The Writing in the Tablets

Although I am scientific minded and evidence based, I exhibit a bit of a contradiction; I am superstitious. After each transfer, I have made sure that I had just enough progesterone on hand to make it through to beta day, as I refused to order anymore until I received my results. Obviously, I feared that procuring an advanced provision of extra progesterone would some how jinx the outcome. Even thought I knew such actions exerted no influence, and wouldn't even be wasteful as I would need the supplies for my next transfer, I still kept to this ritual. A few days after my transfer, I started to count the number of tablets in the bottle in my bathroom, as well as the one I keep in my purse for on-the-go dosing. It turned out, I had exactly enough Prometrium capsules to get past my afternoon dose on beta day. Right to the point in time where Misery would be telling me to stop all my meds if my test results were negative.

My stomach twisted into knots. This was definitely a bad omen. Not a good prognostic indicator at all. I shared this news with my friend Isabelle, who asked if I were using Endometrin. No, I replied. I've been prescribed Prometrium, or whatever micronised progesterone the compounding pharmacy whips up for me. Suddenly, I remembered that I had received a box of Endometrin from a fellow blogger earlier this year. I used it for a few days during FET#2 and I found that I liked it much better than the Prometrium capsules. Endometrin comes with its own applicator, so I don't have to use the Pre-Seed Lubricant applicators. (Top Tip: Pap smear cytobrushes are the perfect tool for cleaning these applicators. They work well for cleaning the straw and spout of your water bottle too. Steal some at your next visit!) Best of all, I found that the Endometrin didn't muck up my underwear nearly as much as the Prometrium.  I didn't have too much hope with that transfer. It was a Hail Mary Grade 2 Blast to possibly avoid a second fresh stimming cycle. After a few days, I switched back to the Prometrium, as I decided that I would save the preferred Endometrin as a reward when/if I ever became pregnant again. What can I say? This girl knows how to pamper herself.

Now I had to acknowledge; was there something to be said for the fact that my preference for progesterone tablets and planned use in the event of a pregnancy aligned perfectly with the timing of my results? It sounds absolutely ridiculous as I type those words. Yet, these kinds of things appeal to the meticulous nature of my mind. I always try to look for patterns. I love palindromes. I get excited when I see a sequence of numbers. Why was something so silly giving me more confidence than the top grades assigned to my euploid beautifully expanding blast, which was placed perfectly by the skilled hands of my RE?

I can't explain it either. I went into the lab for my beta test with a surprising sense of calm, that I haven't had with my previous situations. After my first fresh transfer 'The Day 3 Desparation' I truly had no expectations. I felt over-confident with FET#1 'The Chosen One' as I was mentally clearing my schedule to return for beta#2 and my ultrasounds while waiting for the phlebotomist to call my name. I had an impending sense of doom with FET#2 'The Leftovers' and with FET#3 'Haven't Named It Yet'. I was merely going through the motions of having my vein poked in order to wait for a phone call to tell me something I already knew. This time, I didn't have that same intuition that forcasted failure. It's not the same thing as believing that I might have a positive result, but hey; I'll take it.

The call came in around 2 PM. I quickly cleared the alert from my phone and I refused to look at the length of the message to avoid applying the Thin Envelope Theory. Fortunately, I had a pretty busy day, which included dealing with possible treatment failure for a patient with an ectopic pregnancy. I was more preoccupied dealing with her beta results than my own. At last, after a long day at the office, Cross-Fit and waiting for Husband to come home from his hockey match, we played the message just after 8PM.

"Hi Jane, It's Misery from Dr Somebody That I Used to Know's Office." I've told both her and New Girl that I don't have any other contacts with their names, so they don't need the full identification when they call, yet I was trying to determine if I could pick anything up from the tone in her voice. "I'm calling with your test results, your HCG..." oh fuck, she's struggling to get the words out... "Congratulations. It was 175. You are pregnant."

All I will ever remember from that moment is the smile on Husband's face. I don't think he has ever looked more beautiful to me. As we've been through two loses, we know that beta results don't always mean baby, and I once tried to dismiss their importance completely. It has taken three failed transfers to resonate their significance. We got our break. We're still in this game.

Lady in Waiting

I was scheduled to teach a contraceptive methods course in Sacramento on the day after my transfer, which meant I got to sleep in that morning. I rolled over and found Husband was already scrolling through his phone. As I rubbed my eyes, he presented a picture of Mrs Robinson and her twins. After a month in the NICU, everyone was finally home. "That will be you in nine months." he declared, "expect with only one baby" he added. When he delivers lines like these, I find myself loving him a little more, yet hating him at the same time.

After waiting for AF's arrival and hoping it would permit my baseline scan, laminaria placement and removal and follow up scan to coordinate with my trip back east, there was one more logistical hurdle. I had signed up to run a half marathon. When New Girl handed me my tentative schedule, my transfer was planned for a Monday, and the race was on Sunday. Six days post transfer and a day past the five day rest period. Of course, I should have been suspect that anything could align so perfectly. When I went back for my final lining check, Dr STIUTK asked if we could move the transfer to Tuesday, as he had a surgical case on Monday and as XYZ tends to be busier, they may not provide a time that would work for him. As I always do, I had snapped some pictures of my own schedule and it was actually easier to move my Tuesday patients. No problem, I agreed. I actually forgot about the half, until I received an email update later that day, and also noted that it was on Saturday, not Sunday.

So that would be on my fourth post transfer day... As the race location was a ninety minute drive away, I wouldn't have minded not getting up at 0430 on a Saturday, but the complicating factor is that one of my friends heard I was planning to do this half, and she signed up with me. Additionally, she took care of the cats while we were away and her requested payment was that I drive us to the event and pick up the tab at our post race breakfast. Just to hear what he would say, I asked my RE if I could run. "I'll leave that up to you to decide..." was his non-committal answer. Husband pointed out that he did not say 'yes', while I interpreted it as he did not say 'no'.

I just wanted an evidence based answer. Of course, I doubt there are any published papers about patients running half marathons and long distances after a transfer. There isn't any evidence to support that bed rest offers any benefit. In fact, one article I read performed a comparative analysis and noted similar pregnancy rates between bed rest and non bed resters, but the women who were on strict bed rest had a lower implantation per embryo rate. I've even heard some REIs wonder outloud if bed rest may have a harmful effect, that it's better for uterine blood flow to be up and moving. Just maybe not moving 13.1 miles.

I dug up my post transfer instruction that I received from my first cycle. As a five-time guest to the XYZ Embryology Suite, they no longer give me the hand out. I have been compliant with these instructions with all my previous transfers, and it didn't make a difference. "No strenuous exercise for five days". Strenuous is the key word. My ego wants to say that running 13.1 miles isn't strenuous for me. It only take me abut 4 weeks to train for a half. Yet, I've done this course before and found it to be tough, especially if it happens to be a hot day. Plus I haven't ran much in that last few weeks. And I'm recovering from a cold. Also, are you aware that this is your fifth transfer after three consecutive failures? "Jane, you and I both know that whether or not you run won't make a distance, but I don't want to see you blaming yourself if you run and it doesn't work." Husband offered.

The logical side of my brain agreed, as she tried to tell my ego that if it were an easier course, cooler temperatures and if I had been able to squeeze in a few more practice runs, then I could have done it. Then I received another email from the race organisers announcing that they decided to add a 5K distance to the event. It would follow the last three miles of the half marathon course. Now, that was something I could do!

They offered a shuttle service from the start of the half to the 5K start. While walking to the meeting point, I ran into a woman who I'm guessing is about 28 weeks pregnant. "I signed up for the half, but I obviously can't run it now." she explained. I decided to try being open about my situation "We're doing IVF and I had a transfer done earlier this week." "Oh. I had a friend who did IVF." she replied as she pulled out her phone and quickly became engrossed by it. Sometimes you can tell how fertile someone is by how uncomfortable they are discussing infertility.

I overheard two or three conversations on the shuttle to the 5K start, "so I was planning to run the half, but then I found out I'm pregnant!" I also caught a group of guys who had intended to run the half under the team name 'Sweating for the Wedding'. The Groom (I'm presuming) had written on his bib 'Hoping she'll love me the way I am'. Apparently they didn't realise how long 13.1 miles was and didn't train appropriately. So, this 5K distance would be composed of pregnant women and people who aren't fit enough to run the half marathon. I'm neither; but I'm feeling more closely aligned with the didn't properly train group.

After the shuttle dropped us at our start, we had to wait about 45 minutes for all the elite runners to pass. Those who keep a less than 7 minute mile pace and would clear the ten mile maker in less than one hour and fifteen minutes. We were able to hang out at a winery, receive shelter from the pouring rain, enjoy hot coffee and tea as well as indoor plumbing. It was starting to resonate that switching distances was a very smart decision.

I ran the 3.1 miles rather gingerly. I disabled my timing chip so that there would be no official record on how slowly I ran the course, but it was very slow. As I was waiting for the race to start, I received a text from Robin asking how we were doing. "You two are going to be amazing parents, whether it's in nine months or a little longer." Suddenly, I had a new perspective on the two week wait. I am merely waiting to see how long I will be waiting...

Serving To Stay In The Match

The tenth month in the calendar year has represented several anniversaries. Husband and I met in the month of October and we moved to the States in October. In October 2011, I removed my IUD so we could start trying to conceive, but I made Husband use condoms, least we be one of those couples who score on the first attempt. A year later, we fell asleep early and missed having sex on the night of my positive OPK. I thought we were the most pathetic TTC couple in the world. Ha! Little did I know we were still amatures at that time. Last October I started my first IVF cycle and here were are at the end of October in 2014, preparing for our fifth transfer.

As we arrived at XYZ Fertility Centre, the staff went through the familiar instructions for us. Husband and I both pointed out, not only is this not our first time at the rodeo, we're five-timers! I do realise this is not exactly something of which to be proud. However, I am proud of my pelvic floor muscles, as they came through for me and my mega full bladder. Dr STIUTK felt the transfer could not have been smoother. Sigh of relief. We spent some time talking with the embryologist about our embryo quality. As four of my embryos were frozen on day 6, I wondered if they were inferior in any way. I was prepared to hear the embryologist (donned in her Hello Kitty scrub cap) explain that while chromosomally normal, as my embies are formed from a 38 year old and a partner with male factor, they actually suck.

Well, apparently they are all grade 1, which is they highest grade assigned at XYZ. When they have CCS tested embryos, they rank them by the confidence report of the chromosomal analysis. Although both she and my RE disputed that the day 6 embies could be of poorer quality, the first two chosen for transfer, were the ones frozen on day 5. Interesting. She also described that the process of performing the biopsy acts as a form of assisted hatching. Finally, the the embryo thawed well and the expansion was "awesome". Fuck. I forgot to ask my RE to take the report with him. I made that request last time as I didn't want to add to my photo collection of unfulfilled blasts. He had already left by the time I made the discovery. Now this transfer has to work as I have the picture.

Meanwhile, while I was resting, Husband received a text from Barney. He acknowledged that he felt badly about sharing their news as he knows of our struggles, and he asked how we were doing. He also confirmed our suspicion; they were a one hit wonder. Barney thought it would take about six months and was hoping to enjoy a lot of 'practice'. Instead, he notes he'll be doing a lot of self-practice from now on. Barney may come across as a crass lad, but he is genuinely a caring friend. Husband brought him up to speed. Just transferred a Grade 1 euploid embryo. "Wow." replied Barney. "I just googled what that is. It sounds like you can't get much better than that."

This is exactly what I would want to hear. Well besides hearing the words, 'your beta is positive and you are pregnant.' I've been asking myself would I rather hear the embryologist (in her French accent) explain, 'Your embryos are shit. There's not a chance in hell that you'll become pregnant' just so I'd have an explanation if it doesn't work? Obviously not. It's just that I've heard all the favourable reports before and they no longer mean anything to me. Why should I go out on a limb and let myself beleive that this transfer could be any different? Yes, we made a few modifications to this time, but they were emperic. They may or may not have any effect. We've gone though some many rounds of treatments with the thought that this could be the one! It feels so daft to think that way anymore.

This line of thinking led me to confront another question. If I don't actually believe that this may work, why am I continuing to transfer my embies? I have to admit that after our last BFN, the temptation to just walk away from it all was enticing. If we're going to eventually be defeated by infertility, why not lose on our terms, our command. Yet how much time would pass before regretting that decision? Would the spector of our remaining embies always haunt me whenever I saw children and would think about what could have been? C'mon Jane, you're allegedly a rational person. Somewhere inside that pessimistic skeptical being is a shred of hope. If you really didn't have any faith, you wouldn't got through these procedures.

Yet at the same time, it also seems prudent to ask how many times can we torture ourselves with this process? How many times can we welcome that faint ray of hope, only to have it extinguished so quickly? The smart alec in me has the answer. We're just serving to stay in the match. Down a set and a break, and our opponent is dominating her serve. Defeat feels inevitable. In fact, we haven't even managed a point [of an HCG] during her last three service games. We're just trying to hold our own serve to prolong the game. Maybe make the final score look better to reflect our efforts. Sometimes it's just the message that holding sends. You may be en route to victory, but I'm not going down without a fight. You want this win? I'm not going to give it to you. You'll have to earn it on your racquet. So we hold. Pause for a few minutes as we change sides. Await for our opponent to deliver her first serve. Maybe, just maybe, we'll get our break.

An Advocate for Stress?

I've previously written a few posts that have attempted to disconnect the association between fertility and relaxation, and I have been careful to mention that I'm not advocating for stress. Stress reduction has important benefits for mental and physical health, but a relaxed state will not necessarily enhance fertility. However, my recent conversation with Myrtle is making me reconsider my position on stress. She suggested that Husband and I take a trip to Hawaii after a transfer. Eye roll. Face palm. Head shake. God Damn, fertiles just cannot get off that vacation notion. Apparently, one must be on a sandy beach with a Mai Tai in hand in order for implantation to occur. Of course a fertile wouldn't understand how stressful it would be to try to coordinate a trip around the time of a transfer. Nor could she appreciate that it would be hard to fund an FET and a holiday in the same month.

Although many have commented about how tolerant I am of Myrtle; I have a bit of a confession. The academic in me really enjoys schooling her when she comes up with some pretty ridiculous shit. "Jane, your job is so stressful. What if you just took a few days off?" Once again, we ran that play last time. My transfer was on a Wednesday and I had PTO for the rest of the week. I worked on a presentation, which was more time consuming than a stressful task. To complete the relaxation cliche, I had a facial and a massage. Since XYZ won't assign a time for my transfer until the night before, I have arranged to take the entire day off, so that I'm not cancelling patients at the last minute, although on two of my transfers, I could have worked through the morning session. I've just wanted to avoid the clusterfuck that occurred with my first transfer.
                 
When my RE called with my fertilisation report, he tried to assure me that we would be able to transfer on day 5, but I sensed he was holding something back. Three days after my retrieval, my cat Angus followed me from room to room and repeatedly meowed for no apparent reason. I know it sounds crazy, but I felt he was trying to tell me that I would be transferring that day. Shortly after I arrived at work, my medical assistant informed me that a radiologist was calling with a stat report. As I was the only provider in the office at that time, I had to take the call.

It was a patient who had recently miscarried and the radiologist suspected she had retained products of conception. My colleagues and I have often observed that the radiologists tend to over read retained products. However, this radiologist just wanted an answer, what did I want to do with her now? During this time my phone rang, displaying my RE's office number. Oh fuck. It was barely after 9 AM and he was calling as soon as he arrived in his office. This was not a good sign. I had to let the call go to voicemail. Meanwhile, I needed to deal with this patient situation.

I called my colleague who had seen the patient and ordered her ultrasound. It was her day off, but fortunately she answered her cell phone. She shared my skepticism on the interpretation and noted that the patient wasn't bleeding too heavily, so she thought she could be managed medically. I called in the prescriptions, had my medical assistant schedule a follow up appointment for her and asked our nurse to go to the radiology suite to review the instructions and plan with the patient. Surprisingly, this only took ten minutes.

When I was finally able to call my RE, he had already started seeing patients. I waited on hold for over ten minutes, before I hung up and called back to inform them that I couldn't wait any longer. I now had three patients waiting in rooms and I was running twenty-five minutes behind. "I'll pull him out of the room" Misery offered. Another bad sign. Five minutes later he came to the phone and delivered the recommendation to proceed with a day 3 transfer. I had promised Husband that I would call him as soon as I heard from my RE, but I had to start seeing some patients. Especially if I were going to be leaving the office early.

Fortunately, those first three patients were relatively straightforward and weren't too upset about the long wait. I brought Husband up to speed and then called my RE again. During my freak out over the possibility of twins, he let it slip that due to my 'poor prognosis,' it actually wouldn't be unreasonable to transfer three embies. I wondered if we should proceed at all. Disaster was written all over this plan. I told our office manager that I would have to leave for the afternoon to tend to a "family emergency," which was technically kind of true. I rushed out of the office leaving a mess of paperwork on my desk, phone calls unanswered and I only glanced at my results to see if anything was urgent.

Husband and I talked during the drive to XYZ Fertility Centre, which prohibited me from drinking the required amount to fill my bladder, as it wasn't sufficiently full by the time we arrived. The hottie embryologist described that our embies weren't too bad, if we only had more, we could have held out until day 5. I was questioning my decision to proceed with these two as my RE was placing them inside my uterus. My thoughts oscilated between panic about twins to fear that the entire cycle was a bust. I felt extremely tense during this transfer and it was the most uncomfortable of all four procedures.

For almost a year, I have been trying to understand how an abnormal embryo of mediocre quality could implant under unfavourable circumstances, while three superior quality embryos failed in an allegedly ideal transfer situation. Did the stress of that day have a positive effect? Was there something about my release of cortisol or endogenous adrenaline that helped implantation? I've argued against the "just relax" theory by pointing out that pregnancies occur in many stressful situations, physicial attacks, famine, war, etc...We often see a bump in the birth rate nine months after a natural diaster or other catastrophic event as people decide to do something life affirming. Once I countered that as Husband has decreased sperm production and I have a long follicular phase, we may be too relaxed!

I acknowledge that I'm absolutely grasping at straws, but it did spin some wheels in my mind. Should I try to induce some stress into my transfer day? I thought about not taking the day off work, maybe calling in sick for a morning transfer, or trying to work in the morning if I were scheduled in the afternoon. My conscience forbids me from doing that. I hate cancelling patients at the last minute. Instead, I looked through the schedule for the week and made recommendations for my medical assistant on where she could reschedule patients. Maybe we'll get delayed by traffic, although that's unlikely as Husband will be scouring the traffic reports and will build in plenty of 'oh shit' time. The fact that I have to keep a super full bladder is nervewracking. Not only is it physically uncomfortable, I worry my cup may runneth over. I'm scared that it will be another difficult transfer and I'll feel doomed right from the start.

Thus, I suppose the situation alone should represent enough stress. This is our fifth transfer within a year, and possibly the penultimate one. We running out the clock. Our enthusiasm, our patience, our resources and our hopes are all fading. I feel a particular sense of desperation that I didn't have a year ago. Maybe that's just the difference I need.

A Trio of Announcements

Back in January, Husband was selected to umpire some top level field hockey matches on the east coast. The question of wheather I would join him on the trip was predicated by our first FET. If it had been successful, I would have been 34-36 weeks pregnant during that time. Not only would I not have been able to travel, Husband would have been worrying about being on the other side of the country during the late stages of my high risk pregnancy. Fast forward a second stim cycle and a total of three failed FETs later, I was holding my breath to see if this October trip would conflict with my up coming FET prep. Fortunately, I was able to take advantage of my clinic's 'if AF arrives after 4 pm, we consider the next day to be your CD1' rule, and everything fell into place.

Going back home is just so weird. I had to negotiate borrowing my mother's car to go visit Myrtle. I came home just after midnight and she and my father had fallen asleep in the living room. This took me back over twenty years: did I break curfew? Did I even have a curfew? Was I going to be in trouble? I gently shook my mother to let her know I arrived home safely. "Is my car okay?" she asked. Oh. She was waiting up for her car, not me. I hid my Lupron and related supplies inside the lining of my suitcase, an action Husband considered paranoid. Yet sure enough, my mother reached inside my suitcase, "can I see your travel case? I need a new one.." Um, it's a travel case. Use your imagination. Despite needing to conceal my meds, I never missed a dose.

Husband went into his company's New York office on the days when he was not umpiring, so he didn't have to use as much vacation time. He shared the news that one of his colleagues is pregnant. "They struggled for a few years and went right to IVF, as she had just turned 41. They conceived with their first transfer." I started to feel the familiar sensation of hapulosy. Any pregnancy is a victory for all infertiles. Yet perhaps because I've only met her on two or three occasions at thier company's holiday parties (although in that short time, I discovered that she is really cool, she will be a fabulous mother, and she looks amazing for her age) I found myself addressing a stronger sense of jealousy. Pregnancy rates are much lower after the age of 40, even with assisted reproduction, which makes it even more atypical that she was a first time success. Then again, I wasn't supposed to produce 14 mature eggs and have them all fertilise at the age of 38. In the end it doesn't really matter what your lab values and projected stats are; it all comes down to what can happen in the lab and in the uterus.

A few days later, Husband and I were enjoying a drink at a bar in Boston, when he received a text from Barney, a fellow ex-pat. Barney is an accountant for a large corporation, and his wife Robin does sound editing for a critically acclaimed TV programme. Last year, she revealed that she wasn't sure if they wanted to have kids, which made sense given the demands of their careers. This was after I told her about our issues and she advised me to "just give it some more time". There was a sonogram picture attached with the text, as it announced that Robin was nearly 12 weeks along. We joined in the messages of congratulations and well wishes, and went through the routine of discussing due dates, potential names and some very specific questions for me regarding genetic screening and ultrasound diagnoses. This should be us! We should be making this announcement! I just couldn't suppress those thoughts from my mind. Husband was right, we wouldn't be the first of the ex-pats to procreate. I also couldn't help feel frustrated that someone who wasn't sure if she even wanted to conceive, did it so quickly. Especially as she pronounced that I needed to be more patient. Is another year enough fucking time?

Then there was my visit with Myrtle. As Husband would be seeing her first, I asked if he could encourage Myrtle not to bring up the subject with me. "Nope" he replied. "I think that will make things worse. You two should talk face to face." As we were alone together, the opportunity presented. Fortunately, I did most of the talking, and she did more listening. There were a few cringe worthy comments, "why don't you shove all three [of my remaining euploid embryos] up there?" and a face palm or two "have you thought about going to Hawaii after a transfer? Think about it Jane, how many people become pregnant on holiday?" but it was a good visit. Even when I asked about Melissa.

Melissa was a mutual friend from our high school days. She can best be described as a chronic underachiever. She abandoned many projects and quit sports teams, but nothing was ever her fault. She always had some excuse or placed the blame on a coach or teacher who didn't like her. She was the type of girl who practised her signature with a guy's last name after their second date. Oh, and she had an attraction to losers who lacked ambition, but had mummy issues. I long lost interest in her when I left for college, but Myrtle kept in touch with her, although she admits it's mostly for my amusement.

Two years ago when I went back home for Myrtle's shower, I learned from another high school alum that Melissa (at that time briefly married to Husband #2, after a failed engagement followed her divorce from Husband #1) was having trouble conceiving. I wasn't too surprised, as I always suspected that she has PCOS. Yet, even though I had just learned about our moderate male factor diagnosis and it had only been seven months, I started to think, oh great, I'm just as much of a loser as Melissa! I can't conceive either!  "So..." I asked Myrtle "have you heard from Melissa lately?" "Well...I didn't want to tell you..." she hesitated, "she had a baby boy last year." Hmm. The news didn't bother me. I acknowledged that being infertile does not make me a loser, and just because she has a baby; she's probably still a loser.

When I first saw little Myrtle walking hand in hand with Myrtle, my heart melted. She's absolutely beautiful and a very sweet little girl. As soon as I entered their house, she invited me to play with her. She is remarkably well behaved for a two year old and shows gracious social skills. Myrtle and Mr Myrtle tought her to say "cheers" and she raised her sippy cup of milk as Myrtle and I clinked our wine glasses. Although jealousy will always be at my core, I felt an overwhelming sense of pride for Myrtle. She is doing an amazing job as a parent, even if it is still an adjustment for me to hear her address herself as 'Mommy'.

Some bloggers warned me to prepare for pain when visiting with little Myrtle. That occurred when Myrtle and her daughter came for brunch with my parents. The sights of little Myrtle reaching for my mom to pick her up, as well as my Dad crouching on his bad knee to play with her, both brought tears to my eyes. Fortunately, the moment was broken with laughter as little Myrtle called my parents' cat Sookie "Soopie". It's been interesting to process these different reactions and emotions. The same event of a pregnancy or birth announcement can evoke several different responses. Oh, there was something else that gave me a smug sense of satisfaction; Myrtle has a really big ass, and unlike mine, hers is not from sports.

Denial is Not a River in Egypt

A few years ago, I was reviewing the records for my New OB patient, Ida Know. She was in her late 30s and this was her forth baby. She had her first two in her 20s, but remarried another man and had her third child two years earlier. During that pregnancy, she developed severe pre-eclampsia and was delivered at 34 weeks. As I looked deeper into her records, she was actually noted to have chronic hypertension with super imposed pre-eclampsia. Six months before this visit, she went to her primary care provider for a routine physical and her blood pressure was elevated at 160/100. Ida expressed that she wanted to become pregnant again, and her doctor discussed the importance of controlling her blood pressure first. He increased the dose of her Labetalol and recommended a follow up visit in two months. Ida thought stopping the medication all together was a better idea.

Sure enough, she conceived quickly and she was 10 weeks at the time of her first visit. Her blood pressure was 180/120. I had to send her to Urgent Care for supervised blood pressure lowering as well as to her Primary Care to evaluate for end organ damage. She would ultimately require maximum doses of Labetalol and Hydralazine, but super imposed pre-eclampsia set in at week 29, and she was delivered at 32 weeks. Ida didn't really have an answer for why she stopped her blood pressure meds, except that she thought it would be better for her baby. An emergency early delivery at 34 weeks didn't teach her anything about the importance of blood pressure management? I ,walked into my colleague's office, and asked the rhetorical question; "why are people so stupid?"

After Dr STIUTK confronted me about my own blood pressure issues, I decided that I would not stick my head in the proverbial sand, but I did need more data. I started checking my own measurements everyday at alternating times and found my readings were in the low 130s/high 120s over low 90s/high 80s. While admitting that I do have mild hypertension, it isn't that bad. I began taking the Labetalol at 50 mg twice daily and found that my numbers hadn't changed much at all. I started to make the argument that I didn't really need the medication; it wasn't exerting much of an effect and my blood pressure wasn't that bad! My Primary Care thought otherwise, and recommended increasing to 75 mg BID. Around that time, I started my luteal phase Lupron, and noted that my readings had bumped up to 140s/100s. It was time to leave denial and start taking my medication like a good girl.

The medical assistant who works primarily with my Lead Physician recently asked how I was doing and what my next steps were. I brought her up to speed on the plan, including addressing my blood pressure issues. "Well, you know you'll eventually need to be on medication anyway, so you might as well start it now." she stated flatly. "Don't be like Ida Know" she added for extra emphasis. I truly respected her for being so candid and upfront with me. Mostly because I know she is right. " Yeah" I replied, "My birth plan will be getting sectioned for pre-eclampsia." We both laughed a little, but silently acknowledged the probable truth in that statement. The hardest aspect about admitting I have hypertension is that it makes me feel as if I am too old and too unhealthy to be attempting a pregnancy. I can't reverse time, but I can lower my blood pressure readings.

Meanwhile, I went into my RE's office for my laminaria placement. Laminaria are small sticks of seaweed that expand as they absorb cervical mucus and promote cervical dilation. They are primarily used to prep patients scheduled for a second trimester D&C procedure, and my RE felt placing one could help make my transfer go smoother. "Did you take anything?" asked New Girl as she ushered me to the exam room. "No" I replied, surprised by her question. I was only having one stick inserted in my cervix. I used to place 4 or 5 and I never pre-meded any patients, nor do I recall anyone reporting much pain. "Well, you might want to..." she suggested.

The placement was rather easy and practically painless. As I was forbidden from doing any exercise (which could displace the laminaria) I decided to take a glass of wine when I got home. A few hours later, the cramping took effect. O-M-G, holy mother fucker, it hurt. I took 800 mgs of Motrin. When that didn't touch the pain, I went with the Tylenol with Codeine tablets left over from my Hysteroscopy. Still no response, I tried the Vicodin which was prescribed for my D&C. Plus, I took my daily baby aspirin. I applied a Therma.Care heat wrap to my back and snuggled under a heating pad. Feeling nauseated from the pain, the drugs, or both, I popped a Zofran. I was still uncomfortable by 1 AM, so I downed two more Vicodin and finally fell asleep. I set my alarm for 5 AM, just so I would wake up to take another 800 mg of Motrin. By the time I rose to get ready for work, I was finally pain free.

So, maybe I'm not as tough as I think I am. While I never had any particular aspirations to do the whole unmedicated natural birth thing, there was something in the back of my mind that wondered if I could. After emptying my medicine cabinet just to get through a night with laminaria; not only is that answer a resounding 'no', but avoiding labour pains with a Ceasaerean delivery sounds appealing. Except the discomfort comes later during the post-op recovery, and no one offers you an epidural. You have to suck it up and care for an infant.

However, I may be (just maybe) as smart as I think I am. At the beginning of my cycle, I reminded my RE of our discussion to alter my estrogen priming. He started me off with only one 0.1 mg patch, rather than two. On CD 10, my lining was only 8.5 mm, which is more aligned with my fellow bloggers, and is less than all my prior measurements, which were above 10 mm at this point in time. I was planning to only increase my patches to two rather than three, which is what my RE instructed me to do. He is also having me come in for a final lining check before I start my progesterone. Even if it still doesn't pay off in the end, I feel really confident about the adjustments during this cycle.

If I Ever Lose My Faith In You...

A few days after my BFN from FET#3, my Lead Physician approached me to ask how I was doing. I gave her a run down of my RIF research and mentioned that I had contacted the other RE who has visited our office. "Are you going to switch?" she jumped in to ask. I paused a second before answering. Initially my decision to do some outreach wasn't so much about seeking another opinion; it was laziness on my part. I had to finish a presentation that weekend and I decided to outsource the task. Fortunately, my RE had to reschedule the appointment, which gave me time to do my own work when neither responded. I hadn't admitted to myself that maybe I was also looking for some words of wisdom from providers with more years of my experience than my RE. While I have no doubt that my RE is up to date with the most current litterature, especially as he doesn't seem to have much of a life outside the office; he was born in the same year as Louise Brown, while the other two graduated medical school around that time. Perhaps advanced age can provide an extra measure of reasurrance.

I wasn't too surprised by her inquiry. She almost exclusively refers her patients to his group. "Well, we already have the embryos..." I started to explain. Husband and I had discussed that if our second stim cycle was only projecting 6-8 mature eggs again, we would cancel the retrieval. We didn't have a follow up conversation, but I would have considered CCRM at that point. Call it huburis, but I just couldn't accept that with my AFC and AMH, that my ovaries couldn't produce more. My RE made all the right adjustments to my second cyle, and he managed it brillinantly. As he himself noted that an REI is only as good as the embryology lab, they could not have performed any better at XYZ. They fertilised all 14 of my 38 year old eggs with sperm from a man with moderate male factor. Changing providers would require transporting my embies, which involves additional costs and risks, unless I enlisted with an XYZ doctor. That would involve waiting to arrange a new patient consult and getting on to their schedule, just to transfer the same embryos in the same place.

Co-worker was not so subtle about sharing her opinion. After I brought her up to speed with her RE's recommendation to do the endometrail receptor assay, it was clear to her that I needed to jump ship. "You're had three failures, and your RE wants to take you in this direction," as she motioned with her hand "and my RE wants to take you in this direction..." she motioned her other hand in the opposite direction. I found her tone a bit patronising and I thought it was an over simplified description of the situation. I discussed the limited data within the study I read. "Pursuing the test is not a straight forward decision." I commented. "Well, you shouldn't have to make the decision." She quipped "The doctor needs to make the decision." I recall during her treatments, she described that he was very proactive, but operated on his agenda. I felt that I had a more collaborative realtionship with my RE.

"Obviously, I'm biased." She admitted. I have a bit of bias too. A patient that I referred to Co-worker's RE contacted me about switching to another provider. She was frustrated that he kept forgetting that she has Premature Ovarian Failure. Sort of an important detail to remember. Additionally, I was concerned during her final IUI, as she had at least 5 mature follicles and her partner has a billion sperm on his post wash TMC. She was very lucky not only that she became pregnant, but that it was only a twin pregnancy and not higher order multiples.

I've developed such a newfound respect for the subspecialty of Reproductive Endocrinology and Infertilty. There is so much scientfic application and skill involved, but at the same time, so much of their practice, their business, their reputation, is all down to chance. I never looked up any stats for my RE, because someone else's case doesn't apply to me. I never read any reviews about him, because the only opinion that matters to me is my own. One of my younger colleagues knows him from her residency (they're Facebook friends, which has made me mindful of what I post to her page) and I've noted that she doesn't refer many patients to him, although the location is an inconvenience to most of our patient population. I've been tempted to ask about her experience working him, but I doubt it would differ from my own observations: very serious, thorough and calculating, hard worker, bland personality.

It also seemss that we have a bit more invested. Misery is nice to me on a regular basis, and Husband feels we've both connected on a personal level with New Girl. "I think she genuinely cares about us." he observed. As she has texted me from her own phone on a few occasions, I imagine I'd keep in touch with her with an update or two, should I ever become pregnant. The prospect of starting from the begining with a new clinic just feels exhausting, although I know that's not a reason to stay. We've come so far with him, and he recently acknowledged how long and hard this process has been. We're ten yards away from the endzone. We could be just one transfer away from achieving what we want, although I know how naive that sounds, given that has been our motto for the past three transfers. If the next one does not take, and there is a good chance that it won't, I'll arrange a phone consult with CCRM and I may do the endometrial receptor assay, if for no other reason than to bide time until the new year. At times, it's just so hard to have any faith in this process. It's hard to put your faith in another person, but at least for now, I don't feel that my chances would be any better in any other hands.