Monday, 2 June 2014

Moment of Truth

One day, while I was working at a hospital in Connecticut, my colleague and I were in need of some continuing medical education credits and some free food, so we dropped in on the lunch time lecture in the primary care department. The speaker was a cardiologist, who discussed various medications and how they can affect a patient's blood pressure or cholesterol levels. He concluded his talk by expressing "isn't that really part of the fun of medicine? You give a drug and you watch numbers change!" My friend leaned over to me and whispered, "this is why I hate internal medicine; it's such intellectual masturbation..." I bit my lip to suppress a giggle so that we wouldn't be exposed as the gynae crashers. Although I really agreed with her description, and feel I should use the term 'intellectual masturbation' more often, I could see his point. There is something satisfying about getting feedback from your interventions. We don't really have the same opportunity in Ob/Gyn. I thought about the intangible numbers that are present. I prescribe many contraceptive methods and I hope my actions are decreasing the volume of unplanned pregnancies and abortions, but I have to wait for the yearly stats from the Guttmacher Institute and they don't reflect my individual efforts. Actually, the most gratifying procedure in my field is performing and I+D for a bartholin's cyst or abscess. It's the one occasion when you can make some one feel better immediately.

Anyway, returning to our cycle currently in progress... The evil Si and Am triggered my LH release at a time that would lead to my cycle starting while I was away for a few days. As I was speaking with Misery to arrange my baseline scan, I asked if the delay could be detrimental. "No, not at all, when you're on Lupron, you can stagger up to 10 days." Oh Phew! So starting 1-2 days after CD2 didn't seem like a big deal. If only I knew that ahead of time, freak out #1 could have been averted. Actually my uterus was surprisingly cooperative and didn't announce AF's arrival until the day before my appointment. It would seem as if everything were on track to start my stims as intended. As my prior SD4 estradiol level was twice as high as my RE wanted it to be, it was logical that he reduced the starting doses in half. I began with 75 units of Menopur and 75 of Gonal-F.

As I was awaiting for my first E2 results, I noted a small blob of EWCM. Ah, a sign that I was producing some estrogen, let's just hope it wasn't too much. I kept staring at my phone waiting for it to ring. In the two minutes that it took my Lead Physician to update me on a patient in labour, I missed the call. Hi Jane, It's Misery from Dr Somebody that I Used to Know's office. Based on your estradiol level, he'd like you to increase the Gonal-F to 150. Keep everything else the same and we'll see you on Monday. Have a good weekend!
Hold on... what was the number?
I called her back immediately with my inquiry.
"It was 41." She replied
"41?" I confirmed "As in FOUR - ONE?"
"So, it's all or nothing with my ovaries, either too much or too little?"
She went on to explain that no two cycles will be the same. [no shit.] I replied that I can appreciate that fact. The different variables in play are that we've reduced my stim dose in half, added Lupron and my ovaries have aged six months. So is there not enough stimulation, is the Lupron too suppressive or are my ovaries too old? For the record, I did inquire about rechecking my FSH/E2 and AMH as all that data is now over two years old, but my RE thought that was unnecessary. I asked Misery to double check with Dr STIUTK to make sure my Lupron dose didn't need adjusting.

Cue freak out #2... I was trying to reassure myself that I have been on perhaps the lowest of stim doses (although there is a 37.5 marker on my Gonal-F syringes) and this may be a better scenario than if my levels were still too high. It just felt that my three days of shots accomplished nothing and I was still starting from scratch. Yet, what if this was indicating a poor response? When Misery called back to confirm that my Lupron dose was to continue unchanged, I asked her if there is any hope to salvage this cycle or should I realistically prepare to discover that I'll be cancelled come Monday. She was very quick to disagree, and commented that he didn't seem too concerned when he saw my results, and just had a rather nonchalant response of "oh, she's responding slowly" (um slowly, or not at all?).

It was a long wait until Monday. Almost as agonising as the final 48 hours of a 2WW. I was glad I spoke with Misery the second time and I felt a bit better after hearing her description of my RE's reaction.  Yet I still couldn't stop wondering if I may be in the process of another therapeutic misadventure. My ovaries are seemingly like Goldilocks, first stim cycle was too much, this one may be too little. Do I trigger and see what we come up with, or cancel and try to find what is just right with a third stimulation attempt?

Alas the moment of truth had arrived. I had 4 follies on my right ovary and 6 on my left. All were about 10 mm in size. New Girl pulled my records from my last cycle to show that the synchronisation was much improved. So something may be actually working. My RE projected that I'll probably continue stimming for a total of 11 to 12 days. He couldn't speculate on a final oocyte tally at this point in time. I expressed to him that if it falls less than my prior cycle, I'd prefer to waive the retrieval and attempt to stim again. As I was walking out of the clinic, I heard him call my name. After I caught up to him, he tried to reassure me that despite the slow start, this could be my best cycle. Yet at the same time, he estimates there is an 80% chance we'll make it to retrieval. It was comforting to know that we are on the same page.

My estradiol level came back at 586. He wants me to continue on my present dose. I didn't ask him how he was making his 80% calculation. Maybe it is all just intellectual masturbation. I'm just hoping that his mind is a bloody good wanker.


  1. This sounds like wonderful progress! 10 relatively synchronized follicles is fantastic! I think he probably should have anticipated that you would need more of a bump after downreg to wake up your ovaries, but it doesn't sound like it was to any real detriment. I hope things continue to progress swimmingly!

  2. Intellectual masturbation - love it! I use the same phrase often at conferences!
    Good luck with your gentle growers - sounds promising.

  3. 10 follicles is a great count so far! Yay! Keep plugging away little follicles :)!!

  4. My clinic always wanted to see my E2 levels double from check to check in the early days, so going from 41 to 586 more than does that. And 10 synchronous follies is amazing! Something I've never been able to manage, at least. So give Si and Am some credit!

  5. It sounds like things are progressing great, even if a little slow. The slow and steady might be perfect to win the race, right? I'll be wishing those 10 follies some fantastic growing over the next days!

  6. I've always seen that slow and steady seems to prevail. I'm so so happy that this cycle seems to be turning around for the better! Keep on doing what you're doing!! :)

  7. I don't know anything about what the estradiol numbers are supposed to be, but 10 follicles all the same size sounds pretty good to me. Keep growing, little guys!

  8. My boss is a former politician. Intellectual masturbation is the most accurate term I've ever heard to describe his daily interactions.

    I'm cheering on your follicles to keep growing!

  9. I really get this... high AMH means we want ALL THE EGGS! Particularly after a failed IVF cycle. I'm not sure what would feel like "enough" now. My doctor said a second protocol would be similar and I just stared at him... "huh? don't you think we should double it? Start off guns blazing? GIVE ME EGGS!!!" I'm sorry that things have been rough so far. I really understand how hard it would be to decide to cancel and try for better or push through with what you have. I think the awesome thing here is that they're all the same size... that's wonderful! Hoping that they all keep growing together and that you've got some solid, really healthy eggs on their way!

  10. I got to say that even growth in abundance is the most exciting thing when it comes to an IVF cycle. Yay!

  11. I think we're always worried about finding that goldilocks amount, but the fact they started off with a smaller dose is good, because you can always turn up the heat easier than you can if you've overstimulated. Your response seems to show that. 10 follies close in size is great and there's a good chance you'll have more by the time retrieval rolls around. I agree with Suzanne too, slow and steady usually always wins the race!

  12. I'm hoping that he is right and that 80% is right on…and this is your best cycle yet!!!

  13. Intellectual masturbation is an awesome term.
    10 follicles sounds pretty good, I hope they keep cooperating! My numbers started out slow, and dipped a few days before retrieval, which really wasn't supposed to happen, but in the end all those steps worked out perfectly... hoping they will for you, too!