Can't Buy Me Love

The HBO premiere of The Normal Heart truly had a profound effect on me. As I wrote previously, the film encouraged me to reflect upon my personal and professional experiences with HIV and AIDS, and it made me confront the inevitable decline and death of my beloved cat, Angus. I've kept it on my DVR's playlist, and it has now become my choice for background noise while I'm cooking or cleaning. One day, perhaps in an effort to procrastinate from my chores, I started to Wiki search the bios for the actors in the film, and I discovered that half of the main cast are gay. I know that performers do not like to identify themselves as a 'gay or straight actor' in a 'gay or straight' role, but it does add an element of authenticity to the mission of the production.    

I also took note that one actor has three children with his married partner via surrogacy. I almost never think that a little everyday person such as myself, ever has anything in common with a celebrity, but I was more struck in this situation. He's fluent in my language. He knows the terminology of a day 3 embryo or a day 5 blastocyst. He understands the significance of rising HCG quant numbers after enduring a two week wait. I never would have imagined that our worlds could overlap in any way.

Last year, when it was announced that Jimmy Fallon and his wife had a baby with the use of a gestational carrier, he was praised for speaking openly about their fertility struggles. "It wasn't a secret, my wife and I had been trying for a while to have a baby. We tried a bunch of things... and one who's tried, knows -it's awful. So, we had a surrogate." While I appreciated his sincerity to identify with the common infertile people, my inner skeptic couldn't resist this critique; yes, but it's a little different when your monthly pay cheque covers the expenses of surrogacy. I scoffed when a fellow blogger wrote about disclosing her infertility treatments to her boss, who responded, "I watch Bill and Giuliana, so I understand." As if that made her capable of relating to someone else's infertility experience. I've since done a little Wikipedia research on the Reality TV couple, and while I don't want to come across as if I'm celebrating their struggles with a BFN and a recent miscarriage, I appreciate that their show illustrates the facts that IVF and even surrogacy aren't guaranteed solutions.

A few months after Jimmy Fallon joyously announced his new arrival, actress Aisha Tyler opened up about her experience with infertility and the disappointment of unsuccessful treatments. Presumably diagnosed with a diminished ovarian reserve, she went through the ultimately futile exercise of self administering stimulation injections in pursuit of a 5% chance for a take home baby. Even if cost is not a barrier, it still difficult to accept the option of donor eggs. I know many have commented on how hard it must be for me to work in obstetrics while infertile; but I truly felt for Aisha, as a pregnancy had been written for her character on the (brilliant) animated series Archer. Perhaps it was a little easier, as she only had to look at a cartoon version of herself in a pregnant state, but I imagine it still stung. I'm sure there are other actresses who have had to portray a pregnant woman or a mother, while struggling to conceive themselves. Some actresses best known for playing many maternal roles, whether by choice or biology, never had any children in real life.

When I first made the observation that the aforementioned actor and his partner were versed in the REI adventure, my initial reaction was akin to Husband describing his friend who needed to go through IVF due to his vasectomy; it's just not the same experience. Yet, after giving it some more thought, I had to concede that their situation is actually much more daunting. So many more decisions; selecting a surrogate, anonymous egg donor or asking family member in order to increase genetic representation, determining whose gametes will be used. Not to mention the challenges after conception. I've known some lesbian couples who each became impregnated with the sperm from the same donor, so the siblings share a genetic link and both women experienced a pregnancy. I've also had to have some awkward conversations with my lesbian patients and their partners advising who likely has better eggs, or who would be more suitable as the tummy mummy.

During my most recent stimming cycle, Husband opened up to his physical therapist, who revealed that she and her wife went through IVF at the same REI clinic. They decided to transfer the embryos fertilized with the younger partner's eggs into the other woman's uterus. This was perceived to offer the best of all worlds, one had a genetic connection, the other a biological one, and as both embryos successfully implanted, the boy/girl twins are full siblings. She shared that they experienced a few miscarriages and BFNs as well and offered some 'don't give up hope' encouragement. When I attended the infertility conference almost two years ago, one RE admitted that he requires a psychological evaluation for any same-sex couples seeking his services, and I called him out for engaging in a discriminatory practice. The physical therapist revealed that my RE's partner who did their treatments, asked them at least 3 or 4 times if they planed to stay together. My RE has never inquired about the status of our marriage and we engaged in a 36 hour silent treatment stand-off just last week!

While I was working in Connecticut, I cared for a patient who was serving as a surrogate for her brother and his partner. They used an anonymous egg donor, and transferred two embryos that were fertilised with sperm from each man. At the time of her visit with me, her RE had already confirmed the successful twin pregnancy. As it was still really early in my career, and this was one of my first IVF patients, I thought IVF worked that easily. I now have a much greater appreciation for the fact that only one or no embryo could have implanted. She was ten weeks along at the time of her visit, which is always my favourite time to scan, as the foetus actually looks like a baby. I've done ultrasounds with thousands of couples, but the reaction of those two men is among my fondest memories. Seven months later, I contacted the  L+D Nurse Manager to request an exception to the one support person in the operating room policy. She agreed, and both dads were present during the Cesarean birth.

I know I shouldn't have such trivial concerns, but I do fear that when I go public with our IVF journey (hopefully with a pregnancy announcement) that I'll be labelled as an elitist within my own little microcosm. It is important for me to be very honest with the details; not only did we need to do IVF, but it took X number of cycles and transfers. My bet is that Myrtle's father will be the only one tactless enough to ask straight out what we've spent; but inquiring minds want to know, and it's not too hard to do the maths when you know the base price of a cycle (which doesn't include meds or many other hidden expenses). I can picture Michael Scott gossiping with our practice manager, 'well isn't it nice that she could afford IVF.' Mostly, I feel for one of our front desk receptionists. She saw me as a patient a few years ago; she had irregular cycles and her husband was diagnosed with male factor issues. I know that even if they scraped and saved for a few years, it would be a stretch to finance just one IVF cycle.

Financial resources may provide a means to obtain treatment, but money can't alone defeat infertility. No one is immune. Jimmy Fallon is right. Any couple who cannot procreate with their physical act of intimacy knows -it's awful. I've had to accept that fertility is not mine to command. So have many others.

Let Her Go

Well, you only need the light when it's burning low,

Only miss the sun when it starts to snow,

Only know you love her when you let her go,

Only know you've been high when you're feeling low,

Only hate the road when you're missing home,

Only know you love her when you let her go,

and you let her go...

Staring at the bottom of your glass

Hoping one day you'll make a dream last

Yet dreams come slow and they go so fast 

You see her when you close your eyes

Maybe someday you'll understand why

Everything you touch surely dies 

Well, you only need the light when it's burning low,

Only miss the sun when it starts to snow,

Only know you love her when you let her go,

Only know you've been high when you're feeling low,

Only hate the road when you're missing home,

Only know you love her when you let her go,

Staring at the ceiling in the dark

Same old empty feeling in your heart

Because love comes slow and it goes so fast

Well you see her when you fall asleep

But never to touch and never to keep

Because you loved her too much

and you dived too deep 

Well, you only need the light when it's burning low,

Only miss the sun when it starts to snow,

Only know you love her when you let her go,

Only know you've been high when you're feeling low,

Only hate the road when you're missing home,

Only know you love her when you let her go,

and you let her go.

Reversal of Fortune

It was just after midnight when Husband and I returned home from the Veterinary Clinic where we said our final good bye to Angus. He cleaned up the dinner that we never ate, while I fixed us a cup of tea. It was near half one when we finally went to bed and neither of us slept very well. The next morning, I opted not to swim and sent emails to notify my parents and other east coast friends as I waited for the shower to warm up. Except it didn't. Our hot water heater was broken. There was no greater metaphor than a cold shower to represent our mood.

We had actually replaced the hot water heater last October, so it was still under warranty. As a matter of fact, I think this is the only appliance that hasn't waited until the guarantee expired before breaking down. However, we would still be responsible for the labour costs and it took over a week to order a new unit. I made it to the gym or went swimming everyday, but it was really just so I had access to a hot shower. Later that day, England was eliminated from the World Cup, after they scored only two goals, garnered one only point and finished last in their group during an exceptionally disappointing appearance. It was officially a crap week. However, it was during this time that we received our PGD results. Rather unusual for us that an infertility report was bringing us good news and was a highlight.

Once again, I am laughing over the way that I thought the year 2013 was unlucky. So far, the summer of 2014 didn't have much going for it, but at least things couldn't get any worse -right?  Apparently not. Last week, I had an accident using a mandoline slicer. I won't give any gory details, but I knew right away that I would need stitches. I twisted a paper towel into a makeshift tourniquet, thus utilising the skills earned from my Girl Scout First Aid Merit Badge, and prepared to drive myself to the ER. This was the one time I wish I drove an automatic transmission. Husband was away at a hockey tournament, which was probably a good thing as I think he would have fainted. It was another situation that would have been even more difficult if I had a baby with me.

I didn't have too much fun with
the fact that it was my middle finger

I was very fortunate, as the cut and its repercussions could have been much worse. I especially needed to remind myself of that fact after waiting forty-five minutes for my five minute visit with the hand surgeon. (I've watched a lot of HGTV in the past week...) It was also a good opportunity to clean out my Yahoo in-box and in doing so, I uncovered an email from New Girl informing me that they needed my consent forms in their hands in the next two days, otherwise XYZ would not let me proceed with a transfer in August. Groan. The tentative date is still over a month away, and they've previously collected my paperwork as late as on my CD10 monitoring. Why the urgency? It was probably best not to question. I had blocked off a generous amount of time for the finger follow up, so I could swing home and deliver the forms.

As I was driving, I heard an odd noise and noted that my speed was quickly dropping. Fortunately, I was just coming up to a junction and was able to pull off the motorway. After reaching the bottom of the ramp, I turned the car off and tried to restart it. Nothing. No sound, no action. I don't think a defibrillator could have jump started it. As I was on the phone with  AAA, I began to accept that this was probably it for my car. I tried not to think about the cosmic message that my car broke down as I was en route to deliver forms required for my upcoming transfer. While I waiting for the tow-truck, at least five people pulled over or offered to help. Feeling reminded that there is humanity and compassion in the world today was suppressing my urge to pout and whine. Although there was some drinking of wine later that night.

The dealership called to report that the timing belt had snapped. If the timing belt were the only issue, it would cost about $1,500 to fix. However if the cylinder were damaged, then it could cost up to $5,000. It wasn't even worth it to try to see if the less expensive option would be possible. I called time of death for my Jetta. Naturally, this prompted Co-worker and another colleague to point out the the timing was impeccable to upgrade to a family sized car. Grrrrr

There were two other events that soured my mood. I was summoned for Jury Duty, but I actually don't mind the civic duty. As a naturalised immigrant, my father always viewed Jury Duty as a privilege he had earned. He is a lawyer's voir dire dream. To this day, he views his service as the foreman who delivered a first degree murder conviction, as one of his life's accomplishments. As I was submitting my time off request, I was informed it would be applied to my Paid Time Off (PTO). I thought employers had to grant a release for Jury Duty in the same way that the poster in our break room indicates that we're entitled to time off for voting on Election Day. Whatever. I'm not even going to bother arguing, as it's probably indicated somewhere in my vaguely worded to seem fair; but later subject to creative interpretation, contract. I've previously succumbed to the reality that agreeing to work as an exempt employee surrenders one's rights under the Labour Board and you might as well sell your soul and work for Satan.

I'm truly whining here, as I know I'm fortunately to have a job and to have four weeks of PTO. When I added it up, one week will be used for my trip to Connecticut in October, another week in August will go toward my on-line CME requirement. I took a few days when I went to Nashville, and the remaining time will have been used for infertility treatments and now Jury Duty. This is why I am so bitter and unfairly judgmental over Co-worker's spa day during her baby bonding time, but I will own it. While she was receiving her pampering treatments, I had to work the day after severing my finger, not only because I had a schedule full of patients and was the only provider in the office, but I didn't want to burn any additional PTO. I won't have anything in a reserve if I need to do another transfer or if need a day off for anything pregnancy related. Husband suggested maybe I don't go back to Connecticut, but could just take a few days off and stay home. O-oh, a solitary stay-cation while he visits our friends and family on the east coast? How fucking depressing is that? Wow, suddenly I found cause to be excited about my holiday to Connecticut.

The day after I handed in my consent forms, I received a letter with my RE's return address. It was an invoice requesting $3,390 for our upcoming transfer. Fucking A! We already paid for the transfer at the beginning of our IVF cycle when she asked if we were intending to do PGD testing. I'm guessing she's presuming that our first transfer failed and this is the second one? Is it too much to expect her to check my records and be accurate with my account? At least I am hoping that is the situation and it's not indicating that my decision to delay the transfer means we lost our previous deposit, in which case I'd be preferring incompetence. I indulged in a nice fit of tears as I frantically searched for the original invoice.

I dried my eyes by the time I found the paperwork. It was all too tempting just to pour a glass of wine, climb into bed and drown in my own tears. I want to retreat from the world for a while. At times, I feel that I don't even want to proceed with transferring any of my four embryos. Why risk being disappointed four times over and falling further into debt? Maybe I should just resign myself now and accept that I'll always be girl at the club who has to watch the purses as her friends get asked to dance. I know we've come so far, and it seems that the end may be in sight; but I'm still hesitant to reach out any further on this ledge. Husband has already started applying the theory that we're more likely to succeed with our transfer since we've been though such a bought of bad luck.

It almost sounds plausible, except it defies all logic. None of our recent experiences have any bearing on whether or not the embryo implants. Plus I'm not sure if everything can be classified as bad luck. Angus's death and the end of my Jetta's run were both inevitable, we just thought we had a few more years with each. It just really sucks that both events occurred a month a part. Perhaps the only random incident was the malfunction of the hot water heater. I have to confess that I was using the guillotine (I mean, the mandoline slicer) without the guard, which officially categorises this episode under 'stupid things that I have done...'

I admit that I am among the population who is afraid to face how a great part of one's life is dependent on luck. Partly because I believe that one cannot rely on luck and must control his or her own destiny. Ya put on your big girl panties and you deal with things. I called the billing woman at my RE's office only to learn that she doesn't work on Fridays. Fuck me, am I the only person in the world who is working? I decided that even if I had a baby on the way, I don't want to drive an SUV. I love the reliable German engineering and the handle of the Jetta. Plus, when I'm not driving with a bloodied hand, I prefer the control afforded with a manual transmission. My medical assistant announced that she would find a car for me. I should have chastised her for not working on patient care, but I'll own being a hypocrite too. After a few internet searches, she scheduled me for some test drives.

"You're a lucky girl..." that was the conclusion of my hand surgeon, while I couldn't decide if I should be insulted or flattered that he called me a girl. My injury could have been much worse and it healed much better than expected. I attribute it to the prompt and excellent medical attention I received, as well as my diligent daily care; but maybe I had some good fortune on my side as well.

Oh, and there was one more fortunate event in our life:

Introducing Tyler Felix! 

There's an app for that...

"Were you planning a pregnancy at this time?" I asked my standard question to a new OB patient. "Well, we stopped using condoms, but we weren't doing anything." she replied. "You mean you weren't doing anything proactive." I clarified "I think you did something..." That brought out a laugh. "Oh, um...yeah" she giggled "Well, we were doing it; but we weren't on a schedule or anything like that." you know, like a crazy infertile person... She elaborated. "One of my friends has been trying for a while and she was telling me that I needed to download all these apps. It was three different apps! So I told her 'that's crazy!' I just want one app! I mean, my banking is just one app!"

Well, it seems she used the the 'just have sex' app. There was something so genuine about her, I could look past any jealous feelings that she succeeded in conception without really trying. My follow up question was to ask when she confirmed her pregnancy. "Well, I had a regular period in March, and then I had some light bleeding in April. I didn't get a period in May, but it's not usual for my period to skip a month now and then. When I didn't get one in June, I thought I should take a test, as we had been trying, but I wasn't expecting that it would be positive." I proceeded with her exam. Heavy make up covered her acne scars. She had a male hair pattern on her abdomen. I started to wonder if she may have Polycystic Ovarian Syndrome. She probably wouldn't have had any luck with any fertility apps. She used the blind pig finds an acorn method.  

I started counting all my 'apps'. I have a menstrual cycle calendar app on both my iPhone and iPad. I downloaded the app from Freedom Fertility to use during my stim cycle, but found it really cumbersome and very disappointing. I went old-school and printed a calendar from timeanddate.com to record my meds and results. Currently, I'm using both the Clearblue Fertility Monitor, which measures both estradiol and LH off a first morning urine sample, and I'm checking for an LH surge with the smiley face test kits at noon. I've seen enough egg whites to make an omelet, but my low progesterone level confirmed that is a defective app. One of those free apps that totally sucks.

My 'P.log' app on my iPhone issued a reminder that my period is due in 3 days, but as it was CD25 and I still hadn't received any indication of impending ovulation, I know that was not going to happen. It was time to message my RE to determine when we would declare this an anovulatory cycle and induce a withdrawal bleed with Provera or Prometrium. Not surprising, he wanted to see me for an ultrasound. It was time to upgrade to a better app. My lining was 13 mm, indicating there has been some estrogen production and there was a 17 mm dominant follicle on my right ovary. Maybe my stim cycle hadn't put Si and Am out of commission after all.

It was another moment of feeling like the most ridiculous infertile. I was going to such extremes to determine when I would be ovulating and not directly for procreative purposes. In fact, it would be another occasion when spontaneous conception would not be advised as I'm planning to violate my endometrium. Before we needed to reach for the stash of condoms in the bedside drawer, Husband flew out on a red-eye flight to the east coast for another hockey tournament. Sure enough, the next morning, on CD28, I was finally reading 'high' on my CBFM, which was confirmed at noon with the presence of the little happy face. Ah yes, the google calendar with our travel schedules. So many times when we were trying to conceive, that app was the ultimate ovulation predictor. Nice to see that Si and Am are still keeping with tradition, even when it's irrelevant.

As it turned out, my patient was actually 20 weeks pregnant, which was fitting with her last menstrual period dating. To a certain extent, she was living my dream; just wake up one morning and discover you're five months into a seemingly normal and healthy pregnancy. Yet, she reacted as if she overslept and was late for an important event. I could appreciate her response. She must have had a sense of disappointment that she missed half of her pregnancy experience. It's quite a contrast to potentially being negative seven weeks pregnant.

Whoa oh, what I want to know, where does the time go?

Like so many other people, I cannot believe that the calendar says it's mid July. I recently overheard Co-worker making some calls to schedule the one year check up for her twins and sort some details for their first birthday party. Seriously, can she not take care of these tasks on her day off? "OMG! I can't believe they're already a year old!" she loudly exclaimed, just in case we weren't already eavesdropping. It was two years ago this weekend that I hosted Myrtle's baby shower. "I know in my heart that I'll be hosting a similar event for you very soon!" she wrote in her thank you note. While it feels as if the time just evaporated, as little Myrtle is only two months away from turning two years old; this is not exactly soon.

It feels like it were merely weeks ago, when we were ushering in the New Year, and I was waiting for AF to arrive, so that we could start the prep for our first FET. It was exactly six months ago, but in Infertility Time, that was only 2 FETs and a fresh cycle ago. Infertility Time operates in strange ways. Sometimes it flies by so quickly. I still won't be pregnant by the time I reach another phantom due date, although I'm grateful for the delay as I don't want place any additional burdens on our next embryo.

Then there are moments in Infertility Time that creep slower than a snail's pace. The two week wait feels more like a two month wait. Minutes are like hours when you're anticipating a call with your beta results. Forty-eight hours between blood draws seems more like a fortnight. The time between your final beta and first ultrasound might as well be a year. Yet, the most enduring delay is determining ovulation, just so you can plan the next step in the process.

My previously unpredictable ovaries have now achieved some consistency. I'm officially a long distance follicular phase cyclist. Earlier this year, I went to my primary care doctor to follow up on my blood pressure issues. I lied and made up a date when the medical assistant asked me for my last menstrual period. It was much easier that the alternative explanation; No, there's no possibility of pregnancy. I know it's in your protocol to run a test for anyone who is more than 28 days from her last period, but I didn't ovulate until day 20, so my period is still over a week away. Plus my Husband was on the east coast when I ovulated, but it wouldn't matter as we've got this infertility thing going on. Please don't humiliate me by requiring a urine test. I know you are only doing your job, and I'll only cause more attention if I argue. It's easier for us both if I lie...  

Waiting for the little happy face or egg symbol on the Clear Blue Fertility Monitor was stressful enough when it only involved scheduling coitus, now I'm just trying to coordinate my endometrial biopsy and future transfer date. Additionally, I need to take some time off in August to complete an online CME course. I have to work around my other colleagues's vacation requests and Co-worker's baby bonding time. I know maternity leave in this country is absymal compared to the rest of the world, but she took four and a half months last year and now she gets an extra six weeks. I don't begrudge her at all for taking every minute that is entitled to her; it's just that I'm very bitter as I don't have a baby and her absence makes my work days much longer. Slaving away at the grindstone while she's excused for baby bonding just seems to imply that she is special and I am not. It's also tough to see her mother post on Facebook, "Spending quality time with the twins while their mother enjoys a lucious spa day!" (sounds more like baby abdandoment rather than bonding) Fortunately, I have a bit of flexibility with my course, so hopefully I'll be able to transfer during that week. Maybe I'll be able to fit in a spa treatment as well.

Hopefully, of course is the operative word.  Despite the fact that my CBFM was medium on CD 10 and I had some misleading cervical mucus, there was no indication of an LH surge by CD19. As endometrial injury prior to FET is a relatively new practice, there isn't a consensus on when it should be done. One meta-analysis that I read notes success rates were highest when the biopsy was performed 3-4 weeks prior to transfer. Accordingly, my RE advised the procedure to be done on CD 19 or 20. I checked my progesterone level, just in case my monitor was inaccurate. It came back at 0.2 ng/ml, I hadn't even begun my luteal phase. This could lead to a gap of five weeks or more between injury and transfer. I sent an email to my RE with these details, and he agreed it would be prudent to wait until I had confirmed ovulation. Although, I think he's just indulging me with the plans for a scratch, so I suspect my concerns over a "premature cytokine release" induced an eye roll or two.  

CD 21, CD 22, CD 23... still "medium". Waiting another 24 hours just to test again feels like I'm waiting an entire month. If I had started the prep with my post retrieval period, I could be resting from my transfer right now. In addition to my insistence on roughing up my endometrium, I thought my body deserved a break after such a high count egg retrieval. I briefly considered using a Nuva ring, which would have coordinated my withdrawal bleed, but after 12 days of injectable gonadotrophins, going au natural seemed like a good idea. C'mon Jane! I thought you were smarter than that! Now I appreciate that I probably still had higher circulating levels of estrogen which inhibited production of FSH. Probably the nicest thing I could have done to Si and Am after the way they came through for me, would have been to suppress my hypo-pituitary axis.

CD 24 and no sign of impending ovulation. Ugh. It feels like it will be forever until I'm finally able to transfer, and yet at times forever feels too soon. Like someone with good intentions for a New Year's resolution; post retrieval I refined my eating habits, hit the gym, the pool and my running trails and actually lost a few pounds. Maybe this time it's for real. That's the other scary aspect, I'm dreading receiving my beta results. That potentially life changing thirty second voicemail that could forecast waiting for more beta draws and an ultrasound or waiting another month for the next opportunity to transfer embryo #2. Another month...it might as well be a millennium.

Logically, I must acknowledge that there may be some good news resulting from that phone call, which is also a bit daunting. I might actually experience a pregnancy with a good outcome, and I'm not sure I know how to handle that. I've become so proficient in dealing with disappointment. I'm now anticipating that my transfer may be around the third week in August at the earliest. I'd be receiving beta results in early September, four months after I started the Lupron for this IVF cycle. If it sticks, I could be 8-9 weeks by the time I visit my parents in October. Still too early to announce, even with a known euploid embryo. Had I transferred with my first opportunity, I could have been 14-15 weeks, lightyears ahead in terms of pregnancy security. While it's not ideal, I'll accept that scenario to the alternative -  prepping for transfer of euploid embryo #2 before the three year mark of our first (unintended) act of unprotected intercourse. Alas, time marches on.

Don't Count Your Chickens...

Even if you have an answer to the inevitable inquiry, 'so when are you going to have kids?', you still have to be prepared for the follow up questions. So how exactly do you spend your time and money? My parents enjoy asking when we plan to take a vacation, or what will be our next renovation project. Fortunately, I've become just as skilled at evading these questions as well. It's hard to plan a holiday due to Husband's busy umpiring schedule. We can't decide just what exactly we want to do to improve the gardens, so we're just maintaining what we have now.

Actually, that's a lie. A stronger than usual wave of depression swept over me as I looked out at the pitiful state of our back garden. We have a great space with so much potential, but it's fallen to the wayside of neglect. When we began trying to conceive, we started working on some simple projects, but we soon discovered that both procreation and renovation would be expensive investments. I thought back to our spontaneous conception. Husband viewed it as if we had won the lottery. Not only for the miracle of life, but he saw the savings offset by avoiding infertility treatments. The sad condition of our garden has become a tangible example of our road not taken. Oh, what we could have done if I were holding a baby right now and the bank accounts didn't take such a hit... In my despondent state, evil thoughts creep into my otherwise somewhat rational mind. Jane, you knew that you may have had a septum present. Maybe you shouldn't have gone swimming that morning...

It is especially frustrating when your partner who knows first hand why we haven't booked a holiday or decided our next DIY project, asks the same questions. Earlier in the week, he asked about when we should take our time share in Hawaii next year. I  suggested that we postpone that discussion for few more months, until we know when or if anything major will be occurring next year. "That's why I was thinking December. It works with my hockey schedule." he replied. Um, no. While I appreciate that we can't make any tentative plans, waiting a year and a half before we take a proper holiday does not sound appealing. Okay, maybe a small part of me would like to do the baby moon thing. Tonight, Husband announced that he reckons we can remodel our master bathroom for $25,000.

He carried on talking, but I tuned him out as I focused on chopping up vegetables. If Husband had his way, he would have leveled our entire house and rebuilt it entirely. He often over estimates what we actually need to have done and he fixates on unnecessary items. During the planning of our kitchen renovation, he wanted a top of the line sub-zero refrigerator; which I agreed he could have if he would cook us gourmet meals every night. He insisted on a double oven, and for the record we've only used both ovens at the same time once. However, I do concede that it helps our re-sale value. My father and I had to talk him out of installing new cabinets as ours were in excellent shape and I'm a skilled painter. If I had relented, we probably wouldn't have been able to pursue IVF when we did as we would have been climbing out of a $20,000 debt on superfluous cabinets.

I started chopping louder and quicker in a passive aggressive attempt to express my annoyance. What was really irritating me was the fact that he's banking on our first transfer being successful. As he talks about 'paying off IVF', it strikes me that he's not anticipating any additional costs. Have you learned anything from me? I thought back to my second pregnancy. I had given him strict instructions not to be optimistic, and for the most part he was compliant. Yet one night while he was in LA at a hockey tournament and perhaps after too much sun and/or beer, he started talking about attending the event next year and leaving me at home with a four month old baby. I went slightly ballistic, which prompted him to end the phone call abruptly. I wanted to cry. Pregnancy and the anticipation of a baby should be a happy occasion for a couple. I was denying him that aspect. However, after the inevitable miscarriage, Husband understood why I snapped at him that night.

It was time to ground him once again. I pointed out that there is a 25% chance that an euploid blast won't implant and we could be receiving yet another BFN. Even if it does implant, a miscarriage can still occur. If we make it through the first trimester and an anatomy scan does not reveal any significant structural defects; then maybe, just maybe, we can exhale a sigh of relief and start accepting that we might actually be having a baby. "Well we're ahead of most regular couples as we know we have a normal embryos." he contended. I shook my head. "We've merely eliminated one possibility. The everyday woman is not thinking about how many different ways she can experience a miscarriage." We may have identified a pathway, but we're still a long way from being out of the forest.

A few days earlier my medical assistant emerged from the exam room with a report on my next patient. "She's 22 years old and she should be about 12 weeks. She's French and is moving back to France tomorrow. I'm not quite sure why she's here since she's going to be receiving all her care in France..." She was here today for one reason only. The little black and white ultrasound photo to show to parents their future grand baby. Especially if her parents weren't too thrilled about the pregnancy,  an adorable ultrasound photo might soften the blow.

I recognised the patient as I had seen her for a routine visit last year. She was attending a local University and couldn't decided if she wanted to stay in the States or move back to France after her graduation. I started by asking when she confirmed her pregnancy. It was just days after her missed period. She decided to stop taking her birth control pills as her prescription expired and she was curious to see what would happen. She received her BFP just days before she was due to register for classes in the Autumn term, so she withdrew herself from the University and ended the yearly  lease on her flat. She had shipped most of her stuff and would be going home to finish packing after the visit. She expressed how she wanted to be close to her family during the pregnancy and early infancy, as well as guarantee French citizenship for her baby. Her fiancé had started the process to gain a Visa, which hopefully would be granted by the time the baby is born.

Her uterus felt smaller than expected on her exam. Fuck. Maybe she just wasn't as far along, which is very common for women who are just coming off birth control pills. Although, if that were the case, she wouldn't have had such an early BFP. The Crown-Rump length measured 7 weeks and 2 days without any evidence of cardiac activity. Fuck. She burst into tears when I described what this meant. Instead of a photo for her parents, she would be going back to France with my office notes so her doctor in France could manage her early pregnancy failure.

"O-M-G! I can't believe she would make so many plans without having an ultrasound first!" exclaimed one medical assistant after I asked her to print up my notes and place them in a sealed envelope. "I know, seriously!" echoed another who was standing near her. Both of them were in their early twenties when they had their firstborn, and I doubt either waited for an ultrasound before announcing the pregnancy or purchasing some baby items. She is a young girl who should have been able to make such long range plans as soon as she saw two lines on the stick. She shouldn't have to think the way I do. No one should.

Checkmate

I have previously described that navigating infertility treatments is like playing chess. Although, I confess I'm just using a literary reference; I don't actually know how to play chess. I can't remember the names of the pieces beyond their descriptions of the 'little horsey' or the 'castle thing' and I'm so confused about how they can move. I am aware that chess is the ultimate game of strategy, where a player must anticipate his or her opponent's response and plan two or three moves ahead as he or she contemplates each turn. A skilled player is one who can appropriately react to the opponent's challenges and revise tactics as the game is played.

Prior to starting any infertility treatments, I had read some intriguing articles advocating for endometrial injury prior to an embryo transfer. Additionally, I had one patient who had experienced secondary infertility after the age of forty. As she had pre-term deliveries with both prior pregnancies, her RE strongly insisted on single embryo transfers. Her first two attempts were unsuccessful, so she had an endometrial biopsy prior to the transfer of her final embryo, which resulted in a BFP and successful pregnancy. I also worked with a patient who was pursuing a donor egg IVF cycle at an out of state clinic. She failed two cycles with her own eggs, which were judged to be of low quality. She had selected a proven donor, but her RE still wanted her to go through an endometrial biopsy. A transfer of two embryos resulted in healthy twin boys. I recall one blogger mentioned that her RE will perform a biopsy for a patient with two or more failed transfers. Why wait for someone to fail multiple times? I thought to myself. As this is a relatively easy and inexpensive intervention with data demonstrating that it increases success, why not employ it?

As I had intended to do PGD testing with my first cycle, I was also conspiring to have an endometrial scratch prior to transfer. Of course, I hadn't anticipated the need for a day 3 transfer and the resulting pregnancy. Although I wasn't surprised when I learned that the pregnancy was non-viable and later learned that it was due to a trisomy, this information challenged my thoughts on pursuing an endometrial biopsy. I didn't bring it up when my RE suggested waiting for one normal cycle before prepping for the FET. I figured that the D+C accounted for endometrial injury, but as it took over seven weeks for AF to return, I wondered if it offered any benefit by the time we transferred The Chosen One. As I had such little faith in our clean out the freezer transfer, I never gave any thought to aggravating my endometrium. I was really ready to move on to another fresh cycle and didn't want to invoke any additional delays.

I admit that I've become a bit superstitious; I didn't allow myself to make any plans for a transfer until I received my PGD results. I tried to prepare myself that all six could be abnormal. However, by the time my RE called with the news that we had four euploid embies, I was on CD3. AF arrived on a late Saturday afternoon, before I had an opportunity to coordinate a biopsy. My RE had offered that he wouldn't send my endometrial sampling to pathology in order to reduce the costs, but I have other resources at my disposal. There aren't many perks to working in Ob/Gyn while you're infertile yourself, but one of them is that I can walk down the hall and ask a colleague to rough up my endometrium. Saving a few hundred dollars is merely a drop in the bucket compared to our total costs, but as I've mentioned before; infertility has made us chavs. This time I didn't mind the delay. It gave me time to grieve over the loss of my cat, Angus and start the process of welcoming a new kitty into our family. It also offered me more time to evaluate my long term strategery.

When we transferred The Chosen One, Husband did some research and found statistics that demonstrated transferring a high quality embryo in a woman of my age yields a 60% success rate. Data from the XYZ Fertility Centre cites a 75% pregnancy rate when a known euploid embryo is employed. According to the math, we gained a confidence interval of 15%. I can understand why my RE repeatedly conferred the lack of cost effectiveness.  Yet while I can appreciate the facts, the peace of mind afforded by our CCS testing is priceless, even if it only increased our chances by 15%. Not to be a glass three-quarters empty person, but a 25% failure rate seems high with an established euploid embryo. It's hard to quantify the advantage of an endometrial biopsy, but some studies have conferred higher implantation rates.

I want to approach my next transfer with the fortitude that I have done everything in my power to increase the potential for success, while simultaneously preparing myself that it still may not work.  If it yields a BFN and represents my third consecutive failure, I'll consider re-evaluation of my uterine cavity. My RE wanted me to do another sonohystogram prior to my first IVF cycle, and I argued that it wasn't necessary as I had a hysteroscopy 8 months ago. Reluctantly, I agreed to it, and not surprising, it was normal. In my future scenario, I would probably advocate going right to a hysteroscopy prior to another single embryo transfer.

In addition, I would consider The Endometrial Function Test, as years ago, I attended a lecture from Dr Kliman and I appreciated his methodology. My RE noted the data from his test doesn't seem to be reproducible (I doubt the pun was intended) but reported that his colleague will sometimes utilise it for difficult cases. If that one doesn't deliver, then I'll proceed with a final transfer of both remaining embryos. If we end up with twins, so be it; although I'm starting to believe that we're too infertile to be concerned about twins. This also presumes we don't encounter any lost embryos during the thawing process. While I realise how fortunate we are to have the number of embryos that we achieved; at times it still feels like it's not enough.

Where would we go from there?  At least for the present, that would represent our end point. It's mostly a logical decision. I can't imagine we would exceed our current yield with a third cycle. Even if we got a decent production,  I wouldn't want to be back at the XYZ transfer suite with my RE and the hottie embryologist trying to convince me that 'the fifth euploid embryo is the charm!' I also recognise that we wouldn't gain any advantage with donor gametes. I recall reading that CCRM recommends moving toward a gestational carrier if there are three or more failures with good embryos. Not only is the GC price tag hard to swallow, I would struggle to accept that option without having a conclusive answer on why my own uterus is ineffective. Prior to my second stimulation cycle, I had two colleagues ask if I had considered adoption, which is an infertility journey milestone in itself. There is a lot to say regarding that topic, but it the interest of brevity; it would be much more of an acceptable option if we were ten years younger. Not that we'd be provisionally rejected because of our age, although I think we'd be seen as unsuitable candidates as Husband is not yet a US Citizen, I used to work at an abortion clinic and we are atheists. After spending three years navigating through the maze of infertility treatments only to find there is no way out, I just don't think we would have the stamina to endure the uphill battle of adoption.

Enough. No Más. I'll go back on birth control, preferable one that will induce amenorrhea. There is a surprising sense of calm that comes with having an identified end point, although I acknowledge that I am writing from the perspective of someone who feels slightly hopeful at this point in time. I doubt that I'll feel as calm if we turn up empty after a somewhat decent first cycle and a kick ass second IVF cycle. At least we would be able to say that we did all we could, and now we would be moving on. Wow. What would I do with all this energy that would not be devoted to all things procreation and infertility related? Maybe I'd find the time to write the great American novel.