The Parenting Test

Last April, my cat A was diagnosed with diabetes. His care required me to check his glucose levels and administer his insulin shots twice daily. Amazingly, he did quite well with all his injections, but he gave me a hard time when I tried to get him on the scale for his weekly weigh-ins. I had purchased a baby/pet scale from Amazon.com (the first purchase where using the item for a baby was an afterthought) but he was so non-cooperative that I ended up holding him while I stepped on my scale. Within a few weeks, we had settled into a routine and at his first three month check up, his fructosamine level (kitty A1C) showed his glucose was under excellent control. Then one day, I came home from the gym and thought he had a glazed look in his eyes. I checked his blood sugar and it was 35, which is critically low in humans. I fed him a bunch of cat treats and an hour later it was up to 72. I contacted the vet, who noted that his diabetes may have gone into remission, but she warned it could return. Six months later his weight is stable and he is still euglycemic!

As I was starting our IUI treatments at the time when A was diagnosed, I viewed it as a type of parenting test. (Those of you who have children can just burst out laughing now) As an only child, I'm inherently selfish with my time. When I lived alone prior to getting married, I loved having the freedom to come and go as I pleased. As long as I filled A's food and water bowls when I left the house in the morning, it didn't matter when I returned (although I received a very judgmental look when I once came home the next morning). Fortunately, I married a fellow only child who also values his independence and I still have a lot of latitude with my free time; I just have update him with a text message. Caring for A's diabetes required me to adjust my schedule around his twice daily insulin injections and gave me a slight representation on how I would have to arrange my daily routine based on someone else's needs. (Even if you don't have kids, feel free to laugh...)

At times it feels that there are certain expectations for when you are in a pre-children state. A few years ago, I went to England to speak at a conference. Husband stayed behind as we were in the process of closing on our house. During my visit, I met up with three friends, all had two kids and one was pregnant with her third. They were too keen to live vicariously through me. "You had better be hungover..." the pregnant one threatened as she picked me up from the train station. Oh, I could oblige their need for details. I spent the previous night in London with two of my old hockey teammates who were still single. We went to a wine bar, I flirted with an Irish banker and scored an accidentally on purpose breast graze. We walked home from a chip shop at 5 in the morning, and for reasons that I cannot remember, I was barefoot. As it had been so long since any of them had been out for an evening, they were enthralled. When we were still deciding if we wanted to pursue having kids, my cousin's husband encouraged us to have a final adventure as a couple before taking the plunge. It ended up being our trip to Hawaii where we purchased a time share so we could return with our child for family vacations.

As I now know that if we had started trying to procreate years ago, we may have been able to conceive spontaneously,  and who knows maybe that pregnancy might have stuck. Perhaps, I could have a toddler running around our house right now. Is it a bad thing that I see an upside to the birth canal not travelled? I can't help to wonder how our life would be different if we had a baby earlier. We may not have acquired our time share or renovated our kitchen, but I'm not too bothered by the tangible possessions. I think about the experiences we may have missed in this alternative universe. I may not have started swimming, Husband may not progressed through the ranks of collegiate field hockey umpiring and we both may not have discovered cross-fit. Maybe having a baby at a younger age would have strained our relationship rather than having it strengthened by our infertility and RPL experience. Then again, maybe I'm also wondering what we'll do for an encore if we're still childless.

The Aftermath

While I was in cycle limbo, I decided that it would be prudent with regroup with my RE. As I was sitting across from his desk, I was shocked at the size of my chart. Prior to infertility, I can only think of four occasions when I had to access health care for non-routine services. The binding was frayed and there wasn't much space left under the wire clips. I feared my file would soon be established as 'Jane Allen: Part 1 of 2'.

RPL Evaluation
A bit to my surprise, my RE began discussing RPL testing after acknowledging the aneuploidy on my path results. Although unlikely, there still could be more than one contributing factor. I was curious to hear his approach. He identified five categories. Uterine anatomic abnormalities, general endocrine (thyroid disorders, hyperprolactinemia and diabetes) hypercoagulable (spontaneous and inherited) and genetic factors (referring to the products and the parents). I specifically asked about what hypercoagulable labs he requests, as there is a lot of controversy in this area. He listed lupus anticoagulant, anti-phospholipid antibodies and Factor V Leiden deficiency. As I feel I have an explanation for both my losses, and don't have any other symptoms or family history to suggest another confounding mechanism, I didn't think much of the testing seemed necessary. I did agree to do a karyotype for myself and Husband. Although the yield is low, if a balanced translocation is found (i.e. pig and elephant DNA won't splice) we would forgo transferring our existing blasts, and do a fresh cycle where would need to do PGD testing.

Preparation for FET
We again revisited the process of a natural versus a medicated preparation. As I have blood pressure issues with exogenous estrogen, it would seem beneficial to do a natural cycle FET. However, my RE described that it requires much more frequent monitoring and is very unpredictable. "I know you are really busy..." he commented. I quickly recalled how arduous it was travel back and forth to my RE's office every other day during my stimulation and I knew what a drain it would be if I were to be monitored daily. "We wouldn't have any advance notice of your transfer date..." he mentioned. In ten plus years, I have never once called out sick. There have only been three occasions where I needed to cancel patients at the last minute. Once when I had a delayed flight, once for my first miscarriage and most recently when I needed to do my day 3 desperation transfer. "A natural cycle is ideal for patients who ovulate consistently" he offered. Well, that's not exactly me. Left to their own chagrin, my ovies can ovulate anywhere from day 12 to day 19.  I finally received a 'high fertility' reading on day 20, but as I've received both false positive and false negative readings with this monitor, I'll be waiting for AF to determine if this is real.

I quickly rationalised that the stress and strain of making twice daily visits to my RE's office could not only affect my blood pressure and general sanity, but could also suppress ovulation. The other option would be to use Femara and a trigger shot to coordinate ovulation, thus taking some pressure off my ovaries. However, when we were using this approach during my IUI treatments, I'm pretty sure my ovaries went rogue and prematurely ovulated on their own for at least one cycle. Simply stated, those girls cannot be trusted. They're like the Siamese cats from Lady and the Tramp. Husband often asks the question 'what is your time worth?' The other concerning factor with a natural or modified medicated cycle is that we could miss the window, conditions may not be optimal and we would need to cancel the transfer. Thus costing ninety minutes of driving time daily, consuming my 'why I need to leave the office' excuse, as well as the tangible fees for the visits and labs. Oh, and much frustration and disappointment.

The Embryos
My RE glanced at the report before reviewing that one looks really good and one is not so good. "It just met the criteria for freezing." He commented, just before he recommended thawing and transferring both. Recalling my meltdown over the possibility of multiples from my day 3 transfer, he quickly added, "it's not the same risk for twins as if we were transferring two high quality blasts." I indicated that I understood, yet it's still not a risk I'm willing to take. I know a lot of embryologist reflect that they've seen a lot of beautiful babies born from ugly embryos, after a short lived pregnancy with a aneuploid embryo, I'm not too keen to transfer a subpar embryo and possibly endure more devistation.

Re-cycling
I asked this question, even though I already knew the answer. If we were to encounter a BFN after a single transfer with our good embryo, he would recommend doing a second fresh cycle rather than cleaning out the freezer. "Of course he would..." Husband sarcastically commented as he made a cha-ching! sound. "Not necessarily" I countered, pointing out that he could also be accused of wasting our time and money if he advised a single transfer of a poor quality embryo. Additionally, I had received a break-down of our IVF expenses earlier in the day. At least from what I could determine, my RE was only billing for my ultrasounds, retrieval and transfer. The other charges were divided between the lab, anesthesia, embryology, and facility fees. Talk about it takes a village. Prior to my own experience with infertility, I held the impression that the 15 grand per fresh cycle went right into the RE's back pocket. I'm not denying that REI is a lucrative subspecialty, but I feel that I have a little more perspective.

My RE followed his answer by adding that he'd work on adjusting my protocol to try to get better quality eggs. I felt satisfied that he was acknowledging disappointment with my cycle, although he didn't specifically use such words. Prior to the start of my stimulation, he seemed upbeat about our prospects. "I never promise anyone a baby..." his voice trailed off, but it left me with the impression that I had a better than an average shot. Now he seemed much more subdued, seemingly accepting that the odds were longer.  I  disclosed that I started to prepare for second cycle after he projected my retrieval would only yield 6-8 mature eggs. "I think that's accurate." he replied. "It's not a matter of thinking positively or negatively, but being realistic." I truly appreciated those words. I often found myself defending my cautious position to Co-worker and my Lead Physician, who were encouraging me to be more hopeful. I  always planned that if I ever heard my RE make such a suggestion, I would counter; 'if you have a patient with a failed transfer, would you ever attribute it to her not exhibiting enough positive thinking?'

I often leave my RE's office with the feeling that I'm asking for directions as I'm navigating through the land of uncertainty. I may know where I'm going, but I still feel lost. The possibility of having a baby seems more tangible, yet seemingly still so far out of reach.

CD Who Knows?

"Gareth used to prefer funerals to weddings. He said it was easier to get enthusiastic about a ceremony one had an outside chance of eventually being involved in. "

Four Weddings and a Funeral 

Although I wouldn't allow myself to conjure a due date or day dream about decorating a nursery during the five minutes of my pregnancy, I did permit some thoughts about parting with my RE's office. I decided this was permissible, as whether it is successful or not, one way or the other we will have our final treatment. We will eventually be finished with this process. While I'm so eager to be done with juggling my life around these brief monitoring visits, there's a part of me that admits I'll miss some aspects. The office manager who sits at the front desk is sweet and always pleasant. I've really warmed up to New Girl, as she seems to genuinely care for us. I hadn't seen Misery at my last few visits, so I wonder if New Girl has replaced her, but even Misery was starting to exhibit some compassion. I've enjoyed having the opportunity to swap clinical cases with my RE, and I feel that I've learned a lot during our exchanges. I've obtained a cheeky curbside consult for a few of my patients and he gave me some tips when I had to perform an endometrial biopsy for a woman prior to a donor egg cycle at an out of state clinic. There have been occasions where I've exposed my personal vulnerabilities and I think at times, he's revealed a humbler side of himself as well.

Shortly after I accessed my own pathology results, I emailed my RE's office to let him know I was informed. I figured I would spare him the awkward phone call. A few weeks later, I received an email message from him: "Hi Jane, have u started your cycle yet?" Ugh. Taking prompt notice of the absence of the letters 'y' and 'o' that complete the word 'you', I started subtracting intelligence points from his Ivy League diplomas. My elementary school teachers, as well as my mother, placed so much emphasis on proper grammar and penmanship during my early education and it has stuck with me. "Whether it's fair or not, you will be judged on those traits" I heard those words so many times. I even had a teacher who marked your answers as incorrect if you dotted your 'i' with a little circle or a heart. I'm old enough to be from the days when teachers could get away with that shit. Now they'd be penalized for suppressing creativity or individuality. Nonetheless, attention to grammar does make an impression on me. When I was chatting with the irresistible Kiwi, who would have been my lone one night stand, his accent alone was pumping my estrogen levels faster than Follistim; but it was his accurate selection of pronouns and astute application of the subjunctive that really got me out of my knickers. Okay, I'll give some credit to his context; my mates and I noticed you as soon as you walked into the room...would you object if I were to kiss you? My vajay-jay was all a-tingling when I later discovered that he shares my annoyance for improper utilization of 'your' and 'you're'...Young lads take note, good diction can help get you laid. Anyway, I am digressing...

So, had 'i' started my cycle? I didn't quite have an answer. Earlier in the day of my D+C, I performed an IUD insertion and I watched my medical assistant hand my patient a perfect size wingless post procedure pad. Annoyed with myself that I didn't think to shop in our office supply closet, I grabbed a few pads from the drawer and stashed them in my purse. It would not be the first time in this process that I've been over prepared; I had no bleeding after my D+C. Not a drop. I shared with a colleague how I had wasted so much time performing a consumer reports survey in the feminine hygiene products aisle before purchasing my first ever box of pads. "Well, just save them until you're post partum!' she replied. But, I may never be post partum. That thought immediately flashed through my mind. I wondered if it was just an automatic defensive pessimistic reflex, or if I really had a premonition that I would never be in a post delivery state. All I knew at that moment was those pads were now tainted by her words, possibly cursed. I had to get rid of them.

Although she was trying to be thoughtful, my colleague couldn't understand that I can't do anything to prepare for a potential baby at this point in time. Husband did a shopping trip while I was pregnant and later found it hard to eat those foods as he had selected them with me and the baby [embryo] in mind. I thought about giving the pads to Co-worker, as she has heavy cycles, but she'd turn them away and encourage me to be more hopeful. It would be fun to send them to Myrtle, who after being penetrated by six different men and pushing little Myrtle from her hoo-ha, is still afraid to use tampons. However, when we were purging our pantry of gluten staples to donate to the food bank, I noted that 'personal items (soap, deodorant, etc...)' were included in their wish list. I figured that you can't get more personal than sanitary protection and I threw all the pads in the donation box.  

So getting back to the original question; had I started my cycle? Well to quote Chris Rock, not really. Although in many ways I felt an instant sense of relief moments after my D+C, I still felt as if I were under the fog of a hormone hangover, which I projected would last about two weeks. Sure enough, two weeks after my procedure, I started bleeding. I never went in for a two week follow up, as even in my delicious Ativan/Norco induced delirium, I commented that such visits are not evidence based. Initially the bleeding seemed like a normal period (well, normal for me) and although I knew that this wasn't an ovulatory cycle -would it count? I decided to reset my Clear blue monitor as if it were a CD1. However, to commemorate the debut of some new underwear, I continued to spot. For 12 bloody days. As of day 19, my monitor still hasn't registered a high reading.  A 'normal' period may be more elusive than I thought it would be.


NB: I'm not opposed to using 'u' and other abbreviations in a causal message between friends; I'm holding my RE to a higher standard as it was in a professional context.

Star Struck

If you haven't figured it out from my prior two hundred plus posts; I'm basically a big dork. The one place I'm most likely to let my geek flag fly is at a conference of reproductive health professionals. I become a bit star-struck meeting the authors of books and articles I've read, and I feel like a groupie as I can quote much of their work. Unfortunately, as the picture reveals, if I've consumed more than one glass of wine at the cocktail reception; it can lead to having my thigh signed by the editors of Contraceptive Technology...

What happens at RH 2009...Stays at RH 2009...

Recently, I took note of a patient who was on my schedule for her yearly gyn exam. The scheduler commented that she needed to have a Pap smear prior to a procedure. Often, this is a requirement prior to an organ transplant... I started to look through her prior notes. She consulted one of my colleagues for an infertility work up in September. Her day 3 FSH was 18.1 and her AMH was 0.28. After I introduced myself, she wasted no time explaining that she needed to have a Pap smear and exam prior to starting IVF at the Colorado Center of Reproductive Medicine, as she handed me a form that needed to be faxed. Prior to my own personal experience with infertility, professionally I was oblivious to the reputation of CCRM. "It should go to the attention of Dr. Schoolcraft." she informed me. "Schoolcraft?" I repeated as I jotted down the name on her intake form. I was trying not to show that I was aware of the fact that his name is a household word among infertiles. I'm also ashamed to admit that I was a bit giddy over the thought that my notes would be sent to CCRM and would be read by the renowned and esteemed Dr Schoolcraft.

My patient didn't say much to me during her visit. Her only issues and concerns were getting this exam done so that she could proceed with her first IVF cycle. There was a part of me that wanted to share with her that I had gone though IVF recently, but the story of a miscarriage after your first transfer is not exactly the type of inspiration one wants to hear before embarking on this process. I offered her a hug, wished her well and extended positive thoughts that we'd see her back soon. I performed a spell check on my notes, and practiced my signature once before signing her paperwork and faxing it off to CCRM. A few days later, I was brought back to reality as Jessah from Dreaming of Dimples  revealed that Dr S doesn't spend much time reviewing his patients' charts.

Family Balancing

A few months ago, a fellow infertile shared with her co-worker that she was going through an IVF cycle. After describing the process of her injections, retrieval and transfer process, the co-worker asked, 'Why are you putting yourself through all that torture? Why can't you just be happy with the fact that you have one baby?' It was the typical thought process from someone who has never experienced infertility. Little did the co-worker know what a struggle it was for them to conceive their first child. Nor did this woman know how close the infertile woman is with her siblings, and how much she wanted her progeny to have that same opportunity. However, what bothered me the most about her comment is the fact that society can't wait for fertiles to have more kids. As soon as the placenta is delivered, everyone is asking, "so when are you going to have another one?" If the second baby is the same gender as the first, then everyone wants to know "when are you going to try for a boy (or girl)?" Yet, for a couple who manages to survive infertility, her prevailing message was "shut up and don't be greedy infertile, you're lucky to have what you have."

It's a little hard for me to appreciate the experience of secondary infertility, as I'm still dealing with primary infertility, but also as our grand master plan has always been to have an only child. Even before we encountered our issues with infertility and recurrent loss, our intention was to have one and be done. I can imagine how much more frustrating this journey must be for couples who planned to have two or more kids. Just as it is so hard to see others' children and feel reminded about what you want, it must be even more difficult when you're looking at your own. I'm sure expectations are higher going through infertility treatments, as it worked once or twice already. I wonder if your resolve is different pursing baby # 2. It must be challenging to manage all the injections and monitoring while caring for a little one, and I'm sure financial constraints have adopted an entire new meaning.

Thus, 'at least we have one...' is not a bad consolation prize (biased perspective from an only child). It also somewhat alters the dynamics when relating to infertiles who are seeking their first baby. When I was a participant on the online infertility forum, one member tried to establish a special group for those who were over 35 and childless. She expressed that she wanted to interact with others who were facing challenges due to advancing maternal age, and she also noted that she found it hard to identify with women who already had two kids and felt their hearts were breaking for baby # 3. The group was shut down by an administrator who chastised the member for "perceiving your pain to be greater than others". I didn't think that was the case, but that member left the forum to establish her own blog, as did I. While I was involved with the forum, I took note of some members who were going through IVF after a tubal ligation or vasectomy reversal to conceive baby # 4 or even # 5. I know this will sound a little judgmental, but my first thought when reading these posting was shouldn't you be interacting with your kids rather than spending so much time online? Maybe I felt a little bitter as sure enough, many of them were first time IVF winners. They were able to get pregnant as they weren't ever infertile.

A little closer to home, Husband has become close with a fellow hockey umpire who lives on the east coast. When Husband shared our infertility struggles with him, he was surprised to hear that his friend went through IVF as well. The circumstances were a little different. T had two kids in his early 20s and then had a vasectomy. He was divorced by age 35 and in his early 40s, he remarried a woman in her mid 30s. Rather than attempt a vasectomy reversal, they decided to go straight to IVF and succeeded with their first transfer. While I'm so happy that he can talk directly with someone who understands this process (although T went through testicular sperm extraction and didn't have the wank in a cup experience) I can't resist thinking -it's just not the same... Yes, they went through the stress of waiting for a fertilisation report and the post transfer uncertainty, but there was nothing wrong with their gametes. Although not guaranteed, they were much more likely to succeed.

When the other area REI visited our office recently, he discussed the topic of gender selection for patients who are opting for PGD. Initially, their policy was to not let any patients determine their potential baby's gender (unless it was necessary to avoid any inherited X-linked disorders). During his prior presentation, the RE admitted that they would occasionally allow patients who experienced multiple failures or losses to transfer the embryo of their choice. They would not accommodate a fertile couple who wanted a boy after having five girls. Three years later, they decided to revise their procedure. "We recognise that 'family balancing' is very important to some couples, and we are willing to help them" he explained. (Read: we're not too principled to turn away a paying customer) Personally, I would find it difficult to be in the waiting room of my RE's office knowing that the patient sitting across from me was going through treatments just to balance her family with an offspring of a particular gender. Some of us are groveling for crumbs, while others are going for the icing on the the cake.

Recently, a fellow blogger posted about how her day was crushed when she received a Christmas card from an old friend. If it wasn't hard enough to see pictures of her two children and their family activities, the friend revealed that she was expecting baby #3. Most pregnancy announcements are hard to endure, but when it's three or more, it just hits harder and stings a bit more. It feels like the rich are getting richer, while we're figuratively getting poorer. I experienced this first hand when checking in on Facebook. My friend Penny posted photos from her son's 6th birthday. #wantonemore, she included in her post, thus announcing that she joined Twitter and is trying to conceive. Want one more. Those words stuck with me for a while. C'mon mate, some of us are wanting just to have one.

Chasing the Duggars

We tend to get a fair number of patients transferring their obstetrical care around the first of the year due to new insurance plans. If I can make one plea to my pregnant friends; unless there is a legitimate reason (moving, insurance or your old OB was really bad) please do not transfer care in the middle of your pregnancy. Especially if you are a high risk pregnancy. It can be really difficult to transition to a new practice while maintaing continuity of care. Anyway, I am digressing... My latest transfer was 38 years old and she was coming to us as her husband's job switched them from their Kaiser Permanante insurance. I was already groaning. I have nothing against Kaiser as a healthcare system, but it's so annoying to get their transfers. Their printed records are often out of order, contain a lot of duplicated reports and are ultimately incomplete. In this instance, my patient's husband bound her records in a clear plastic binder. Remember when you were in the third grade and figured that if you put your book report in a clear plastic binder it would guarantee you an 'A'? That type of clear plastic binder*. Oh, and there was one more detail. This was her 13th baby.

I always take an interest in looking at the new patients forms, as I feel they tell me volumes with a single double sided page. Penmanship, spelling and grammar is a starting point. Answers that are too detailed or too sparse are informative as well. It's also intriguing when patients (who do have prior pregnancies) presume that they can just skip the section on obstetrical history. Although this patient let us know that we didn't include enough spaces (6) to accommodate her, and thus felt she was allowed to omit this information. "So, how many pregnancies in total?" I asked her. "Fifteen" she replied "I had two miscarriages." Wow, I thought to myself. She's had the same number of miscarriages as I've had and she's having her thirteenth child and I'm waiting for my first. Anyway... this baby will be her fourth girl; she's had nine boys. Out of curiosity, I asked her if she noticed any different symptoms between a girl or boy pregnancy, as I've had a few other grand multiparous patients report that they could distinguish. "Nope." she replied "In fact, I don't ever have any pregnancy symptoms. My cycles are irregular, and I often don't know I'm pregnant until I'm done with my first trimester. I know there are some women who have issues with nausea, so they stop after their second or third, but not me! I kept going..."

After more than ten years in clinical practice, I like to think that it's pretty hard to offend me. Upon hearing that comment, I nearly threw up in my mouth a little bit, and it wasn't due to the residual HCG still in my blood stream. Earlier that week, I saw a patient who had been hospitalised with her 'nausea issues' as she was severely dehydrated and had lost 8 pounds in less than a week. More so, I was irritated that not only did she expect everyone to have easy pregnancies like her (she probably has no concept of the word 'infertile') but apparently we're also supposed to produce enough offspring to field an entire starting line up for a soccer team (with two available subs). We've made a lot of advances in modern medicine and we no longer live in an agricultural society. My grandmother was born in 1901 as her mother's 12th child, as only five of her siblings lived past the age of five and her parents needed the kids to work on their farm.

Flipping through her plastic binder bound records, I saw that her Kaiser providers had asked her about birth control on a few occasions. The notes read: patient refuses any method of contraception. She states she will have as many children as she is granted. "So, is she trying to catch up with Michelle Duggar?" my medical assistant asked. I just never have been able to fathom how some couples accept having a large brood of kids, just because they can. Biology may have granted them seemingly unlimited fertility, but that doesn't mean they're not entitled to some self determination. More so, isn't a house full of screaming kids sufficient as birth control? Seriously, how to they find time for a quick shag, let alone capturing their fertile window? (sorry, I'm going to sound a little judgmental here) I also think it's a bit irresponsible in regard to the environmental effects of overpopulation. I've joked that the Duggar offspring alone are going to bring the world population to 8 billion. Last year, I attended a lecture that projected if each couple produces an average of three children, the would population will be at 16 billion by 2100 (it's is also perceived that 12 billion could be incompatible with life). That forecast is a little scary, as it means our children may not live to see their grandchildren. The speaker concluded, "it's not just a matter of if an individual family can afford a third child, but can our society afford your third (or more) child?"

Speaking of financial matters, how does one afford a family of 15 on a single salary? I once read that the Duggars (even before their reality show) are debt free, as they have several income properties. However, the cost of living is significantly cheaper in Arkansas than in the Bay Area. I often wonder how we'll managing financing one child, let alone a baker's dozen. How do they handle doctor's visits, back to school shopping, field trips, before approaching orthodontics, college tuitions, weddings... Perhaps it is my perspective as an only child, that I just can't comprehend growing up with so many siblings. I wonder how many children are sharing a room. How do they manage family dinners, vacations or other childhood experiences? At what point does it feel redundant? Do the milestones seem less special? Does it occur to them that they seem to be having kids for the mere fact that they can? I may be jealous of her fertility and easy pregnancies, but I wouldn't want what she has. May the force be with them.

*While I appreciated their efforts to present her records in a nice and neat manner, it created a lot of extra work. I had to take a scalpel to scrape off the dried glue, just to be able to separate the pages, and our HIMS clerk had to make photo copies of her records as the original papers still had glued edged and wouldn't fit through the scanner.
                                   

An Extra Measure of Empathy

Among the well intentioned things that were said to me after my first miscarriage; both Co-worker and my Lead Physician commented, "you'll be even more emphatic to your patients who are miscarrying". Maybe I was a little more sensitive in that state, but I took their words as a criticism. Although I would never deny that there is always room for improvement, after delivering such news a few hundred times, I feel I've at least become proficient. Yet, in spite my many years of experience, it is still one of the most difficult and dreaded aspects of my job. As soon as I recognise that the ultrasound findings are not what they should be, my heart drops into my stomach, which then twists into knots. Once I'm satisfied with my scan, I'll instruct my patient get dressed. Somehow it just seems worse to recall that you were half naked when you learned this awful diagnosis. Often I'll stand outside the door and listen for when the movement stops, so I can re-enter the room as quickly as possible.

Once I start my spiel, the words just seemingly flow, but I still stutter to deliver the opening lines, "I am so sorry to be informing you of this situation. I know this was not what you expected this visit to be..." My mouth goes out auto-pilot while my mind is reading my patient. What does she seem to need right now? An answer or an explanation? A plan for what to do now? Reassurance for the future?  Even before my own miscarriage, I could appreciate how overwhelming this situation must be. I know we many not be able to address every issue at this time, but I need to figure out what is the most important piece of information she needs to take with her now. Watch her eyes. Sometimes we need to stop to cry. There are times I'll leave the room for a bit to let my patient and her partner console each other. If she's alone, I'll offer my own shoulder and I'll almost always embrace her before she goes. Some patients have even thanked me for the way I supported them at that time.

As part of her campaign for grandchildren, my mother tried to appeal to my professional ambitions "You'll be a much better provider to your patients if you've experienced a pregnancy and motherhood yourself..." I actually had some anecdotal evidence to counter her argument. I've heard some comments from patients who noted that they preferred a male obstetrician or a nulligravida female one for the fact that they hadn't ever been pregnant. Some found that the parous practitioner spent a lot of time talking about her own pregnancies; and in particular if she hadn't had any complications, she couldn't necessarily relate to her patients. While I didn't have a particular criteria, I must admit I felt a bit relieved when we settled with a male RE. I knew I'd never hear any stories about his ovulation, and although he's put on some weight, I knew he'd never enter the exam room displaying a baby bump. As far as I know, he has not fathered any children and I don't even think he's married, although the absence of a wedding ring doesn't mean anything, as I don't wear mine. Actually, as he once complimented my toe nail polish and commented that black is a good colour on me; I'm not sure if he's straight.

Interestingly, I've found there have been a few occasions where pursuing pregnancy has made me slightly less empathetic. During my final days of stimming, I had a newly pregnant 30 year old PharmD student in my exam room toward the end of my afternoon session. I had been on and off the phone with New Girl for most of the afternoon, as we were scrambling to find an extra dose of my antagonist, since my RE was pushing my retrieval yet another day forward. Admittedly, my patience was worn pretty thin. When it came time to do the ultrasound, she became very fearful of the vaginal probe. "Can you do it abdominally?" she begged. Unfortunately not, she was just over six weeks and was rather 'fluffy'. I showed her that only a small part of the probe goes inside the vagina and it is actually less invasive than a Pap smear. She was still reluctant and was retreating on the exam table in a manner that was surprising given her age and the fact that she is a health care professional. It took all the restraint I could muster not to burst out, 'do you know how many times I've had a transvaginal scan done just this week?' 'Oh, and I'm sorry that your boyfriend has a small dick.'

A week earlier, I was having a particularly shitty day. I had four new OB patients on my schedule, and the first three were non-viable. For the record, it marks the third time in my career when I've had three non-viable patients within one day. After the second, I wanted to cry and go home. After the third, I suggested to my medical assistant that she should think up some reason why we had to cancel the last patient. Our LVN looked at the scheduling comments, "she should be 14 weeks, so she'll be good for you." I had seen this woman for her annual earlier in the year, so I reviewed my notes: planning to conceive toward the end of the year. "So here you are right on time!" I greeted as I entered the room. "Well actually, we had decided to wait a little while longer, but then it happened anyway..." There was a clear tone of annoyance in her voice.

My first thought: STFU, do you know you are talking to an infertile woman who just told three patients that they are miscarrying? Suddenly I remembered the words of my mentors when I first started volunteering in a family planning clinic. "Never presume how someone will feel with a positive or negative pregnancy test. Always ask before you offer any comments." Maybe she or her husband may be facing job redundancy. Maybe they wanted to delay as they have a trip planned -I know someone who can relate to that. All I knew at that point in time was that she was viable. I didn't need the ultrasound to reveal that she was going to be having her fourth baby, while two of my no-go women were trying for a second and the other one was pregnant for the first time. Still, she was my patient and she deserved my empathy.

There is another case from over a year ago that also stays with me. She was about my age and was diagnosed with atypical PCOS. My colleague had her go through six unsuccessful rounds of Clomid before referring her to an RE. She went for her consultation and was preparing to start injectable IUI treatments when her next cycle started. Only AF never arrived. She called our office asking for a prescription for Provera in order to induce a withdrawal bleed. The pre-requisite pregnancy test was positive. At her visit, we laughed as she was now one of those couples. The ones who get pregnant spontaneously right before their appointment with the fertility specialist. As if the threat of injections and other invasive procedures seemingly intimidates the gametes into cooperating.

Unfortunately, her ultrasound revealed a small empty sac that measured about five weeks. As her last period was months ago and she had no idea about possible ovulation, I had no basis for dating, but her HCG was much higher that she should be if she truly were only 5 weeks. I was quite confident that she was non-viable, but as I didn't have any reference other than her HCG levels, I couldn't exclude the possibility of an early pregnancy. Thus, she would need to return in a week for follow up. I always hate these situations, and sometimes feel that they can be worse than a clear-cut miscarriage as it drags out the process and dangles the faintest sliver of hope. I truly hoped there was still some special magic to her story and her subsequent scan would deliver a miracle. Unfortunately, I've been doing this job for too long...

I thought about her during my run on a Sunday afternoon. Her follow up visit was on Monday morning and I was dreading confirming the inevitable with her. I hate informing anyone of a non-viable pregnancy, but it just seemed so much harder and so much more unfair with someone who is also infertile. However, she took the news exceptionally well, and admitted that she had accepted that this was a miscarriage after her first scan. Maybe infertiles are just more accustom to disappointment. I was in the middle of my own two week wait and was unaware at that time that the exact same situation would unfold for me. Positive pregnancy test right before starting an IUI cycle. Suspiciously small and empty gestational sac on my scan. By the time she came back to me for her follow up visit, I had completed my own miscarriage. I didn't have to live through the same experience to affect the amount of empathy I had for her.

I especially didn't need to go thought it twice.

Plus 16 is the loneliest number...

Hours before the ultrasound that revealed the doomed fate of our embryo, our office was visited by another area REI. A few years ago he did a lunch time inservice to share the latest updates in the field of infertility, and to discuss how bread and butter Ob/Gyns and REIs can improve the referral and transfer processes for patients. He left us with his email contact, and I consulted him on several patients, including a particular "patient" who was actually myself. I considered revealing that I was pregnant after my first IVF cycle and was awaiting my viability scan, but I never had quiet moment alone with him and secondly, I knew better than to tempt fate like that.

During his previous visit, he delivered a power point presentation and distributed hand-outs; this time he was not as prepared. He discussed using the Anti Mullerean Hormone (AMH) level as the novel new way of measuring ovarian reserve; as my colleagues and I exchanged glances acknowledging that we've all been ordering AMH tests since he informed us about it three years ago. That was it. He then asked if we had any questions. When no one else raised his or her hand, I decided I wouldn't pass on an opportunity to pick an RE's brain. I went wild with my questions. What factors determine a choice of protocol? (experience from prior stimulation is the best guide) How about endometrial injury prior to a FET? (gaining more support in the literature, his group is reserving for recurrent implantation failure) Thoughts on 'mini-IVF'? (a gimmick) What is your percentage of day 3 versus day 5 transfers? (25%-75% based on the fact that day 5 embryos are likely to be of a higher quality, but if a day 3 transfer results in a pregnancy, it's not more likely to be chromosomally abnormal than a successful day 5 transfer) He then introduced the concept of Pre-implantation Genetic Diagnosis (PGD) and its utility in allowing for more single embryo transfers and higher pregnancy rates.

Some of our medical assistants, who were learning about this technology for the first time, were fascinated. "Wow! So you wouldn't have to do any screening or an amnio?" "Can you find out right away if you're having a boy or girl?" "That's so cool!" I was screaming inside my head; "THIS ONLY HAPPENS IF YOU HAVE ENOUGH EMBRYOS TO TEST!!!" All the promises of PGD are taken off the table when you get this call from your RE: [in the voice of Bill Lumbergh from Office Space]
"Hey Jane... what's happening... yeah... you see, your embryos kind of suck... I'm gonna need you to come in and transfer your embryos today...Yeah...if we could just go ahead and transfer your embryos today, that'd be great...or maybe it won't be...mmmkay?"

I knew it would take a little longer for my pathology results to come back due to the holidays, but I overheard one of my colleagues taking about abnormal results on a patient who had her D+C just about the same time as me. Since the products were sent to a hospital within our shared computer system, I asked my Lead Physician to access them for me. "It was abnormal +16" she wrote in her text message. (Husband and I decided that we did not want to know what the prospective gender would have been) Trisomy 16. The most common trisomy that occurs in more that 1% of all human pregnancies. An abnormality that is not compatible with life.

My first reaction was one of relief. "It's sort of good news!" I described to Husband. We have an answer; a explanation for our loss. It would have been disheartening if we had learned that the embryo was euploid and may have been a healthy baby. We would be left asking 'why?' and may never would have known the reason. I feel fortunate that the demise was discovered so early and did not progress any further. Yet, it's still another loss, another opportunity denied.

Thus, I feel a bit annoyed, although I acknowledge that it would be much more frustrating if we didn't have an identified cause. This was the situation I wanted to avoid by doing GPD. This is why I shared with my RE that "it seems a bit daft" to speculate about the best looking embryos and merely hope for the best. There was a reason why I would have preferred to do a day 5 transfer (two other bloggers had chromosomal abnormalities confirmed after a miscarriage with a day 3 transfer). I sensed there was a measure of desperation with the recommendation to transfer on day 3. I was right to be so guarded and so cautious. I saw the writing on the wall from the moment my RE projected the retrieval would only yield 6-8 mature eggs. All my instincts were correct, I just failed with the execution.

There is nothing to be gained by wasting time looking over my shoulder. A few hours after my transfer, my RE called to query if we wanted to biopsy my remaining embyros for PGD testing. Husband and I took a few minutes to conference and decided against it. The embryologist and my RE had managed to convince us that our transferred embryos were decent and that we had a reasonable chance to produce a pregnancy. Husband joked that if we spent the extra five grand to test those embryos, it would guarantee the success of this transfer. As I didn't have much confidence in those embies, I didn't want to spend the extra money only to learn two days later that none progressed to day 5. We were both mentally preparing that we would need to do a second fresh cycle and PGD testing for those embryos didn't seem like a good investment at that time. Additionally, selection of a euploid blastocyst would not guarantee implantation nor eliminate the possibility of a miscarriage. I need to keep reminding myself of that fact.

These results do provide reassurance as I look ahead. I've had two miscarriages. One (I believe) was attributed to a uterine septum, the most common uterine abnormality to contribute to a miscarriage, and the other due to trisomy 16, the most common chromosomal abnormality. Additionally, if this embryo were euploid, I would have higher doubts about whether or not our fro-yos were normal. The embryology lab estimates that ten eggs are required to yield 1 euploid embryo. If you factor a two-third fertilisation rate, you'll have six to seven embryos. Only half of those will advance to become blastocysts (approximately three) and only half of the day 5 embryos will be normal (thus leaving you with one or two useable embryos). The implantation rate with a euploid embryos is about 75%. We only had eight eggs, five fertilised, two were transferred and two of the remaining three became blastocysts. My RE reported that the embryologist noted that one looks "really good" and the other was just good enough to freeze. So is one of those two a normal embryo? Husband and I are speculating that we might want to place our bet with the sub par one...

Those are strings, Pinocchio

I've described in some of my previous posts why I haven't shared any of our infertility and pregnancy struggles with my parents. After this recent miscarriage, I paused to reconsider that decision. Although it felt a bit more like an obligation, rather than needing to share with my parents to gain emotional support. Perhaps it's my only child up bringing that established independence from my parents at an early age. I was never the child clinging to her mother's leg on the first day of school. When my mother was considering going back to work, I encouraged her to go and let me be a member of the latchkey kid club. The only 'I want my Mommy!' moment that I can remember, occurred when I was sick (and misdiagnosed by the student health centre) during my third year of University. I called the restaurant where my mother was attending a holiday party (this was in the day before everyone had a mobile phone) to tell her I was ill. "Jane, what do you want me to do? (she was obviously past her second glass of wine) I'm five hours away. You'll have to take care of yourself." While her words may sound harsh, it was the advice I needed to hear. The next day I drove myself to an urgent care clinic and was diagnosed with pneumonia.

I know that in this situation my mother can't kiss me on the head and promise to make everything better. I know much more about procreation, assisted reproduction and pregnancy than she does. I feel that I would probably be the one providing moral support to her. I also fear that if I share the details of our infertility with my parents, my mother will likely discuss with her sister and Myrtle's mother. As I've outlined how clueless Myrtle is, keep in mind that the apple doesn't fall from the tree. In addition to wanting to surprise my parents with the joyous news of a successful pregnancy, I want to disclose to our extended family on my terms and properly educate them about infertility and assisted reproduction. I don't need Myrtle's mother telling mine that I just need to stand on my head like she did while trying to conceive Myrtle's brother; or to have my aunt offer that we'll likely get pregnant once we stop trying all this test tube experimentation.

I refused to do this during the ten minutes of my pregnancy, but I plugged my dates into the gestational wheel of fortune. I would have been 13 weeks at the end of January when Husband has his trip back east. Provided that things had progressed and my genetic testing was normal, I could have flown out with him to announce the pregnancy to my parents. Husband suggested informing them about our situation over the phone while he is visiting, but I think this type of news has to be delivered by me in person. However, as we'll (hopefully) be doing our FET in January/February, I can't leave during that time. I also looked ahead to the first week in April. My dad and I are taking a father/daughter trip to the University of Connecticut National Championship Invitational (I mean, the NCAA Women's Final Four). I envisioned that it would be a little awkward to be sharing a hotel room with my dad while five months pregnant, but I could have learned to get over it.

Speaking of things that are awkward, Husband and I both agreed that we probably should bring them in the loop if we get to the point of doing a second fresh IVF cycle. Then Husband said something to the effect of, "I'm sure they would offer to help us financially". He then started thinking out loud, "If they could help with the cost of meds, that would be great." He also added, "I'm sure they would, as my parents gave us $1,500."

AGGGUUHHHH! Now this discussion is starting to get very uncomfortable. When we purchased our house, we had to borrow some money from my parents to make our 15% downpayment. It was really humbling as I earn more than both of my parents, but I had to accept that without their assistance we would be continuing to throw  money away while renting. We paid off the debt in less than two years, but I felt like I was under scrutiny during that time. Could I really ask them to help fund their grandchild? Furthermore, I don't want to create a tit-for-tat between the potential grandparents. Although I could make the case that Husband's parents didn't specifically give us $1,500 for IVF expenses; it was their leftover vacation money, as they didn't go anywhere or do anything while they were here. I'm sure it just made more sense than losing value again on the currency exchange.  I recall how my mother insisted that I adopt her method for cutting up an avocado for guacamole. I can only imagine her potential to be controlling if she's invested in my baby... Sigh. I'm remembering a time when the only possible awkward procreation related interaction with your parents was if they walked in on you while you were having sex...

Neither a lender or borrower be .... William Shakespeare.

The IF-RPL Stages of Grief

Although the Kuber-Ross model describing the five stages of grief often experienced while facing a terminal illness has been applied to other situations, I've noted that I seem to be going though a unique five stage approach following my second miscarriage.

Frustration
This emotion seems to have replaced denial and anger. I think I did a pretty good job of repressing any expectations of optimism, so much so that the news that the pregnancy wasn't viable wasn't even a surprise to me. I prevented myself from feeling any sadness at the time, but the sadness creeps up on me at times if I think about where the pregnancy could be at any given time. This is when I transition to frustration. I'm ready to be done with procreating. I'm ready to be finished with the frequent visits to my RE's office and the accompanying lies and excuses. I want to end the secrecy. I'm tired of feeling as if our lives are on hold.

Although this is petty, I really wanted my last pregnancy to work as it would have granted Husband fatherhood before his 40th birthday. Waiting two more months feels like two more years at our age. Even more petty, my friend in Maryland is lapping me -she's pregnant with her second while trying to conceive in the same time period as us. I'm starting to prepare myself that Myrtle will be pregnant again soon. Although this could be the least of my worries, I resent that I could have to share the spotlight if we were to be pregnant at the same time. I'd have to endure hearing about her uncomplicated, perfect pregnancy while I'll be a high risk mess. I never thought I'd feel this way, but infertility and pregnancy loss makes you bitter and spiteful.

Perhaps anger could also be replaced by regret, which is sort of a subcategory under frustration. I regret that we didn't start trying to conceive sooner, I regret that we didn't start IVF sooner. I regret wasting time regretting about the past when I should be focusing on the present and the future. I'm so fortunate that we have our embryo insurance, but at the same time, it's frustrating to think about going through another two week wait and ensuing uncertainty. I'm also preparing myself that we shouldn't expect our FET to work, just because our first transfer resulted in a pregnancy, which could mean waiting even longer for our next transfer. I feel like I don't even want to know the numbers of any positive beta results. Beta numbers mean nothing to me. I once joked that I won't accept that we're having a baby until my hands are behind my knees and I'm hearing someone instruct me to push. Now that's sounding much more realistic.

Consumption
As we drove separately to the visit that discovered our embryo's arrested development, Husband arrived home before me and had a glass of wine ready for my entrance. While I didn't feel the need to drink, I just appreciated that I could. Fortunately, the eating part of this phase was short lived, but it included a shameful trip through the Burger King drive through. I turned into a dead-end street and parked in the cul-de-sac and devoured the oh-so satisfying while yet so horrifying fast food. I then tossed the rubbish and took my car in for interior cleaning to cover up the crime. Until I had my D+C, I felt that it didn't matter if I ate healthily. Once my uterus was reset, I restarted my good eating habits.

Research
I have yet another two week wait until the results from our products are received. I figure a chromosomal abnormality is just too straight forward to be our answer, so I'm preparing to learn that our embryo was euploid. Fortunately, I've not have any recent patients with RPL, so I was overdue for a refresher.  Seemingly, ever article seems to start with a discussion on how difficult it is to study and analyze RPL. Even women with RPL may have different explanations for each loss and two individual women with RPL may have separate etiologies. Making matters more complicated, the expert groups (American College of Obstetrics and Gynecology and American Society of Reproductive Medicine) lack consensus on what defines recurrent loss and what type of evaluation should be performed.

Statistically speaking, 15% of pregnant women will have a spontaneous loss, but just 2% of pregnant women with have two consecutive losses. This is actually slightly lower than the observed frequency alone (0.15)(0.15) = 0.0225 or 2.25% which does allow for mere bad luck to be a plausible explanation. However that mathematical model doesn't account for the inherently higher risk due to my age. Accordingly, my miscarriage risk with a future pregnancy is now 24-29% as I have two losses recorded.

Interestingly, I uncovered some information I hadn't read previously. A uterine septum is the congenital anomaly associated with the poorest reproductive outcome and it is the most common uterine abnormality to cause RPL. Although some women with a septate uterus can carry a full term healthy pregnancy, (with a higher occurrence of malpresentation) it is proposed that decreased blood supply to the septum may lead to poor implantation and the miscarriage rate may be as high as 60 percent. My RE felt that he couldn't conclusively attribute my first miscarriage to my septum, especially as mine was relatively small, but I intuitively felt that it was to blame. Now, I have some data to validate my instincts.

Some other information to consider is that there is an increased risk of miscarriage in the setting of abnormal sperm morphology (defined as fewer than 4% normal forms -Husband only had 1% normal on his complete semen analysis). Although I felt confident that my level of exercise and activity wouldn't cause a miscarriage, I kept quiet about what I was doing as I feared I would be judged negatively, given my history. Now I have it in writing that exercise does not increase the rate of a sporadic or repeated loss. Regarding celiac disease, more evidence is indicating that even subclinical disease may contribute to recurrent pregnancy loss and treatment in the form of a gluten free diet seems curative. However, as it is the end effects of gluten enteropathy that may create a poor reproductive environment and not the gluten itself,  a gluten free diet would not offer benefit in the absence of celiac disease.

The other controversy in the field or RPL research is the role of thrombophilia evaluation and treatment in the setting of first trimester losses. Recent recommendations suggest limited testing to Anticardiolipin antibodies and lupus anticoagulant (uterine cavity and thyroid testing are also suggested as part of an initial RPL work up. Karotyping of both partners should also be considered, although the yield is small, the findings of an imbalanced translocation could represent a game changing plan requiring PGD) My RE and I had discussed that there seems to be a low pre-test probability of performing hyper coagulable testing with early losses, but I'm reconsidering as I experienced an episode of aura a few days after I learned the pregnancy was non-viable. I had been instructed to continue all my meds so that I wouldn't pass my products spontaneously, and I honestly can't remember if I took my estradiol that morning. However, all forms of exogenous estrogens are contraindicated in women who experience aura (with or without migraine) as that combination produces a higher risk of stoke. Thus I wonder if the supplemental estradiol contributed to an increased hyper coagulable state, which may have played a role. I know such a theory cannot be determined with testing for inherited thrombophilias, but I'm still curious to see my panel.

Planning
As I anticipated, my RE wants me to wait to have one normal cycle before proceeding with a FET, so if AF cooperates, we're looking at February. He's proposing that we do a natural cycle transfer as it seems that I have more than just blood pressure problems with exogenous estrogen. (on a side note, I'm so bummed that I won't be able to take HRT when I go though menopause!) Although the concept of a 'natural cycle frozen embryo transfer' sounds like an oxymoron, I like the idea of using fewer drugs. However, I'm reluctant to rely on my unpredictable ovaries and my borderline uterine lining. I'll be gutted if we miss the timing and have to wait another month, but more so I fear wasting our good blastocyst if everything isn't perfect. Other options to consider include using transdermal or intravaginal estrogen to avoid the liver's first pass effects, and/or anticoagulating. Fuck me, why does this seem so complicated?

The other part of my plan is that I am going to trial going gluten free in the month of January to see how I feel with it. In the past few years, I've had some patients describe how (even in the absence of celiac disease) they went gluten free and it seemingly changed their lives and they feel so much healthier and happier. My inner skeptic questioned if it was merely a placebo effect, but over time I came to accept that if you think you feel better, who cares about the validity of the variable, if you're feeling better -good for you! A few bloggers have also reached out to me with their gluten free success stories. As I used to eat cereal two, sometimes three, meals a day, I am pretty sure that I do not have any form of gluten intolerance, so I know that the data does not indicate that there would be any benefit. However, it's a relatively easy intervention and I figure what do I have to lose? (maybe a few pounds!) We cleared out our pantry and made a donation to the food bank whilst discovering the gluten free section in the store. Additionally, as we found a gluten free beer, Husband is willing to do this with me.

Embracing
This is essentially the same as the Acceptance phase, but I thought 'embracing' implied a more positive connotation. It's the process of appreciating the things you can do in your non-pregnant state. After running a half marathon in the middle of August, my training went on hiatus while we spent our weekends preparing for the in-laws arrival. I resumed my routine in October, but shortly had to taper my activity level as I reached the end of my stimming phase. I was back in the pool on the 6th day after my transfer, but I was still feeling a little delicate from the effects of my retrieval, so I moved myself to a slower lane. However, once the temperatures dipped below freezing, I decided against swimming in an outdoor pool. I skipped a month of Cross-fit during this time, and my Thursday evening tennis group stopped meeting just before Thanksgiving. Once I learned that we were non-viable, I ceased all activity.  Although exercise cannot disrupt a healthy pregnancy, I feared that it could potentially cause me to spontaneously passing my products, and I didn't want to take that risk.  Funny how your perspective can change. I went running a few days after my D+C, and discovered just how much my fitness had declined.

Once again, I've become a cautionary tale to be careful about what you wish. When it was originally proposed that we would do a freeze all cycle, I liked the idea of being able to recover from the stimming and retrieval and get myself back into shape for my transfer and possible pregnancy. Wish granted. I signed up for three 10Ks in January and a half marathon in February. I ran 5 miles on Christmas morning, just to prove to myself how committed I was. Husband and I re-enlisted in Cross-Fit. As the yoga classes have been temporarily suspended from the Cross-Fit schedule, I picked up a few DVDs to do at home. I joined another session of Thursday night tennis. After taking almost six weeks off, I'm looking forward to getting back in the pool.

Perhaps my objective is to keep myself so busy that the time passes quickly, but I welcome a break from all the medications, blood draws and ultrasounds. It's been a struggle to keep up with my workload as I've been running out of the office so much, so I'll try to get ahead in anticipation for my FET preparation.  Mostly, I appreciate this time as I feel protected from disappointment. While I'm anxious to move forward with our next steps, I'm also fearful.

Brand New Day

Happy New Year!

For the third straight year, I welcomed the dawn of the new year by running/hiking a 10K race. If it seems impressive to be doing something active while the rest of the world is recovering from a hangover, this is the course map:

When I reached the 2 mile mark and started the climb up the hill, I took the opportunity to reflect on the many good things that happened in 2013.

• I am blessed with good health, and such blessings have been shared with my close friends and family
• Successful correction of uterine septum
• Competed in 5 swim meets, 1 open water event
• Joined Cross-Fit gym
• Started playing tennis again
• My cat A's diabetes is in remission!
• Sad goodbye to our friend Pierre. We're gutted that you were granted such a short life, but we were so fortunate to have been a part of it
• Andy Murray wins Wimbledon!
• Co-worker gave birth to two healthy boys
• Another Ex-pats reunion at a wedding in Arkansas -the Green Penguin lives on!
• Family vacation in Hawaii
• Celebrated seven years married to the love of my life
• After the bombing during the Boston Marathon and days of terror that followed, the city celebrates the Red Sox winning the World Series
• First IVF cycle -yielded 4 usable embryos
• 5 bloggers finally had their babies. 15 finally received BFPs and are still pregnant. (5 in the past two months -take that Infertility!)
• Completed 2 Half Marathons (almost established a new PB), 12 10Ks and 1 5K
• New fuel pump resuscitates my 10-year old Jetta
• Finished painting kitchen cabinets! 

When I reached the top of the hill, I selected one particular song as I prepared for my descent and started thinking about the new year (side note: this was our wedding song).

When all the dark clouds roll away

And the sun begins to shine
I see my freedom from across the way
And it comes right in on time
Well it shines so bright and it gives so much light
And it comes from the sky above
Makes me feel so free makes me feel like me
And lights my life with love

And it seems like and it feels like
And it seems like yes it feels like
A brand new day, yeah
A brand new day oh

And the sun shines down all on the ground
Yeah and the grass is oh so green
And my heart is still and I've got the will
And I don't really feel so mean
Here it comes, here it comes
0 here it comes right now
And it comes right in on time
Well it eases me and it pleases me
And it satisfies my mind

And it seems like and it feels like
And it seems like yes it feels like
A brand new day, oh
A Brand New Day