Final Day of Bedrest

I realize that no one really cares what I do on bedrest, but I'm bored, so I'm going to talk about it anyway. Yesterday my DH worked from home and was able to fill my water, bring me lunch, etc. in between meetings. During the day I read the 300 page book "Breakfast at Tiffany's", I watched "Eat, Pray, Love" and I did a meditation which led into a 3 hour nap. Mixed in there was writing on this blog, sending a few emails and just staring into space.

Today my DH had to go into the office. He prepped a cooler for me with some snacks and drinks, and put a plate of food in the fridge ready for me to pop in the microwave. I've got "Charlie St. Cloud" loaded in the DVD player and a few other movies recorded on the DVR, along with a few magazines within arms reach.

The bedrest pains have set in. My lower back, sides and shoulders ache from lying on them for 42 hours so far. But as predicted, the hardest part is not being able to interact with my DS. Sure he comes running over every once in a while to give me a high five, and I did get him to sit on the couch with me while we read a book on Sunday, but he's just not really the kind of kid that sits still to snuggle. He's off and going. I'm very much looking forward to tomorrow where I can finally give him a proper snuggle hug.

Tonight I'll start to prop myself up with some pillows and let my body start adjusting again. From past experience, I've about passed out my first day off bedrest because my blood pressure gets so low. I've got a doc appt at 9 am tomorrow to check my blood and see how my estrogen and progesterone are doing, then a full day of work.

As for my little embryos, nothing to report there. I'm hoping they are getting all comfy and burrowing in, but it'll be a while before I know anything. There are all sorts of symptoms, or lack of, that you can read into during the 2WW, but I'm attempting to not obsess on it all and just see what happens.

Current Rx Cocktail

Now that the stimulation injections are complete and my embryos are back in my oven where they should be, my drug mix has changed slightly. Here's the current daily cocktail:

When I wake up:

> Synthroid - for being hypothyroid. Keeping my thyroid under control is crucial for getting pregnant and preventing miscarriage as I have increased odds of miscarriage.

> Progesterone - while I used to do injections in the booty at night, this time around I use a cream instead.

At breakfast:

> Prenatal vitamin

> Calcium supplement

> Prednisone - steroid to help suppress my immune system to allow implantation

> Selenium - can help decrease the chance of miscarriage due to thyroid issues. Not totally proven, but won't hurt.

> DHA - omega 3 fatty acid (fish oil) to help with early fetal development

> Folgard - I have MTHFR which is a genetic mutation (homozygous, or two copies, of the A6777 mutation) meaning I don't absorb folic acid and can have blood clots. This drug is mega doses of folic acid, B6 and B12 to help me absorb the folic acid which is critical for early fetal growth to help prevent neural tube defects.

> Baby Aspirin - again for MTHFR, this helps to prevent blood clots which can mean not enough blood gets to my uterus to help the baby grow.

> Pineapple core - yes, that's correct. I actually cut up fresh pineapples, save the core and munch on it throughout the day. It's a natural form of bromelain that can help with implantation. You can buy it as a vitamin supplement, but the correct dose is difficult to determine. Eating fresh pineapple core is actually better. Over the last 10 ART procedures that I've had, I've eaten enough pineapple core to last me a lifetime. But once again, I'm crunching through it.

In the evening:

> Lovenox - blood thinner that I inject in my stomach to help prevent blood clots (again related to MTHFR). This does cause massive bruising on my stomach and burns when injected. While not at all fun and a little controversial as to its benefits, it worked last time and I took it the entire pg, so I'll do it again.

> Folgard - second dose of the day

> Prednisone - second dose of the day

What's coming up:

I'll be going in for blood tests every other day to check my hormone levels. I will most likely need to take Estrogen supplements. So at some point I'll start wearing an estrogen patch that will be changed every 2-3 days, along with taking oral estrogen 3 times a day.

Back to bedrest for now...

(a post on the actual transfer is listed below)

Transfer Time

I went in for transfer on Sunday, after dropping DS off at a friends house at 7:45 am. We talked to the doc about the quality of the embryos. Of the 4, two were 8 cell, one was 6 cell and the last one was only 3 cells. One 8 cell has a little fragmentation, the other 8 and 6 were listed as "grainy", whatever that means. The doc, DH and I all agreed to transfer the two 8 cells and the 6 cell. They aren't perfect, but they still look pretty good. Once I'm off bedrest, I'll post their pictures. The 3 cell one will be allowed to grow until day 6 to see if it will be a blastocyst and ready to freeze, but I doubt it.

I was feeling quite comfortable with my valium and watched as our 3 little embryos were inserted right back into me. You can actually see them as a white spot on the ultrasound as the 3 little dots swooshed out of the catheter and at least one of them will hopefully burrow in.

I also asked the doc about the whole 3 vs. 5 day transfer issue. He said the nurses do the schedule and standard protocol is a 5 day transfer if there are 4 embryos. But as soon as he saw that it was me, he also told the nurse I need a 3 day transfer. At least we were all on the same page on that one. Naturally speaking, days 3-5 is where the embryo travels down the fallopian tube sloughing off some of it's outer shell (hatching) so that it's ready to implant in the lining of the uterus. Day 5 transfers more closely resemble nature, but that's only if the embryo will survive in the petri dish. While my embryos are back inside me and already in my uterus, implantation (if it happens) still wouldn't occur until probably tomorrow. One of the procedures performed on the embryos prior to being transferred back is called Assisted Hatching where they slightly scratch the surface of the embryo to allow it to hatch on it's own, since it doesn't have the benefit of traveling down my fallopian tube like it would naturally.

Transfer day counts as day 1 of bedrest. 1 day down, 2 more to go.

Fert Report

Got the call, 4 out of the 5 eggs fertilized. This is good. They wanted to do a day 5 transfer initially, but I said no. I've always done a day 3 transfer and no embryo has ever lived to day 5 in the culture. Doc called back and agreed to day 3. I'm really thinking there was some miscommunication and my RE didn't really think that with my history trying to make a day 5 with only 4 embryo's was a good idea. That's a little crazy actually.

Anyway, transfer is Sunday at 10:30 am. Then 3 days of bedrest for me. We'll have to wait to find out the quality of the embryos to decide how many to put back and we don't know that information until we're in the room ready to go.

Retrieval Results

The day started off ominously when we got in my Acadia at 6am and the car wouldn't start. Of all the steps in an IVF cycle, the timing of the trigger shot and the retrieval are the most crucial. After about 10 minutes working with my car, we ended up having to take DHs Subaru WRX STI, which is entirely uncomfortable with swollen ovaries, and we got there in a record 31 minutes going 85 mph to make sure we weren't late.

We walked into the building with the doctors and had a little chat in the elevator. I met the RE doing my retrieval and told him I only have 3, maybe 4, eggs and he needed to get them. He said not to worry, he's pretty greedy and he'll get everything he can. After doing paperwork we chatted with the RE for another 30 minutes just hanging out. We joked with the embryologist and told him to pick out a girly looking swimmer this time. Just to be clear, it was a joke. While it is possible to do full gender selection, we are not doing that. We did a lot of chatting with the docs before the procedure, it's a very different feel on a holiday when the staff is limited and just there for a few retrievals and transfers vs. other planned surgeries and a full days work.

A mystery was solved during my chat with the anesthesiologist. I'd mentioned before that the hysteroscopy surgeries were really kicking my butt and I was sleeping for 3-4 hours afterwards. Apparently that's because with those I have IV anesthesia along with gas (general anesthesia) and it takes a while for all the gas to work out of your system. For the retrieval, it's just IV anesthesia (sometimes called "twilight") and moves through your body faster. I felt pretty good after the surgery, napped for just an hour and was fully able to cook Thanksgiving dinner for DHs family.

But I'm getting ahead of myself. The retrieval. As I was moving into the OR and saying bye to my DH, I said "We're hoping for 3, 4, or maybe more." My first question in recovery of course was how many eggs. Oh yeah, we got 5! Now, we don't actually know if all the eggs are mature, if they will fertilize or survive the culture for the next 3 days, but for now we've got smiles on our faces with 5 eggs, which is more than we had expected.

I should be getting a call later this afternoon with the fertilization report. Come on, embies, fertilize, grow and come on back to me!

Insurance Companies and IF Etiquette

This one is purely a vent.

Insurance Companies

I pre-registered at the hospital and then got the call that insurance has denied this retrieval and it will cost $2,800 out of pocket. First off, you don't spend $3,800 on Rx and then not do the retrieval, so I'm pretty stuck. I called insurance and they said I already had 4 oocyte (egg) retrievals, which is not true, only 3. Apparently one of the claims in 2008 went through twice and everything has to go to the medical review board. In the meantime, I have to shell out the $2,800 upfront to have the retrieval done. Small glimmer of hope is that since the retrieval will be on a holiday, I have to go the surgery center rather than the usual hospital. Since the surgery center is partially owned by my doc and they know the situation, there's a chance I won't have to pay upfront and can wait for this to all get sorted out. We'll see.

My policy also states that I am allowed 4 oocyte retrievals, then with a live birth up to 2 more. When I asked about this, stating that since I had a live birth even if your records say I had 4 already, I should still be allowed 2 more regardless. Then they started analyzing the actual policy and stated that it's 4 total so this would be my last one covered by insurance. That is clearly not how the policy is written. If this IVF fails, I'm going to need to file an appeal with insurance before we move forward with the next one. The other part is that they asked if I ever submitted paperwork of a live birth. Hmm, didn't you pay for a c-section, newborn screenings and my DS is on the policy? Apparently my RE has to submit stating that the live birth is a direct result of the oocyte retrieval (and I didn't have a surprise pg). Did I mention that as a part of IVF it really helps if you remain stress free, yeah right.

IF Etiquette

I'm a member of RESOLVE the national infertility association and active on their chat boards. One discussion that I recall from the first time I went through infertility treatment was etiquette in the waiting room. Meaning, if you happen to have a child, don't bring them to the waiting room of an IF clinic. That's just rubbing salt into the wound. The first time around, it rarely happened and when it did I just tried to ignore the child. It was too painful. We all understand that going to the OB/GYN for the annual exam will be traumatic. Swollen bellies just staring at you, excited talk about ultrasounds and fetal growth, babies crying, kids all over the place. That's to be expected and you steel your nerves and forge ahead. But at an IF clinic, that's your safe place. The one place that you shouldn't have to look at another child while you mentally spiral downwards in the "what if" game should you never get pregnant.

This time around, I don't think I've ever been in the waiting room without another child there. How did times change this much in 2 years? Why are there so many kids in the waiting room? From the previous discussion, I understand that SAHMs might need to bring their kids since they have no alternative care. But today, a mother, child and grandma show up. And the grandma is talking loud playing with the child. If you look around the room, most eyes are averted and looking at the floor, very actively trying not to look at the reminder of what they might never have.

For me, I will try my hardest to never take my DS to the clinic or the hospital. I just cannot do that to my fellow IF women in pain and anguish. It can take a huge physical and mental toll to be in a situation like that and not feel increased anxiety and stress.

Retrieval on Thanksgiving....

Monitoring Update

Well, on Monday I went back in and those follies just did not grow enough over the weekend. Left had 15 and 19, while the right had a 17 and two at 11. My E2 was 709. We discussed ER being on Thursday (Thanksgiving) rather than Wednesday as planned. Got the call later that after reviewing my labs, I needed to do one more day of stims and Ganirelix.

Today I went back in and they are looking better. Left has an 18 and 20. Right has a 20, and a 14 mm that might grow enough to be mature. We're looking at 3, possibly 4 eggs. Sometimes they find more in retrieval that don't show up on u/s, but it would only be 1 more. Sigh. Such is my body that I just don't respond or produce much. I'm still waiting for the final call, but I'm expecting to do my HCG trigger shot tonight.

In the past, the IM shots had to be done in the butt. We did that for the trigger shots and progesterone during the 2WW and then the whole first trimester. Progesterone is a thick oil requiring a 25 gauge needle, rather than a 27 or 32 gauge sub-q injection. But my clinic has changed protocols and they no longer do any shots in the butt. My poor DH has done roughly 115 shots in my booty, staring at my ass like a meat map to find the best spot that doesn't already have a knot in it. However there was a mix up with the drugs so my HCG trigger shot is an IM shot rather than a sub-q. DH will just have this last chance to jab a needle in my booty.

Thanksgiving

Did I mention that we're hosting Thanksgiving for DH's out of town family that is staying with us? Kind of throws a kink in the plans. I've been doing a little bit of cooking each night. When I thought retrieval was Wed, I made a lasagna that we could just toss in the oven for dinner that night while I sleep off the anesthesia. Now it's going to be Thursday, so I'm going to need to prepare the stuffing, green bean casserole, potatoes, bread, etc. as much as possible ahead of time. IF stuff never really sticks to the schedule. Which also means I've had to rearrange care of DS a few times as well. Luckily with this new timing, DHs family will watch him for retrieval and I've got an awesome friend who even while hosting lots of her own family/friends agreed to watch him for the Sunday transfer.

Still waiting for the official call to give the go-ahead. Tonight would be one shot in the butt and start antibiotics. Tomorrow will be blissfully injection free!

Monitoring Update - On Track

I had another ultrasound and bloodwork on Friday. Everything is on track and looking good. The left side has 2 follies at 13 and 14. The right side has a 12, 9, 7 and 6 mm follies. It looks like I might be able to get about 4 eggs if the 12, 13, 14, and 9 are all mature at the same time. Based on the follicle size I started the Ganirelix injections last night as well. This will prevent my LH surge from happening which triggers your body to start ovulating the eggs. We want to keep them growing.

Estrogen came in at 565 and is rising appropriately now after the kick start of increasing my meds. FedEx shipment of the new drugs arrived right on time and I have exactly enough medication to take me through Monday night if I have to take full doses of the Menopur, Bravelle and Ganirelix. Anything additional needs to be ordered Monday for delivery Tuesday for evening injections.

Based on all of this I'm estimating egg retrieval to be on Wednesday with embryo transfer on Saturday. Which means bedrest would be Saturday, Sunday and Monday. Considering I'm hosting Thanksgiving with DHs family this will be interesting. I'll attempt to prep the ingredients and get as much ready to go as possible since I'll be out of commission on Wednesday and still in pain on Thursday for Thanksgiving.

I was talking to the nurse and making my usual assumptions about the cycle and at one point she turned to me and said, "Lisa, you just know too much." That statement is so true. For TTC#1 I did 13 medicated cycles (4 clomid, 6 IUI, 3 IVF) and you gain a lot of knowledge in that amount of time.

As for my body, I'm in the usual amount of pain. I'm pretty much uncomfortable most of the time due to the pressure of my enlarged ovaries. They are typically the size of a grape and during this time swell up to the size of a golf ball (and I have just a few follicles, it's worse for people who really respond well). The prednisone steroids are causing chest pains and general flutterings of pain in random places.

However the prednisone is also causing me to lose weight. I've lost 5 lbs in a week. The side effects are that you gain weight on prednisone, so I'm a little concerned about how effectively it's working. The first time I took it, I also lost weight and that cycle ended up being converted from IVF to IUI due to a large cyst. The second time I took it (my BFP cycle) I gained 5 lbs in a week. As usual, I'm googling for any indication of this being good or bad, although I assume bad. I'm taking prednisone to suppress my own immune system and help allow implantation to occur by not rejecting the embryo. While I officially only have anti-thyroid antibodies (ATA) and my other immune issue markers (ANA, APA, NKA, etc.) are negative, after 12 cycles my RE and I decided I might as well try immunosuppression and it worked. So yes, this all just goes to the point that I know too much. It's tough to sit back, relax, and let it all happen when I have so much data to compare everything too on previous cycles.

But for the rest of this weekend at least, I'm going to try to chill and let those follies grow. By Monday, I should hopefully get the news that I'm ready for my trigger shot and looking for a retrieval on Wednesday. Come on follies, grow!

The Cost of Drugs

For my initial set of drugs, I ordered them from IVFMeds in Europe and it's ridiculous how much cheaper they are there than in the US. 1 vial ranges from $30-$40 and I was planning on using 5 vials a day. In the US, 1 vial is $90. While I still spent $2,335 on the initial order, I actually saved about $3,400 by ordering overseas.

Now that I'm on a higher dose (8 vials/day), I need to get refills and can't wait for the overseas delivery time so I have to order in the US. I ran out of Rx insurance coverage in 2007 when I hit my $10,000 lifetime limit, so everything is out of pocket. The US pharmacy I normally use was at $90/vial. My doc's office said they use a different one now and it is actually a bit cheaper. I had to pay a $10 membership fee to get the the reduced rates (whatever) but it was $68/vial of Bravelle and $54.90/vial of Menopur. It's still another $1,236.50 to pay for 14 more vials, but overall I saved another $1,400. I like to focus on the savings and not the money I'm actually paying. I won't calculate the savings I would have had getting it all from Europe.

Bottom line is that these drugs cost a whole lot of money and so far I'm only talking about a few of the injectables. Not even the pills, patches and creams. Dang US pharmaceutical industry overcharging as much as they can on all the drugs!

Reality Check

Ultrasound this morning showed that the follies have grown so that's good news. Left side has 2 around 10 mm and the right has 1 at 10 mm and then a few smaller ones on both. It's good that there are 3 around the same size, so if they grow at the same speed it's easier to know when to do the trigger shot vs. having them all at different sizes.

Bloodwork just came in and my E2 level has moved up to 226, which is better and gives a glimmer of hope. Each mature egg should have an E2 level of about 150 - 200. I'm on day 6 of stims and my BFP cycle at this point I was at 628 and had 5 mature eggs. It will be less eggs this time, which I somewhat expected. While there are a number of follicles, it seems likely that they won't all have eggs in them.

Here's the reality check - somehow over the last two years of being pg and having DS I had blissfully been lost in the world that I had worked so hard to achieve. Now I'm sucked back into the reality that a 2nd pg might not be possible. My main symptom of infertility is my AMH level which is beyond low, meaning Diminished Ovarian Reserve. I have a tiny amount of eggs left and the ones I do have aren't that good. My body has to work well beyond what an average person has to do just to produce one egg. Which means I also am a poor responder to stims, even the artificial Rx can't make my body produce eggs. Generally people doing IVF get 15-20 eggs at a retrieval, I've had 1, 4, and 5 respectively.

The outlook does not look good. DOR, FSH = 15, E2 not rising. The reality is I'm probably at the very end of whatever reproductive life I have left. The initial thought was possibly cancel this cycle and try again for a better one. But I don't think there will be a better one. This is it. I'm 2 years older, my eggs are crap, and my body once again does not respond. All I need is that one magical egg to push to the top and make it through the rigors of being sucked out of my body by a needle, dumped in a petri dish, have a sperm manually injected into it, and then grow in a culture for 3 days until it's put in a catheter and shot back up into me. Is that really asking too much?

I hit the doc again on Friday, come on follies, grow!

Uh-oh, Low Estrogen

I had another ultrasound and bloodwork done on Monday. Things were looking good from the ultrasound. 5 follicles on the right, which is about normal. Even 3 on the left, which is really good considering the left side normally doesn't produce anything. But even a few follicles doesn't mean they'll all end up being mature so we're looking at still around 3-5 possible eggs.

Then I got the phone call. My estrogen (E2) level is really low. For baseline at the beginning of the cycle it should be below 60. Mine was in the 20's which is good. For CD6 which was Monday, it should have been over 200, but it was only at 68. This is bad. It means my body is not responding to the meds. This is a new problem for me, I've never had to worry about my E2 levels before. Just goes to show that even having a protocol that worked one time, doesn't mean it will work again. My hormones are different, I'm 2 years older, and my body has changed.

They increased my dose. I'm now doing the maximum amount of drugs at 300 IU Bravelle and 300 IU Menopur. My bloodwork on Wednesday will be the indicator of if this is working or not. If my E2 doesn't increase to an appropriate level, we'll probably need to cancel this cycle and start doing more testing, try a different protocol, etc.

As a reference, each injection at the prior dose is about $300. At the increased dose it's around $500. So I shove $500 a day into my stomach (not counting all the other oral Rx I take). You would think that losing the money and cancelling the cycle would hurt, but I am so numb to the amount of money it takes to make a baby. We just paid $600 to have the infectious disease bloodwork done for both DH and me in the even that we ever have an embryo that survives to be frozen, which we won't but have to pay it anyway.

What really hurts is the thought of not being able to have another baby, or to spend a few more years trying while not being able to focus in the moment on everything DS is doing. DH and I had a pep talk last night, I meditated this morning, and I'm sending super estrogen thoughts to my ovaries right now. Come on follies, grow!

And so it begins...again

IVF #4 for TTC #2 has finally begun after months of preparation. Had my baseline ultrasound and bloodwork today and everything looked good. I started stims this evening. DH did his infectious disease bloodwork and I'll do mine at the next visit.

Here's the stats:

Antral follicles - 5 on the left, 4 on the right

FSH = 9 (lower than my previous 15 in 2008, but higher than the 6 that I had in July)

E2 and P4 are all within normal limits

A look at the meds needed to make a baby. If only getting drunk and doing it in the backseat of a car would really work, it would be much easier.

It took a little bit to steel my nerve again for the injections. It's been about 16 months since I did the last shot, which was Heparin as a blood thinner. It took a bit longer to mix up the 5 vials of powder, but it's all coming back to me now. To think I used to do this in bar bathrooms, cars, and friends houses all the time. Luckily the injections are at night and since I'm generally home to put my DS to bed, it should be a bit tamer this time around.

I did 225 IU of Bravelle and 150 IU of Menopur, plus 5 mg of Prednisone steriods twice today. I assume I'll be packing on the pounds again due to the steroids, but I know it's all worth it in the end. I'm using the power of my birthday wish to hope that this one works for us and we get pg with another LO on this cycle!

3rd Hystersoscopy - Check!

Just had another hysteroscopy on Thursday and the news was good - only minimal scar tissue grew back. The surgeon was able to remove all of it. I'm back on estrogen for a week to help keep the uterine walls from sticking together. The other piece of good news is that even if this first IVF fails, he doesn't think the tissue will grow back that quickly and I won't need to have a hysteroscopy before each and every cycle - whew!

I've got all my drugs in the house. I've got an appointment for my baseline bloodwork and ultrasound next Friday. I seriously never thought that I would be excited to see a needle again, but after 5 months of "preparing" to start trying for #2, the prospect of actually moving forward is very encouraging. If all goes well at my baseline, I'll be ready to stick a needle in my tummy next weekend!