Thursday, February 27, 2014

One vs Two: The Great Embryo Debate

I wanted to devote a separate post to our decision on how many embryos to implant. This was a difficult decision that was only further complicated by my stay in the hospital and physical turmoil my body's already been subjected to.
The guidelines indicate for someone my age without any prior history of failed cycles, that 1 or 2 embryos be implanted. The recent push has been for implanting one embryo, especially if it is a high quality blastocyst (i.e. Day 5 transfer). In general, the odds of successful pregnancy increase from 50 to 60% with a second blastocyst, but the odds of twins increases from essentially nothing to 30-40%. Twins can be born healthy and without complications, but the risk for both maternal and infant complications is much higher than with a singleton pregnancy.
Personally, the idea of twins terrifies me. I am well aware of how big of a deal, how dramatic a life change, one baby causes. The idea of doubling this is very overwhelming to me. Not that it wouldn’t be possible. It’s just overwhelming. Carrying two babies to term. Breastfeeding two babies. Two different sleep schedules. Two toddlers toilet training. Yikes!
C is actually a big fan of having twins. He says that it would be "cool" to have two, and then points out the more practical reasoning of being assured that our child will automatically have a sibling without necessarily going through this again. He said that it didn't want to see me go through this again and with two there might be less pressure for this. He acknowledged the huge undertaking that twins would entail but said he was confident that we are both on the same page with a lot of things and have a lot of support from both of our parents. His other reasons were primarily financial. 
For me, the bigger factor was related to money and success rates. We are spending a majority of our down payment on this one cycle. For even a 10% improvement in odds, that’s nothing to balk at in the world of infertility. That’s almost the average success of any given Clomid cycle, depending on which statistics you look at.
It angers me to think about all the ways that money has influenced my infertility journey and how different decisions I may have made with insurance coverage. We probably would have a waited a few months before going straight to IVF, trying less intense options first. I would have been more inclined to opt for a single embryo transfer. I wouldn't have been as stressed every time they asked to come back for another monitoring appointment or required us to purchase two different types of triggers, "just in case."
I wish that I could say that I had better, more profound, reasons for choosing to implant two embryos. I wish that it was more meaningful than “maximizing my investment” and the vote of my husband, although his vote was clearly important. I wish that infertility treatment was not considered a luxury and was not an industry driven by money. I wish that we have one, or two, healthy babies when this is all said and done.

Wednesday, February 26, 2014

Embryo Transfer: Boring In A Good Way

When I give feedback to families and talk about behavioral observations or emotional scales that are rated as either clinical or average, I’ll often get to report that these findings were “boring, in a good way.” There was no suicidal thoughts, no psychosis, no significant behavioral abnormalities. They had good social skills, a positive affect, and were cooperative. In short, my observations are mundane, but this isn’t always a bad thing.
And frankly, after my crazy retrieval debacle, that was my hope.
C and I went for pancakes and I began drinking water like it was my mission before the procedure. I was nervous about having my bladder be too full that it caused pain, which has been the norm lately, or not full enough, but they told me it was “beautiful” so no worries there. Some of the ladies had heard about my trip into the ED and then inpatient unit and asked me about it. Once of the nurses seemed to minimize my experience, saying that “everyone gets a little discomfort,” which pissed me off. They all seemed to be impressed with the number of puncture holes and bruises I had in both my hands and arms and took extra good care in drawing my blood for my estrogen and progesterone levels.
The actual procedure was only slightly more uncomfortable then a pap test. The worst part was in the beginning when they insert the scapula and “clean” me. I always thought this was weird; why does it have to be cleaned? I didn’t actually feel the catheter at all.
C was able to put on scrubs on and attend, which he wasn’t expecting. It was nice for him to be a part of it. They had a large TV monitor on the wall where they showed us the embryos in the petri dish and then watched them being sucked up into the catheter. They were huge (on the screen) and looked exactly like what you see online or in textbooks. We then watched the tiny catheter on the u/s monitor screen until there was a small white dot, which they told us was a small air bubble to indicate where the embryos had been placed. They checked to make sure that both embryos were out of the tube and then removed the speculum and congratulated us. The doctor performing the procedure was cute, earlier in career, and got really excited for us when they were in. They gave us these pictures of the growing embryos and also the petri dish that the embryos were living for the past 5 days as keepsakes. Baby’s first cradle. I was wheeled back into the recovery room and went to use the restroom after about five minutes. We both changed back into our street clothes and bid the nurses goodbye.
We intended to go see a movie afterwards, which was C’s awesome idea. He is sometimes so thoughtful that I wonder how I got so lucky. Unfortunately the show time listed on the website was not consistent with the sign on the theater’s door saying that they didn’t open for another two hours, so we went home instead. I did a little more paperwork to prepare for today and then a little more relaxing. My sister started some drama that I got completely sucked into and upset about, but I won’t dwell on that, and then I went to bed.
Easy peasey. If anything, it was anti-climactic. I’m not complaining. This is exactly what I was going for – low excitement, calm, and collected. Now I may be implanting some embryo(s) as we speak. No big deal.
First Pictures

Monday, February 24, 2014

Recovery and Preparation

I decided to take off both Monday and Tuesday from work, even though my original plan was to only take off the day of the transfer and retrieval. Well, that got screwed up as soon as the ambulance was called. Sitting in the hospital bed, I decided it would be silly for me to return on Monday only to be gone again on Tuesday and I would like need the extra day for ongoing recovery. And that has been what I've been up to.

Yesterday was all about regulating my GI system again, which sounds a little ridiculous but it was a full day process that involved a lot of crampyness and discomfort. That's what happens when you take lots of narcotics and don't eat for two days, I suppose. I also decided to document my "war wounds". Given that my bleeding was all internal, I don't have much to show for that pain, but I do have some lovely puncture wounds.

(I briefly contemplated having people scroll down like you do for u/s or baby pics, because this might turn people off, but in a totally different way of course!)

My left hand/wrist with four different IV punctures that are beginning to bruise 
My right inner elbow, which was the primary location for taking blood the past week as my other veins are all more difficult to locate (see above). By the end, they weren't able to use this location either because the vein had too much scar tissue. 
I do want to mention again that the internal bleeding is one of the rare complications that happens to an estimated 1 of 800 IVF retrieval procedures. If you're about to go through this, rest easy knowing that I took one for the team and you should be complication free. :)

Today was all about preparation for tomorrow and returning to work. I actually started to be more mobile and accomplish a few things. And by few, I mean that I did two loads of laundry and logged into my work account to do paperwork for about an hour. Mostly, I continued to prepare for tomorrow, which means being well rested and as fully recovered as possible, so I spent a lot of time relaxing. I had some help of course...

Marv is the best at relaxing. Pay no attention to the socks that were placed on his paws. I'm bored.
Hamlet, formerly my parents car, has officially adopted us and is also great at helping me relax. He's got a really deep purr and enjoys claiming any article of clothing within seconds of it being placed on the bed, in this case a belt. 
I am still getting random cramps and a pinching sensation in my lower abdomen and it still feels like I lost all the strength in my abdominal muscles overnight, but otherwise I am feeling pretty good. I am trying not to be nervous that these pains and irritability will make my body less cozy and hospitable for some embryo(s) to implant. This and the fear that tomorrow will send my body back into attack mode and bring on the spasming pain are my only real worries right now. The rest I'm letting go, keeping my zen state. 

I actually picked up the phone this morning when the lab called with my update. Up until this point I had purposefully let it roll to voicemail as the phone sat right next to me. 1) I hate talking on the phone and it gives me anxiety. 2) I was nervous that I was too drugged to remember what they told me and that I would have no record. 3) I thought I might want to listen to the  message over and over for comfort. 4) I was nervous that I'd begin asking too many questions about exactly how many cells and the rates of the division and the grades and then give myself more anxiety. I wanted to be ok with whatever information they chose as important for me to know. 

Today I was wide awake and sitting next to C. Today I had faith in myself not to ask too many questions and knew that I wouldn't have a need to listen to message again because I never really did that. Plus, I wanted to make sure that I completely understood the instructions for tomorrow. So I answered the phone without any expectation. 

I have 9 embryos that are growing exactly on track and two more that are straggling a little behind but they're hopeful might catch up. There are two additional embryos, putting us at the 13 number I was given yesterday, that are very far behind and they are doubtful will catch up. So the number is between 9 and 13, but more likely between 9 and 11. I very happy with this, despite the fact that I generally hate odd numbers. 

Tomorrow is the day that I fill my bladder, get another blood draw, and then remain calm during another medical procedure. Tomorrow is the day I become pregnant unless proven otherwise. 

Sunday, February 23, 2014

Updates on Embryos, Health, and Family

What a boring title. Oh well. This is what you get when attempting to wean off narcotics and return to a normal diet.

My embryos are doing well. The lab has called me daily and reported that initially all fifteen embryos were growing and dividing on track, but that today we are down to thirteen that are still growing. Surpassing my low expectations, this is still fantastic news. We are officially a go for Day 5 transfer, although they will contact me tomorrow with the specifics. I have purposefully had the lab leave messages and not asked any more questions about specifics, because there's nothing to be done about it at this point and any more information might just cause unneeded stress.

My big focus has been to regain my health before transferring back in the embryos. I'm trying to wean myself off the pain medications and return to a regular diet. The hardest past has been the constipation so I've made "have a bowel movement" my number one goal and accomplished that this morning! My abdomen is still very sore and somewhat crampy, sort of reminding me how I felt after my appendectomy. I still walk hunched over, but I am at least able to mobilize myself without assistance so that's a huge step forward.

The other excitement around here has had everything to with my sisters. Technically, it's about me as well, but I am refusing to get involved and let it affect me. I have bigger things to focus on now and sister drama is not in my plan of remaining calm and relaxed.

Remember how I explained that my one sister is also going through infertility and copes with it in a very different way than me, and often has managed to step on my toes while doing so? Well mostly since this post, I've just accepted this about her and kept my distance when I couldn't handle her, and focused on my own well-being. One of the biggest differences about our coping style is that she is much more open (AKA attention-seeking) than I am. Well, she decided that she needed to make a huge announcement about her infertility struggles on to let the world know what she was going through. Fine. To each is own and I know that other people have done this and found it helpful. I personally do not feel the need. I do not hide my struggles but I am also not one to openly announce them. While I did appreciate how this could make it awkward at times with people knowing about her but not about me (e.g. when our relatives comment to me about "poor AE" at family functions), I also appreciated that she should not let me impact what she needs to do to cope. She gave me some advance notice, which was nice. Otherwise, it's no big deal.

Until the big announcement came on the exact day of my oocyte retrieval procedure. Of all the 365 days in a year, this otherwise random Thursday was the day she felt the need to draw the world into her struggles. I noted to my other sister how it was impeccable timing, and likely reflects AE's lovely tendency to be self-absorbed, but otherwise I was in a lot of pain and on drugs and didn't let it bother me much beyond this.

Well the other sister, E, was not on drugs or in pain. She decided to voice her concerns to AE about how this was very un-empathetic and inappropriate timing. AE responded that E was insensitive to her infertility needs and that everyone only ever cares me. Yelling and crying ensued. The two are currently not speaking to each other and somehow the last few days have revolved around AE's hurt feelings. Personally, I'm a little amazed at how she manages to make it about her, every time, intentionally or not.

Mostly, I don't care. I'm remaining calm. I'm letting outside stressors bounce off my protective tranquility bubble and focusing only on my health and well-being. However, I am a little curious about where others might stand on this issue, as it does bring up some interesting controversies.

Have you or do you feel the need to make a public announcement about your fertility struggles? Do you think the timing of this should be influenced by what other's are going through or should it just be based on what works best for you? At what point does your own self-care infringe on others?

Saturday, February 22, 2014

Oocyte Retrieval: "In very rare cases..."

Thursday morning I woke up with plenty of time to get dressed and send out a quick email for work, but made sure not to leave too much time that I would want to eat something. Considering how full I felt from the follicles and large ovaries, I wasn't really hungry anyways. They took me and C pretty quickly into the back room where my medical history was reviewed. My mom is a nurse anesthetist and one of her good friends and former colleagues now works at the center where my procedure was and agreed to give my anesthesia. It was very nice to have a friendly face with me in the OR and the last thing I remember is talking about how her children are doing now, as I used to babysit them when I was in high school.

The next thing I remember is some voices and then eventually opened my eyes to look at the clock on the wall, almost exactly an hour from when I went into the OR. C was there and his calm presence was comforting. I can't remember who I heard from, but they pretty quickly informed me that 23 eggs were retrieved! I was floored, as the largest count I was ever given in the monitoring appointments was 20. They weren't able to tell me how many of these were mature so I just assumed that half of them won't be mature enough and not all of those will fertilize. I was am still focusing on having low expectations to hopefully curb the disappointment, which clearly had worked for me up to this point.

I felt really sore in my shoulders and abdomen, as if spent all time under anesthesia doing crunches and should raises. The shoulder pain was what surprised me, but the nurses told me that this was pretty normal and weren't concerned. They were a little concerned that I couldn't urinate. I tried at least three times before I was able to produce anything, each time sitting calmly and relaxing on the toilet and running the water in sink to hopefully stimulate things. Despite feeling totally relaxed, the urge to urinate was completely absent. They told me that my bladder was likely descended from all the fluids I was given and the longer I went without urinating the harder it would be. Finally I was able to produce enough to fill one of those urine cups (I estimated) and we all agreed that this was enough to let me leave. They went over all the discharge papers with C and they instructed us to call if there were any concerning signs, but that some pain and discomfort was to be expected.

C drove me home and put me into bed. The only way I could be comfortable was with all the pillows in the house propping me upright to a nearly fully sitting position, which was not so comfortable for sleeping. He had to run to campus for a few hours and I felt OK as long as I didn't move. My dad was home and he came to check on me in the afternoon. I couldn't get up without extreme pain shooting from my shoulders down through my pelvis. It felt like this whole part of body was having a Charlie Horse, or extreme muscle cramping, and then would then completely lock up so that I couldn't move. As long as I didn't move, I felt OK, but I still couldn't take full breaths without having pain near my diaphragm. My dad helped me to the bathroom again and then he had to go out to run some errands. I figured that I would just stay put and be fine. Discomfort was to be expected, although I was beginning to be concerned about how I was supposed to get to the work the next day. I remember jokingly asking my mom if she could steal some heavier narcotics from work because the medication they gave me wasn't doing anything.

C arrived home and I was doing OK in my upright position and taking slightly shallow breathes. Until around 6:30 in the evening when, completely out of the blue, my whole body cramped up and pain shot from my shoulder through my pelvis and wouldn't let up. I wasn't able to breath in regular breaths without excruciating pain and it felt like I wasn't getting enough air. Imagine the worst leg cramp you've felt, but in your chest and abdomen. My dad had just arrived home and they decided to call the ambulance because I couldn't move enough to get into a car. The paramedics were able to get me out from my bed with a combination of carrying and walking. In the ambulance they determined that my heart rate was normal but very elevated and that my oxygen was a little low so I got some O2.  They weren't able to get in an IV because of my tiny veins, dehydration, and the fact that I'd been stuck so many times this past week that most of the "good" veins had scar tissue.

Getting in an IV was also an issue once we got to the ER and it took over two hours for them to get me any pain medications. Luckily, the spasming had subsided and I was back to my normal amount of pain as long as I didn't move an inch. Unfortunately, this wasn't conducive for them to move from the gurney to the hospital bed, examine me, take a chest x-ray, or especially attempt to do an ultrasound. Each of these activities reactivated the spasms and the medications they were giving me were not even touching the pain. Within the first six hours of the ER and ultimately hospital stay, I had been given IV doses of Percocet, Oxycodone, Morphine, and Dilaudid and felt no effect from any of it.

Testing came back to indicate that I was having internal bleeding from my right ovary. The blood and fluids were causing increased pressure in my abdomen, which was causing the pain. Apparently there is some nerve that travels from your shoulder to your abdomen, which is how the shoulder got involved. Luckily, blood work came back relatively normal so they were hopeful that the bleeding would get reabsorbed on its own and would not need an additional surgery. I ended up being admitted at the main hospital (requiring another bumpy ambulance ride) for monitoring and pain management.

The pain management finally seemed to arrive around 9am the next morning, a full 15 hours after the most severe pain began. They explained that all the drugs needed time to catch up to severe pain, which is why the first several doses of their most serious stuff weren't doing anything. Eventually I did notice some relief with the Dilaudid and Morphine and they even sent me home with oral Dilaudid, which I've heard is some pretty serious stuff. By the late afternoon, my vitals and blood work had all stabilized without the need for any additional intervention or surgery, and I was cleared for discharge.

Two of the RE physicians came by, along with the RE Fellow and an OB resident, so I felt very well cared for once being admitted (the ER was another story and is a lovely testament to how little even medical professionals know about IVF). They explained to me that this is a complication from IVF seen in approximately 1 of 800 cases, and was further complicated by the fact that I have PCOS and large ovaries. They were all very confident that this shouldn't affect my transfer, which is something I probably asked at least six times to anyone I thought might know the answer.

The story, as far along as we are into it, does have a happy ending. While in the hospital, the lab called and left message. Of the 23 eggs retrieved, 13 were mature. They injected (ICSI) the thirteen mature eggs and then allowed the others to be inseminated. The grand total of eggs that were fertilized by the next day: 15!

I'm at home resting now. I called off work for both Monday and Tuesday to give myself more time to recover. I am still very sore and not walking normally, but generally feel much more human than before. Hopefully this is the most excitement I get until of the pregnancy test.

Friday, February 21, 2014

Temporary post - retrieval update

The retrieval went ok but then I ended up having severe pain and called an ambulance that evening. They ended up admitting me because of some internal bleeding. I'm stable, I think, but still in a lot of pain and inpatient now so I'll give more of an update later. My big fear now is that this will impact the transfer. Oy vey. 

Wednesday, February 19, 2014

IVF Monitoring Appointment #5: Cleared for Retrieval

My last monitoring appointment was yesterday. My estroidal only raised to 3500ish, which is great, but they still decided to go the Lupron trigger route. The follicles grew a little, but to be honest it wasn't a significantly noticeable difference. I now have 20 follicles between 10mm to 24mm. This sounds like a lot, but I know that some of them won't be mature and others might be "past-mature." I'm working on not having unrealistic expectations and setting myself up for disappointment.

I've taken the trigger shots. I've cancelled all my patients and cleared my schedule at work. I've showered and have my outfit picked out. I had a large dinner to prepare for being NPO after midnight. I've told everyone I wanted to tell that tomorrow is part one of the big day(s).

My very first therapy client as a graduate student was a young mother who had a little lower-then-average intelligence. She would have numerous worries related to her children's safety, especially when they were out of her sight at school or with their father, despite any evidence to suggest that there was any need to be concerned. She would get herself very worked up over this and had difficult focusing on other activities. We talked a lot of the purpose of anxiety, how it motivates us to take action. When we're anxious about a test, we study harder. When we're anxious about the snowy roads, we drive slower. But when there is nothing to do, when we have no control about a situation, the anxiety serves no purpose. It is wasted. This woman and I developed a mantra, "There is no point in worrying about something that you cannot control". Maybe it was that this woman was a little slower and needed a lot of repetition. Maybe it was because she was my very first client and therefore our appointments were much more salient. Whatever the reason, this mantra also became engrained in me.

There is no point in worrying about something I cannot control. This is where I am now. It's out of my hands.

Because we strive to maintain our immature sense of humor.

Monday, February 17, 2014

IVF Monitoring Appointment #4: Good and Bad News

The Good News:

On Stim Day #10, I have lots of follicles. Twenty measuring over 9mm to be exact, with another 18 or so that are smaller. The exact break down is as follows: 1@21mm; 1@19mm; 2@16mm; 4@15mm; 2@13mm; 3@12 mm; 3@10mm; 4@9mm. Everyone kept asking if I "felt full". That's one way of putting it. At least it felt validating for all the discomfort I've been feeling. I was actually beginning to understand how some women complain in their 8th month of pregnancy and say that they "just want this baby out of here already". Replace "baby" with "eggs" and that's how I feeling. Right up until I was told that I might have to trigger today if my bloodwork is too high. Then I began to get panicky. But we get there, there's more good news. 

Our nurse today was great and I love her. Ok, that's not really news, but it made my morning better. 

I got an email today from my administrator. Apparently my hormonal hissy-fit last week caught the attention of several people, and not entirely in a bad way. The higher-ups decided that they could understand how daily harassing (my words, not theirs) emails "devalues your hard work" (their words, not mine), and have a proposed a compromise of sending only one email per week of a summary of any outstanding notes on that day. What's more, they decided to make this a policy for my entire department so everyone else will be able to benefit as well. Honestly, I couldn't have asked for a better outcome. This was actually more exciting than my morning appointment, probably because of mixed news of this appointment. 

The Bad News:

My estroidal levels more than doubled again, from 1100ish to 3100ish in 48 hours. The big concern is that they would make me trigger early and we'd miss a majority of those smaller follicle that would never have an opportunity to mature. Luckily, the doctor on service today is known for pushing people and is allowing me to stim for one more day. The reality is that I am now almost guaranteed to have to trigger with Lupron. Which means that will certainly require the Progesterone in Oil, intra-muscular injections, along with extra estrogen support. I was really hoping to avoid the daily ass-shots. 

They hired a new phlebotomist and today was her first day. She was horrible! I have small veins to begin with, but I purposefully drank a large glass of water this morning to help waken my veins up. This was not helpful and despite two pokes and lots of prodding, she was still completely unable to find my vein. Plus, she left the computer screen open to the list of all the patients on today's schedule, a total HIPAA violation, and C was very upset about the increased infection risk she created by feeling my arm for the vein after she rubbed me with alcohol. Luckily, the very lovely nurse asked how our experience was with her, given that she's new, and we were both very honest. 

C just informed me that he bombed his nursing test and is in jeopardy of failing this class. If that happens, he will likely be kicked out of the program because it's just ridiculous. So, yeah, this is very stressful and a huge damper on an otherwise pretty good day. 

The Bottom Line:

You can't win them all. I go in for another monitoring appointment tomorrow morning. I will very likely be triggering tomorrow and scheduling my retrieval for Thursday. I am remaining calm and trusting in the professionals and trusting the universe, not getting bogged down in the numerous hypotheticals (with both my body and C's education). 

Sunday, February 16, 2014

IVF Monitoring Appointment #3: Good, I think

Saturday (Stim Day #8) was my third monitoring appointment. I now have 8 follicles over 10mm, with the largest at 17mm. My estroidal levels jumped from 400ish to 1191, making me feel a little silly for asking the nurse if they can be too low and that being problematic. They want to keep me at the same Follistim dose of 150iu, which is the same dose I've been at from the start. On the one hand, I think this means things are going well and they don't want to mess with it, but I am actually getting a little bored with this dose. I am also continuing the Ganirelix at F'ing 6am every morning.

It was interesting to have a monitoring appointment on a Saturday because there was whole different crew and atmosphere. The nurse today was great, and I'm little sad that she works at another location during the week. The ultrasound tech, yeah, she was very pregnant. I had to wait in the regular ultra-sound waiting room, meaning that there was also a pregnant woman waiting there with her daughter of less than a year old. My blood work had be drawn in the regular hospital lab, which is always crowded and full of sick people. None of these things bothered me, partly because I think I was too tired from the shitty sleep and lovely wake-up call of a needle in my abdomen.

I'm happy that my follicles are growing and are all relatively consistent. However, I'm confused about if I should be less than thrilled that there are only 8 follicles at this point. They only measure the ones over 10mm, so it's possible there could be more by retrieval day, but considering I've started off with ">20 under 10mm" of both sides, I was hoping for more. The nurse said they like at least three over 18mm, but preferably wait until there are at least 3-5 closer to 20mm. So knowing that we still have some time yet, is 8>10mm alright? I totally should have figured out how to word this question before she called me back. I will definitely have to ask at my next monitoring appointment tomorrow.

After the appointment, I had to make another short trip to the pharmacy and drop another $400 on more Follistim and Ganarelix, bringing my entire medicine total to a clean 2K. This trip was much less exciting than the first.

The other exciting thing is that, when C was flicking the pre-filled syringe of Ganirelix Saturday morning, he accidentally dropped it on the floor and bent the needle! Again, I was too tired to really get upset about this. Plus, he's almost done with his nursing schooling so I trusted him to figure out. And he did. He got an empty syringe that was supposed to be used to for something else, and squirted the medicine from the bent syringe into this, then used the new syringe to inject me. It may have been more technical than this, but I stayed in bed.

I've got another appointment Monday morning so the earliest retrieval date would be this upcoming Wednesday, but I'm betting it will be at least Thursday or Friday. Actually, this is my hope because Wednesday would be a tough day to miss work. We're also hoping it's not Saturday because C is not allowed to miss his nursing clinical days and that would really complicate things. It feels weird to admit the factors that we think about affecting our fertility timing, but I'm working on not making fertility all consuming. It's all part of my plan to remain calm and low key. And on the weekends, I'm pretty good at this.

Saturday, February 15, 2014

IVF Monitoring Appointment #2: Moving Right Along Despite Speed-bumps

On Thursday (Stim Day#6) I had my second monitoring appointment and then my third today (Stim Day #8). I'm still waiting on the call for all the results from the today's appointment, so I'll focus on the second appointment.

On Thursday, I had three follicles over 10mm and another four follicles that are not far behind between 8-9mm. My estroidal levels raised from 200ish to 400ish. They kept my Follistim dose the same at 150iu until I come back in two days. The big change was that I began the Ganirelix to prevent premature ovulation. I need to take it as the same time every morning, which kinda really sucks, because the latest time that C could give it to me was at 6am due to his nursing clinical schedule, meaning I now have to get by 6am every day from now on. Have I mentioned I'm not a morning person?

Physically, I am definitely starting to feel the effects of my body working overtime. I get minor pains in my ovaries and feel bloated. Yesterday I was convinced that I've gained 5 pounds so I weighed myself and I'm actually down a pound from when I started. This was surprising, but it's probably because I haven't had much of an appetite since Wednesday and I'm sure I'm eating less. I have not been sleeping as well as I usually do, likely due to discomfort, and this coupled with the many morning appointments and the fact that I'm limiting my caffeine intake, is leaving my chronically fatigued.

Work has been very challenging this week. I had taken on several more patients than I usually do so I was working late hours. My plan to counter-email all of the harassing billing emails seemed to start a ripple effect that resulted in one of the heads of the hospital getting involved and a meeting with my administrator. I was am having a very difficult figuring out how much of my emotional upset was due to the circumstances and how much was due to my hormones, but it amounts to feeling under-appreciated and overwhelmed.  In the end, I stood my ground. My administer was receptive to my feelings and assured me that she and my boss were very happy and appreciative of all the work I've been doing and not concerned with the billing issues; however these harassing emails come from higher-up as an official hospital policy and likely can't be changed.

Finally, C has been battling a nasty cold, hoping it's not the flu. We both got flu shots, but know that it doesn't protect you from all the possible variations. Because it is imperative that I don't get sick, he's been sleeping in the spare bedroom and we've been avoiding being too close to one another. It actually feels like I'm quarantined, and we have both mentioned the irony that avoiding one another is the best way to make a baby right now. Hopefully he feels better in time for the retrieval day (i.e. fresh sperm collection day) and I stay germ free.

I had big ambitions for this weekend, but I'm fairly certain that I will instead be focusing on taking care of my physical and emotional well being.

Friday, February 14, 2014

Intimacy with IVF

In some rather interesting ways, our relationship has not only gotten stronger, but also more intimate as we've moved on to more intense infertility treatments.

We've always had a strong relationship. We worked out most of the glitches in the first 6 months of our marriage/first time ever living in the same city since we began dating. That was fun... Now we communicate well and express our opinions without upsetting the other, most of the time. We spend much more of our time together laughing and enjoying each others' company than arguing. Yes, I would say that we entered the infertility realm as a strong couple. And for us, things have only gotten better.

First of all, I've actually taken to enjoying our nightly injection ritual. Every night, C and I share in an uninterrupted moment where we are working on the same goal. He treats my abdomen in a tender and even intimate fashion and I feel very close and connected to him at these moments. After all, I am trusting him with a needle filled with hundreds of dollars of medications that he jabs into a very sensitive part of my body. I've also realized how nice it has been for him to be the sole person responsible for giving me my injections, making him a very active and necessary person in this process that otherwise treats the males largely as bystanders.

Another key benefit to IVF that I've noticed is that sex is no longer stressful. There is no pressure and specific formula. We can just enjoy ourselves and each other. We don't have to force it based on a calendar or what color my urine turns a stick. We initiate it when we feel like it. And when one of us does initiate sex, the other one isn't wondering about ulterior motives in the back of their head. I forgot how enjoyable stress-free sex can be.

The entire process up to this point has forced us to have more difficult conversations, share in more secrets, and come up with more agreements than I would imagine most other couples at this point their marriage. And if practice makes perfect, we've gotten a lot of practice at navigating tough situations as a team. Sometimes I notice how some of our friends interact as couples, how disconnected or hierarchical they appear, and I smile inside with the same pride that I imagine parents feel knowing their child is succeeding and happy.

Whenever I think about the silver lining, my relationship with C is always the first thing that comes to mind. This is probably the most sappy I will ever be, so happy Valentine's Day, and I now need to vomit.

Wednesday, February 12, 2014

IVF Monitoring Appointment #1: Boring

Yesterday I had my first monitoring appointment. C was hoping for lots of activity as he informed me that he had a dream about the two of us needing to save a bus full of kids. The actual appointment was much less exciting.

I have one follicle on the right that measures at exactly 10mm and then a whole bunch more that are smaller. My estradiol level was 237, which is a nice rise that they feel happy with, so they’re keeping my medication dose the same (150 iu Follistim) for the next two days and then I return for a second appointment on Thursday. C was disappointed that there weren’t more big ones, but at this point in the game, I’m pretty content that there are bunch of small possibilities. It could still turn out to be a bus-fill, I suppose.

I’ve been feeling ok, less some hormonal irritation and some minor intermittent pain where I imagine my ovaries are rapidly expanding. I haven’t been sleeping great the past few days and I’m wondering if the growing ovaries is to blame. Otherwise, I’m just continuing to remain chill.

Tuesday, February 11, 2014

P.S.A.: Don’t Mess with a Lady Injecting Herself with Mega Amounts of Hormones

I have been making a very conscious effort to remain calm and find my inner zen state. I am focusing on my breathing and on being mindful. I’m trying not to sweat the small stuff, or even the big stuff. I am trusting in the universe. Of all the non-medical adjuncts to infertility treatment, I personally believe that stress reduction will be the most impactful for me.

Yet sometimes it seems like the universe is working against me. My job has been extra stressful lately. I’ve had a lot of requests to take on extra patients, although I don’t have the time, and the expectation is that I “make it work”. My annual performance review is coming up and I have to prepare for that. I need to submit a paper before an approaching deadline. My clinical outcomes were due last week, which required a full extra Saturday of work to complete. I have an upcoming Grand Rounds presentation that I must prepare for. My emails explode each day and it’s nearly impossible to keep up. Patients are stressed out and parents call me in distress.

The biggest frustration at the moment is from our billing department. The expectation is the all charts are closed and billed within 48 hours, although sometimes I’ve heard 24 and my boss has told us he doesn’t really care as long as it’s within a week. Writing notes are the bane of my existence. I hate it. When I’m stressed and had a rough patient day and feel physically shitty (cue infertility drug effects), my chart notes are the first thing that I slack on. The billing department  has taken to sending daily emails to “remind” us of our outstanding notes (as in incomplete, not exceptionally brilliant and well written), which are then CC’d to five other people including my supervisor, administrator, and several other peoples that I don’t even know what they look like! Then, sometimes, these people decide that I need the email forwarded to me again, just to rub it in.

Usually I just ignore these emails. My boss has assured me that he doesn’t care because I always get the notes done in a timely fashion, just not quite as timely as the billing department would like. But coming up on my performance review, it still doesn’t look good. When I open my email on my phone as I’m sitting in the waiting room of the fertility office and see these emails, I can’t help but get annoyed. Plus, the whole principal of the this action gets under my skin. What a horrible way to motivate people! They don’t ever send positive emails, praising me for taking on additional patients, for working 13 hours in a day, and for closing the charts that I do get done on top of this. The system is entirely based on negative reinforcement and, frankly, is horrible for moral.

Plus, I’m jacked on hormones.

Today I decided to change my tactic. I am no longer ignoring the emails. I am now sending emails of my own, a mocking reply if you will. Their emails typically go something like this:

Good morning Dr. Psychologist,

The following charts are open….(bullet pointed list of patients). 

Please complete your documentation and billing. Remember that we are not able to bill for the service until the chart is closed. 

Thank you,
Ms. Billing Person

My nightly emails will be sent out to each of the 5+ people that have been receiving the negative news about me, and will say something along these lines:

Good evening Ms. Billing Person,

The following are charts that have all been completed and billed along with the other services that I provided for today that were not billable… (Bullet pointed list of all patients that I saw or communicated via email/ this amounted to over 9 hours of patient contact). 

I am aware that not all charts are complete, as many of these charts require additional scoring or other follow-up, but I assure you that I am working on these charts and am aware that they cannot billed and I cannot get credit for the hours that I’ve spent with these families until this is complete. 

Thank you, 
Dr. Katie

Yes, I am aware this is passive aggressive. Here are my goal(s): either a) force them to acknowledge or at least be aware of the positives that I do (i.e. reply to the email with positive reinforcement vs negative) or b) annoy the crap out of them so that they see how irritating it is and tell me that nightly emails are not necessary, which I can then reply that daily emails in the morning are equally unnecessary. At the very least, having nightly emails of all the work that I have accomplished each day will make me feel better.

I’m about to force some behavior change here, people. Watch out! And if it all blows up horribly, you bet that I will be blaming the fertility meds and going for pity. Because infertility has to at least be good for a Mulligan every now and again.

Saturday, February 8, 2014

This Shit Just Got Real

This was the text I sent to C and my best friend, as the large bag of drugs sat in the passenger seat besides me. Over sixteen hundred dollars worth of drugs.

Reality has a nice way of presenting itself when you must pull out your wallet. The previous futuristic, abstract concept and idle fantasy of beginning IVF are no more. This is really it.

As a bit of education, I will now list all of my medications and their purposes. I will then discuss the two strategies I employed to save some money overall. Please excuse the incredible boringness that is to ensue.

Brand Name: Follistim
What is does: Makes the eggs grow big and strong
When/how you take it: A subcutaneous injection given early in the cycle, once per day in the evenings until the eggs are a sufficient size (typically 10-14 days later).

Brand Name: Ganirelix
What is does: Stops my body from ovulation prematurely (i.e. before they want)
When/how you take it: A subcutaneous injection given at exactly the same time each morning (this may prove to be difficult), beginning when the eggs are in double-digit sizes up until they want you to ovulate

Name: 10,000 iu HCG
What is does: stimulated ovulation and gives them one final burst to mature
When/how you take it: A subcutaneous injection given a specific number of hours before the retrieval

Brand Name: Lupron
What is does: May be used in place of an HCG trigger because there is less of a chance of OHSS (Ovarian hyper stimulation syndrome) - My doctors made me buy both because it will likely be a last minute decision
When/how you take it: Similar to HCG I believe, it's subcutaneous and is given at a very specific time before the retrieval is scheduled

Brand Name: Methylprednisolone
What is does: A steroid that is used decrease the chance that my body "will reject the embryo as a foreign body" as the pharmacist explained it
When/how you take it: Right around the retrieval/transfer for a few days. This is an oral medication.

Brand Name: Doxycycline
What is does: An antibiotic that prevents me from getting an illness that could reject the embryo
When/how you take it: An oral medication taken right around the time of retrieval/transfer for a few days

Brand Name: Estradiol
What is does: Replaces the estrogen to restore some hormonal balance that the other medications have severely f*d up
When/how you take it: A transdermal patch that I apply post-transfer for many days (unsure of the specifics here)

Brand Name: Progesterone
What is does: Helps to support a pregnancy and prevent miscarriage
When/how you take it: An intramuscular injection (ouch!) that is usually given in the rump daily immediately before the transfer and then up to 10 weeks into the pregnancy if I should be so lucky.

My insurance covers no medications that are used for infertility treatment. I'm fairly certain the antibiotic and steroid were covered, but nothing else. The birth control cost me absolutely nothing, so feel free to roll your eyes along with me in irony. I employed two basic strategies to save money.

1) I filled out an application for cost savings. There are many out there but the one my doctor recommended was FirstSteps. The application was actually quite easy - the hardest part was locating our tax forms from last year. You could qualify for 25%, 50% or 75% off on the qualifying products and we qualified for 25%. Initially I was bummed out by this because I was hoping for more, but then C reminded that this a pretty sizable chunk of change.

2) I charged the medications on my credit card that is offering 5% cash back this quarter for pharmacy purchases. I calculated the savings to ~$65 back, so it's something. Even if you have a credit card that offers 1% back, it's still something. As long as you pay it off immediately. Otherwise you're losing money. I also plan to pay for the IVF this way, although we'll only be getting 1% back for that.

We also have a specialty pharmacy in town and I picked up my meds during my lunch hour rather than having them shipped. I'm not sure if this is something that they charge for, but I didn't want to risk it. Also, the idea of having this much money worth of medications in the hands of a courier service freaks me out, especially with the weather the way it's been.

Wednesday, February 5, 2014

IVF Baseline: Signs and Coincidences

I find it interesting how we find "signs" in those things we want to believe and call it a coincidence if it doesn't support our desires. If it's a sign, we are somehow supposed to have greater knowledge that we're making the right decision and that the universe is looking out for us. Coincidences are random and this makes us feel uncomfortable. Unless, of course, the sign is negative, suggesting our decision is wrong and that we should turn back immediately. We'll just call that a coincidence as to not induce panic.

A very large snow storm moved through our area last night. We were all given warning and schools began announcing their closings before the first flake descended. I didn't pay much mind to this, just planning to leave a few minutes early. Growing up in the "snow belt" has made me immune dramatizing winter weather.

I made it halfway down our winding driveway, on the way to my baseline appointment. I was only very slightly nervous that my cysts would not have dissipated or that my estrogen levels would be too high. Apparently just nervous enough to walk out without remembering to bring my work shoes to change into, rather than wearing clunky snow boots the entire day. In an effort to save time, I began backing down the driveway to return for the shoes. This resulted in me veering slightly off the pavement, over the stick sticking up 5 feet to warn me where the driveway ends, and getting stuck in the frozen grass and snow piles. My dad heard the tires spinning and I also woke up C to participate in the fun. Because pushing my car out of a snow drift in his pajamas and snow boots is exactly what he was hoping to wake up to.

After this adventure, I was counting on making up lost time in the normally 30 minute commute to the doctor's office. This, however, was not the case. The freeway was packed with cars that refused to move faster than 10 miles per hour. I could do nothing but crawl along, eventually making it to the doctors' about 75 minutes later. My only saving grace was that I called into work to find that my morning patient had cancelled due to the weather so no one was specifically waiting for me.

The appointment went well. Lots of little follicles. No cysts. Low estrogen levels. Good to officially stop the birth control pills, hopefully inducing a period, and begin stimulation medications on Saturday. As I sit now, nuzzled under the blankets, warm in the house and protected from the harsh weather outside, I take solace in this coincidence.

Quantifying Pregnancy Status Update Reactions

On a scale of -10 to +10, where 0 is neutral and the other numbers are self explanatory range from the most positive to the most negative, I will now quantify my reactions to various fertility status updates**: 

+10:  My very own positive pregnancy test (this is an assumption, of course, as I've never actually experienced this).  

+9:  A positive pregnancy announcement of a fellow IFer who got pregnant from IVF. This brings me joy for them and hope for me. 



+6: A positive pregnancy announcement of any other IFer. Joy for them alone.



+3:  The first baby announcement of a friend. I am happy that they do not have to go through what we are going through. Mild jealousy. 



0:  The random first baby announcement of a "friend". Great job at being fertile and avoiding this misery. I don't really care. 


-2:  Celebrity pregnancy announcements. Why do people care so much that it has to plastered all over the front pages of magazines that you can't avoid but seeing when you just need to pop into the grocer to by some milk and bananas? No baby is that important, unless you're religious and then I'll give you Jesus Christ, but even he didn't get this amount of publicity. 



-5:  Second, third, or fourth pregnancy announcements and further status updates on or otherwise. I get it - you're fertile. Get over it already and stop rubbing it in. 



-8:  Hearing pregnant women complain about their pregnancy or parents complain about raising children, especially when said complaints are given directly to me (vs stated generally over the FB). I have pretty good empathy skills, but I can't begin to understand these woes.


-10:   The news of a failed IVF, chemical pregnancy, or miscarriage from a fellow IFer. This brings me such sorrow for them and also sheer terror for myself. 

**Subject to change upon further deliberation, emotional state, or my own fertility status updates. How would you rank the following?

Monday, February 3, 2014

Too Cold, Too Hot, Just Right

As I tell others about our plans, I am struck by their reactions.

I have now disclosed to my best friend, my parents, my youngest sister, and a few other close friends of our plans to begin IVF in just a few short days. My sister (not the one with the rivalry) responded in a very nonchalant, casual manner. I found this unsurprising from her, who can't get excited or emotional about anything, and slightly off-putting. This was not a casual decision. This is fraught with emotion.