Thursday, 14 November 2013

Life happens while you're making other plans...

Every now and then, I'll encounter a patient who has an elaborate or unrealistic birth plan; and I'll gently remind her that she'll need to be flexible and ready to roll with the punches. Labour and delivery is so unpredictable and situations can change without a moment's notice. It somewhat amuses me when patients seem to have a script for their birth performance. Although I obviously have no personal experience, I'll often mention that the lack of personal control during the birth is only heralding the absence of order that will accompany the arrival of baby chaos. I haven't even made it past six weeks gestation, but I've been discovering that nothing related to procreation is mine to command.

Pausing for a brief moment to recall that my procreation plans originally included conceiving early so that our baby would be born in 2012 and could be a leap year baby like me. I wanted to avoid having a baby born in the unlucky year of 2013 (wish granted!) and I'm not holding out for 2014. Although the Universe has been ignoring virtually all my requests, I will mention that 3/14/15 would be an awesome birth date as it's Pi Day out to five places. Until Husband pointed out that technically it's not, as the full date is 3/14/2015 and that it's American Pi Day, as the proper way to write the date is 14/3/2015.

Perhaps equally ridiculous, is the fact that I thought I could plan my first IVF cycle. My RE mentioned a few times that you don't know how things will unfold during a cycle until you start the process. Non Sequitur Chica offered sage advice when she described her first IVF attempt as a diagnostic cycle. Yet I thought I was still operating within reasonable expectations. I knew I wouldn't be a chicken that would produce twenty or more eggs. In fact, I accurately predicted the dozen oocytes retrieved (I just underestimated their maturity). I was surprised when my RE initially expressed concerns for a possible over response.
"What is his rationale?" Husband asked, "I need to see the maths." Here is where hubris would get the best of me again. I've felt that I've been sitting on a goldmine in the form of my AMH of 4.53 (Day 3 FSH 7.1). When I first received that result, I questioned it as an AMH >4.0 can be suggestive of Polycystic Ovarian Syndrome (PCOS) in the presence of clinical features. I emailed another local RE to get a consult for a "patient". I listed my age, lab values and noted how much exercise I do to explain that my near overweight BMI is due to muscle mass. He replied: you can reassure "your patient" that she has a good ovarian reserve. (Air quotes were not actually used, but I'm sure they were implied)

My RE was actually the one who initially suggested doing a freeze all cycle. When I asked him about PGD testing, he responded, "You're a good candidate for it" as he noted that he often has patients who are in their early 40s who ask for it, not realising that they won't have enough embryos that will progress to that point. The unknown variable with our cycle would be how my eggs would fertilise given that we are dealing with male factor issues.

Thus, I felt that I had it all planned out. I would produce a decent yield of eggs for an old bird, and hopefully a good number would fertilise and could be biopsied before being sent to the freezer. The PGD testing would allow us to transfer euploid embryos only and thus could prevent the heartbreak from a miscarriage due to a chromosomal abnormality. I even got greedy dreaming that we could select a female embryo. Most of all, we could only transfer one embryo at a time and nearly eliminate the possibility of twins.

From the moment I heard my RE project that we'd only obtain 6-8 mature eggs, I became discouraged. I knew we'd be working with fewer embryos. Although there were concerns about fertilisation, Husband's boys were up to the challenge. His Wank In a Cup (WIAC) results boasted a concentration of 29 million with post prep at 9 million, higher than any of our IUIs. It was his best sperm day ever. His motility was unusually low at 30%, but who cares when you're doing ICSI!

Seemingly, all my plans went out the window when I heard my RE recommend transferring two embryos on Day 3. On a minor detail, I was looking forward to having the stimming and retrieval and the transfer and waiting to be two separate events at different times. I had just refreshed my lingerie collection and wouldn't even get to wear my new underwear once before they would get yucked by progesterone suppositories. Dare I even think that we could select the time for our FET and chose when we wanted to try to get knocked up. I wasn't going to be able to do PGD testing to select a normal embryo for my transfer.  I was being asked to surrender my intention for a single embryo transfer.

I believe my RE was very perceptive when he forecasted that I would regret a day 3 single embryo transfer if it were to fail. He was right. I would know that the lone transferred embryo was a dud and I would wonder if a second one may have implanted. If my beta is negative, then at least I can feel relieved that I'm not facing the possibility of twins. If I am pregnant with twins; I will be pissed. I will be pissed at myself for not sticking to my resolve on a matter that was so important to me. My RE commented that even when we were attempting conception with intercourse, there was still a risk of twins. I smirked. Did he not note how pathetic we were at trying to conceive the natural way? This is part of the reason why we're here. Even with ovulation predictor tests, I couldn't figure out when I was ovulating and whether we could manage coitus was another obstacle. Still, there is a difference between an occurrence of twins as a random event in nature and acknowledging that I uttered the words, "we'll transfer two..." to the embryologist.

I'm ashamed to admit that I had a bit of an outburst when my RE first reported the embryo status and his recommendations. While I appreciate that the ultimate worse case scenario would be not having any embryos to transfer or freeze, I still needed to lament frustration about this cycle. It was more than petulant whining that things weren't going to plan or that I wasn't getting my way. I felt that I had failed to meet expectations. I had to transfer my embryos earlier and in greater quantity as their prognosis was poor. "Jane, Jane, Jane...Jane!" My RE tried to avert me from going off the deep end, although it was a bit too late.  "A Day 3 transfer is not a desperation measure," he reassured. Really? Then why did it feel as if it were. It's never easy to discover that you're not as good as you thought you were.

Even as I'm finally accepting that I have little control over this process, I can't resist trying to plan our next steps. I'm curious to hear my RE's postmortem analysis of this cycle. Would I have been able to produce more eggs if I didn't have to reduce and sometimes hold my stims?  Going forward with another cycle, would it be better to start off at a lower dose and then increase? Would Husband be able to equal or better his awesome WIAC performance? If we have any fro-yos, when would we want to transfer? I'd like to attempt endometrial injury prior to an FET, can I have one of my colleagues do my endometrial biopsy?

Then again, maybe life is what happens to you while you're busy making other plans...


  1. I think the only thing that gets me through my current cycle is planning my next (and hoping I never need to use it!) Xoxo

  2. Aubrey is right, this is classic "I'm preparing for failure this cycle by planning the next one already" behaviour. And I'm just as guilty of it. It's totally a coping mechanism that makes you feel like you have some sort of control over this process, because you know you have absolutely NONE over what's going on in your ute right now. I am very much hoping this is putting the cart before the horse, and you won't need a postmortem with your RE or any of your other plans.

  3. It is always scary to feel like we have so little control through out this whole process. I understand your fear of twins... having too much medical knowledge makes twins all the more frightening (as I am learning). I am sending good thoughts your way.

  4. I completely agree with Aubrey and Aramis. It's the mind game we all play to protect ourselves from more hurt. You can't be as disappointed if you never thought it was going to go well in the first place. I've practically moved on to donor eggs when mine haven't even been fertilized yet (severe MFI; no sperm found thus far). I very much hope that things work out the way you want them to. Oh, and, I've been reading for a while, sorry that it took me so long to comment.

  5. I think it's impossible not to have a minor (major) freak out when things don't go according to plan, especially when it's about something so important to us. I've been thinking about you, my friend, and hope that you don't have to use that back up plan.