Sunday, 29 December 2013

2013 Challenge: Completed!

As you may recall, Husband and I issued a challenge at the beginning of the year to see which would be accomplished first; getting pregnant or finishing painting the kitchen cabinets. I'm not sure how to score this. Technically, I did become pregnant while the final doors were still in progress, but I was no longer pregnant when I completed my last clear coat. I'm going to declare it as a draw, as there were times when I doubted either event would be completed before the year's end. Here's a look back at the progress leading to the final product.

Message to our embryos: You could be coming home to a kick-ass kitchen! This is a Price Is Right showcase showdown kitchen completely tricked out with a microwave drawer, retractable exhaust fan and a wine fridge (remind me to get a lock for that). I've applied two coats of sealant to the cabinets anticipating projectile puking. I have all the original paints, so if you draw on the walls, we'll just get out the rollers and brushes. I may be a little more tolerant that other mothers -try not to take advantage of that. Maybe a kitchen doesn't mean that much for you, but your parents are pretty skilled. Think about the possibilities for a tree fort, or a bunk bed loft... all you have to do is defrost, implant and grow...


Demo begins...

Installing the hard wood floor
The Island is erected! 

Granite installation

Finished at last! (forgive the poor light)

Finally,  Amanda from Beloved Burnt Toast posted earlier this month about her decision not to put up and decorate a Christmas tree this year. Several other bloggers commented that they were also forgoing a tree, myself included. A few others notes that they had stopped exchanging gifts with their spouses and some family and friends in order to save money for infertility treatments. I'm included in that category as well. It angers me as I feel that this is just one more thing that infertility takes from you. However, I received a beautiful humming bird ornament from Teresa at Where the *Bleep* is our Stork? Teresa also arranged an ornament exchange, and I received a Disney themed ornament from Heather S. at I should B.... I like to think that whatever happens in the future, I can unpack these ornaments each year and remember all the amazing people I met during this journey; and with this simple action, I can feel like I'm taking something back. 

Thursday, 26 December 2013

The Smallest Gesture

A few years ago I saw a patient "Martha" for a routine OB visit. Without going into any specific details, I noticed that something didn't look right on her ultrasound and I called in a colleague to confirm my findings. Martha was already in tears when we re-entered the room. I held Martha's hand as my colleague moved the ultrasound wand over her abdomen. She looked at me and nodded and I felt Martha's grip tighten.

Martha was pregnant again about 6 or 7 months later. At the end of her visit, I asked if she had any intentions to delay announcing her pregnancy this time around.
"We told everyone as soon as we had a positive pregnancy test." she replied "We figured that we are going to need all the love and support from family and friends that we can get, and we need it right away!"
I smiled. Her energy was absolutely uplifting.
"You know, I'll never forget what you did for me that day."
"I can only imagine how hard it must be to come back and see me. I would understand if you wanted to see someone else to avoid bringing back any memories."
"No. I was referring to when you held my hand while the other doctor was doing the ultrasound."
"Oh Martha! I had just delivered the worst possible news to you. I felt so helpless. It seemed like it was the least I could do..."
"It meant the world to me at that moment" she replied.
Thus, I learned never to underestimate the power of even the smallest gesture.

Myrtle and I chatted on the phone over Thanksgiving weekend and she asked how things were "health-wise." I didn't want to tell her that I was barely pregnant, so I explained that we would be resuming treatments in the new year, after taking a break due to the holidays. I knew that if the pregnancy were successful, she would figure out that I was withholding the news. After learning that we were non-viable, I realised that my lie had become a self fulfilling prophecy, and I considered not telling her about this miscarriage. The next day, she texted asking for Christmas gift ideas. I wrote back with instructions not to bother; we didn't want or need anything at this time. Then I felt badly about giving such a pissy reply, and perhaps because I am an idiot, I informed her about my second miscarriage. "I'm so sorry" she wrote back and let me know that she'd be available to talk later if I wanted. "Was this a natural conception or IVF?" she inquired.

I chose not to reply. A week later, I phoned her on her birthday. The conversation swung to Husband's trip east and she asked me if I was making the trek as well.
"No. Not this year."
"Awww. Why not?"
"Well, Connecticut in the middle of winter is not an ideal destination..."
"Any other reasons?" she hinted.
"It's just not practical with everything we have going on." I admitted.
"So, we didn't establish this earlier, was this a natural conception or because of IVF?"
"It really doesn't matter. The outcome is the same." Apparently this detail was important to her.
"Yes, it was an IVF pregnancy."
"Oh, I didn't know you had started that process."
"This was our first IVF cycle and we'll do another one in February (this was easier than explaining the process of a FET)." I briefly described how I couldn't let myself even accept the idea of the pregnancy, as I feared this could happen again. Although she hadn't asked about him, "It's really hitting Husband hard." I informed her. "Today he learned that a guy from University, who could be described as emotionally unstable at best, just had a kid, and another old hockey teammate is expecting his fourth. We started joking that if Logic procreates, then we'll engage in a mutual suicide pact."

[Background] Logic (his nickname in real life) was the flatmate of one of Husband's hockey friends. A rather unattractive and socially awkward bloke, the guys pitied him a bit and would sometimes include him in some social events. He lost his virginity in his mid 20s when he visited a brothel during a trip to Amsterdam, and probably hasn't been laid since. Now as an adult in his early 40s, he lives alone and participates in multiple fantasy cricket leagues. He'll occasionally travel with an organised group to watch some cricket tournaments, but he's never been in a relationship and I don't think he's even tried to date anyone. I've often wondered if he has a form of Asperger's syndrome.

"Well, look at Propeller-head and Olivia. They got married and have two kids."

[Background] Propeller-head (also his nickname in real life, as he reminded Myrtle of the Calvin and Hobbes cartoon where Calvin wears a multi-coloured beanine with a propeller on top) was a work colleague who persistently pursued Myrtle. After exhausting the usual lines, "I don't date people from work," "I like you only as a friend," "It's not you, it's me..." she decided that the only way to stop his advances was to set him up with someone else. She called up Olivia, a gawky, socially awkward girl from our high school class (think Amy Farrah-Fowler from The Big Bang Theory) who was still living at home with her mother in her late 20s, to see if she was interested in being set up with Propeller-head. Myrtle made reservations at a nice restaurant in town, and I accompanied her on this introductory date. We ducked out before dessert and they started dating and became engaged a year later.

"So, what's your point?" I asked
"That there's a lid for every pot." she gleefully replied
"Myrtle.... Not helping."

"What a fun time was that double date -NOT!" she continued, not getting the hint to change the conversation.
"Well, Karma certainly rewarded you for your matchmaking efforts." I commented, thinking that Karma seems to be overlooking the fact that I assisted with that date.
"Absolutely! Isn't that right Bay-bee?" she asked her husband who was in earshot.
"Go back to enjoying your evening. Happy Birthday." Click.

I know it's so hard to find any words that can provide any comfort in the setting of devastating news. Many bloggers will comment that there are no words that can be said, yet merely acknowledging someone's pain and anguish speaks volumes. Words often seem so small and inadequate, but their power cannot be underestimated.

Thinking of you...
Sending you a hug...
I'm outraged by the unfairness of it all..
I hope you find some answers...
Take care of yourself...
RPL sucks...

'Thank you' seems so inefficient to express my appreciation for all the love and support I've received from my fellow bloggers. I never imagined I could develop such an intimate relationship with people who only know me through my written words. All your words mean the world to me.

Especially, as I've not received much sympathy from my friend of over thirty years...

Monday, 23 December 2013

In the Words of Stephen Colbert...Moving On...

Upon leaving my RE's office with a diagnosis of an impending miscarriage, I notified my colleagues who are in the know. "Was it an official sonogram?" asked my Lead Physician, as she offered to order one for me. Not necessary, I replied; but I did have intentions to obtain a second opinion. The moment the clock struck five on Friday afternoon, the office staff filed out of the building like rats fleeing a sinking ship, leaving me with access to repeat my own ultrasound. Despite the orientation challenges when scanning yourself, the resolution and detail is much clearer on our machine than the one in my RE's office. I identified the fetal pole and measured it to be 0.48 cm, which corresponded to 6 weeks and 1 day -nearly two weeks behind. The faint flicker of cardiac activity was still present. Two weeks ago, such a sight would have produced emotional tears of joy. Now I resented the presence of the heartbeat.

My heart wanted to hold onto hope, but my head is much wiser. I'm thankful for my ten plus years of clinical experience. I've never seen a good outcome from a situation like this. An embryo that is measuring two weeks behind will not produce a healthy baby. Seriously, how could I even calculate a due date based on this delayed growth? If the heartbeat didn't stop by my next ultrasound on Monday, it would likely stop within the following week. It would be the right decision to proceed with my MUA, and not just because I already submitted a PTO request and my afternoon schedule was cleared. It just seemed that fate was adding one more cruel twist, requiring us to end the pregnancy when our little embryo was making such a valiant effort to survive. I spoke with my Lead Physician, who went through a similar situation when her baby was found to have a low heart rate. "Waiting those two weeks until the heart finally stopped was much harder than I ever imagined" she shared with me. "It was such a relief when I could finally proceed with my D+C". I discussed the situation with Husband, who was in agreement that we didn't need to wait for the inevitable. Come Monday, it'll be alright. Come Monday, my life starts again.

I went to the pharmacy to pick up the pre-meds that my RE ordered for me. I also needed to get a heating pad. When we moved three and a half years ago, I thought I uncovered not one, but two heating pads in our linen closet. Now that I needed it, I couldn't find one. I also realised that I needed some non-tampon sanitary protection. As I quickly mastered the skill of using tampons, I never had any pads beyond what was provided in my Growing Up and Liking it! menarche starter kit (if you're in my age group, you know you had one too...) I just remembered that pads were large and bulky and it felt like you had a Buick between your legs. My how things have changed in 25 years! Now pads are much thinner, but they have wings and they are both wider and longer. So now the wings pool blood onto your inner thighs and the longer pads ride up your butt? I fail to see how any of this is an improvement. More so, what is with the names? 'Always: Radiant Infinity' -what the fuck? Dressing it up with a distinguishing title doesn't grant any dignity to your product. After studying the selection for more than fifteen minutes, I was finally ready to make my purchase. Just to complete this Are you there God, It's me Margaret moment; there was a rather attractive guy standing behind me buying cough syrup.  I'm sure he took note of the products in my basket (Prescriptions for Doxycycline, Norco and Ativan, CVS brand heating pad and Kotex super absorbent pads) and wondered what hot plans I had for the weekend.

Once again, we were back in my RE's office for the third consecutive week. He measured the fetal pole at 0.46 cm. "I can't see any cardiac activity." he announced. "Can you?" He turned the screen toward me. I hadn't told him about my findings on Friday. This time I couldn't appreciate any flicker of light. "I can't either" I replied. Privately, I was exhaling with a sigh of relief. The absence of cardiac activity was actually welcoming. It represented the first time in this entire IVF cycle that a situation was straight forward. We would proceed with the MUA and send the products off for chromosomal testing.

Alas, after being reluctant to admit that I was pregnant, and being technically not  pregnant, while pregnant for over a week; I am officially not pregnant. Although I didn't have any side effects from any of my meds, after injecting, inserting and ingesting exogenous hormones for the past two month, I'm happy to have a break from these drugs. I moved all my luteal phase supplies into storage and dug up my Clearblue fertility monitor and ovulation predictor kits. I was about to make arrangements to give those away, as I figured I was at least past that phase of this process.  Sigh. Just when I thought I was out...they pull me back in!

Lastly, I gathered our fertilisation report, embryo and ultrasound photos and my pregnancy test and placed them into a memory box. I can now literally close the book on this pregnancy and start moving forward.

Friday, 20 December 2013

The Imposter

Our swim team's annual holiday party is a rather strange event. As we swim before the day light breaks, we don't really recognise fellow swimmers without their caps, goggles and swim attire.  Thus, it's a bit strange to see each other in smart dress, and we actually wear name tags indicating our lane assignment or best stoke. As families are invited to the party, there are a lot of kids and unfamiliar looking spouses present                                                          
Last year, the party was a welcome distraction. I had miscarried a few days ago, but I was enjoying sipping cocktails with my teammates. Suddenly, I felt something soft brush against my thigh. I turned in my chair and saw it was the 16 month old son of our breaststrokers. Without hesitation, he climbed into my lap. "Your son?" asked my lanemate who was sitting right next to me. No, I tilted my head toward the direction of his mothers. "Oh, he looks like he could be yours." I looked down at the little blond tot and wondered if I were to have a baby if he would look like him. He seemed content sitting on my lap, so I just let him stay there as my fellow swimmers chatted about some of our most dreaded workout drills. Two others commented that he looked like he could be mine, and sheepishly, I was enjoying hearing it. Then he turned around and his hands reached for the neckline of my dress.

The gig was up. The imposter was revealed. I picked him up and walked over to his mothers. "He's hungry and he was about to be quite disappointed." I reported as I handed him off to his Tummy Mummy, who proceeded to feed him. She pointed out that we actually look pretty similar. I had never noticed it before, as I never saw her out of her swimwear. We're about the same height, have long blond hair and we were both wearing a simple black dress. It must have been a case of mistaken identity. Although the non-Tummy Mummy wasn't so sure. "We were really surprised to see how comfortable he was sitting with you. He's going though a phase of stranger anxiety."

I wondered if like animals, small children can sense sadness, and maybe there was more than the resemblance to his mother that drew him to me. Interestingly, I saw their son at a few of our meets later in the year, and he never again approached me. As I was getting ready to go to this year's party, I wondered how he would respond to me. Unfortunately, my car died as I was backing out of my driveway (good news, we think it's just the fuel pump and not my transmission) and I never made it to the party.
Husband and I met up with some friends for drinks instead. All week I had been reluctant to admit that I really wasn't up to going to this event. It just seemed too odd to be going through the same motions again.

Monday, 16 December 2013

History Repeats Itself

This past weekend, I flew to Southern California for a Continuing Medical Education Conference. While I was in the queue for Security, I noticed they were sending everyone through their Porno Scanner (term adopted from Keith Obermann). Paranoia began to creep in. The rational side of my brain knows these scanning machines are safe for pregnant women. Although I can argue that when TSA makes that claim, they are referring to normal women carrying a healthy pregnancy. I have a delicate little embryo who is already measuring four days behind. I felt that I couldn't expose myself to something that could pose the slightest risk; even while I was acknowledging how absurd I was being. I started planning a little speech. I would tell the TSA agent that I'm finally pregnant after two years and multiple fertility treatments, so forgive me for not taking any chances.

I placed my items on the conveyor belt and walked over to the TSA agent, ready to deliver my spiel. Then I froze.
"I'd like to opt out of the scanning." was all I could get out.  
"Well, you do know that it's totally safe. It just uses sound waves similar to your cell phone." The agent informed me.
Or like an ultrasound...I thought to myself. "Mmm-hmm" I nodded.
"And you'll have to wait a few minutes as I need to call a female officer for your pat down..."
"That's fine." I quietly replied.

As I waited for the female officer to feel me up (which is actually the most action I've seen in a while...) I thought about what transpired. I couldn't even say the words, 'I'm pregnant' out loud. I couldn't say it to someone as inconsequential as a random TSA agent. Until I know this is a viable pregnancy, I don't feel I'm entitled to use that description. I'm still just a hopeful wannabe mother. Also ridiculous, I feel a bit superstitious; as the moment I acknowledge the pregnancy, it will all be taken away from me. Continuing with my previous baseball analogy, it's reminiscent of how no one in the bullpen or dugout will mention the words 'perfect" and 'game' when a single pitcher has consecutively retired every batter he (or she) has faced. Except our situation has been anything but perfect, and this isn't a game.  

It all felt eerily familiar to be back in my RE's office on a late Monday afternoon. It was at that moment, I realised I was here exactly a year ago. The third Monday in December. Looking at my ultrasound and recognising that things didn't look right. The once hard to identify yolk sac was now prominent and suspiciously large. The fetal pole still only measured 3 mm, exactly the same as last week. There was no growth and no progression. It was as if my uterus was frozen in time like Miss Havisham's house. There was a faint, slow flicker of cardiac activity, but it was too feeble to bother calculating a rate. "This is really disappointing." my RE expressed, seeming a bit deflated himself.

We're now 0 for 2. Well, technically 2 and 0. I'm a Gravida -2 Para -0. A two time loss-er. Apparently, I suck at being pregnant. Six weeks appears to be a major stumbling block. Last time my uterus rejected the contents at six weeks and this time around the growth stopped at six weeks. Some people get pregnant twice and have two kids; Co-worker's SIL has been pregnant twice and will have four kids as both were twin pregnancies. I've been pregnant twice and have nothing to show for it. Except a new diagnosis. I can now add Recurrent Pregnancy Loss (RPL) to my resume.

My RE wants me to come back in a week. He'll perform a final scan to confirm (just in case my embryo wakes up and realises, 'Oh shit! I forgot to grow! Let's make up for lost time!') and then will proceed with an MUA (Manual Uterine Aspiration). We'll send the products for chromosomal microarray testing. Remember when I was considering PGD testing, as I didn't want to discover a trisomy on a pathology report after a miscarriage? Now I'm hoping for that scenario. There will be more questions generated if the results indicate this would have been a euploid fetus. My RE and I discussed ordering the RPL lab work to determine if I might consider aspirin or Lovenox for a potential future pregnancy. I haven't asked for his thoughts, but I'm already planning to go gluten free, should there be a next time.

In the most twisted, fucked up way, I feel validated. The annoying Little Miss Know-It-All inside my head is proclaiming, 'I was right!' I knew there was a reason to be cautious and guarded. I knew better than to get my hopes raised. I knew it was a good call not to tell my dentist that I was pregnant a few weeks ago, as I have a follow up appointment tomorrow. Co-worker tried to encourage me to be more positive, but I defended that I wasn't being negative, but being realistic. Even after learning about the pregnancy, I still felt it was a long shot. I never let the pregnancy news settle, so this development is passing right through me. Maybe some day I'll get around to processing it all.

As we arrived home, Husband picked up the post. We only received one Christmas card and it had Myrtle's return address. Once again, without fail, the cosmic connections align so that images of the gorgeous little Myrtle show up on the coat tails of my disappointing news. I admit that I'll sometimes take a little creative license to tweak some details for more concise story telling; but this one my friends,  I promise I cannot make this up. Additionally,  I learned that my friend in Maryland (the one with one ovary who wished me a 'two-for-one' with my first IVF cycle) is pregnant. When I visited her this summer, she informed me that they wanted to become pregnant by the end of the year. I relented, just accept that she is going to be pregnant before you...She's due on 5 June. I can already hear the annoying Little Miss Know-It-All declaring 'I was right!' 

Friday, 13 December 2013

Working for The Man

When New Girl called with my final beta results, she offered to schedule my first OB ultrasound at 12:30. While I appreciated that she remembered my preference, and I felt a deeper appreciation that she was willing to work though her lunch break to accommodate me; I really wanted their last available appointment. Whether the results were good or bad, I just wanted Husband and I to be able to go straight home and be together. I didn't think I'd be able to focus if I had to rush back to the office with news of a viable pregnancy (and potentially twins), but I especially feared that I could have a breakdown in front of my OB patients if we weren't viable. Thus, I had Co-worker block my schedule in the final hour and my medical assistant re-scheduled two patients.

When I learned that we would have to repeat our scan in a week, I was almost tempted to bite the bullet (and maybe exert a little optimism) and just take a lunchtime appointment. Yet, all my previous reasons were still valid (except we've nearly excluded the possibility of twins) and they seemed a little more pertinent after waiting an additional week. I exchanged a few emails with the office manager trying to secure their latest appointment. I was originally scheduled for Monday, and I was almost willing to delay until Wednesday, just to minimise the disruption to my patient schedule. I remembered that my RE once told me that I should also view myself as a patient in need of medical care, and that I shouldn't feel guilty about canceling and rescheduling patients. The later is easier said than done. The latest time that would  work for me and Husband was Monday at 3:30. It meant moving three patients, one was a patient who had previously miscarried and was now scheduled for a new OB visit.

It was now late Thursday afternoon, and I wanted to get my medical assistant moving on this as soon as possible, especially as I had an opening for the new OB on Friday. The office manager was out, so once I again I asked Co-worker to block off the time on my schedule. I figured I could keep my discretion too, as the office manager probably wouldn't have even noticed if I left the office early. Well, Big Brother at the main administrative office took notice that Co-worker was blocking my schedule. The Director of Operations sent an email to our office manager informing her that Co-worker was not supposed to be blocking my schedule (even though she was granted the password that gives her such powers...) and furthermore she insisted, 'your provider (yes, that is how she referred to me) needs to submit a PTO request to take that time off'.

Fuck you. I am a salaried employee. I work many hours over the forty hour work week designated in my contract, but I never receive an dime of overtime pay. I routinely work though my supposedly hour long lunch break. I come in on the weekends and before the work day starts to catch up or get ahead. Does the Bean Counter ever see that? No she doesn't. The administrators only see me in terms of my billable hours. Least I should ever think that I'm entitled to take an hour out of my scheduled patient time to seek care for myself without paying for it with my PTO time.

I jokingly asked Co-worker if I should start submitting PTO requests for when I have to do my twice weekly Non-Stress Tests? (For the record this represents the first time I've allowed myself to imaging the pregnancy progressing that far.) Co-worker (who administers NSTs for our patients) noted that she could set me up during my lunch break. We both laughed a little, but silently acknowledged to ourselves that is probably what will end up happening (presuming I make it to that point).

My original plan (just insert laughter whenever you see those words) was to start my prenatal care with the providers at one of our other sites, and transfer to my office once my pregnancy was announced. I wouldn't want any fellow staff members to learn about my pregnancy from discovering my genetic screening results on the fax machine (although unlikely as they rarely clear the incoming fax tray) or to be privy to any of the information such reports contain. Now I was considering keeping all my prenatal visits with the other office, just so I would be reducing my number of billable hours and thus piss off the bean counters. Then Co-worker reminded my that I have an HMO plan with my insurance and may not be able to see the other group. I checked the benefits on my card. She was right. The health insurance that is provided by my employer will not let me see other providers who are employed by the same affiliate. As that makes sense. Way to go Establishment.

Interestingly, I was not copied in on this email from the Bean Counter and I didn't receive any further correspondence from her. Thus, I treated the information that I learned from Co-worker to be like the proverbial tree that falls in the forest. If I didn't hear it, did it make a sound? Who knows. If Bean Counter does approach me, I will point out that I accommodated two patients by adding them into my administrative time (which is thus increasing my billable hours on two other days). I appreciate that she is just doing her job, and doesn't know the reason for my absence (it probably doesn't help that my cover story for my staff is that I'm going to watch one of Husband's hockey games). However it just gives me a sour feeling about how I'll manage the rest of my prenatal care, let alone working while parenting. It's another reminder that I'm working for The Man.

Tuesday, 10 December 2013

Lights are on, but no one's home

Shortly after Co-worker and I started working together, we decided we need a covert way to communicate if a new OB patient had a non-viable pregnancy. I think she coined the phrase, 'the lights are on, but no one's home' and it seemed to stick. Thus we had a more subtle way to alert other staff members to the situation and could avert any awkward interactions with the patient. The medical assistant would know not to issue any due date confirmations, the phlebotomist understood the message and would not draw the full prenatal panel. The front desk receptionist would know to book her follow up as a GYN return visit and not a return OB. Most importantly, this discreet phrase would help prevent any staff members from unknowingly offering words of congratulations, or require the patient to provide an explanation.

I often think about that phrase when I am breaking the bad news, as one of the questions patients often ask is, "am I actually pregnant?" The answer is technically yes; it's just not a pregnancy that will produce a baby. I started to warn some patients that they will still have a positive pregnancy test, as I once had a young girl who called our office the day after I diagnosed her miscarriage, claiming that I was wrong as her digital test told her she was still pregnant. "Why do I have symptoms of pregnancy?" is the other question that usually follows. Well, HCG is just a cruel bastard that will mislead and mess with you. I often think that is adding insult to injury; to endure the misery of pregnancy symptoms without anything to show for it. "But, I'm not bleeding..." I explain that before early first trimester ultrasound was adopted into practice, this is how patients presented and how practitioners would make the diagnosis. We're now recognising non-viable pregnancies earlier, prior to the inevitable bleeding. Yet, bleeding during pregnancy is so strongly associated with a miscarriage, that it becomes hard to accept one with out the other.

It somewhat becomes much easier to inform a patient of an impending miscarriage when she has bleeding, cramping or some type of warning sign. Yet, most patients who present to me with bleeding turn out to be fine, and the majority of my non-viable pregnancy diagnoses are in asymptomatic and unsuspecting women. That is the aspect that makes the situation even more difficult; the fact that they are completely blindsided by the news. The patients who make me nervous are the ones who come into the office with complete confidence of a good outcome. The Dad who has the camera ready to start recording the ultrasound images. The ones who bring their kids to introduce them to their new brother or sister. Some times it is a little easier with couples who are familiar with this process, as they know what to expect to see in their ultrasound. It's always heartbreaking when I hear couples coo 'look at our baby!' as I'm recognising a non-viable pregnancy. However, the diagnosis seems to be a bit harder to accept when couples have had two or three normal pregnancies. This is not consistent with their prior experience. Everything worked out for them in the past, why shouldn't it now?

Thus, I felt prepared for bad news as we approached our first ultrasound. Not only did I have professional experience acknowledging the commonplace nature of miscarriage, but I have doubts about our embryo quality as well as a general dose of skepticism. I had a surprising sense of calm on the night before our scan; but once morning dawned on the moment of truth day, I became a bundle of nerves. After counting down the hours, I was finally back in my RE's office. I shared my photos at the start, and as anticipated, he just responded with "well, let's take a look." I saw him calculate measurement of the single gestational sac, which was now 11.5 mm -appropriate progression from prior measurements. There was a clearly identifiable yolk sac, and something that my RE called a questionable fetal pole. He measured it at 3 mm, which along with the gestational sac corresponded to 5 weeks and 6 days -align with my prior calculations. However, there was no evidence of cardiac activity.

Although cardiac activity should be seen with a measurement of 5 mm, (some say 3 mm) the threshold for diagnosing an early pregnancy failure is absence of a heart beat in a fetal pole measuring 7 mm. While he admitted that he would prefer to see cardiac activity, my RE reported that he was satisfied with these findings. He added that he is still a bit guarded with our prognosis. Once again, I was laughing inside my head. As if it were possible that anyone could have less confidence about this pregnancy than I already do. New Girl somewhat scolded me for my preview scanning. "You're just making yourself more anxious!" she perceived. Quite the contrary. If I went into this scan believing that I should have been 6 weeks and 3 days and discovered that I was measuring behind with no cardiac activity, I would be suspecting that the growth arrested. Rather, it is reassuring to know that I have been consistently four days behind, but progressing appropriately. As Husband pointed out, our progeny seems to be taking after me already; takes forever to get ready and shows up late. We are scheduled for a follow up in a week. I promised New Girl I would keep the probe away from my vagina. I've broken enough hearts and crushed too many dreams already; I can't deliver such news to myself.

Yet, we're still in the game. I'm still at the plate and I've evened the count. We think there is somebody home. We're just waiting to see a flicker of light.

Sunday, 8 December 2013

Membership has its Privileges

I appreciate that many of you have commented that it must be difficult to work in obstetrics. The response I give to people who inquire IRL is that some days are harder than others. For the most part it doesn't really bother me, I've been working in this field for such a long time and for most of those years I wasn't trying to procreate. Actually, there were times when my work almost seemed like a deterrent for getting knocked up. I'd see a very uncomfortable post term patient and feel relieved to have an empty uterus. Even after I started trying to conceive, I saw a few patients with significant vaginal varicosities and almost changed my mind about pursuing pregnancy. I'm not easily squeamish, but that is one of the few things that can get to me. Seriously, if they want to reduce teen pregnancy rates, these school programs need to show photos of vaginal varicosities. Years back, when I was working on the Labour and Delivery unit, I had a medical student following me (who very well could have been my RE). After performing a routine delivery with him, I checked in to get his impressions. "Um, that just completely killed my libido" he revealed. ...and my work here is done!

I was happily living in the moment and wasn't thinking about what could be going on in my uterus, until last Wednesday when our LVN presented a particular patient. By her last menstrual period she was 5 weeks and 6 days, just two days ahead of me. Her ultrasound revealed a single fetal pole that measured 6 weeks and 3 days with positive cardiac activity. The patient admitted that she merely guessed at the date of her last period, as is often the case with women who aren't actively trying to conceive. She reckoned it may have been a week earlier. Yet, I now couldn't stop thinking about what I might see on a scan at this point.

I decided to take the plunge and scan myself. Although my betas have been suggestive of a singleton, I wanted to know about the possibility of twins as soon as possible, preferably to avoid losing my composure in my RE's office if he were to make such a discovery. Additionally, as the gestational sac arrested around five weeks last time, I thought it would be useful to document this early stage. In fact, my RE might even find it helpful, I tried to convince myself. If for no other reason, I figured there must be some advantage to working in this field when you're infertile.

Husband was at a hockey game, which allowed me to work a bit late. I waited until everyone in the office left and then dragged an ultrasound machine into an empty exam room. For those of you who are curious, I did it standing up with my foot on the counter. There was one small sac present with a slight decidual reaction. I couldn't get a view of the sac in the transverse view, but based on the two measurements I obtained, I calculated a size corresponding to 5 weeks exactly. Four days behind where I should be. The next day, I showed the photo to one of my colleagues, who seemingly gave me a 'let's wait and see' smile.

I still couldn't wait until my officially scheduled scan. Fortunately, the office clears out much earlier on a Friday afternoon, and I was alone with the ultrasound again. The sac was definitely a bit bigger -2.5 mm to be exact, and I was able to get a measurement in the transverse view. The measurement was corresponding to 5 weeks and 2 days, still running 4 days behind, but there was appropriate progression. I thought I could faintly detect a yolk sac. Most of all, there is definitely only one gestational sac, but as I've missed two monochorionic twins on a scan before six weeks, I'm still holding my breath. However, the advantage of day 3 embryos is that they are less likely to split into identical twins.

Shamelessly, I went back into the office on Sunday to catch up on charting/scan myself again. Sure enough, the sac had appropriately increased in size. It was now measuring 9 mm (5 weeks 4 days). Yet I still couldn't clearly identify a yolk sac and there was no fetal pole. By my transfer date, I should be 6 weeks and 1 day. My official ultrasound was originally scheduled for Monday, we moved it forward a day as Husband had a scheduling conflict. It was less than twenty-four hours before they were expecting to see a embryo with cardiac activity in my uterus.

They say don't ask a question if you don't want to know the answer. I learned that this is (most likely) a singleton pregnancy, but I now have doubts if it will be viable. I'm honestly not sure what to make of the sac measuring four days behind. We are taught that any measurements within a week of a last menstrual period are considered to be within normal limits, presumably to account for variations in time of ovulation, implantation, etc. There is no ambiguity here, we know the exact moment when the embryos were placed in my uterus. However, a gestational sac will often measure a little smaller than a fetal pole, which is why it's measurement is considered irrelevant once a Crown-Rump Length can be calculated. I also know that a gestational sac will progress in size when it is a blighted ovum. I would feel more reassured if I could clearly see a yolk sac. Or better yet, a fetal pole.

Now I'm back to waiting for my RE to perform my official ultrasound, although I think the resolution is actually better on our machine, which is much newer. I feel satisfied in a few respects. I confirmed that there was one sac in my uterus and it progressed appropriately over four days, which was further than I was with my previous pregnancy. I remember when my Lead Physician was discussing her miscarriage and she commented, "you'll tell yourself things that you wouldn't say to patients." I fear the four day lapse in corresponding measurements is an ominous sign. I am hoping that my inability to see a yolk sac is due to the limitations of scanning yourself. I searched the infertility forums; it seemed that for every incidence of slow growing gestational sac that became a viable pregnancy, I could match it with a story of an eventual miscarriage. Searching my own case files, within this past year I had two patients who had empty appearing sacs when each should have been much further. I suspected a blighted ovum, but to my surprise a follow up scan revealed a viable embryo. However, I know I also have had many more cases where things didn't add up early on...and we would discover there was a reason why. As with so many things pertaining to this IVF cycle, nothing is straight forward and nothing is easy. Yet, I'm still in the game. I'm still at the plate. I'm just behind in the count.

I decided that I needed to do some actual work to justify having the security guard let me in to the office on a Sunday. On top of my scanning pile was an ultrasound picture from someone's first OB visit. My documentation confirmed that I saw a yolk sac and cardiac activity and the CRL measured 0.47 cm. Just in case I needed to be reminded of what a scan should look like at 6 weeks and 1 day. I received an email message from the patient I had scanned earlier in the week. Not really trying, unsure of dates; she measured 6 weeks and 3 days when she should have been only 5 and 6. She was now inquiring about terminating her pregnancy. Sigh. Some days are harder than others.

Wednesday, 4 December 2013

It Comes in Threes...

Husband was on the east coast for a hockey tournament over the Thanksgiving weekend. I don't like it when he is away. Firstly, I really miss him, which must mean that I truly do love him. Secondly, I fear that anything electronic will break while he is gone. Myrtle gave me the first season of Call the Midwife for Christmas last year.  As Husband has absolutely no interest in the series, it would be the perfect opportunity to finally watch it. However, I'm afraid that if I try to work the DVD player, I might not be able to watch regular TV again. Somehow, it's not just as easy as pressing the 'source' button. Sadly, one of the reasons why I hope this pregnancy takes is so I can have someone else to work the electronic devices in our house.

It is often noted that things seem to break down in groups of three. The shower in our master bathroom started dripping. I tightened the faucets and tried putting a washed behind the head, but it continued to drip. It was really irritating to hear the sound of water splashing on the tile as I was trying to sleep, but I really don't sleep that well  when I'm on my own. I'll get in on my usual side off the bed, but I'll wake up in the middle of the night and find that I'm on Husband's side of the bed and my cat is stretched out next to me. I would like to participate in a sleep study so I can see how a 12 pound cat can move a 150 pound human.  

Every now and then there will be a spree of break-ins around our neighbourhood, which is the other reasons why I don't sleep as well. I just feel a little more vulnerable when I'm alone, which also involves broken item #2. Our alarm kept coming up with a message of "chimes disarmed" for the door leading into the garage. I looked up in the instruction manual but couldn't find anything about re-arming the chimes. I figured that if a would-be intruder were to enter through the garage, he or she would probably be maimed by the junk lying around. Nonetheless, I decided to place my tool box in front of the door.

The third thing to break down was my transmission. My car is a 10 year old Jetta with almost 140,000 miles. I struggled to accelerate from an intersection and I was hoping that I had accidentally left it in third gear, but I knew I hadn't. I managed to drive home, and took it out later that night and could appreciate that the clutch kept skipping. Once again, I'm at a crossroads deciding what to do with this car. I accept that regardless of what progresses inside my uterus, we eventually need to replace this car. However, I'm still not ready to let it go. It's a heap of crap, but I love it. Oh, and as we'll be paying off our IVF expenses for the next 21 months, it would be stretch to work a car payment into our budget. Fortunately, we have a good friend who is also an amateur mechanic and he replaced my clutch 55,000 miles ago. Even better, his fee is $500 and a six-pack of beer. So hopefully he can resuscitate my car again and we can sustain it for at least two more years.

Fortunately, Husband came home on Tuesday and repaired the cracked pipe that was causing the shower to leak and fixed the alarm in about two seconds. The other bright spot of my week was that I received these socks from Rach at A Little Bit More. Thanks to Risa for initiating the sock exchange!

Monday, 2 December 2013

Carpe Diem

This time around, Husband and I decided we would approach the pregnancy very cautiously. We cannot get ahead of ourselves. Just focus on one task at a time. The next beta result, the first ultrasound and the ones that follow. The genetic testing and the anatomy ultrasound. If we pass all those markers, then we can accept that we're not merely pregnant, but actually having a baby. Thus, I refuse to calculate my due date. We won't allow any discussion about how and when we'd disclose the news. I've not purchased a single pregnancy or baby related item. While I was shopping for greeting cards, I retreated as soon as I walked near the New Baby section.  So far, in the first ten days since we received the news, we've managed to hold to this commitment. Husband's one slip was asking about my short term disability offerings at work and how I would arrange my maternity leave. I placed my hands over my ears and started singing "LA-LA-LA-LA-LA!" Finally, I discovered an event that I could get excited about, without getting ahead of myself. I needed to refill my progesterone in oil.

Like any savvy infertile consumer, I wanted to do some price comparisons, so I didn't order the PIO with my initial shipment of stimming meds. Of course, I also thought we'd be doing a FET in the new year and I could apply the cost of the PIO to my 2014 FSA expenses. After my retrieval, my RE instructed me to start my luteal phase support in the event that we would need to do a fresh transfer. This meant that I would have to purchase locally as Freedom Fertility wouldn't be able to ship in time. I went to a compounding pharmacy that I use for some of my patients and they also prepare our kitty Prozac. I had a print-out from Freedom and I asked the pharmacist if he could beat their price. "Oh definitely" he replied and then added, "We'll also apply our employee discount for you." Oh yeah, I've got connections.  

When I picked up the prescription, the pharmacist asked, "Is this what I think it's for?" I nodded. He then revealed that he and his wife were infertile. Their first two IVF cycles were unsuccessful. They transferred any embryos they had on day 3 and never had any that made it to the freezer. After their second BFN, the switched clinics and did a new stimming protocol which yielded 5 blastocysts. A fresh single embryo transfer resulted in their now two year old son. He noted that they were preparing to do another transfer soon. I was immediately comforted to have found a kindred spirit. It meant a lot to know that not only was I supporting a local business, but I was being supported by a pharmacist who prepared my PIO knowing exactly what is involved with receiving this prescription.

The pharmacist spotted me while I was waiting at the counter for my refill and approached me. I quickly filled him on the details including the day 3 transfer of two embryos and my most recent beta results, while pointing out that we were feeling extremely cautious. "When is your transfer?" I asked. "Oh, we already did it. It didn't work." he revealed. Oh, fuck.  I had now become that person who showers her good news in front of someone nursing a BFN. They must have done their transfer just days after ours. I was so self consumed at our first discussion that I didn't ask any details and simply presumed it was going to be in a month or so. I quickly expressed that I was sorry to hear about their disappointing news and inquired about the next steps. They'll take December off and transfer two fro-yos in January. I etched that in my mind, should I find myself back in the pharmacy at that time. Alas, it was another reminder that for an infertile, not even something as innocuous as disclosing your pregnancy is as smooth as you envisioned.

Co-worker came back to work recently, and as we were chatting, I asked how her SIL is doing. "Miserable" she replied thought somewhat gritted teeth. "She [the SIL] says that these two assholes are making her miserable." O-oh. "She wrote that on Facebook." Co-worker added. Ew. I was now cringing a little. I could tell that such comments really angered Co-worker, but as I've previously mentioned, her SIL is not a normal person. She's truly a piece of work -and we're not talking art.

Actually, I pitied her. Although I've been lamenting a bit how it sucks that infertiles have to feel so cautious and guarded even after finally becoming pregnant, perhaps we have a deeper appreciation. Co-worker's SIL never had to wait more than two months to see two lines on a stick, could she understand the elation that follows when you've waited more than two years? It was easy for her to take her pregnancy for granted as she's never had the promise of a baby snatched from her uterus. I may not yet be excited or be able to think about the future, but it affords me more opportunity to treasure the present. Each day I'm thankful to be pregnant. Although, it's been tough enduring this two week wait leading to our ultrasound, at times it wish it were longer. I know that each task or each test could bring us closer to the end. I want to enjoy this pregnancy for as long as I can. Carpe Diem.