional drama. To be honest, I expected more drama from my family's side but that's not how it went down.

On Thursday, everyone came over to my parents' house. My one sister boycotted because she's still in her teenage rebellious phase, despite the fact that she is 23, but we knew about this ahead of time. She called later and we had a nice talk. We still had my other sister and her husband, uncles, cousins, and some family friends. "The more the merrier" is definitely a value my family holds dear around the holidays or any other celebration. The sister who came is the one whom I'm not really talking with. We were pleasant with each other, but definitely more distant than we would have been if not for the incident. At one point, we talked for about twenty minutes about the stress happening in her life and then she eventually changed the subject to a TV show without asking about how things were going with me. This was expected. She was very dramatic throughout the evening about how rough her life is going. This was also expected. 

Otherwise, the evening was nice and relaxing. I have no nieces or nephews from this side of the family, my cousins are all single, and most of the conversation focused on my uncle getting remarried rather than family building in the child-sense. There was no pressure and no awkwardness. Marv (our dog) probably enjoyed himself the most and had to sleep most of the next day to recover from the excitement. 

Saturday was different. All three of C's sisters were there, with husbands and a total of 9 nieces and nephews in tow, plus two aunts and his parents. It was also a very full house but with a much different tone. C's dad is in the middle of testing for some medical issues he's been having, and there is talk of cancer. I'm sure this made all the emotions run higher and know that his mom was definitely different than normal and had cried earlier in the day. His oldest sister was also in rare form and, at one point, threatened to leave and drive the 3 hours back to her home after getting in a dumb argument with C. Later in the evening, she gave us all the silent treatment because of something else that C had said. Personally, I think he was sort of pushing her buttons but her reaction was completely disproportionate. The other sisters were taking bets about why she was more difficult and emotional than normal, and pregnancy was top of the list. This made my heart skip a beat. I also couldn't help but get a lump in my throat when (emotional) sister told us of her plans for the parents for Christmas: a family tree with the parents in the trunk, the four children in each of the branches with their spouses, and then all the grandkids as leaves with thumb-prints. I wondered if our branch would really look as sad and barren as it did my imagination and if there would be space for us to add our thumbs prints later or if this was her idea of the family being complete. 

It wasn't all bad. In fact, I laughed and probably had more fun overall. I am very close with his one sister but she lives 4 hours away so we don't see each other as much as we'd like. We had some great talks, she and her husband were super supportive of our difficulties and said all the right things, and we did a lot of bonding via making fun of the other sister (discreetly of course). 

This is family. When we have children, I want it to be like this. I want my children to have the same family values that C and I both grew up with. In good and in bad, despite the drama, your family is there. They love each other. There will be fights and there will be different personalities and opinions. There will also be laughter and support and a common bond that no one else could understand. For this, I am thankful.