P.A.L.

  1. Pregnancy After Loss (miscarriage, stillbirth or infant death)
  2. also Parenting After Loss

PAL

 

I am excited to be writing the final installment of my fertility series. I have written this post a thousand times in my head, but I have waited a long time (9 months to be exact) to get the words just so. I am thankful to all of you who have followed me as I navigated the back roads of infertility and pregnancy loss. Your kind words, prayers and shared stories have meant a lot to me. If you have stumbled upon my page because you are also unwillingly on this journey, allow me to reach out and give your hand a virtual squeeze. I will never stop praying that you too find your rainbow.

rainbowbaby

Pregancy after loss is … uneasiness. 

It’s carefully comparing the pink lines on the multiple HPTs (home pregnancy tests) you have taken and wondering if it’s just you or have they gotten lighter instead of darker. It’s then googling “pregnancy test line getting lighter” to see if this has happened to anyone else and how it turned out.

It’s finally having fantastic off-the-charts beta hCG numbers and naturally assuming that you are having a molar pregnancy because it is the only type of miscarriage you have yet to experience.

It’s having having ultrasound after ultrasound in early pregnancy and always being the most surprised person in the room that this baby is ACTUALLY still alive and growing inside you. It’s reaching deep down inside yourself- where that baby lives- to find the courage to hope. The courage to talk to this baby, to give it a nickname, to try to guess its sex. Because these are the things that normal people expecting a baby do. Except you are not a normal person expecting a baby. And because you know that sometimes hopes are dashed, and the pain from that is long lasting.

It’s sensing that first flutter of movement and immediately feeling the relief wash over you and then recede as quickly as the tides. Because before you know it, that flutter is gone, and you can’t remember when you last felt it. The kicks get stronger and more frequent as the months go on. Of course, this is reassuring, but there are times that the baby goes quiet (how dare that baby sleep!) and, at those times, the uneasiness returns. You lie quietly on your side. You wiggle and shake your belly. You hold your breath. Soon, you enlist the help of your five-year-old who sings lovingly to your belly.  There is a kick and a wave of movement, and you squeeze that five-year-old tight as you both chuckle over how the baby likes her the best. What a great big sister she is going to be!

It’s making an appointment with a perinatologist for a fetal cardiac echo because some study somewhere said that IVF babies may have an increased chance of cardiac defects (Rest assured, this is standard protocol and has nothing to do with the fact that you are neurotic). It’s squinting at the screen while the ultrasound tech explores the chambers of the babies heart trying to spot a defect before she does. It’s being told that that baby looks great and is still measuring ahead and thinking, surely now I can relax. Except you don’t. Not really.

It’s cursing God just a little bit for allowing mosquitos to carry something called the Zika virus that only really affects the unborn children of pregnant women. Like you really needed something else to worry about. Now you can’t leave the house without applying mosquito repellent. And you have to let your husband and daughter travel to FL without you, and this is not ideal because Daddies do things like let little girls drive in golf carts without wearing a seatbelt while an unlicensed driver is driving. And do they really reapply sunblock every 90 minutes and brush the very back molars like you do? You find solace in the fact that your baby’s head is measuring in the 90th percentile, so it seems highly unlikely that it has microcephaly.

It’s not going into labor early, as you had with your daughter, and hardly being able to stand the anticipation. It’s finally scheduling an induction to take place two days after your due date because you don’t think you will be able to handle it any longer than that. It’s going into labor one day prior to your induction and packing up your bags and heading to the hospital with contractions five minutes apart only to have them completely stop as soon as you arrive.  It’s rejoicing that they find a reason to keep you because, in your mind, you refuse to go home.  This baby has to come out now.

It’s having the most grueling, unmedicated, knee-knocking, teeth-chattering delivery. The bed is soaked. Your glasses keep slipping down on your nose. You barely feel present in the room, and a nasty thought creeps into your head. “Oh my God, I’ve come this far. Is it me who is going to die? How is it possible to feel this bad.” It’s summoning your inner Goddess. The one they talked about in prenatal yoga. The one who can get you through anything. You give one last push and hear the most beautiful sound in the world. It’s a boy, and he’s peed all over you.  And although you are too tired to fully digest this moment, you know it is one of the greatest moments of your life.

And you get to thinking it wasn’t so bad after all. It wasn’t all uneasiness. It was belly rubs, comfy pants and checking out your growing side profile. It was baby hiccups, strangers smiling at you in the grocery store, and having a best friend with you at all times.

It was being pregnant one last time, and it was beautiful. And so is he.

Cnewborn

 

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If you want to learn more about my fertility journey, you can read my fertility series and IVF series here.

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If At First You Don’t Succeed, Try, Try Again (IVF #2, FET#3)

When we last left off in my IVF series, I was blissfully recovering from a blighted ovum in Hawaii. It was my favorite family trip ever, and I was feeling really good about our little family unit.  My daughter and I discussed how it would be ok if we remained “The Three Musketeers.” J said she had her cousins, and we could always get a dog.  A dog! That seemed like the perfect solution.

The following Christmas break, I had two whole weeks off, so we looked into getting a Golden Retriever puppy.  Turns out, Golden Retrievers are a little hard to come by, so we started looking for chocolate, golden or silver labs. We found two litters that would be ready around  Christmas time.  Unfortunately, you have to wait until a puppy is 8 weeks old to bring them home. I guess that’s reasonable seeing as you are basically taking it away from its Mommy. Neither of these litters was available to go home until the end of December.  I started researching crate training and general puppy care. Did you know a puppy may need to pee as often as every 30 minutes? One week off was not enough. DH would need to work from home, or we would have to hire someone to puppy-sit. We could enroll the puppy in doggy daycare but not until the 12 week mark.  The more we researched, the more it became apparent- babies are just much easier!

So we returned to the business of baby making. I started my birth control at the end of Christmas break and began my stimulation cycle in January.  This time, my doctor recommended a Micro Dose Lupron Flare protocol.  I was a bit offended when I read that it was for “poor responders.”  We retrieved 17 eggs during my first IVF, and while only 2 panned out, that seemed to be an egg quality issue more than poor stimulation.  My doctor, who is a pretty smart guy, explained that the goal was not to produce a lot of eggs, but a good number of quality eggs.  I could hardly argue with his expertise, so I endured the five injections per day this protocol required.  You heard that right- FIVE! I injected myself with Lupron and Gonal F both morning and night and Menopur at night only. The Menopur requires a little more work than the other injections (see video here) and burns when it goes in. I had more symptoms during the stimulation cycle (flushing, headaches) than with the Long Lupron protocol, but less symptoms before and after the Ovidrel trigger, as I did not produce as many follicles and was, therefore, not overstimulated.

I was paying full price this time around as there are not too many studies wanting women with four miscarriages under their belt!  Being the thrifty girl I am, I learned a few tricks.  Namely, they had changed the Gonal F pen to where you dial a dose, and the window reads 0 if the entire dose is delivered or tells you the number of units left to complete that dose.  This comes in handy when using the pen’s overfill, which exists to give you the ability to prime the pen before first use and get rid of any significant air bubbles with use.  Each 900 Gonal F pen is supposed to have 126u of overfill and the 300s are supposed to have 115u (in my experience, I found that is not always true but there is always extra in there, and it’s like liquid gold so why let it go to waste). That is why so many people request 300s over 900s as you will use that many more pens and get that much more free Gonal F.  The proper way to utilize the overfill is probably to use 100% of each pen as you go along, which would mean giving yourself an extra injection every couple of days.  I saved all my used pens to the end, which  meant I gave myself 7 injections a day for the last days.  Saved me one whole pen, so worth every stick mark!

At retrieval, 12 eggs were retrieved: 8 fertilized normally, 3 were discarded and 1 was held for observation.  By day 3, 8 embryos remained in culture and 6 of these looked promising.  By day 5, the first day to freeze, none of my embryos had made it to freeze quality (expanded blastocyst), and I began to panic.  If you’ll recall from my first IVF, I had a large number of embryos make it to blastocyst, but only two of these ever made expanded blast, and that happened on day 5.  I began to prepare myself for a cycle that could potentially yield no usable embryos.  <By prepare myself, I mean I shed copious amounts of tears> Finally, on day 6, two embryos of good BB and BC quality were frozen.  The rest were allowed to go to day 7, but no more made it to freeze quality.

Again, we found ourselves in the position of having only 2 embryos and the decision whether to implant two to give us a better chance of one making it, or do an elective single embryo transfer.  Last time around, it was an easy choice as my doctor was 100% on board with SET.  This time, however, he mentioned that the protocol for my- ahem- advanced maternal age was to implant two.  We struggled and struggled with this decision, and in, the end, decided to implant just one.  I saw another RE on decision day, and (money aside) he thought we had made the right choice, so I felt pretty good about it.  I was also encouraged by the fact that I had been attending acupuncture throughout my stimulation cycle.

On the day of my frozen embryo transfer, I went to acupuncture both before and after the transfer (and voted in the presidential primary!). I ate  warming foods and brazil nuts and pineapple core to assist implantation for five days because I had nothing to lose at this point.  I also continued with my acupuncture appointments. I was scheduled for a blood test nine days post transfer.  My husband begged me not to pee on any sticks until the blood test, but I don’t like surprises so I was UNABLE to comply. Six days post 5 day embryo transfer (6dp5dt), I had my first positive home pregnancy test. 9dp5dt and the morning of my blood test, I had my second. This embryo became known as “Pinky” in honor of the two pink lines on the pregnancy test, and we decided instead of being cautiously optimistic, we would go “all in.” We recruited an army to pray for Pinky, prayed ourselves and talked to my belly daily, encouraging this little baby to grow, grow, grow.

We entered the infamous beta hell, except it turned out to be not so bad after all. My first beta at 4w0 days came back at a whopping 451, progesterone 10.9 and estradiol 187.  I began to wonder if they messed up and implanted two embryos. The rest of my betas were as follows:

4w2d: HCG 1456, Prog 12, Estradiol 225 (doubling time = 29 hours)

5w2d: HCG 15, 956, Prog 15, Estradiol 347 (doubling time= 48 hours)

6w2d: HCG 55, 319!, Prog 12, Estradiol 357  (I began to get nervous about a molar pregnancy vs. triplets???)

I intentionally scheduled Pinky’s first ultrasound for the end of the sixth week at 6w5d so there would be no ambiguity as to whether we should see a heartbeat.  I spotted the flicker on the screen as soon as the image became visible. Tears stained my eyes.  Dr S. congratulated us, and DH and I  began talking and laughing so much that he had to scold us so he could carefully listen to Pinky’s heartbeat. Pinky was healthy and measuring ahead at 7w1d!

6w5dultrasound.JPG

A little shy of 8 wks, we had our second ultrasound and Pinky’s heart was still beating away. He/she had done quite a big of growing and was measuring a whole 5 days ahead. Dr S. informed me that he would be cutting me loose. Whereas, just two years ago, I was puzzled as to why he was following me at all after achieving pregnancy, now I was hesitant to let go.  I fought the urge to beg him for weekly ultrasounds and accepted my transition paperwork to return to my OB-GYN.

At 10 wks, I saw my OB-GYN. It had been a while since we had connected, and I know she was truly happy to see me viably pregnant.  No one was more surprised than me to see a very ALIVE, dancing baby on ultrasound, measuring in the 88th percentile. My due date was set as November 13, just weeks before J’s birthday. We had opted not to perform pre-implantation genetic testing on our embryos, but we did agree to the Harmony testing.  All the results came back normal.

By 12 wks, I was visibly pregnant . . .

11w5d

And soon after, we announced it to the world.

sidekickannouncement3

We had moved beyond trying to conceive (TTC) to pregnancy after loss (PAL), and THAT was a whole new ballgame!

 

 


 

If you want to learn more about my fertility journey, you can read my fertility series and IVF series here.
Frozen

Frozen

How do you begin to tell a story when you know it doesn’t end well? Well, I guess, having just revealed the ending, there is no better place to start than the beginning…

F.E.T

Prepping for a frozen embryo transfer is a joy compared to what one must endure in a fresh IVF cycle.  There are no needles.  Yes, you heard that right. No needles are involved.  Well, except for a blood draw to check serum progesterone and estrogen levels and another to check for HCG to confirm or deny pregnancy.  It is really quite easy and made me wish all over again for more than two frosties. Dang my aging eggs!

My FET cycles went something like this:

  • Baseline ultrasound on cycle day 1, 2 or 3 to ensure there were no cysts that would prevent moving forward with the cycle
  • Start 2 mg oral Estradiol on cycle day three 2x/day
  • Increase estradiol to 3x/day 1 wk later
  • Day 14 lining check to make sure lining is adequate for transfer
  • Progesterone blood draw on day 16 to ensure no spontaneous ovulation. If ok, drop estradiol to 2x/day and start crinone vaginal gel 2x/day
  • Embryo transfer of day 5 blastocyst on day 21
  • Quantitative HCG test 9 days later

Estradiol

To elaborate on the above:  estradiol is a little green pill. It’s the same pill that postmenopausal women use to combat the adverse side effects of menopause. It’s job, in the case of a FET, is to build the uterine lining to entice one of those thawed embryos to implant and grow a baby. It has a few possible side effects:  headache, stomach ache, nausea, vomiting, possible hair loss. I noticed a thinning of my already fine hair. My heart also felt like it was racing immediately after my evening dose. It came with a $0 copay, which in the world of fertility meds is amazing.

crinone

Crinone is progesterone in gel form taken vaginally. It is easy to use, but a little messy. I recommend investing in some panty liners. Also -TMI warning- it is recommended that you manually clear out the extra Crinone every few days while showering. If you do not, it may irritate the cervix and you will end up with discharge that looks like coffee grounds. This is actually old blood mixed with crinone, and will freak the heck out of you while you are in your nine day wait. Just suck it up and clear out the crinone. Crinone has similar side effects to rising progesterone in early pregnancy: headache, fatigue, nausea, bloating and mood changes. Husbands should really not mess with you while on Crinone. Crinone is responsible for supporting the lining along with estradiol. It is critical in supporting the pregnancy if implantation is successful. In a natural cycle, the corpus luteum would produce the progesterone needed to maintain a pregnancy. Since this is a hormonally-induced cycle, there is no corpus luteum and progesterone supplementation will need to continue until the fetus can take over at 10 wks. Crinone may or may not be covered by insurance. In my case, it was, but the copay was high. Luckily, there is usually a manufacturer coupon available, or you can join a savings program like the one featured here. Actavis also has a drug assistance program for several medications including Crinone.

In addition to the above meds, I took my usual supplements including a prenatal vitamin, B-50, CoQ10, fish oil, turmeric and baby aspirin. I also went to acupuncture 1x/wk leading up to the embryo transfer and twice on the day of transfer (immediately before and after transfer).

On the day of transfer, I was prescribed an oral antibiotic to take approximately 1 hr prior to my procedure. When I arrived at the fertility surgery center, I was given a Valium in order to relax my body for the transfer. Then, they start pushing liquids as the procedure works best with a full bladder.  This was probably the worst part for me as my RE is nearly always late! There is no anesthesia. You and your significant other walk to the surgical suite, and you are placed in stirrups (if you have ever given birth, it is exactly the same set-up). The embryo(s) are then loaded into a thin catheter, which is passed through the cervix into the uterus. Ahead of time, you are asked to confirm that the identifying information on the embryo(s) matches yours, which OF COURSE, is a good idea. After a period of brief cramping passes, the RE carefully confirms the placement of the embryo(s) in the optimal position, which is the midpoint of the uterine cavity. The catheter is withdrawn, and the procedure is finished.  Some clinics make you lie on the table for a specific amount of time and then send you home on bed rest. My clinic feels that studies have proven that FET has the highest success rate when women resume their normal activities. I, therefore, walked out of there on my own two feet with only two restrictions: no vigorous physical activity and pelvic rest (code word for no orgasms of any kind).

#1

Our first embryo transfer was such a lovely experience. We were in the middle of a whole house renovation, so I had to trade breakfast in bed and a tranquil bubble bath for a whole lot of hammering, drilling and sheetrock dust. Nonetheless, it was nice to start my day off with acupuncture followed by a rare middle of the week lunch with the hubby. We had chosen to put back only one embryo at a time given my fear of multiples and the fact that we only had two embryos available. Everyone at the fertility center was thrilled with the quality of embryo #1. We were given several pictures, and everyone complimented us on our perfect little embryo. Isn’t he/she beautiful?

Post-transfer relaxing consisted of acupuncture followed by going to the rock yard to pick out granite for our kitchen. The nine day wait flew by. I was given strict instructions by the staff not to pee on any sticks (POAS). DH also pleaded with me to resist the urge. Alas, he was out of town in the few days leading up to the blood test, and I just could not wait any longer. After doing a lot of online research, I picked up a box of First Response Pregnancy tests. On day #8, I POAS, looked hard and long at it, squinted and saw a faint second line. Interesting. It was so faint that it was difficult to tell if it was a positive or an evaporation line, so I just stuck it back in the box. The next morning, I took another and got a similar result. I was pretty sure by now that I HAD to be pregnant, but I was going in for my labs that morning so would have my confirmation soon enough.

At the end of the work day, my IVF nurse called to let me know that I was indeed pregnant. That was the good news. The bad news was that my HCG level was only 21. They like it to be at least 50, and upon further reading [obsessing], it would ideally be >100 to be a good indicator of a viable pregnancy. It was possible that my embryo was a late implanter or that this would turn out to be a chemical pregnancy.

I did not take this news well. In fact, in confronting DH with it, I completely fell apart. It was an ugly sight, complete with lip quiver, a fair amount of hysterics and lots of feeling sorry for myself. It was a rough two days until I retested and HCG fell to 10. Chemical pregnancy was confirmed- an early miscarriage in which the embryo implants and stops growing shortly thereafter, presumably due to  chromosomal abnormality. There was nothing to do but pick up the pieces and carry on.

#2

FET#2 was a different story. DH and I tried to recreate our romantic lunch-time experience, but were running short on time and settled on take-out.  I did not carefully read the label on my antibiotic and accidentally consumed it with dairy, which made me feel like I would hurl in the moments prior to my procedure. No one complimented us on our beautiful embryo. In fact, the embryologist told us not to worry about the apparent debris around it. What! Do you mean our embryo is ugly? It was such a striking difference that we mentioned it to the team in the surgical suite. They laughed and laughed saying many an ugly embryo made a perfectly healthy and attractive baby.

The nine days ticked by, and it was once more time for my blood test. This time when the IVF nurse called me, she had better news. Not only did I have a BFP but HCG was 178. A strong positive.  I was thrilled! My estradiol was a little low at 189, so they increased my estradiol to 3x/day. I then began the torture known as beta hell. This meant at regular intervals, I went to the lab to draw levels for HCG, Progesterone and Estradiol. During the first four weeks of pregnancy, HCG should double every 48-72 hrs. By 6-7 wks, it takes an average of 84 hrs (3.5 days) for HCG to double. HCG levels reach a peak around 8-10 wks of pregnancy and then decline and level off for the rest of pregnancy. My levels were as follows (I obsessively used betabase to interpret the finding):

  • 5/23: 4 wks: HCG 179, Progesterone 11.3, Estradiol 189
  • 5/26: HCG 387, Progesterone 15.5, Estradiol 244 (doubling= 64 hrs)
  • 6/2:  5w3: HCG 3154, Progesterone 13, Estradiol 212 (doubling= 56 hrs)
  • 6/9:  6w3 : HCG 13,172, Progesterone 17, Estradiol 224 (doubling= 81 hrs)
  • 6/16: 7w3: HCG >39,000

A gestational sac can be visualized on ultrasound once HCG > 1200. I had my first ultrasound at 6w3. At this time, a gestational sac and fetal pole should be visualized. Most of the time, a tiny flickering heartbeat can also be seen.  At my ultrasound, we saw an appropriately sized gestational sac and what we think was a fetal pole. No heartbeat was seen. DH and I were very disappointed as we had been down the road of blighted ovum before. Our RE told us that blighted ovum was a possibility, but that it was too early to make presumptions. I was scheduled for another ultrasound 1 wk later at 7w4.

This time, it was clear. There was only a large gestational sac. No fetal pole was seen and no heartbeat. Our baby dreams had been dashed again. This time there were a few tears and a brief nap before picking  J up at school. We had told the RE that we would take no further action at this time. I would go home and wait out miscarriage. For two weeks, I walked around wearing the most super-sized maxi pad I could find and black spandex shorts under my clothes in case, god-forbid, my miscarriage started while I was out and about. I work in a swimming pool for 1/2 of my working hours as a Physical Therapist, so I had to pull myself out of the pool for obvious reasons. I really, really wanted this miscarriage to be over quickly. But my body seems to be oblivious to lack of development of a fetus. Initially, I think my HCG was continuing to rise. I say this because at 8 wks, I started to experience morning sickness. The smell of bacon cooking would send me scurrying off to my patio, gagging all the way.

It was also around this time, that DH decided we needed to go on vacation. Either that, or I needed to see a shrink. I chose vacation (duh), and we started to plan a last minute trip to Hawaii. My BIL lives in Kauai, and DH has a client in Honolulu that had been asking him to come onsite for a while. Of course, this messed with my timeline for a natural miscarriage because if I eventually required a D&C, I needed a two week buffer between my surgery and flight to ensure there were no post-op complications.  In the end, we decided it would be best to schedule me for a D&C at the two week cut-off and hope I wouldn’t need it. Except I did. Guess my body is as reluctant to become un-pregnant as it is to be pregnant. The good thing that arose out of having a D&C is that the genetic testing could be done on the fetal tissue.

The test results came in about a week later. I had miscarried a chromosomally normal boy. The significance of that is this. If the test results come back “normal female,” the lab automatically assumes they accidentally tested your own tissue. After all, the majority of miscarriages are attributed to chromosomal abnormalities of the fetus. My result, however, could not be a mistake, and it was heartbreaking. Difficulty getting pregnant. Repeated pregnancy loss. And now miscarriage of a presumably normal embryo. This was clearly not good for my prognosis. My RE recommended I consult with a repeated pregnancy loss specialist in Tennessee to get to the bottom of this. But I could not worry about that now. I was going on my dream vacation with my family, and I was determined to have a good time.  And guess what? We did.  The time of our lives.

 

 

 

 

Retrieval

The alternate title of this post should be: Grow Embies Grow!

After my somewhat traumatic trigger, I had exactly 48 hrs to embrace the positives of this new plan:

  1. Extra recovery time: I was feeling pretty awful even though I was taking cabergoline to prevent ovarian hyperstimulation syndrome. I was so bloated that I looked at least five months pregnant (the irony!), and there was not a single pair of pants I could zip (seriously thought about digging out my Bellaband). I also developed constipation despite chugging Milk of Magnesia and staying hydrated as instructed by my nurse.  Having a month to detox before embryo transfer was starting to sound appealing.
  2. Acupuncture: I cannot say enough good things about acupuncture.  The best I had felt during this whole journey was those few months when I was receiving acupuncture alone or in conjunction with my fertility treatments.  Because I was enrolled in an IVF study, I was not permitted to do acupuncture simultaneously.  In fact, if you get pregnant through the study, they follow you all the way up to the birth of your child, and that means no acupuncture at any time.  As someone with two previous miscarriages, I had always envisioned doing acupuncture for miscarriage prevention. Perhaps being kicked out was the best thing that could have happened to me.
  3. FET success rates: At my fertility clinic, they prefer freeze-all cycles. In my age group, approximately 34% of fresh transfers with non-donor eggs result in a live birth. For frozen cycles, 40% of transfers result in a live birth, and the actual pregnancy rate is quite high (>50%).
  4. Consideration of single embryo transfer: The study required that two embryos be transferred on either day 3 or day 5 (depending on individual embryo growth). This made me a little nervous as I am not exactly confident in my abilities to take care of two or more newborns along with a pre-schooler. I told my RE that I would likely cry just a little bit if he told me I was having twins. I would, of course, come around eventually.  Two baby heads to sniff is quite a gift. But I would be terrified.  Ask my husband, and he will tell you differently.  Then again, I can probably count the number of poopy diapers he’s changed on my two hands. Hmmm.

IVFeggretrieval

I had my retrieval done at St. David’s Fertility Surgery Center, which is two buildings down from my fertility clinic.  We had to arrive very early, so J had a sleepover with her cousins.  I later found out that she had told her teachers that Aunt Liz had to bring her to school so Mommy could get her eggs taken out. Oh my! Will have to be careful what I say around that child.  The procedure itself was fairly easy.  My nurses were fantastic, and my anesthesiologist was the kindest man ever.  I was knocked out while my eggs were retrieved, and before I knew it, I was back in my room.  Any type of sedation knocks me for a looper, so I do not remember even talking to Dr. S after he performed the retrieval.  My first memory is of the embryologist coming in and telling us that we retrieved 17 eggs. Wow! I felt like a rock star.  High fives all around.

DH and I went home to rest before we had to pick J up from school.  I use the term “rest” rather loosely since we were in the middle of a whole home renovation, and those do not tend to be very quiet.  Fortunately, they were working on the other side of the house, but we were without a bedroom for the time being and sleeping on a mattress in the middle of my daughter’s play room.  Try as they may to let me sleep, the crew had to interrupt me several times to ask my opinion on one thing or the other (insert sigh).

We received our first FERT report the next day. Of the 17 eggs retrieved, 16 were mature, 13 fertilized normally and there was 1 more in culture that they were unsure about. On day 3, we still had 14 eggs in culture: 10 of acceptable quality and 4 that were fragmented or falling behind.  On day 5, two blastocysts of grade BC quality were frozen and they were continuing to watch 8 additional blasts. They embryologist felt that things were looking good for getting a few more frosties.  Then, on day 7, we received the DEVASTATING news that none of those 8 made it to freeze quality.  So of my 17 eggs, only 2 were normal enough to freeze.  I was disappointed to say the least.  IVF is a lot of work, and to have gone through this entire cycle only to get 2 embryos was a bit of a bummer.  But at this point, I was simply too tired to spend too much time lamenting.  I was just looking forward to being drug free for at least two weeks before I started my frozen cycle.

I.V. {Freakin’} F.

pregnancyinfantlossawarenessmonth

In October 1988, President Ronald Reagan proclaimed October as National Pregnancy and Infant Loss Awareness month.  In 2006, the U.S. House of Representatives passed a resolution making October 15th Pregnancy and Infant Loss Awareness Day.  Through my infertility journey, I have encountered many strong women who have dealt with some form of miscarriage or pregnancy loss.  These women (and their supportive partners) are your friends, your neighbors, your co-workers. Chances are, you have no idea they are even suffering because they are doing so in silence. Hard to believe when life is a blur of Facebook and Twitter, and everything seems so very Pinterest-ing. How is it that pregnancy loss is still so taboo? I don’t have the answer to that, but this month is for you, and I’ll be praying for your hearts to be healed. You see, I am one of you- having suffered four pregnancy losses of my own. During the month of October, I will be chronicling my IVF story in the hopes that it will be therapeutic for me and for others who have yet to share their stories.

*****

Weighing The Options

When I finished my infertility series, I had experienced an ectopic pregnancy after conceiving with the help of Clomid.  After that encouraging pregnancy and with the clock ticking down my 36th year, we hit the ground running with two more rounds of Clomid alone followed by Clomid and intrauterine insemination (IUI). My husband, especially, was bummed by our failed IUI so we turned to alternative medicine for help.  We did two months of fertility acupuncture (herbs and needles) followed by one month of acupuncture, Clomid and IUI.  My charts were encouraging. My acupuncturist felt all the signs were leading in the right direction. My reproductive endocrinologist said I was stimming beautifully! But still no pregnancy.

With my lining thinned from repeated cycles of Clomid and me about to turn 37, the next step in the treatment cycle was IUI with injectables. This involves injecting oneself with a follicle stimulating hormone (FSH) such as Gonal F starting on cycle day 2 or 3. As the FSH stimulates the ovaries more aggressively, more follicles are developed and there is the potential to ovulate more than one egg.  This increases the risk of multiples including triplets. Yikes! Suddenly, I had a flashback to Octomom, and I definitely did not want to be her. In my age group, the relative success rate for IUI with injectables is 15-20% per cycle, and the projected cost is $2500-$3500 including drugs, monitoring and the procedure itself. That’s quite a hefty price tag for one shot at a pregnancy.

Fortunately, the informative lady in the billing department of my RE’s office was kind enough to remind me of an IVF study for which I qualified. Dr. S had mentioned it to me eons ago when I was not at all ready to think about IVF. The typical cost of IVF including doctor fees, hospital costs and medications is $12,000-$17,000. This study cut the cost in half with a 30-35% chance of success for a fresh cycle and the chance to freeze any remaining eggs for future frozen cycles. The study’s goal was to prove that Afolia (a drug already being used for IVF in Europe) was just as safe and effective as Gonal F, the gold standard in the U.S.  The study was in its third and final phase before being FDA approved, so I felt it posed little risk to my personal health. Besides, everyone knows I love a bargain. Perhaps I would also be playing a small part in introducing competition to the marketplace, thereby decreasing the future cost of IVF??? One can only hope.

The Waiting Game

For the next few days, I ran around like a banshee getting multiple vials of blood drawn, yet another HSG, a pap smear and attending couples IVF orientation all in the hopes of qualifying for this study.  I passed with flying colors! Now the only thing standing in the way of me and my study money was an antral follicle count i.e. the number of follicles measured by a baseline day 2-5 ultrasound.  The study said I had to have at least 10 but no more than 20, and I had no idea what my number would be. To make things worse, the study coordinator could be reached only via email.  I would email her cycle day 1 and check my email obsessively for her response.  The first month, my cycle occurred too close to Thanksgiving, so I was only able to do more blood work, which also turned out great. The second month, my cycle occurred one week before Christmas, and the study coordinators had closed to study to further participants until after the holidays. Come on! I was getting antsy. The third month, I finally had a win. In January, I had my first study visit and my antral follicle count was perfect! I was promptly started on birth control pills to suppress my ovaries and allow the follicles to get in sync. Being in a study requires a lot of baselines so I had what seemed like a million tubes of blood drawn, but aside from that, the first month was easy peasy.

And So It Begins

Approximately three weeks after starting on birth control, I had my study 2 visit. There was another ultrasound to make sure I had no cysts and was ready to begin Lupron for down regulation. Lupron is a drug often prescribed to men with prostate cancer or women with endometriosis or fibroid tumors. It’s off label use in IVF is to shut things down, so to speak. You start Lupron injections approximately 7 days before your period is due and continue it throughout follicle stimulation to prevent ovulation. This would involve injecting myself in the belly every morning, and was rather intimidating. DH (dear husband) came with me to learn how to give the injections just in case I wimped out.  I did the opposite. I essentially stabbed myself thinking the needle had to go all the way in when, in fact, I only had to inject it far enough to release the drug.  Practice makes perfect.

DH and I also signed our lives away at study visit 2. Since IVF produces embryos- each a potential life- there are a lot of ethical considerations. You must decide whether you will send your embryos to long-term storage if not used within six months. You must also decide what to do in the event of leftover embryos that you do not intend to use- will you discard them or donate them to science or another couple for potential implantation? What happens in the event of death of one or both spouses? What do you do with the embryos if you, as a couple, decide to divorce? These are some heavy questions folks!

For the next 11 days, I gave myself a Lupron injection at precisely 6:50 AM every morning. Then, I had another ultrasound and more bloodwork to ensure my hormone levels were appropriate to begin FSH. On day 12, I was cleared to begin stimulation and was randomized to the control group. This would mean I would be getting injections of Gonal F- the tried and true FSH drug. While I did feel a little less important than had I been randomized to the experimental group, it was somewhat of a relief to be doing things the “proven” way. The big difference with the study protocol is that they require you to use a low dose of FSH for five very long days before the dose can be increased to the usual 450 units. This is to avoid study drop-out due to ovarian hyperstimulation syndrome (OHSS), a potentially dangerous condition I also wished to avoid. I continued to inject myself with Lupron in the morning and the Gonal F pen in the evenings. I was not a big fan of the pen method of drug delivery. You must dial the dose and then press the button pretty hard to release the medicine into your belly.  Once the dose is dialed, there is no going back.  I was so fearful of messing up that I pretty much watched the instructional video every time I did my injection. You can watch it here.

Though I alternated my Lupron and Gonal F injections from side to side of my abdomen, I was one big bruise by the time they upped my dose. I stimmed for a total of 12 days, and by the end, I actually had a small hematoma on one side of my belly- probably from pushing the pen down too hard. Injections suck. May I never get insulin-dependent diabetes! As I stimmed, I had several ultrasound visits to keep track of my developing follicles.  I was doing awesome.  My estrogen level was great. My lining was super thick. We were keeping our eye on 21 follicles by the last visit. Some would inevitably be too mature or too small by retrieval, but I was psyched. The study required that I implant two day 3 or day 5 embryos, and I was hoping to have leftovers to freeze. Come on frosties!

Trigger

When enough eggs are deemed ripe, you have more blood work to check estrogen and progesterone levels. The nurse then calls you with the results and the timing of your trigger shot. The trigger shot, called Ovidrel, is essentially a dose of the pregnancy hormone HCG. It tells your body it is go time. Egg retrieval is scheduled for exactly 48 hours after the Ovidrel injection so they can retrieve your eggs before you have the chance to ovulate.

When my nurse called me to give me the time of my trigger shot, she also had bad news. My progesterone level had prematurely risen to 1.8. It needs to be <1.5, or it is thought that the endometrial lining has gotten out of sync with the follicles and the chances of implantation are poor.  My fresh transfer would have to be cancelled, and this meant I would also be dropped from the study. A million thoughts were swirling around my head as my nurse attempted to give me my final instructions. My egg retrieval was still scheduled for that Wednesday, and I would convert to a frozen cycle after my next menstrual period. Were they going to take back my study money? No, she assured me. None of this was my fault, and all my information would still be included in the study.  We prefer frozen cycles, she said encouragingly.  Still, I cried so hard in telling my husband over the phone that he left work early lest I fall to pieces. To make matters worse, at this point, my belly was very swollen from all the developing follicles, and I was feeling pretty awful. They were fearful that I may develop OHSS, so they prescribed a medication to lessen the side effects, which would surely worsen after trigger. Did I mention that we were also in the middle of a whole house renovation, and I was presently sleeping on a mattress on the floor of my daughter’s play room and living out of her closet? I nearly wished for the earth to swallow me up whole and relieve me of this misery, but I could not. I had 48 hrs to pull myself out of this hormone-induced darkness and wrap my head around the change in plans. I promptly stabbed myself with Ovidrel and encouraged my follicles to grow, baby, grow.

I’ll tell you all about my retrieval next time around. For now, everyone else is sleeping, and so should I. . .

 

Ectopic

This is the final installment (for now) in my infertility series.  I have delayed in posting it because the emotion is  still raw.  I do want to pause to give thanks for the number of personal notes I have received in response to my writings.  There have been words of encouragement, stories of hope and similar struggles and gratitude for having the courage to speak out.  Writing has always been an outlet for me, and I am glad to have a made a small impact on others, if only for a moment.

For DH and me, our miscarriage experience brought to light the fact that we were “trying.” They say ignorance is bliss, and we certainly found this to be true.  We were well aware that we were taking no precautions to prevent pregnancy, and at least 15 months had passed in this manner. We probably should have been concerned, but I think it helped that we were terrified by the notion of a second child for at least half that time period.  The fact that pregnancy #2 occurred without overthinking it was, well,  lovely.

Now we were determined more than ever to give J a baby brother or sister.  I, for one, was not looking forward to “trying,” but it ended up being less stressful than I anticipated.  DH was 100% on board, and it was like an unspoken agreement between us. I charted only once to make sure my cycle had not changed.  My periods were still like clockwork every 28 days with ovulation occurring around day 15. Seemingly perfect. Twelve months went by without success, and my OB-GYN urged me to go back to the reproductive endocrinologist. I was, after all, 35 and the clock was ticking.  Fifteen months went by, and this time it was DH who was dragging me to the RE’s office. What pushed me over the edge were the results of a blood test my OB-GYN ran. Anti-muellerian hormone, or AMH, is a substance produced by early ovarian follicles. It is thought to be an indicator of a woman’s remaining egg supply, her ovarian reserve. The normal range is 1.5-4. My result came back at 0.6. Time to see Dr. Magic.

The RE was not concerned with my AMH value quite yet. He said, it being a new test, there was a lot of potential for error if not performed by a reliable lab.  He sent me for a very thorough panel of bloodwork via ReproSource in Boston. All my values, including AMH, fell within the acceptable range, and my egg retrieval score was good, meaning average for my age. On my 36th birthday, I had a repeat HSG, and this was also normal. DH’s swimmers were deemed plentiful as well. We were so normal that we were given a diagnosis of “unexplained infertility.” Our recommended treatment plan was either continue on our own or try fertility drugs in an effort to speed up the clock.

We chose Clomid, which I took one time while trying to conceive J. As you may recall, I hated it.  I experienced all the listed side effects- hot flashes, night sweats, bloating, headaches, breast tenderness, extreme irritability. It was an evil little pill, and I was not excited to give it a second try.  I started my 5 days of pills and waited for the ugliness to begin. I waited. And waited. And waited. Still, I felt nothing. I told the doc as much when I saw him for my follow-up ultrasound.  My ovaries told a different story.  I had several mature follicles in each ovary. Sneaky Clomid!

The protocol is to have extra friendlies every other day while tracking luteinizing hormone with an ovulation predictor kit. Once the luteal surge is detected, ovulation is anticipated to occur the next day.  They gave me a lab slip to go for a pregnancy test 2 weeks after my surge. Not one for unnecessary bloodwork, I called the office the day the lab was due and told them I was going to skip it as I had taken several home pregnancy tests in anticipation and had yet to get a BFP. The secretary agreed but urged me to go if AF did not arrive within two days.  I decided to take one more HPT, and this time there was the faintest positive. When I looked back at the previous day’s test, there was also a very faint positive I had missed. Oh glorious Clomid!

I quickly snapped a pic of my test and made J pose for this adorable picture with her Cabbage Patch Doll (mine from my childhood). The shirt was handed down to us by her cousin, and I was saving it for a time when it rang true. I sent the pics off to DH and hopped in the car to get my bloodwork done.  DH was ecstatic. I was cautiously optimistic.  The projected due date was Oct 9, the day before DH’s bday and a week before our anniversary and my birthday. How could this fail?

A slight miscommunication between the hospital and lab resulted in a delay in receiving the results.  The blood test came back positive, although the HCG level was low. My progesterone, on the other hand, was through the roof, indicating that I had ovulated more than one egg.  My second blood test two days later revealed that the HCG had more than doubled so I was cleared to go one week before my next blood draw. I was feeling pretty confident at this point. My breasts were sore and enlarged. I was having minor cramping in my expanding uterus as I had with J. My belly was hard and swollen likely due to all the progesterone on board, but I preferred to think of it as a little baby belly.

And then it all fell apart.  I received a phone call after my third blood draw informing me that my HCG levels had remained low and had not come close to doubling as expected. The doctor was concerned I may be experiencing an ectopic pregnancy and wanted me to come in for an ultrasound the next day. DH was out of town on business, and I had to break the news to him on the phone. I also had to arrange for childcare for J so I could go to the ultrasound by myself. DH and I stayed up late talking on the phone and googling “HCG not doubling” and “ectopic.” We clung to hope from stories of other women with low HCG or suspected ectopic pregnancies who had gone on to birth healthy babies.

When I finally went for my ultrasound, all hopes were dashed. Although my HCG was rising just a tiny bit with each new set of bloodwork, the number was less than 500, grossly below what one would expect at nearly 6 wks pregnant. The words “not a viable pregnancy” passed from someone’s lips and attention turned to determining whether the pregnancy was in-utero or ectopic. They were unable to make that determination.  Two doctors and an assistant probed me. They debated it while I held my breath and pressed my lips together hoping to hold back the tears for a few minutes longer.  I was sent home with firm instructions to call the doc on his cell phone and report to the ER if I experienced any severe right sided cramping. I was to come back in two days.  The worry was that if the pregnancy was in the tube and continued to grow, it may rupture my fallopian tube and cause me to bleed internally. This is one of the leading causes of maternal death and not something I wanted to experience.  Also, as someone who has a hard time getting pregnant, I could not afford to lose my right tube. I did not go home with a picture of my suspected ectopic, but it looked similar to this.

Because my HCG number was still rising, I  felt a glimmer of hope. Maybe this baby was in my uterus and was a late bloomer? I didn’t want to feel pressured to terminate a pregnancy if there was still hope, so I turned to my OB-GYN for further guidance.  I found her to be more personal and sympathetic than the RE. She took the time to explain what the HCG numbers meant, why mine indicated a failing pregnancy and my options should it turn out to be ectopic. Talking to her was like a breath of fresh air.  I may have mentioned earlier that my RE is slightly cocky, and he has every right to be. He is very talented at what he does. However, as appreciative as I was for the close monitoring, I was not ready to herald him champion for saving my tubes just yet.  I simply wanted him to pause for a moment and acknowledge my loss. Was this too much to ask?

DH accompanied me to our next visit which fell on Valentine’s Day. Seriously! DH has long been boycotting VDay as a commercial holiday, so I was not expecting candy and flowers, but this was ridiculous! They were still unable to make the call,  and the HCG number continued to creep up, so it was getting urgent. The recommended protocol was a shot of methotrexate. This is a chemotherapy drug that would effectively terminate the pregnancy to stop it from growing. If it became too large, I would require surgery and risk losing a tube. Still, no one wanted to inject me with a chemo drug if this was a natural miscarriage waiting to happen. So I was send away again.  I was told not to panic over bleeding as this was sure to occur, but to call with significant right sided pain. I experienced both and ended up having to call my doctor at home on a Sunday evening. Fortunately, the pain was not severe enough to be emergency-worthy, but my next appointment was moved up to 7:45 am on Monday.

We had arranged for childcare for J, but she woke up with a fever. So the three of us piled into the car- my pursed loaded with children’s ibuprofen and tylenol- and drove in silence to the office.  My HCG numbers had fallen significantly over the weekend. What was troubling was the spot that was still clearly on my right fallopian tube as well as the right sided pain I was having. I opted for the methotrexate shot and spent much of the morning waiting around to see if my liver was healthy enough to allow this option. Finally, I received not one but two injections and was sent home to rest. Except that I had a sick child, so rest was not possible.  In fact, all three of us ended up getting sick, which was a welcome distraction from the nightmare of the previous week.

As before, time was relentless in its insistence to march on and on and on. I may or may not have thrown a tantrum over planting some peach trees, which I refer to as my miscarriage trees. I remember reading somewhere that it was therapeutic, and I was planning on planting some fruit trees anyway. J named them Ariel and Belle. Please remind me never to ask her opinion on baby names or, surely, she will end up with brother Kristoff or sister Rapunzel.

DSC_0456

We are still trying, and I am not going to lie to you, it is the pits. Most days, I am ready to move on from this chapter in my life. Should God entrust us with another precious life, I will hold him or her to my bosom, breath in the heavenly scent of baby and cry tears of joy. And should we remain parents of one, I will look at my little J with pride and adoration, as I have for the last three and a half years, and know her love is big enough to sustain me.

* * *

Good news, my next post will be significantly more uplifting as I am going to write about J’s Ariel Pool Party (because every three year old needs a pool party).

 

Blighted

(`blit-ed): used as an adjective to describe something that has a condition that makes it weak or unable to grow

There is an old saying, “New house, new baby.” A coworker reminded me of this when we moved into This Old House at the end of May 2012. At the time, I thought perhaps she was crazy or, at the very least, oblivious to the absolute chaos surrounding our move. For a reminder, click here, but I will quickly summarize. In 4-6 weeks time:

  • My parents came to visit, which prompted a lot of home projects as a precursor to their arrival.
  • During their visit, nanny had to be terminated after she confessed to repeatedly stealing- get ready for it- vodka from our bar in order to self medicate. She claims she did this after hours, but this is clearly every parent’s worst nightmare.
  • Impulsively purchased a new house and began the whirlwind of home inspections, appraisals and mortgage paperwork that followed during the ten day options period.
  • Frantically prepared our beloved home to put on the market. Sold in less than 2 weeks time.
  • Also frantically searched for a new nanny, a process which took over a month.
  • Packed up entire house, mainly during nap time and the wee hours of the night and, often times, by myself as hubby was out of town on business three times during the month of our move.
  • Moved into new house and promptly began pool/patio renovations. Oh, and it seemed like everything else started to unexpectedly fall apart!

At the end of all this, I collapsed into a heap and DH and I were lucky to still be on speaking terms. It was a VERY stressful time, and procreation was the furthest thing from my mind. That is until, at the end of July 2012, I began to wonder if I might actually be pregnant. I was spotting at the time and had been for several days before my expected period. This was not unusual for me. I have seen multiple doctors through the years for breakthrough bleeding. This spotting went on for five days without turning into a full-blown period and was accompanied by breast tenderness, extreme fatigue and a strange cramping in my uterus. In short, I felt exactly as I had when I was pregnant with J. I hunted through my medicine cabinets for a home pregnancy test, held my breath and peed on the stick. I was struck by the ridiculousness of it all and was about to shove it back in its wrapper when I noticed two pink lines indicating a BFP. At this point, I nearly fell off the toilet. I felt such a rush of emotions.

Oh yes, a baby!

Oh no, what terrible timing!

Oh no, I’m bleeding! I must be having an early miscarriage.

I picked up the phone, dialed the OB-GYN’s office, described my situation and they wanted to see me right away to draw blood for a quantitative HCG blood test. Meanwhile, I scrambled to draw a picture announcement for J to give to DH and cried as I delivered the good/terrifying news.

DearDaddy

My blood work came back positive and my HCG doubled as expected in the first four weeks of pregnancy. However, my progesterone levels were lower than expected, and I was started on progesterone suppositories and scheduled for an ultrasound at week 8. In my case, the suppositories were inserted once daily at night. They were a bit messy and intensified pregnancy symptoms such as breast tenderness, nausea, bloating and night sweats. They did, however, stop the bleeding, and I began to feel more relaxed about this pregnancy. During this- the longest three weeks of my life- the pool/patio renovation continued, and I also flew to New England for my nephew’s first birthday party. I told very few people about my pregnancy due to the bleeding but broke the news to my sister ahead of time in case I needed to seek medical care while home. Unfortunately, the bleeding recurred during the plane ride over, and I spent several days on bed rest hoping for the best. My ultrasound was scheduled within a few days of arriving home, and I was realistic but hopeful.

I had a transvaginal ultrasound, and as soon as the results became visible on the screen, I knew the news was not good. My uterus looked like a big black abyss. There was no comforting heartbeat to be heard. My OB-Gyn politely searched my uterus while questioning me to see if I might be off on my dates. She knew I was not. There was a big black circle indicating a gestational sac, but no squirming bean inside. “I’m sorry,” she said, ” I don’t think it is going to work out this time. Looks like a blighted ovum.” She offered to recheck in a week and go over our other options once we had time to digest the news. I waited for her to leave the room and began to cry. Even though I knew this was wrong from the start, I could not stop the tears from falling.  I sat in the back seat of the car with J while DH called person after person telling them our sad news. I may have managed to croak out a few sentences to my Mom, but didn’t feel like speaking to anyone else.

blightedovum

A blighted ovum, or anembryonic pregnancy, is when a fertilized egg attaches to the uterine wall but the embryo fails to develop. It’s kind of like a house with an open door and all the lights on. You keep ringing the doorbell, but no one is home.  I went off my progesterone supplements and immediately started bleeding. I wish I could say I waited out miscarriage. I usually prefer to do things the natural way. But somehow, waiting felt morbid and disruptive. I had a D&C one week later.  It was a relatively quick procedure. I had some minor pain for a few days, bloating that made me look at least 5 months pregnant and night sweats that forced me to sleep on a towel until my body rid itself of all the pregnancy hormones.  Life went on. I continued to go to work.  I chased after an active toddler.  The only real change I had to make was that I could not go in a swimming pool.  This may not seem very devastating except I spend 50% of my working hours as an aquatic therapist, was accompanying my daughter to water babies swim class 1x/wk, and we had just completed an 8 week pool-patio renovation.  Bah humbug! The day after my D&C, we had friends over  to swim (clearly DH’s idea), and I dipped my toes in the water while covering up my bloated belly the best I could.

I had two very sad days surrounding my miscarriage- the day of my ultrasound and the day of my surgery. I spent most of those two days sleeping. And then, to my surprise, time carried on. It did not have the decency to stand still for me and my tragedy. I was as busy as I ever was. And I coped a little too well.  I did not give myself a whole lot of time to mourn, reflect or relax.  I talked about it, of course, with a few trusted friends and family members, but the rest of the world was unaware of my pregnancy, and now did not seem the time to tell them about it and its demise. I discovered that the subject is awkward and people- including myself- are not sure how to react. There are those who know but choose not to say anything lest it upset you. There are others who check in too often – “How are you feeling?” “Do you need to talk?”- to the point that you want to remind them that you still have a life to live if only they would stop bothering you. Except you don’t because they are just showing concern the only way they know how.  And then there are those who have been through it before.  Those are the best kind of people. They need say no more than, “I know,” and give you a reassuring hug or glance. And you know that they do know and that is the most consoling of all.

Of course, I would be remiss if I forgot to mention the large category of people who say, “Well, at least you know you can get pregnant.” This includes just about everyone. And while extremely annoying and not the least bit comforting, it is the truth. I could get pregnant, and I began to want to try again…