Thursday, 26 June 2014

How to fall in love again

It has been said that no one is born with the skills to cope with infertility and pregnancy loss. I recently discovered that those acquired skills can be applied to other challenges. Just as I had done after a BFN or miscarriage, upon learning that my cat Angus had a terminal diagnosis, I went into Research and Planning mode. We decided that we wanted him to be cremated. There is a greenhouse window box behind the sink in our kitchen. He wasn't allowed up there, but when he could, he would sneak into that space to watch the outside world and nibble on my chives. I thought that would be the best spot for him. I selected some items to be included with him during the cremation. As the ashes will be on display in our kitchen, I didn't want them to be kept in something that could be recognised as an urn, so I went to a local pottery shop and found a nice vase. The sales woman gave me a 10% discount when I told her about the intended purpose.

I also started looking for our next cat. While we know we can never replace him in our hearts, there are so many animals who need homes, and we think this is a pretty good one to get. Husband argued that Angus would actually want us to give the opportunity of domestic life to another cat, as he experienced the benefits and alternatives first hand. Angus was a feral cat who was trapped when he was 2-3 months old. He and his sisters were found eating out of a dumpster behind a restaurant. If they hadn't been rescued, they may not have lived more than a year. I sat next to him and searched a few local shelters. Perhaps, I was trying to gain his blessings, or just trying to assuage my own guilt.

I was looking for another ginger tom. Like human men with English or England Commonwealth accents; that's my type. I kept re-visiting the profile of a four year old cat named Hugo. The picture displayed was only a close-up of his face, but there was something about his pensive look that was drawing me to him. I kept checking the page every day to see if he was still available. I figured there wouldn't be too high of a demand for an older cat, so he could likely hold out until Angus's passing and our time for grieving. Then one day, I noted that they changed the picture. Apparently they took him to a Kitty Glamour Shots session.

Okay...maybe not... Although it's not the cat's fault that someone thought that a bit of gold bling would make him look more appealing. It just really hit me that falling in love with another cat would not be as seamless as I thought it would be. Taking care of the tangible details of Angus's death was an easy task, dealing with the emotional fallout was not. How could I expect to replace an eleven year relationship in merely an instant?

This was the first picture I saw of Angus. After expressing interest in a few other cats, only to discover that they had just been adopted, I had a strong feeling that he was the one for me. I moved quickly to meet him and my initial instincts were confirmed; he was meant to be my cat, but even then I didn't know just how special he would be to me. "He is very shy, but I think he has the potential to be a very loyal cat." were the words from his foster mother as we finalised his adoption. She was quite accurate with the shy description. He was so skittish that he hid from me for the first month after I brought him home. My parents and some other friends suggested that I consider returning him. "I can't do that. The next family would have the same issues if he were to be adopted again. I'm just stuck with a dud of a cat." Then one day I noted that he was rubbing his eye with his paw. I was able to get close enough to see that it was crusted shut. He likely had conjunctivitis.

I quickly made an appointment for the vet without giving any thought to how I would get him to the vet. Every time I approached him, he ran away, and he was a quick little bugger! I chased him around my apartment for thirty minutes before I trapped him in my room and dragged him out from underneath my bed. We were forty-five minutes late to the appointment. The receptionist took a look at the scratches on my arms and agreed to let us be seen. Once we were in the exam room, I took him out of his carrier. He didn't try to run or hide, so I picked him up and held him in my arms. He didn't squirm or protest, so I held him until the vet arrived. Sure enough, it was conjunctivitis. The vet gave him an oral antibiotic and a steroid eye drop. When we got home, I thought I'd go to the gym and give him some peace and quiet in order to unwind from his earlier ordeal. As I was leaving, I saw him sitting under my table with a sad look to his face. I approached him and he didn't run. I carefully picked him up and moved over to the sofa. I placed him on my lap and he absolutely melted. He began purring loudly and licked my hands. I never made it to the gym that night and spent the next two hours bonding with my cat.

His potential to be a loyal cat had be tapped. From that moment on, he wouldn't leave my side. He slept next to me a night. He would sense what time I was due home and would greet me at the door. Both Husband and my father noted that his eyes seemed to follow me when I walked about a room. Husband often expressed that he was jealous over the amount of attention I gave to Angus, but how could I not reward someone who was so willing to shower me with his affection? Every moment with him was so precious. I'll forever treasure every time he brushed up against my legs. Every time I woke up and found him sleeping by my side. Every meow. Every purr.

I just can't believe that he's gone. I walk about the house and I still expect to find him. Greeting me in the foyer, sitting on the back of the sofa, dozing on my bed, stretched out in front of the sliding glass door to soak up some sun. I see him everywhere, and yet sometimes I fear I'll forget what he looked like. I've been viewing at pictures of him at least once a day. I made a recording of him purring. As I listen to it, I conjure memories of the softness of his fur, the warmth of his body and the sweetness of his face. Sometimes when I'm drifting off to sleep I think I hear the familiar thump, thump of him jumping on the bed. I reach out for him, but he's not there. I've had many flashbacks to my last moments with him, but I had one dream that he was still alive. When I woke up, my first thought was to acknowledge that he's no longer with us. From the day that I welcomed him into my life, I always knew that the time would come when we would say goodbye. I just presumed we had more years together. I walked into our guest room to drop off some blankets and I remembered the last time I saw him in this room. I was making up the guest bed as one of Husband's friends would be staying with us for a few days. He kept jumping on the bed and I finally had to shoo him out of the room and shut the door. At that moment, I had no idea that he would be dead just one month later.

He was given a prognosis of 2-3 weeks at the time of his diagnosis. He held his own during the first week. He would walk into the kitchen and looks at us with his 'feed me' eyes, but would only graze upon his food. Myrtle sent him some cat treats that he went nuts over, so we fed him those whenever he wanted. His last night sleeping with me was the night after my retrieval. He usually snuggled by my shoulder, but this time he positioned himself so he was leaning against my hip. I had recently finished my eighth bottle of Vitamin Water and desperately needed to pee, but I didn't dare move. My RE and the staff at XYZ Fertility Centre all know that holding my bladder for the transfer is absolute torture for me. Burning injections of Menopur, drawing my own blood and self administering IM Progesterone-in-Oil injections; no problem. Yet, I wince and moan over keeping my bladder full during the transfer. I lay still for over an hour, and when he finally got off the bed, I was able to get up and relieve myself.

He became less active and was noticeably skinnier as we went into his second week. I thought about scheduling him to be put down on a Thursday, since my vet has evening hours on that night. It would also work out well as we had plans to meet up with friends the next night and we had a very busy day scheduled for Saturday. We would join some ex-pats in a pub for England's first World Cup match and then catch a baseball game as the Yankees were in town. Great plan to be distracted from our grief. Yet, I had reservations about ending his life around when it was convenient for me. I didn't like the idea about having an appointment for death. I didn't want to his last memories to be in his dreaded cat carrier going to the place he absolutely hated. Every time I walked past him, I held my breath to see if he had peacefully slipped away on his own.

Two days before he would have hit the three week mark, I came home from the gym and found him in the foyer. It would be his last time greeting me at the door. The joy from that moment was short lived as I discovered that he was in distress. He was listless and tachypneic. Husband and I looked at each other, holding back tears in our eyes. We knew it was time. Our vet's answering service directed us to an after hours emergency clinic. I gave him a generous dose of his pain medication and sat next to him in the backseat of my car as Husband drove. There was over an hour wait, and the staff was gracious enough to let us stay in our car, rather than in the dog filled waiting room. He seemed much more comfortable, but Husband and I knew that we needed to proceed. If not that night, we'd be back the next night or the night after that.

So it began in a vet's office, and so it ended in a vet's office. The 'transitions room' featured soft lighting and a few comfy chairs and a sofa. It looked like it could be someone's living room, rather than a clinic. I don't often subscribe to the 'everything happens for a reason' philosophy, but at that moment, I felt that we benefited from infertility and pregnancy loss. It would have been much more difficult to have managed that moment being heavily pregnant, or having a baby on hand. I leaned against Husband and held him in my arms as the vet administered the medications. Once he was gone, we both let ourselves cry. I tried not to be bitter over the time that we were being denied, but I reflected on all that we experienced in the eleven years we had together. A marriage, two apartments and our first purchased home. A cross country flight. Four different jobs. The addition of his kitty little sister. He had a better life because of me and I had a much fuller life because of him.

Good night Angus, my heart and my life are a little bit empty without you. I'll forever treasure my memories of every day we spent together. Goodbye my cat, my companion, my beautiful boy. 
I love you so much.  

Monday, 23 June 2014

"It won't happen to me...."

While we were taking a break before proceeding with our first IVF cycle, (aka, my in-laws were visiting when I was ovulating) I saw a newly pregnant 38 year old. She delivered her first baby about two and a half years ago, and her obstetrician had automatically registered her for an amniocentesis due to her Advanced Maternal Age (AMA) status. I informed her that our group permits patients to make their own decisions if they want to pursue any diagnostic or screening options. I won't even offer a recommendation. My role is merely to provide information regarding her risks and the benefits and limitations of each test in order to guide her decision making process.

We spent a lot of time discussing the testing options during her visit and we exchanged several emails over the next few weeks. The new Non-Invasive Prenatal Testing (NIPT) can provide results as early as 11 weeks, it only assesses the three most common trisomies (13, 18 and 21) but it also detects sex chromosome abnormalities and some common translocations, which is not covered by Full Integrated Screening (FIS). The Nuchal Translucency (NT) ultrasound is a valuable tool as a markedly abnormal NT measurement can suggest a structural defect and prompts further testing, even if a karyotype is normal. The NT scan can also be viewed as a preview for the anatomy survey, as sometimes structural abnormalities can be detected. The amniocentesis would provide the most comprehensive chromosomal analysis as well as screening for neural tube defects, but carries the risk of an invasive procedure and is usually scheduled after sixteen weeks.

Our LVN called her to follow up and spent about 45 minutes reviewing all the information I had provided as she tried to get a sense regarding the patient's concerns and priorities. At last, she had made her decision. She would just go ahead with an amnio only, just like she did with her last pregnancy. I signed the requisition and the LVN helped her schedule her procedure. A week before it was slated she came in for a routine visit with one of my colleagues. She couldn't auscultate heart tones with a doppler and even with our back office ultrasound, my colleague suspected a cystic hydroma was present. "Oh shit!" I commented "That likely would have been picked up on an NT scan..." We both noted that earlier screening wouldn't have changed the outcome, just may have provided an earlier diagnosis.

A few days earlier, I had learned that my first IVF transfer resulted in an embryonic demise. This patient and I had our D+C procedures performed on the same day and the pathology reports each confirmed a trisomy, +13 for her and +16 for me. While she was waiting to see my colleague for her follow up visit, I knocked on the door and asked if I could come in to check in on her. I wasn't intending to mention anything about her decision to skip the earlier screening options, or ask what she plans to do with a future pregnancy, as it would be obviously inappropriate at that time. However, she brought it up. "I knew all the advantages of the earlier testing. I read the brochures inside and out. I had all the forms and the requisition for the NT scan on my desk and I just didn't get around to call to schedule it. I just didn't ever think that anything would be abnormal. I thought I could rely on the amnio to give me a final piece of mind."*
As I returned to my desk, I reflected on how much my thought process differed from hers. Yes, there are a lot of AMA women who give birth to normal babies, but there are a lot who a lot of older women who miscarry due to presumed chromosomal abnormalities. The everyday woman is probably not aware of those cases in the way that I am. Additionally, as I recently saw a 30 year old woman who gave birth to a baby with Down's Syndrome, I felt reminded that despite the increased incidence that spikes after the age of 35, we can't forget that trisomies still occur in younger women. I had accepted there was a high probability that an embryo could be abnormal, perhaps reflecting a measure of my age and general bad luck. I wanted to test as soon as possible. As a blastocyst prior to transfer.

I learned about Comprehensive Chromosomal Screening (CCS) in detail while attending an infertility conference in September 2012. I still laugh as even though I was approaching the six month no conception mark, I signed up for the conference merely because I needed the credits and it would stretch my CME allotment. I actually thought I might be a few months pregnant by the time the conference commenced. Instead we were waiting to see if Clomid could improve Husband's male factor infertility before starting IUIs. My initial thoughts noted that if we had to proceed with IVF, this testing might allow us to avoid an amniocentesis. Then my eyes were opened as the speaker closed his presentation by showing pictures of five different blastocyts and he asked the embryologist in attendance to vote on which ones they would grade as being the best and worst. The embryo that everyone thought looked the best, actually had two abnormalities (45, X- +4) and the embryo voted least impressive, was completely normal.

"Why is this not a routine practice?"** I asked my RE as we were discussing details prior to my first IVF cycle. "Well studies, haven't demonstrated that it is cost effective." he replied, although he offered that he had a 40 year old patient who felt very encouraged when she had four embryos make it to the blastocyst stage. Unfortunately, all four were abnormal, so she saved herself the cost any transfers. On one hand, I concede that there probably are a lot of young women with tubal factors or unexplained infertility who will likely produce mostly normal embryos and will proceed to become a first time IVF success story. I also knew of two bloggers who conceived through IVF only to discover via a miscarriage that an aneuploid embryo was transferred. (One was in her late 20s and the other used eggs from a 32 year old donor). I thought more about the intangible emotional costs involved, and I tried to make that case to Husband, who was loathe to spend one more dollar (let alone two to three thousand of them) on this already expensive proposition.

"Are you going to do PGD testing this cycle?" the billing woman in my RE's office asked as we discussed the fees. "Well, embryo willing." I replied. "I still can't claim that it's cost effective." My RE advised, engaging in the doctor's strategy of hiding behind data. I silently sighed inside my head. A part of me wanted to tell him that I don't blame him for recommending the day 3 transfer with our ill fated embryo rather than taking the risk to see if any would survive for a biopsy on day 5. Instead I replied that I didn't need to see any population studies to demonstrate cost effectiveness. I knew it was cost effective for our situation. After a miscarriage, two failed transfers and a second fresh cycle, Husband was convinced in a way he never could have been last November.

And then there were four. Four euploid embryos. The other two were abnormal. One was 46 +20, another one 45, X- +1, +8. Yes, that is three separate chromosomal abnormalities on one single embryo. Two of my six embryos had no potential to produce a human life. Yet they were grade 1 blasts. I can only imagine the hottie embryologist telling us how perfect they looked. It would be like playing Russian Roulette, except there would be a bullet in two chambers. There was a 33.3% probability of selecting one of the lethal embryos for transfer. PGD testing merely removed the game of chance. I know it's still not a guarantee. Some women have still received a BFN after transferring a known euploid embryo and others have still suffered a miscarriage.

Once again, I know how fortunate I am to be in this position. I also appreciate that not every situation would be amenable to CCS testing. If there are fewer embryos, it may not justify the extra cost and there are concerns that the biopsy procedure may inflict damage upon the embryos. I know first hand about receiving recommendations to do a day 3 transfer because it is feared that no embryos will progress to day 5. "Make the case for the day 3 embryo." I challenged my RE, after I saw in his notes that if we were to do a fresh transfer with my recent cycle, it would be on day 3. "Easy." he replied. "Your body is a better incubator than the most state of the art lab in this world." All right then. Point made. The day after my retrieval, I received a call from New Girl who noted that we needed to sign some additional consents for the PGD testing. "I'm sorry for the inconvenience." she apologised "We don't do this very often. It's the blind leading the blind." I was really surprised to hear that. While I can appreciate that it may not be applicable to perform CCS as a routine practice, I cannot understand how (ethically seems too strong of a word) REIs in good conscience do not at least discuss and offer this option to all their IVF patients.

*That patient is currently pregnant again. This time the discussion was limited to her declaring, "I'd like to do FIS and NIPT and amnio only if those are abnormal." All fingers are crossed for normal results!

**My observation from CCRM bloggers is that CCS seems to be routinely employed for AMA and patients with egg quality issues.

Sunday, 15 June 2014

The Miracle of Life

I remember reading about embryo development in one of my biology textbooks while I was a University student. The author commented that given the number of steps that take place, from chromosome alignment to cell division and beyond, it is truly miraculous that so many normal forms are produced. I didn't interpret his words as a religious or spiritual connotation, but rather as a scientific observation. As there are so many stages of development, each step invites the potential for errors. Applying a mathematical probability theorem, the odds of producing a healthy human being are much longer for an individual, let alone for a population at large. Yet, not only do we expect perfection from our reproductive efforts, we demand it.

I was still in an absolute state of shock days after hearing that all of my eggs had fertilised. Post retrieval, the embryologist described that of my twenty oocytes, 13 were initially mature and one was 'indeterminate'. We thought it was a bonus just to have that egg mature, let alone fertilise. When the nurse from XYZ called to follow up she commented that everyone on their staff was amazed with our fertilisation rate. New Girl echoed that you almost never see a 100% fertilisation with the number of eggs that I had. I had to ask if they were sure that these were our embryos. How could I, a 38 year old woman with brittle ovaries whose parter has low normal morphology, be defying the odds?

One of the reasons why we've excluded my parents from this process, is that we know they would get way ahead of themselves. In the time from my transfer to the BFN from my beta test, my mother would have knit three hats, two sweaters and a blanket, while my father would have built a play house in their backyard. I'm not exaggerating, they really are that zealous. We knew we couldn't get ahead of ourselves either. We may have kicked ass on this round, but there were other rounds that could kick our ass. This just meant that we are starting from a higher point than where we were last time.

In my naive state, I really didn't anticipate that I would be doing a day 3 transfer with my last cycle, and I had to cancel an afternoon session of patients at the last minute. This time around,  on day 3, my afternoon was blocked off as I was due to attend a computer training.  If I needed to do a transfer, I had a built in excuse to leave the office and I would only need to sign up for another training session. However, it wouldn't be necessary. My RE called and reported that nine embryos were in the 'good' category. One arrested and the other four were less than six cells, or were described as 'fair' or 'poor'. Last time, we had three listed as 'good' two as 'fair' and one as 'poor'.

I was relieved to learn that we weren't going to be transferring at this time, although it would have been nice to skip out on my computer training. The bloating really set in on day 3 and I was afraid of Ovarian Hyper Stimulation Syndrome (OHSS). I was quite distended and uncomfortable. Holy shit, is this what pregnancy is going to feel like? If so, why again am I doing this? Additionally, my vagina was really sore. It felt bruised as if it took quite a pounding.

Two days later, I looked and felt much better. I was contemplating a fresh transfer, even though it would mean giving up everything I wanted to gain with PGD testing. I couldn't stop thinking about the fact that we implanted with a fresh transfer and failed with two frozen embies. I had to ask my RE if that were a compelling argument to transfer now, even though it would mean just randomly selecting an embryo with the hope that it is normal. A practice I previously dismissed as being 'daft'. If we fail with our frozen transfers, I fear I would regret not taking a chance with a fresh transfer. My RE didn't feel it was an indication as my prior embryos had thawed well. The explanation for my prior failures was either an abnormal embryo, shitty luck or a combination of both. It wasn't worth the risk of OHSS, as he noted that it's almost universal practice to defer a transfer for anyone with E2 levels greater than four thousand. The high exposure of estrogen makes the endometrium disogranised and unfavourable for implantation. I could risk wasting an otherwise good embryo or be at a higher risk for miscarriage if a pregnancy occurred.  I know OHSS is no joke and my RE takes pride in the fact that he has never had to hospitalise a patient with OHSS. Interestingly, our former mutual patient who went to another group as she didn't like his bedside manner, developed severe OHSS and was admitted for four days and had a total of 9 litres of fluid drained from her abdomen.

Once again, I was the damsel waiting by the phone, hoping my RE would be calling with good news. At last, I heard a beep from my phone. Myrtle had texted me a picture of little Myrtle. Despite our Don't Ask, Don't Tell policy, Myrtle just has this intuitive sense of when I've received some news from my RE and sends a picture of little Myrtle. Her birth announcement arrived in the post on the day we learned IVF was our best option. An invitation to her Christening came in on the BFN from our first IUI. I received a Christmas card that featured little Myrtle on the day of each of my miscarriages. As I was walking out of my RE's office fighting tears after hearing his projection of 6-8 mature eggs during my first IVF cycle, Myrtle texted the most adorable photo of her daughter in a lamb costume for Halloween. I cannot make this up.

I feel such a sense of awe and amazement when I see photos of little Myrtle, in addition to my usual jealousy. She is so beautiful and her hair is getting so long. She was wearing a headband with a bow and looks like such a sweet little girl. The resentment started to gnaw inside me. I want to scream. I want to shout. I want to shake Myrtle and other fertile one hit wonders by their shoulders and yell "do you have any idea how lucky you are?" It just took one month, one act of intercourse, one egg, one sperm, one pregnancy and you hit the jackpot with a perfect creation for the cost of zero dollars! This defies scientific logic! Don't worry, Marty. As long as you hit that wire with the connecting hook at precisely 88 miles an hour, the instant the lightning strikes the tower... everything will be fine!

They would not listen, they did not know how
Perhaps they'll listen now

My RE had been pretty consistent about phoning with his updates at the same time. I waited an hour and then decided to take a shower. It worked. Despite the fact that this man has been inside my uterus, inside my ovaries and most recently, inside my hoo-ha more than my own husband, it still felt awkward to be speaking with him whilst wrapped in a towel. Six progressed to become grade 1 blastocysts and were successfully biopsied. Six. Once again I was overwhelmed with disbelief.  I'm sure I should have asked some intelligent questions. First off, I'm curious to know if any restraints were used during my retrieval as I developed a contact dermatitis on my upper thighs and inner ankles. Now I'm just hoping I don't have to do another retrieval to find out.

As I hung up my call with my RE, I noticed that Myrtle had sent a second photo of little Myrtle. The resentment was consuming me again. It has taken us thirty-one months, many acts of intercourse, twelve missed opportunities, five attempts with intrauterine insemination, forty-five eggs, millions of sperm, three transfers with four embryos, two unsuccessful pregnancies at the cost of nearly fifty grand just to get to this point. Not all of my six embies will be euploid. Even if we do transfer a normal embryo, it still may not result in a pregnancy. Even if it did, I could still have yet another miscarriage. It still feels so elusive.

I had projected that we would end up with four to six blasts, so I was quite happy to be on the upper end of my prediction. "That's all?" replied Husband "Now it's my turn to be disappointed. I was hoping for more." "Shut the fuck up and be reasonable!" I shot back. "Nearly fifty percent of our fertilised embryos went to blasts! Do you know how astonishing that is?" Even as I was admonishing him, I could appreciate from where he was coming. As infertiles we have to accept that not all our eggs will hatch into chickens, while we watch fertiles score with just one shot. Yet, don't think for one second that I don't know how fortunate I am. I know there are so many women who have been waiting twice as long, if not longer, who have spent twice as much, if not more. I know there are many who wish they could be in my position.

They would not listen, they're not listening still
Perhaps they never will 

In the summer of 1995, I went with my parents and their friends to see Don McLean perform in an outdoor amphitheatre on the campus of Western Connecticut State University. He waited until darkness fell so that he could close his set by singing Vincent under a starry night sky. He held the last note of 'they're not listening still' for a few extra seconds, and then extended a pause before piercing the silence with the closing line, 'perhaps they never will..' It gives me chills as I reminisce, until I remember that he came back on stage for his encore and led an audience of old hippies and drunk college students singing a rousing version of American Pie.

Tuesday, 10 June 2014

A Shot to Beat Your Opponent

I develop agoraphobia over most holiday weekends. Fearing larger crowds and a general inconvenience, I often find that it's a good time to take care of some neglected household chores such as clearing out our closets or gardening. This year, I added Mother's Day to that list. I went for my pedicure a day earlier as I figured most salons would be busy pampering mamas. I just wanted to avoid witnessing the celebrations for the women in the club that keeps rejecting my membership applications. However, it was a beautiful picture perfect day in the Bay Area and I was getting cabin fever inside. Yet, I wasn't too motivated to do any work in the garden. Suddenly, I thought of an outdoor activity that would be free of Mother's Day celebrations.

I had fallen of the tennis wagon (again). I was enjoying my Thursday evening sessions, but between some cold and rainy nights and post transfer induced rest periods, my racquets have been dormant several weeks. I went to the courts to sign up for another session. "Do you fancy hitting a few balls?" I asked the guy behind the counter, hoping to coax him onto the court. "Sure, but only for 5-10 minutes." he replied. It's always good for the ego when you feel you can wield your feminine charms on a gay man.  Anyway, after a brief warm-up, the muscle memory returned. I can generate a lot of pace and I like to return pace. Bryce was giving me just what I needed, and we engaged in a long rally of steady hard strokes. Out of the corner of my eye, I noticed that a pair of double players paused to watch us during their change over. Someone started to approach the clubhouse and a distracted Bryce delivered a lazy down the line forehand. I knew it would be unsportsmanlike, but I couldn't resist the temptation. I planted my feet and whipped a blazing backhand winner, which earned some polite applause from the doubles players. Oh, it felt good! I may not be fertile, but I can whack the hell out of a tennis ball.  "Jane, you have such beautiful strokes!" Bryce gushed.

I held my hand up to recognise his compliment in the same way one acknowledges a  cheeky point won on a net cord. I know my shots are technically proficient, as I was often cited as an example for the class by many former instructors . I also know this has been more of a hinderance rather than an asset to my game. My strategy was merely to try to out-hit my opponents. Speed, power and precision must prevail. I never paid enough attention to understand when I should employ certain shots and tactics and I would become easily frustrated if my beautiful strokes weren't tipping the score in my favour. Even worse, I could completely lose confidence in myself if I fell behind to an opponent with weaker shots, although she probably determined that her game strategy would be to feed me crap and watch me implode.

"Jane, you don't win points for prettiness." my coaches often exclaimed, although this concept was lost on me. Multiple mentors tried to work on the mental aspects of my game and to develop me into a more tactically sound player. One even gave me his tattered copy of Winning Ugly by Brad Gilbert, which I would later get autographed by BG himself. I studied that book carefully and even made notecards to keep in my bag. It helped a bit, and rescued me when I was on the brink of quitting tennis. Yet, I still couldn't escape that notion that I just needed to hit the ball harder and go for steeper angles.

One of my first priorities when I moved to California was to find a place to play tennis. After looking up my USTA rating and hitting a few balls with me, the director of a local club placed me in his advanced intermediate player group. The rather friendly coach greeted me, "Okay Jane, Let's see what you've got." As if I needed any more of an invitation. I exchanged a few rallies with a fellow player as we warmed up. She delivered a shot right to the sweet spot of my racquet and I cracked a perfect forehand winner. I looked over to the coach, anticipating some words of praise.

"Jane." he responded, sounding surprisingly somewhat angry "Are you playing Sereena Williams?"
I giggled nervously, unaware that he was asking a serious question and was demanding an answer.
"Jane! I'll ask you again. Are you playing against Sereena Williams?"
"No." I replied defiantly as I placed my hand on my hip and felt embarrassed for the other player.
"Then why are you trying to play a shot that could beat Sereena Williams? Just hit a shot that can beat your opponent."
It was now my turn to feel embarrassed, but at the same time, I felt enlightened. All the lessons my instructors in Connecticut tried to instill in me suddenly made sense at that moment. It was as if that one sentence was the final piece to complete a puzzle. Just hit a shot that can beat your opponent.


"1913" announced my RE as he entered the room for my SD9 monitoring.
"Pardon?" I asked feeling slightly confused
"Your estradiol level. It was nineteen-thirteen."
I didn't pay too much attention to the number or size of the follicles as he was measuring. Last cycle I felt encouraged when I had 12-14 follies at this time, but little did I know that as my estradiol level plateaued at 1500, it translated into much fewer mature oocytes. This was the first marker indicating that this stimulation could surpass my prior one.  Two days later, Husband joined me for my appointment. He counted 9 follicles on my left and 5 on my right. They were waiting for the final report on my estradiol level, but it was probably above 3,000. Wow. I made it into the big girl leagues. Dr Somebody that I Used to Know was planning to reduce the dose of my HCG trigger in order to avoid OHSS and noted that he would most likely recommend doing a freeze-all, even if we didn't end up doing PGD testing. He wouldn't speculate on a possible tally, except to comment that he anticipated there would be more this time around. He patted my thigh, which felt more reassuring and less patronising.

A total of 20 oocytes were recovered, 14 of which were mature. I must still be under the propofol and dreaming, as my RE reported that all fertilised with ICSI. It's time to give some credit where it's due. Si and Am, you're still a pain in the ass, but you came through for us. Big time. To my RE, for coming up with a successful strategy and to Misery and New Girl for their support. Finally, to Husband, who ran my blood to the office each morning and allowed me to make it to work on time. It truly takes a village, and my next appreciation goes to the staff at the embryology lab. We just need one shot good enough to beat our opponent. I know we're far, far away from the finish line, but for the moment we're savouring this as a victory. One with a flourish.

Thursday, 5 June 2014

The Only Living Boy in New York

I first heard the term 'AIDS' on the playground when I was in the fourth or five grade. The year was 1986 or 1987. It was a childish insult to call someone gay, so proclaiming that someone had AIDS just upped the ante of the remark. I vaguely remember my mother confirming that AIDS was an illness that seemed to strike gay men and that it was very inappropriate to joke about it. HIV was not mentioned at all during our sex education classes in 1990, but in the following year, after Magic Johnson's announcement affirmed that it affects the heterosexual population, my school held a special assembly. By the time I went off to University in 1994 (yikes, twenty years ago) it was well acknowledged that HIV was an equal opportunity killer, as it represented the leading cause of death among individuals aged 25-44. In 1996, I went to Washington DC to see the AIDS Memorial Quilt on display. Tears flowed as I discovered the names and stories of those who lost their lives to this disease. I participated in a candlelight march and walked past protesters who felt that AIDS was a suitable punishment for the crime of homosexuality.

Six years later my medical training brought me to a prison. My inner conservative Republican initially wondered why tax dollars were funding the expensive HIV antivirals for an inmate serving a double life sentence. A few days later I sustained a very superficial needle stick after drawing his blood. Fortunately, his viral count was undetectable, thanks to his meds. Rather than take the standard post exposure regime, the Infectious Disease specialist decided to prescribe the exact cocktail of drugs. They were horrible. Even with some accompanying anti-emetics, I had to alternate taking them every other day. I was never worried that I would actually contract the virus. The mechanism of my injury did not constitute a significant exposure. I felt it was harder on the people around me. I went through multiple meetings with the ID team to make sure I was cleared to treat patients and my then boyfriend, now husband preferred to practice abstinence until my 6 month blood test was negative. To this day, I never disclosed the details about that event to my parents.

In 2007, I gave an HIV positive diagnosis to a newly pregnant 22 year old woman. I was able to explain to her that HIV is no longer the death sentence that it was in the year she was born. With antiviral medications, HIV can be managed as a chronic condition, and most importantly we could prevent transmission to her baby. The following year I moved to California and participated in many rallies denouncing Prop (H)8. I have since celebrated the same sex marriages of four friends and feel proud that they are entitled to the same rights and recognition that Husband and I share.

I recently watched the HBO film The Normal Heart. This brilliant production detailed the disease in the days before the red AIDS ribbon and World AIDS day were declared. I knew that many stories existed, but I hadn't ever seen or heard a first hand account. Young, healthy, vibrant men were suddenly becoming sick and very quickly dying. They were dropping like flies. An epidemic was emerging. Yet no one seemed to care. The writers and actors did a masterful job portraying the struggles of the gay community to gain attention and information regarding the mysterious killer virus. It is amazing to appreciate how much has been achieved in terms of activism, awareness, fund raising and research, but the delayed response is another shameful mark in this country's history.

The true heart of the film is a beautiful love story (as well as a very hot sex scene) as the central character watches his partner succumb to the disease. It was the friends and lovers who became the primary caretakers as paramedics often refused to transport and these patients were turned away from emergency rooms. The ultimate measure of unconditional love. Simon and Garfunkel's song "The Only Living Boy in New York" is used to profound effect for the movie's final scene brings the lead back to his alma matter for Yale University's Gay Week, where as a student he feared he was the only gay man on campus and contemplated suicide. As he was appreciating the progress witnessed in his time, I felt proud to acknowledge that his merely symbolic wedding ceremony on his partner's death bed, could legally take place in the state of New York today.

Earlier in the month of May, I noticed that my cat A looked a little thinner. I checked his glucose and it was within normal range. I wasn't too concerned. I've observed over our years together that his weight seems to fluctuate. He was otherwise acting normally. I was a few weeks overdue for his yearly check up at the vet, so I scheduled him on their first available Saturday morning time slot. Then I picked him up and realised he was significantly lighter. I called back and requested a sooner appointment.

"It's probably just hyperthyroidism" I shared with the vet as I explained that he was eating well and exhibiting his usual behaviour. When his lab work came back normal, she scheduled him for an ultrasound. Despite the fact that he was eating, his weight seemed to drop a bit more. The day of his appointment, my alarm went off at 5:20 to wake me up for swimming. As I reached over to shut it off, I felt him beside me. So many times, a warm snuggly kitty was a tempting excuse to stay in bed and skip the pool, and on this occasion,  I obliged. I couldn't fall back asleep, so I just laid in bed and listened to him purring beside me.

I'm going to learn that my cat has cancer. I acknowledged that fact to myself multiple times throughout the day. All the clinical signs were there. How long were they there and how long was I blind to them? I asked Husband to accompany me to his scan. The vet called us back for a consultation. Her body language revealed everything. The news was bad. A mass was found behind his heart. It won't respond to chemotherapy or radiation. Even a successful surgical resection would only give him 6 to 12 months. As he lost another half of a pound and had developed some pleural effusions, she estimates that he only has 2-3 weeks left. Clinically, I knew that was accurate, but it was still a shock to hear.

As I walked in through our front door, I recalled that he was still greeting me as recently as two nights ago. As I looked longingly down the front hall, it stuck me that he will no longer be greeting me. No longer sleeping by my side at night. No more fluffy ginger shadow following me around.  Although he was primarily my cat, Husband is just as devastated. After he let me cry on his shoulder at the vet's office, when I came home from that appointment, I found him sobbing. "I just told K [our other cat]" he cried. A gesture so sweet and touching that it makes me fall in love with him a little more. He was a part of our life together and we're going to miss him so much. If it's so hard to let go of a cat so abruptly, I can't imagine the pain of losing your partner.

It marks another shitty infertility milestone. I'm losing my kitty baby before having a human one. Perhaps he just wasn't meant to share me. I often felt that I didn't want to become one of those women who ignores her cats once she has a baby. I've visited some friends just after their new arrival and their cats would flock to me, seemingly starved for attention. Although Husband speculated that he would be very protective of our baby, I also feared he could be a tired older kitty putting up with a toddler who is pulling on his tail or trying to dress him in doll clothes. Right now, we're trying to keep him comfortable and enjoy every good day he has left. When we're ready, we will get another cat. We know we're not replacing him, there are a lot of cats that need homes and we'll have a vacancy. Perhaps it will mark the start of a new chapter, as a mother to my kitties and biologic progeny.

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.