Breaking the Silence - Here's What's Been Happening

I know I've been silent on here ever since I announced that the first IVF for TTC#2 worked and I was pregnant. Here's the story on why.... It's long, so grab a beverage before you start reading.

Our retrieval was on Thanksgiving and the transfer 3 days later. We made the decision to put back 3 embryos, the same thing we did the past two IVFs. This decision was based on the advice from our RE, our past history of putting back 3, and the fact that this cycle required more and more stim drugs meaning it was getting even harder for my body to produce eggs. This was our last chance. All was going well and I felt some slight tugging and pressure a few days after the transfer, exactly as I had felt with my DS. Maybe this might work.

I went in 8 days after the transfer and my HCG level was 94! A positive result is anything over 20. But we're not out of the woods yet, it has to approximately double every 48 hours. Sure enough, 48 hours later it was 346, the next one was 1373 at 12 days past transfer. For perspective, with my DS on 12 days past transfer my HCG was at 326. My mind went into overdrive, uh-oh, I think we have multiples. I checked out betabase.info and while my numbers fell into the range of a singleton and twins, I knew something was up. DH and I started to prepare ourselves for having twins. Three days later, my HCG shot up to 4378. We had an ultrasound that same Monday at 4.5 weeks, but it was too early to see anything. I went back on Friday and we saw 3 gestational sacs - yes, 3. All 3 embryos that we put back had implanted. I cried right there on the table.

What had happened? Over the past 3 IVFs we've put back 7 embryos and only had 1 baby. How could all 3 have implanted? What were we going to do with 3 babies? The nurses all assured me that it was really early and a lot can happen. Something like 40-50% of triplet pregnancies lose one by 11 weeks. I turned to my Resolve chat boards, poured my heart out, and received amazing support from the ladies on there. We have all been through so many ups and downs together, and these ladies were able to share their own personal experiences around this and talk me down a bit. I started checking out tripletconnection.org to read about families with triplets. How many medical problems were there at birth, how do families cope day to day, what types of developmental delays, etc.

We were thinking that the first ultrasound would show twins and we would be able to say we were pg with twins. But with triplets! How do you even say that? We knew we couldn't look at people and show genuine happiness, we were scared to death, overwhelmed with emotion, financial thoughts, our lives completely turning upside down. I would have to quit my job and stay home. So I took the cowards way out and just posted that we were pg on this blog for those of you that were following the IVF, then remained silence. We had nothing more that we wanted to share at that time. I called family to say that we were pg, but avoided questions of "how many" by saying it was too early to tell.

At 6 weeks, all 3 were growing on track and we could see heart flutters. With Christmas approaching and the RE office closed for a few days, I was given a prescription for nausea since I would have triple the hormones and could have triple the morning sickness. I never filled that prescription. Other than exhaustion, I've felt fine. At 6.5 weeks, they were all growing on track and while we still couldn't hear their heartbeats, we were able to measure them between 104-133 beats per minute (bpm). At that point, the doctor told me he was just going to look around a little bit and make sure we weren't missing another one that might have split. While my feet were in stirrups, my leg started to shake. Another one? Sigh of relief, nothing more was found other than my still massively swollen ovaries producing triple the hormones.

At 7.5 weeks, I went to the OB for my first visit. All 3 were growing on track with heartbeats in the 160-168 range. I asked if my OB could handle this pregnancy. He's delivered hundreds of twins, but only 4 triplets. I was referred to a Maternal Fetal Medicine (MFM) specialist in the Medical Center. My OB told me that he takes a conservative approach to multiples and would recommend bedrest at 19 weeks for triplets, and if we lost one, it would be 24-28 weeks for twins. It's not medically necessary or proven, but the thought is that by staying off your feet and taking pressure off the cervix, pre-term labor can hopefully be avoided. We were all for that plan. After my whole almost dying incident while giving birth to DS, we want to be cautious. But wow, that meant I didn't have a whole lot of time left.

Later that week I saw the RE again, everyone was growing. I started researching the leave of absence and short term disability programs at work. If I stopped working before the babies were born, I would use up all my FMLA and only have 8 weeks after the birth for STD from a c-section. That's not enough especially if they spend time in the NICU. Instead, I'm going to cut back my hours to 25-30/week while on bedrest and hope to reduce some stress. It will be a pay hit for a few months but I should keep all of my benefits, accrue vacation time, and keep my STD and FMLA time for when they are born. The next step about my job won't be decided until after they are born.

At 9 weeks, saw the RE and they were all growing. One nurse in particular has been so supportive during all of this. Talking me through my overstressed and overwhelmed tears, providing the name of a counselor, and just patiently answering all of my questions. At 9.5 weeks, I saw the MFM and we talked about risks. We also talked about my MTHFR (I don't absorb folic acid and can have blood clots). He said that staying on my normal 3 doses of folic acid with B vitamins a day is enough to counteract the MTHFR, and that I no longer need to take the Lovenox blood thinner injections. Woo hoo! That was definitely positive and I stopped that very day. I still will take baby aspirin the whole way through for my own peace of mind.

Another RE visit, but since I was already being seen by the OB and MFM, this was to be my last appointment. I do recall taking a last look back at the office while I walked out the door, thinking that I would never be back. Whatever happens with this pg, I am done. Even if we lose them all, I am just done, I can not go back and do this again. The amount of physical and emotional pain, and the volume of tears that have been shed while trying to build a family had definitely taken their toll. I knew that if we lost them all, we could potentially try naturally, but I would never be back and we would most likely stay a family of 3.

Over the next few weeks we saw the MFM a few times and baby C was was not doing as well. With my age, the fertility drugs, and seeing baby C, we decided to do CVS (chorionic villius sampling) testing on baby A and B to see if they would be ok. It is a painful procedure. We were supposed to have results in 48 hours, but because of baby A and B's placenta being close to each other, the doc wasn't able to get enough tissue for the fast test. In fact, he thought he might have to go in again to get more tissue. Mine was transabdominal and they essentially take a large needle, stab it through your skin, fat, muscle and uterus to get tissue from the placenta to test the DNA cells. It literally took my breath away. Luckily I've learned a lot of coping skills over the years for dealing with physical pain and I used them to get through it. The thought of it being done "again" to get more tissue was agonizing. We waited an hour to see if the lab had enough tissue, which they did.

We waited 2 weeks to get the results. During that time we didn't have anymore ultrasounds. Even with it looking like we were losing baby C, there was nothing that could be done. It was definitely a mixed feeling. We've known all along that we had no idea how to handle triplets, and losing one makes everything more manageable (not that twins and a toddler won't be challenging enough), but we'd seen baby C on the ultrasound a number of times, wiggling and moving. It's heartbreaking to think that we'll never meet our child. The doc told us to take a break from all the appointments and wait for the results. We finally got the tests back on baby A and B and they are both genetically normal (no Down's Syndrome, Cystic Fibrosis, etc) and at this point we're not at risk of losing them. They are also both males. While we were thrilled to hear that they are healthy, DH and I were both a little sad that we wouldn't be having a little girl. We've shed another round of tears over the last few days, losing baby C and wondering if that would have been our little girl. Baby C's picture will be added to our infertility album, which holds pictures of all of our past embryos that never made it.

Here's the last picture we have of the 3 of them together. Baby A is on the far right with hands on his head, baby B is in the middle, upside down with feet at the top. Baby C is on the left/bottom, already looking a little smaller than the others.

But now we are ready to move on! I'm 14w2d, starting the 2nd trimester and ready to be excited about our growing family. I want to enjoy this pregnancy, my last one, be amazed by the kicks in my belly and keep these babies inside as long as possible. We'll be re-using all of DSs bedding, clothes, etc, but just today went out and bought a 2nd set of boy bedding. We're having twin boys, exciting and scary all at the same time!

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.

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!

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!

Waiting until November

Based on my last consult, we realized that since the lab closes for 2-3 weeks each year in December, we can only get in one IVF. Rushing to get it done before we go to Jamaica and either getting a BFN, having a low Beta, or stressing about it wasn't going to do any good. So I'll remain on BCP, have my next hysteroscopy on 10/28, go on vacation and plan to start stims as soon as we get back.

The last day for stims based on the lab closing is 11/29. We should have 8 days of wiggle room in there to make sure we get done. Since I'm always a day 3 transfer, I probably have even 2 more days of wiggle room that they allow for day 5 transfers. What this means is I might be on bedrest during Thanksgiving and we're hosting some of DH's family. Oh well.

Now I need to get moving on working through all the additional drugs I need to order. The Bravelle, Menopur and Antagon are in the house. But I need Lovenox, Prednisone, HCG, Estrogen, antibiotics, valium, and the list goes on and on. I need to pull out my old notes on which pharmacy's had the best rates and get that ready to have all my Rx's called in. Be prepared for some additional venting on how I hate Rx companies over the next few weeks.

While we are definitely not pleased with the waiting game, it has been out of our control based on all the hysteroscopies. Even without the planned vacation, at this point we would only be able to do one IVF this year (I always need a month off after treatment due to ovarian cysts). Mentally, this helps us to feel better about where we are, as we were both frustrated with the fact that we've been trying to get started since May, always planning around this vacation, and the timing has hit this vacation right on the head.

Another Diagnosis

Had a consult with my RE yesterday. He said I have Asherman's Syndrome. It's when a trauma to the uterus (my c-section) results in the formation of scar tissue. There are varying degrees of severity and that is what we still don't know. Will it keep growing back? Is it gone? Will it get worse?

Here's the revised plan. Stay on my current estrogen and progesterone therapy for the full 21 days to let my uterus heal from the last surgery. Go in for ultrasound on day 1, then start birth control (BCP) on day 5. Have another hysteroscopy so they can check to see if the scar tissue has grown back. If it's clear, I heal for a few days while on BCP, then go off, get a day 1 and start IVF. If only minor scar tissue removal needs to be done, I heal for a while on BCP then same thing and start IVF. If it's major regrowth of scar tissue, they remove it and we re-assess.

Any way you look at it, it's all a whole lot of delays. I was really planning on getting at least 2 IVFs in this year (possibly even 3) until all this happened. I've already hit my out of pocket maximum on insurance so I was hoping to get 2 IVFs for minimal money (although the Rx costs are still the biggest hit). Now, I'll be lucky if we get to do 1 this year. Based on all these hysteroscopies/healing/waiting by the time I'm ready to start it will hit my family all-inclusive trip to Jamaica. I already declared that there is no way in hell I will be in any type of a 2 week wait during that trip. I'm either not drinking because I'm happy and pregnant. Or drinking it up because I'm sad.

To put it quite simply, IF sucks.

Familiar Routine

I realized I had some spotting the other day and nothing much else has happened. Hmm, wonder if that was yet again another "blink and you'll miss it" period. I called the doc this morning to say I think I'm on day 3 so I went in for testing. Most of the staff has changed, but it was comforting to go back to the same nurse that told me I was pregnant about 22 months ago.

The ususal chat with reception, bloodwork (with a better nurse than the normal one who unfortunately still works there but was on vacation this week) and then an ultrasound (u/s). My antral follicle count looks promising with about 10 on the right and 3 on the left - if only the left side of my body would kick it into gear. E2, P4, FSH and LH all look good. I'm still waiting on the prolactin level since they don't check that one in the office. But other than that, we're moving ahead. I picked up my BCP today and I'll start it tomorrow. I should be scheduling the hysteroscopy in the next week or two. Hopefully nothing shows up during that surgery requiring additional recovery time or medication.

We talked through the list of drugs they use for IVF. Many of the protocols have changed but the doc and I agreed to do exactly what we did last time. I got my Rx and have started looking at costs from the various IVF drug pharmacies. I think going to Europe is still cheaper, so I need to figure out dosages and put in an order so it can get shipped out. For just one drug for 12 days, I'm already at $1,080. I still have many more drugs to add to that list. I forget the staggering price of medication.

Here's hoping the prolactin level comes back low and my hysteroscopy doesn't turn up anything bad. Oh, and for scheduling surgery, timing would have it fall right on my DSs bday. Considering my horrible delivery and near death experience (botched c-section with 7 blood transfusions and 3 days in ICU), if I were superstitous I would probably avoid scheduling another surgery on the same day.

And We're Off...Like a Herd of Turtles

Well, DS took it upon himself to wean at 9.5 months so we're actually ahead of the plan that was laid out before. Called the RE yesterday and I need to wait through 1 more cycle, then the next one I'll do BCP and get Day 3 labs done to check FSH, E2, P4 and Prolactin to determine if I'm getting close to ready. If so, we'll do the hysteroscopy. If my cycles are at all regular, that means the hysterscopy would be in mid-July and IVF starting mid-August.

Initially DH and I had said we would try naturally for a few months before jumping into IVF again, but with this plan we'll only really try for 2 months before doing IVF - and honestly we're both fine with that since we have no realistic hopes that natural would work anyway.

On the Rx front, I had vented before about not being able to get Folgard from my Rx company. Just an update that it did take 1 month, yes a whole month, but I finally have my Folgard and started taking it this week. Crazy, inept, infuriating, $*#Y$, #@($*, .....

We Have a Plan - well, maybe...

Saw the RE yesterday, we'll call him Doc G. I did not realize how long it would take to get started again. After I completely wean from nursing, he said it takes 2-3 months for my prolactin levels to get back to normal to even try. It will also take about 2 months to wean, so we're looking at about 5 months if I started weaning today.

Because of my near death experience during my C-section, the blood pooling in my uterus could have formed scar tissue which would cause problems. I'll need to have another hysteroscopy (surgery) done before we can even attempt to move forward with IVF. Not what I wanted to hear.

Doc G did confirm that we'll use the same protocol as last time, we won't vary anything even if we're not sure if it's needed, like the steroids for a month and blood thinners the whole time.

On a positive note, it did feel a little bit like a reunion seeing my old doc and 2 of the staff members that are still there. I guess it's been about 18 months since I was there last.

The plan...
- Wean for 2 months
- BCP for 1 month
- BCP for month 2 with hysteroscopy
- Check prolactin levels and day 3 bloodwork
- Possibly begin IVF at least 5 months from now