Thursday, 31 October 2013

The Twins Dilemma

*Disclaimer: this post discusses my brutally honest feelings about having twins. Those with twins may wish to skip this post*

A few hours after I told an old friend about our infertility issues and plans for IVF, she hugged me at the train station and whispered in my ear, "I hope IVF brings you a two-for-one!" On the morning after Marshall and Lilly's wedding, I had the same conversation about IVF with Robin and she responded, "well, you'll have twins, but they'll be best friends for life..." Both comments pissed me off, but I didn't say anything to follow up as in the first situation, as I needed to catch a train, and in the second incidence, I was tired and a bit hung over.

I was annoyed that the first friend presumed that I would want to have twins, and irritated as the second assumed that IVF equals a twin pregnancy, although to her credit, she does have two friends who did IVF and both have twins. It is a little more straight forward in our case, as Husband and I decided long ago that we only want to have one child. As we're both only children ourselves, we've lived through the advantages and feel we're reaping the benefits as adults. Echoing some of the words my dad used when I was growing up 'we're going for quality, not quantity' or 'we're choosing to specalise!" There are a few other practical reasons, as we don't have family nearby to help us, we know it would be quite a struggle to manage twins in our life. Husband frets about the financial implications, and while I'm living in the delusion that I can bounce my body back from a singleton pregnancy, I know twins would wreck me.

In the world of obstetrics, things always seem to come in groups of three. I'll encounter an uncommon condition and within the next week or so, I'll see two more cases. There's often trends with occupations, I'll often note that within a day I'll have three nurses, or three teachers, three hair dressers... Keeping with that theme, earlier this year was Twins Day. It was back in April and Co-worker was really starting to show with her twin pregnancy. There were three new OB patients on the schedule; all IVF pregnancies, all twin gestations. The first had a single embryo transfer which resulted in a chemical pregnancy, and thus they decided to transfer two embryos with her first FET. The second patient had a BFN from a single embryo transfer, but she transferred two on her first FET attempt and had a singleton pregnancy. Naturally, they decided to use 2 embryos for the second FET, which produced twins. The third patient failed three previous IVF cycles and had her fourth cycle cancelled. They decided to proceed with a pair of donor embryos and voila!

Interestingly, I also had two patients who had naturally conceived twins coming in for a follow up that day (truly designating it as Twins Day). Both of these patients had identical twins who were sharing the same gestational sac, but had a separate amniotic sac. About a week later (to complete the theme of three) I had yet another patient with naturally conceived twins, but this time both twins were in the same amniotic sac -the most riskiest type of twin pregnancy. Despite all the controversy regarding assisted reproduction and twin pregnancies, they do tend to yield dizygotic twins, which is the safer form of a twin gestation.

Naturally, all patients were excited to be receiving their education from a nurse who was expecting twins herself. I was in my two week wait from my first IUI and I was surrounded by non-stop twin chatter. When we had a moment alone, Co-worker commented, "maybe it's a sign!" as she glanced at my uterus. Yeah... I barely had a single mature follicle and we only used 5 sperm for the insemination, so I was pretty confident that twins were not in my immediate future. I didn't want to acknowledge to her that often my silver lining for a BFN was the thought 'well, at least I'm not facing twins!' I started to worry a little during IUI # 4 and 5 when I started producing co-dominant follicles, but I knew it was such a long shot at that point in time, that I would look silly expressing such a concern.

As we started to discuss moving forward with IVF, I thought the ability to do a single embryo transfer could reduce my concerns about the potential for twins. Yet what happens if the first one or two single transfers fail? How can you not consider transferring two? Why does it feel that we have to make the choice between twins or no baby? On the advice of Non Sequitur Chica, I wanted to have this conversation with my RE at an early point in time, before I was too loopy from all the hormones injected into my body. He described that for the first cycle, he typically recommends transferring (2) 3-day embryos or (1) 5-day embryo. We both acknowledged why patients desire twins. It's more efficient for those who desire more than one child. It avoids all the uncertainty (not to mention expense) of going through another FET or fresh IVF cycle. Yet he commented, "some just see the novelty of the double pram...they don't ever see the 27 week premies in the NICU."

He then started to share a case from his fellowship of a young woman whose partner had male factor infertility. She tried to conceive on her own for two years before finally seeking evaluation, and their diagnosis prompted an immediate REI referral. She failed two IUIs before starting the IVF process and she responded beautifully. She pleaded with him to transfer two embryos as she had "been through so much..." While acknowledging that her infertility experience was rather short compared to other patients, he agree to transfer two embryos for her. He started scanning my ovaries and didn't finish his story. I didn't ask what happened, but I figured it was a very bad outcome if it stayed in his memory this long.

He summarised by noting that it depends on how much the patient is willing to accept the risk of twins. I reminded him that I have seen the 27 week premies, but the risk hits a little closer to home for me. A few weeks ago, I asked my colleague how one of the patients with naturally conceived twins faired. "Oh, she made it to thirty six weeks" he replied. Wow, good for twins, I thought. "She had severe pre-eclampsia." he continued, "She was in the ICU for over a week." Alas, that is why I can't risk twins. I'm already concerned that my blood pressure issues could pre-dispose me to pre-eclampsia with any pregnancy, but it seems like it would be a sure thing if I were to be pregnant with twins. I just can't take that risk. There is a bona fide concern that outweighs all my superficial ones. This also helps solidify our decision to do PGD and proceed with single embryo transfers. There can only be one bun in my oven.

Tuesday, 29 October 2013

To PGD or not to PGD

I often explain to patients that the decision process regarding genetic screening is complex, as the testing choices are complicated and the feelings and emotions surrounding the testing and results are very complex. I feel there is so much I can say on this topic, but in the interest of brevity; I won't. I strongly feel that all patients should be presented with the option of testing, and the decision to proceed should be placed in their hands.  I'm bothered when clinics or offices require patients to have some form of screening. A few months ago, I saw a 39 year old woman who presented with her first pregnancy. Her infertility work up revealed a large fibroid, and after her RE performed a hysteroscopic resection, she conceived spontaneously. When I reviewed the testing options with her she replied, "Oh, yes. My RE told me we'd be doing this." I started to explain to her that it was actually her choice if she wanted to pursue any screening, but she cut me off. "My RE wants me to have this test done." I quietly sighed inside my head. Such is the power of a RE recommendation. I'm sure if her RE said 'jump', this patient would ask 'how high?' I was really tempted to tell her that especially as this was a spontaneous conception, and her RE had less of a directly vested interest, she probably didn't give a shit what this patient did for genetic screening. Just make your own damn decision woman!

I already knew what my decisions would be. Even before I was officially in the advanced maternal age category, I knew I wanted to do diagnostic testing. I didn't want to rely on ratios. I didn't want to have to wait 7-10 days for a result, and if it were positive, need to wait to meet with the genetic counsellors and schedule an amnio at the last minute. Just go for the gold straight away. I also knew I would want to do this testing as early as possible, so I was initially planning on doing Chorionic Villi Sampling (CVS). We met with a genetic counsellor for a pre-conception visit and to have carrier screening performed. I wouldn't even remove my IUD without those results. I figured if we were carriers for Cystic Fibrosis or Spinal Muscle Atrophy; it would be game over. (Isn't it so cute how over prepared we were?) I told the counsellor about my interest in doing CVS and she quoted their complication/miscarriage rate at 1 in 300. Less than 1% didn't seem too risky.

After our first few months of TTC proved that conception would be harder than we thought, I began to reconsider my plan. The 1 in 300 complication rate was seeming much higher than my probability for pregnancy. I decided my new strategy would be to do the first trimester blood work and Nuchal Translucency (NT) ultrasound. If those results were abnormal, I could do CVS, but if they were normal, then I could have my amnio in the second trimester. As I did back in my early TTC days, I looked ahead to see when my testing window would be if I conceived in May of 2012. The test dates fell right in line with our two week trip back to England for the Olympics.

I started to complaining to Myrtle that this would mean yet another month of postponing conception due to this bloody England voyage. She couldn't quite comprehend why we would delay. "I'm sure you'd be fine." she assured me via text message. "I'm older than you and my baby is healthy." Of all the irritating things that Myrtle has said to me, (and we know there have been many) this one resonates the most. Firstly, as I replied to her, if were to conceive that month, we would be at the exact same age of conception (I now have a year and a half on her). Secondly, I just heard her as bragging; ...and my baby is healthy... Furthermore, I was annoyed by her illogical conclusion. It was as if I was entitled to a good outcome due to the proximity of our friendship. Applying that rationalisation, I should be fertile too. Mostly, I think at that moment, when I saw those words "my baby" it truly hit me that Myrtle wasn't merely pregnant; she was having a baby. I was trying to coordinate genetic testing for a hypothetical baby that wasn't even conceived yet. My baby. Two words I still can't even use in the same sentence. I felt like I was in this scene from Bridesmaids.
"This is my husband, Kevin. You don't have a husband. Shit!"
To Myrtle's credit, she recommended that we try anyway. After all, "you never know..." In particular, we didn't know we were infertile at that time. On our TTC resume, May 2012 would represent our best efforts. We managed coitus every other night during bang week, including my birthday -whoo-hoo! Too bad my ovaries waited until we were in separate countries before ovulating.

Now as I'm in the process of doing IVF, I have the option of pursuing Preimplantation Genetic Diagnostics (PGD). I'm finding that the decision process is complicated and my thoughts and emotions regarding the testing and results are quite complex. In the most straight forward respect, it is consistent with previous intentions to test as early as possible. If I do become pregnant, it's one less anxiety, one less concern. It means I could tell my parents about the pregnancy much sooner. I wouldn't have to deal with ratios or risk an invasive procedure such as CVS or an amnio.

As a footnote to this testing option, it would also mean possibly knowing the potential baby's gender or even being able to influence the decision. This is in conflict with my pre-infertility plans to keep the gender a surprise until birth. I just can't deny my heart's volition that I really want to have a baby girl. While I would be happy to have just a baby, as it is our intention to only have one; if we were to have a boy, I certainly wouldn't be disappointed, but I would mourn the loss of a daughter. Where as I don't think I would mourn the loss of a son if we were to have a girl. (Referring to another Bridesmaids quote, maybe I've been tainted by this description: "They're smelly, they're sticky. They say disgusting things, and there is semen everywhere. The other day, I cracked a blanket in half. Do you see where I am going with this? I cracked it in HALF") Seriously, does semen destroy fabric fibers like that? Perhaps that was my strategy behind keeping the gender a secret until the last moment.  How would I feel if we only had male embryos available? Please accept that these are my brutally honest feelings on this subject.

In most other circumstances, making a decision can be assisted by weighing what you have to gain and what you have to lose. In this case, it's not so clear cut. Certainly this adds to the cost of an already expensive endeavor and ups the ante on a gamble already in progress. It may not be necessary; we could get a decent yield of embryos, select a good one and get lucky on our first shot. Although it seems really farfetched and feels rather daft.  At the same time, transferring a euploid embryo doesn't guarantee a successful pregnancy. It only means that if I get a BFN after our transfer, I won't be left wondering if the failure was due to a chromosomally abnormal embryo.

That's my ultimate gain. Regret Management, as Jessah from Dreaming of Dimples describes it. I've been trying to have a baby for nearly two years and I'm not getting any younger. In fact, Husband and I are really getting close to the age of forty. How much longer do we continue before we feel that we're too old and we loose interest? I don't want to wait any longer than we need to. I'm tired of having my life on hold. I feel an obligation to do whatever I can to help improve the outcome. I cringe when I think about what this is costing. I shutter to think how it compares to Myrtle who got her baby girl on her second attempt. It's the price to pay for delays both self inflicted and unexpected. Having a regret-free conscience: priceless.

Sunday, 27 October 2013

The Calm before the Storm

As I've referenced in previous posts, I participate in a lot of 10Ks and the occasional half marathon. Although it would seem logical that the triumph of the finish would be my favourite aspect; but it isn't. What I enjoy most about a race is the final minutes and seconds before the gun sounds. There is an excitement and palpable energy among the other runners. The nervous newbies who are embarking at this distance for the first time. The veterans who are trying for a personal best. The elite runners who are looking for a win. Those returning from an injury who see the finish as a moral victory. A group of women who plan to walk the course, but use the time to chat and catch up with friends. There is a collective calm before the storm...

I went into for my monitoring appointment before starting my stims. "Did you have your blood drawn yet?" my RE asked after greeting me. "Um no." I had the feeling I had done something wrong. "I didn't know I needed to have blood work." We quickly moved to my ultrasound. Ovies are quiet, so we are able to proceed. I had wanted to talk to my RE about CCS testing a bit, but it was his first day back in the office after being out for a few days, and I know how hectic that can be, so I'd have to wait for another day. After getting the go-ahead, I was to meet with Misery to review my medication schedule.

Now I enjoy my sessions with the transvaginal probe as much as the next infertile girl, but what I was most looking forward to at this appointment was getting the details on just what I would be injecting into my body and when. I wasn't expecting a fancy colour coded chart like the one The Infertile Chemist  put together, but I was anticipating something more elaborate than what she handed me. She only wrote out three days, Menopur 150 (no specification) in the AM and 'FSH' 150 (again no specification) in the PM. "I think you're using Gonadal-F?" she asked. You're reviewing my protocol with me and you didn't even check my chart? Awesome. "I can't really give you a start date, since you need to wait until your period is at full flow and then start the next day." I realise that the schedule may change based on how I respond, but I was hoping for more of an overview. It was a Friday, I had been blotting since Wednesday and I just took my last birth control the night before. My period would likely start over the weekend. "So I'm pretty much on my own to determine if I should start my stims this weekend based on if I have a full flow?" I asked to determine if I would qualify for the weekend service now that I'm an IVF patient. "Well, you can call the medication number and leave a message..." her voice trailed off. Yup, I was pretty much on my own to determine when to start.

Porn Buddy came in to draw my blood for an estradiol level (not that anyone had explained to me why I needed to have this done). I hadn't seen her for a while and she now has a trendy new haircut, which looks really cute on her. "Will someone call me with the result?" I asked. "Oh, yes." she affirmed "She [presumably Misery] will call you later today."

I started to bleed a little heavier on Friday night, and by Saturday it was to the point of needing a pantyliner. My flow is pretty light at my baseline, and after nearly two weeks of oral contraceptives the measurement of my endometrial lining was near postmenopausal range. I was pretty sure this was as full flow as it was going to get. I decided to go ahead and start my meds on Sunday as originally outlined. No one called me with my estradiol levels (quel surprise). Reviewing Lesson One: Do not rely on anyone. Yet I wasn't as alone as I thought. Thank you to my fellow bloggers who included details about their protocols and provided some answers to my questions.

It was the calm before the storm and a bit fitting that I ran a 10K the day before I started my stims. The nervous energy is so palpable. There is a mixture of excitement and fear. An acknowledgement that this course will bring both mental and physical pain, but hopefully and ultimately; triumph at the finish line.

Tuesday, 22 October 2013

I'll Never do IVF...

Yes, I uttered those words on a few occasions. The first time I can remember was when I was 25 or 26. You see, I knew it all at that age and I had the answer to everything. I mean, why couldn't these couples just adopt any of the millions of children out there who need homes, rather than creating more babies into an already over populated planet. Especially when IVF treatments just produced a litter of multiple births, who would be born premature and consume massive sums of health care and later special education resources.

Oh, I was so naive then. I thought the adoption process was as easy as merely saying the magic words "just adopt!" and with a touch of the wand from your fairy godmother, the stork brings a baby to your doorstep! (In a relatively quick and inexpensive fashion too). As none of my friends were trying to start a family at that age, I didn't know anyone who was infertile or had gone through IVF, I was biased by the stories of high order IVF multiples sensationalised on the news. As I was working in an inner city clinic, most of my patients presented with issues related to undesired fertility. If we did encounter clients seeking an infertility work-up, there was little we could offer, as no services are covered under Medicaid.

Fortunately, the one bonus of growing older, is that you do become a bit wiser. Other work assignments and other life experiences would shed some light on issues relating to infertility, assisted reproduction and adoption for me. Yet, when we first discovered that we were infertile, there was still a hesitation to do IVF. I don't think it was much about indulging my 25 or 26 year old bratty former self. There were concerns that we are essentially gambling with a large sum of money. We are defying the natural order of science, and in doing so, may discover that there was an underlying reason why our DNA was not meant to splice. No matter how many times I tell myself that we could have a developmentally delayed or autistic child from a natural conception, one conceived from assisted reproduction just brings an extra layer of guilt.

After our first consultation with Dr Somebody I used to Know, Husband proclaimed that he knew we would eventually need to do IVF. I wasn't ready to confront that notion just yet. We often expressed that we sometimes wished for a more clear cut indication, like a tubal factor and IVF would be our only option. If we hadn't had that glimmer of hope with our natural conception, I think we would have move on to IVF a lot sooner. A few studies have demonstrated that couples who start with IVF get pregnant sooner and spend less money. As we were starting our final IUI cycle, I started to wonder if any of those couples kiss their baby good night and ask, "should we have tried to conceive naturally or used less invasive methods longer before going to IVF?"

It's become another incidence of hearing the echoes of my own counseling. Often when I discuss various options with patients, I'll hear 'well, I always said that I would never ________'. I remind them that it's always so easy to pronounce your intentions when it is a hypothetical. It's a different reality when you find yourself in a situation you did not anticipate.   I never thought I'd be here.

Nor that I would go through everything I did to get here. I needed my maternal instincts to finally kick in to gear. I needed to discover what elation I would feel at the sight of a positive pregnancy test. I needed to experience the devastation brought by a spot of blood.  I needed to get my uterine septum resected. I needed to live through the false promise of progesterone symptoms and the profound disappointment from IUI#4's BFN. I needed to hear my RE say that we shouldn't wait any longer. I needed to experience it all to be ready to proceed with IVF.

Obligatory Photo of Meds
Once you conceptually accept the need and the plan for IVF, you still need to embrace the reality that shows up on your front doorstep in the form of the big box of meds. So this is how it is going to be... this is how it happens... As I checked off the items in my order, it truly felt like a science project. I thought back to when Husband and I were on the market for our house. Like all House Hunters and Property Virgins, we became addicted to HGTV. We would make fun of the couples who would walk into a house and reject it as they didn't like the carpet or the wallpaper. They could only see what was in front of them and lacked the vision to see the potential.

I need to look at these boxes of med and sharps container as becoming boxes of diapers and cans of formula. I need to look at these syringes and see baby bottles. I need to look at my schedule of meds and see a calendar of soccer practices and dance recitals. I need to look at this process and see our baby at the end.

Monday, 21 October 2013

Oh, the Things I Know!

I previously described that if I were to offer any advice to a fellow infertile who is just starting her treatments, it would be 'Expect Delays'. I can appreciate that everyone's situation with infertility is different and each person will have a unique experience, but delays seem to be a common thread for almost all who travel down this road. I now feel that I can add some additional words of wisdom.

I called Freedom Fertility to set up my medication order more than three weeks before I was set to start my stims. My insurance company has an alliance with Freedom Fertility. While ordering the Ovidrel for my IUI cycles, I found them to be reliable with good customer service. After we finished reviewing the list, the agent offered that she would arrange for the big box to arrive two days before S-day (which is a Sunday). I could only imagine discovering on a Friday that an incorrect med was shipped. I felt as if I had to negotiate with her to have them delivered on Tuesday. I informed the agent that my insurance covers 50% of the costs of my prescription medications, but they require prior authorisation. "No problem." she said with a cheery tone. "I'll send this off to our insurance department, and I'll have someone call you on Monday before we ship your order to review the final details."

I switched my phone onto vibrate and kept it in my pocket all day. I felt like such a dork; getting excited for a phone call, but this was the phone call that would bring my big box of meds. Alas, the 'Unknown Caller' rang. "Hi!" another cheery woman greeted me. "I noted that your insurance company will pay for half of your meds, but we need authorisation. We'll go ahead and get that processed for you ASAP!" I groaned silently. This should have been already sorted. I would have thought two weeks would have been enough time to place a phone call or fax a form to get the authorisation.
Lesson One: Do not rely on anyone. To do anything for you. Ever. 

I couldn't disguise my disappointment. "I'm terribly sorry" the agent apologised profusely. "I don't see those instructions anywhere in the notes. Do you remember with whom you spoke?"
"Um, I think it was Daphne. Or Delores?"...something that began with a D?
Lesson Two: Always take note of names
Lesson Three: Consider informing the customer service agent that you are recording the conversation for 'quality assurance'

I knew it wasn't worth getting too upset. After all, "Stacey" assured me that I would receive my order this week. I felt validated that I bargained for the 'oh shit' time, but I was annoyed with myself that I hadn't followed up last week.  I was still in the situation I wanted to avoid; waiting for the meds to arrive at the end of the week and hoping for an accurate order. I glanced at my Google calendar. I had noted "meds arrive" on Tuesday. I was looking forward to that big box arriving in the way I anticipate receiving a package from my parents or Myrtle around Christmas or my birthday. It was a good time to remind myself that I shouldn't get attached to any particular dates, and that every step of this process requires flexibility. I'm not as savvy as I thought. I need someone wiser to tell me to expect delays.

In the interest of full disclosure, someone did come through for me. I sent an email to Misery asking if she would call the prescription for Medrol into my local pharmacy. I found that even at full cost, they had better pricing than Freedom Fertility and my insurance might even cover it, since it's not exclusively used for infertility. I should also mention here that Misery has been much less... well, miserable. I thought about assigning her a different name, but I like to think that first impressions have consequences. As the pharmacy is right across from Husband's favourite watering hole (talk about conveniences), I sent him in over the weekend to check on the status. Sure enough, she took care of it. I suppose it would have been nice to have received some confirmation from her, but I shouldn't hold unrealistic expectations. That's Lesson Four.

Saturday, 19 October 2013

You've Got to be Kidding Me!

In The Reflexive Responsive Pregnancy, I described the situation where one fertile discovers that a close friend or relative is pregnant and then decides to get knocked up as well. I referenced a pair of sisters who are both patients in our practice and their first and second born children are exactly three months apart. That is not a coincidence. I closed the post by noting that as soon as Co-worker announced her pregnancy, her SIL declared that they would be trying to conceive soon.

Co-worker's SIL is the type of person who always puts her self at the centre of attention and anything that happens to anyone else, has to be related back to her. It was speculated that while she would be genuinely happy for her brother-in-law and Co-worker, she would be a little miffed that her twins were not the only set of twins in the family. Co-worker decided to stagger the announcement. First disclose her pregnancy and then drop the twins bomb once everyone was safely into the second trimester. I didn't say anything to her; but I thought the plan had disaster written all over it. As Co-worker works in an Ob/Gyn office, she couldn't pull the 'Well, we went into for our NT scan [as the first ultrasound] and they discovered it's twins!' card. Although a normal person, and in particular one who had twins herself, might understand the need to get past the first trimester before announcing; her SIL is not a normal person. Furthermore, Co-worker did complicate the situation by repeatedly lying to the SIL who kept inquiring, "Are you sure you're not having twins?" I suspect Co-worker just wanted to delay dealing with her SIL's petty feelings, but her delay also incited anger and a major fight developed.

Co-worker and her SIL didn't talk for much of her pregnancy, which was actually a huge stress relief for Co-worker. The SIL did attend her baby shower which was the start of a reconciliation. Co-worker commented that in the final weeks before her C/section date, and in the first few weeks after bringing the babies home, the SIL was genuinely really helpful and she seemed like a changed person. "She's still very manipulative..." I warned. Co-worker added that as the SIL gave her many of their old baby supplies, "I truly don't think they'll have any more kids."

Last week I received a text from Co-worker: SIL is pregnant with twins again. Are you FUCKING kidding me??? I wrote back, wondering out loud if she used Clomid to ensure she's have another set of twins. This is totally a copy cat pregnancy! I noted. 'I know!' acknowledged Co-worker, who then added 'Talk about pressure on [her husband] and me!'

You cannot be serious... I thought to myself as I put my phone down. She just cut the cord on her twins five minutes ago. Both sets of parents know they experienced infertility and went through treatments to have those twins. How can she feel any pressure? I don't get it at all. Then again, I'm an only child and I don't understand anything about feeling pressure to keep up with siblings.

Co-worker came into the office a few days later to attend an inservice and gave everyone the full story. Her SIL conceived on their third attempt (her first twins were a one hit wonder). After those three... long... months... they worried that something was wrong when the stick showed only one line. That worry was short lived as a few days later when AF hadn't arrived, a follow up test was positive. She was now eight weeks. I did the maths and worked backward. They must have started trying right after Co-worker's baby shower in June, which also coincides with the time that Co-worker noted a change in her behaviour. The SIL was giving away her old supplies to make room for brand new stuff for her brand new baby (as they can afford it). She conceived just weeks after Co-worker's twins were born.

"Hey! I can't call you Preggers any more!" commented a medical assistant as she walked over to Co-worker and greeted her with a hug. "Well, hopefully again within a year!" responded Co-worker gleefully.

You've got to be kidding me... Apparently I wasn't the only one with this thought as our LVN noted "You don't have enough on your plate already?" My thoughts more reflected the fact that experiencing infertility for over a year and scoring on the third and final IUI attempt wouldn't make her think twice before broadcasting her procreation intentions... Or maybe discourage her from talking about adding to her brood in front of her friend who may not ever have one. I don't necessarily expect her to have ** radar... but seriously, I was standing right behind her.

In all honesty, I wasn't surprised. Co-worker's family plans were to have at least three, possibly four kids. Her RE commented that her ovaries responded as if they were much older than her chronological age, so I'm sure Co-worker doesn't want to waste any time. I started to wonder if they would jump to injectable IUI cycles right away. Would it be weird if we were still doing infertility treatments together? Would it be much harder to see her pregnant if my IVF and FETs fail? Would it be like watching her pregnancy after my miscarriage? Is it any easier if I at least feel some what prepared for these scenarios? Seriously, who did I think I was kidding...

Thursday, 17 October 2013

It is Just a Number...

"Have you seen some recent pictures of Karen Carpenter?" my father asked me during his recent visit. "I'm not friends with Karen Carpenter." I informed him haughtily. It amused me that my dad is Facebook friends with many of my old friends, and he seems to converse with them more than he does with me. "Well, she's really into yoga and she looks great!" he commented.

Karen was a fair weather person who was only my friend when she wanted something from me during our middle and early high school years. As she was charismatic and skillfully manipulative, I let her get away with it. She was crass and boorish. She would discuss details about going out or getting together with a group, while letting me know that I wasn't invited. When I would call or visit her on her birthday (which fell during summer vacation) she would whine that no one (presumably no one more important or cooler than me) had acknowledged her special day. Two events knocked her down a few pegs. She developed a seizure disorder before our senior year and she gained a lot of weight from her meds. Although she was very smart and was in Honours classes, she barely graduated and was not accepted into a good University.

After we graduated, she finally apologised for being a shitty friend. It was too late, I had moved on and wasn't interested in her any more. She picked up my phone number from a roster for our 10 year reunion and called me out of the blue one day. We chatted for a while and she suggested we get together some time. "Sounds good," I agreed without any intention to follow through. A few more years passed and she found me on Facebook. I declined her friend request, and noted that she looked exactly the same as she did when we graduated -still rather plump. A mutual friend ran into her three or four years ago and reported that she had been living with some guy who had been unemployed for over three years. I noted to myself that Karen would probably be attached to a guy without a job in a good economy...

Curiosity would get the best of me, and a few weeks later I looked her up through my father's Facebook page. I gasped in horror when I saw her photo. The bony arms and prominent clavicles revealed her anorexia. She looks like shit. At first glance, she resembles a gawky teenager. It appears as if she is barely developing breast buds underneath her yoga top. I thought back to when we were young and she was teasing me about being flat chested. "I've got a big ol' bust" she bragged. As you have a big ol' everything else... I thought to myself. I considered explaining that if you were to plot bra size against body weight, there would be a linear relationship and the slope of the line would be represented by your original breast size. However, as she was failing our maths class, I'm sure the concept would be lost on her. Now it was apparent that her original size is barely a slope.

Her face told a sadder story. Her cheeks were sunken and wrinkles were prominent. Husband commented that she looks ten years older than her stated age and in the words that only he can use; "She looked better fat!" He exclaimed after looking though some older photos.  It was the reality check I needed as I've been increasing my workouts and meticulous counting every calorie that passes my lips on MyFitnessPal. While I'm still frustrated that my weight is stuck at 153 pounds; it is just a number. I look athletic. I look strong. Most of all... I look healthy.

Monday, 14 October 2013

I'm One of Them.

"So, can I still pole dance while I'm pregnant?"

I had never been asked that particular question before, and I had no idea how to answer it. As I started to wrack my brain to contemplate some modifications for pole dancing; I recalled she mentioned that the establishment of her employment is both a strip club and restaurant, and I suggested that she might ask her manager about letting her work as a server or hostess. I thought about recommending that she consider finding work outside of the adult entertainment industry, but it might come across as judgmental. I know the reality for young women with a GED certification. She can earn a better living by stripping than by working in food service.

I spoke to our LVN after she met with her to share our thoughts. "Who knows?" she admitted. "Maybe this baby will be the catalyst that encourages her to get her life together, or maybe she won't go through with it." I concurred. The LVN exchanged some emails with her and made some follow up calls. She gave me a report a few weeks later. "I'm not so sure about her" she commented. "She still hasn't signed up for MediCal and thus hasn't done any of her blood work. She missed her window for genetic screening. She hasn't registered with the Methadone clinic and she gives you every excuse in the book. It isn't registering that she needs to take some responsibility." She sighed. "It's just such a shame. So many women out there who are longing for a baby and they can't get pregnant..."

I'm one of them... I had long accepted my membership into the infertility club, but I hadn't really thought about how the rest of the world views infertiles. There seems to be a notion that we are more deserving. That we are more suitable as parents. That we carry a hint of desperation. For the most part, we seem to be granted sympathy, but perhaps others see us as being bitter or resentful.

A few days later, I had a new patient on my schedule. I looked at the demographics. She lives in the northern part of our state and had a nearly ninety minute drive. Without reading any of the notes in the visit comments, I knew why she was coming to see me. At the young age of 24, she was pregnant for the fifth time and she already had two young children. "After my second pregnancy, they gave me a 'mini-dose pill' and I got pregnant on that. Then they gave me a 'low dose' pill and here I am again. Maybe someone will finally realise that 'low dose' stuff doesn't work for me." I felt badly for her. She's burdened by her fertility and has been somewhat misguided in her attempts to prevent an unplanned pregnancy. "It's so unfair" she commented "why do I get pregnant, while there are so many women who try so hard to have a baby..."

I'm one of them... 

Friday, 11 October 2013

The Grief that Can't be Spoken

When I attended the infertility conference last year, I was looking forward to a lecture from a lawyer on ethics. I was hoping the speaker would touch upon the American Society for Reproductive Medicine (ASRM) guidelines regarding when to withhold infertility treatments as I've seen some questionable cases and have been involved in some difficult situations myself (topic for another post). Instead, she spoke about the Pandora's box that has been opened with IVF and embryo storage with regard to posthumous parenting.

Her talk was a bit in contrast to a previous lecture, which advocated for fertility preservation in young men and women who are diagnosed with cancer. She mentioned some cases from her files where parents of cancer stricken teenagers were seeking cryopreservation, or other situations where patients had a very poor prognosis and would not likely survive past the birth. "Are we creating babies to extend our grief?" she asked, as she noted that her role is to determine, who will be the intended parents and who will benefit from a posthumous procreation.

She referenced another case that she thought was very straight forward, but contained a strange twist. A couple was in-between FET attempts when the husband died in a tragic accident. The widow tried to proceed with her transfer, but was blocked by an injunction from her in-laws. They presented emails from their deceased son who confessed that he no longer wanted to have a baby and was considering seeking a divorce. (Furthermore, they suspected that his accidental death was actually a suicide) As the embryo storage facility did not have a specific consent form addressing the situation of one partner's death, a judge ruled in favour of the in-laws.

Our first steps to start the IVF process began by confronting our mortality with the storage facility consent forms. I remember during the five minutes of my pregnancy, Husband started talking about creating our advanced directives and a living will to appoint a guardian for our progeny. I stopped the conversation, not that I was any more reluctant to discuss end of life issues than the next person, but I didn't want to get ahead of ourselves before our first ultrasound. I sent a text to Co-worker, "So...Odd request: Can we designate you as our person to notify the embryo storage facility in the event that Husband and I die?" She replied, "Of course. Is it odd that I'm honoured that you chose me?"

As I'm the type of person who likes to introduce a little levity during serious situations, I recalled a rather humourous post from Yeah, Science!. As her clinic required her and her husband to declare their intentions with his sperm in the event of a death, divorce or natural disaster during the window of time between dropping off the sample and the IUI procedure, she asked;  "WHAT KIND OF APOCALYPTIC SHIT IS TAKING PLACE IN THE 10-MINUTE DRIVE BETWEEN OUR HOUSE AND THE CLINIC??" It gave me pause to laugh as we completed our forms. The next day I was reminded just how serious and real these situations are. I was attending a meeting at the hospital when I learned of a young woman who suffered a traumatic brain injury in a freak accident. She had given birth to her firstborn just a few months earlier.

It's the grief that can't be spoken. A young man is suddenly a widower and a single father. Parents angrily lamenting that you're not supposed to bury your children. A sweet baby who will only know of her mother through pictures and stories from the many people who loved her. Their pain is unrelenting. As she had noted her intentions to be an organ and tissue donor on her driver's license, her family was able to honour her last request. She gave the gift of sight to someone who is blind. Her kidneys freed two others from dialysis treatments. Her lungs gave breaths to two individuals affected with chronic airway diseases. Her skin will be grafted to help burn victims start their long healing process. Perhaps it's the only possible measure of solace. The only way to grasp any understanding from such a senseless tragedy.

The embryo storage consents are only one step and they only address one aspect. It's time to have the conversation, and then to put the words on paper and get it notarised. This shit is real.

Wednesday, 9 October 2013

Skeletons in my Closet

Of all the story-lines on Sex and the City that received critical acclaim, I don't think the ones that addressed Charlotte's infertility were given enough credit. Of course my perspective has changed so much since I first watched those episodes. As I worked with women who were facing unplanned pregnancies, I could appreciate Miranda's annoyance with Charlotte's resentment. Now I can appreciate those clips through Charlotte's eyes. Your friend falls pregnant effortlessly while you learn your only option is with sophisticated scientific intervention. Putting on the brave face and smiling at a baby's first birthday party after your own pregnancy resulted in a miscarriage. I had no idea that those would become my experiences.

As we prepared for the in-law invasion, Husband and I went through the house room by room to clean every corner and to purge anything procreation and infertility related. I packed the items into a box and stashed it under the sink in my bathroom, which I felt would be safe from my mother's curious eye. (Although, I did consider placing it in our safe...) It reminded me of the scene where Charlotte paints over the mural in the room intended to be a nursery. I felt that by hiding these items, I was denying an aspect of myself.

Fortunately, I've become proficient in playing the role of a woman who doesn't want children. During their stay, neither my mother, nor my mother-in-law approached the subject with me. My mother caught a glimpse of Co-worker's twins on my Facebook page and started fawning over them, which I thought might lead her to ask some questions, but perhaps I changed the subject in time. Prior to her arrival, I feared we might have a moment where it would feel right to confess our infertility struggles. That opportunity never presented, and thus my skeletons remained buried in my bathroom cabinet.

My friend H and I once discussed that the maximum duration to be a guest or to have house guests is four days, five tops. Sharing close quarters and surrendering your private space only leads to tension. Unfortunately, the trade off for living so far away from your family is that their visits are for extended lengths of time... and too often violates the four to five day rule. Such would be the case, as my mother and I broke into a fight only hours before her flight was scheduled to depart.

We reconciled before it was time to say goodbye, but I realised that we've been having the same argument for years.  She feels that she doesn't know what to say or how to talk to me, but she desperately wants to have a relationship with me. As I still value her approval, I'm sensitive to anything she says that resembles criticism, which often makes it hard to talk with her. I thought back to the night before the BFN from IUI#4 and how we imagined announcing the pregnancy to our parents in Hawaii.

Of all the potential joys that such a moment would have produced, perhaps the one I was most anticipating was opening up to my mother. I could finally reveal how hard it was to host Myrtle's shower and to hear everyone call her baby 'little Myrtlepants'. We could share a laugh over all the stupid things Myrtle has said to me. Now I wonder if that is just another fantasy. I'm banking on the fact that her elation would eclipse any hurt feelings that I didn't confide in her earlier. That she would understand that I needed to avoid any additional pressures and that it wasn't personal? What if we were informing her that our quest came up empty? Would my secrecy only serve to confound her disappointment?

As I pondered these issues even further, I have to ask myself if, like a dysfunctional couple, am I hoping that a baby can improve relations with my mother? That this is the final thing I need to do to secure her approval -grant her wish of being a grandmother. I've long accepted that we are trying to procreate for our own desires, not our parents, but we can't avoid considering how they will be affected. I can't deny how much this means to them. I like to think that if we have a baby, it will bring my mother and I closer together, but it can't fix the deficits in our relationship, and it will bring much more tension and arguments. Perhaps starting with disclosing our fertility struggles...

Sunday, 6 October 2013

Observations from my Summer Vacation (Part One)

Going on holiday is hard work and almost makes you wonder if it is worth the hassle. I was working 11 hour days trying to get caught up with current tasks while arranging for coverage while I was away.  I am dreading the mountain of work that will be waiting for me, and I considered logging on with remote access, but once you break that vacation barrier, there's no turning back...

I am too old to be taking a vacation with my parents. I used the restroom a final time before we boarded the plane. When I returned (in front of everyone) my mother asked if I washed my hands. As the Dyson air-blade hand dryer didn't completely dry my hands, I wiped the remaining moisture on her back to prove that I did. Treat me like a child, and you reduce me to act like one...

If we had known that my in-laws were really going to come along on this trip, I think we would have opted to go to Maui rather than Kauai. As adventure based activities are so prevalent on this island, it's hard to accommodate two people who struggle just to get in and out of the hired Dodge Caravan.

My cousin's soon to be ex-husband accompanied her for this trip. They had booked their flights and he arranged his time off before they agreed to proceed with their divorce. As we've come to get to know him over the past few years, we've regarding him as family, and it felt awkward to wonder if this was our last time seeing him.

To my surprise, my father became my swim buddy as we swam at three different beaches. Some of my favourite memories include snorkeling with him at Tunnels Beach and watching him and my mother frolic in the waves at Wai'oli Beach Park

As Myrtle's father raises chickens... he would really love this island!

The difference in time zones worked in my favour. I sneaked out of the condo just after 6 AM and sat here to review my protocol with Misery and to order my meds from Freedom Fertility. Will start with OCPs, then Medrol, Gonadal-F, Menopur (yay Nun pee!) Ganarelix, Novarel or Pregnyl, P-in-oil, Vaginal P4 suppositories and some Estrace for good measure...

We did manage to have coitus. Once.

My 31 year old male cousin is dating a girl who was born in 1991. Let that sink in for a moment. I qualified for the state championship gymnastics meet that year, and out of nostalgia, I kept the shirt from that meet. Yes, I have a shirt that is older than her.

Continued on the previous post

Observations from my Summer Vacation (Part Two)

Husband and I observed our anniversary during the trip, but we were quiet about it with respect to the fact that my cousin is in the process of a divorce. I wonder it if would have been hard for her if IUI#4 were successful and we were announcing a pregnancy. Then again, maybe neither event would have bothered her much.

Swimming ~20 metres of butterfly in the ocean is pure bliss.

My father picked up this Hello Kitty doll at the Foodland supermarket (I loved HK as a little girl and currently I have her on my iPhone cover). We took turns posing her in various situations around the condo; tucked into bed...sitting by the coffee maker, holding a toothbrush next to the bathroom sink... I enjoy the fact that we can still engage in silly antics.     

My mother sometimes still speaks to me in a patronizing, condescending tone with a know-it-all attitude. As she walked away in a huff after I didn't follow her recommendation for cutting an avocado... I can only imagine the power struggles that will ensue if I do have a child...
On the last full day of our holiday, I discovered that I forgot to take any of the prenatal vitamins I had stashed in my suitcase. I scarfed them down over the next two days.

Sleeping on a pull-out sofa bed for a week is the best way to appreciate going back home.

Other Notable Observations:
The strong bond between Husband and my father
The love between my mother and her sister. 
Although they're both in their sixties, my aunt looks still up to her older sister and my mother adores her baby sister
Catching my Father-in-Law laugh or seeing my Mother-in-Law smile
Although they are divorcing, it is apparent that  my cousin and her soon to be ex-husband still care for each other
My mother still looks really good at the age of 64, which make me hopeful! 
Discovering that my hard-nosed retired Police Sargent uncle has several pictures of his cats on his iPhone.
My younger cousin seems happy with his much younger girlfriend 
Husband and I acknowledging that if we can survive seven years of marriage, two years of infertility and a holiday with both our families, we are ready to face IVF and what ever it may bring...

Thursday, 3 October 2013

Don't Whistle in an Elevator

"Don't whistle in an elevator" were the words of wisdom Willy Loman offered his son Biff prior to his interview. I believe Arthur Miller's intention was to emphasize how you never know when you are being watched and to remember that you are always making an impression. It seems even more salient in the modern world where almost everything and everyone is connected through the internet. Yet, on a smaller scale, my 'don't whistle in an elevator' moment occurs every time I walk into my RE's waiting room. I seek out a chair in the far corner and bury my face in my book, but I can't help to glance at some of the other women and wonder if any of them were a patient of mine at one time, or if they intend to seek care at our practice if they do become pregnant.

To my knowledge, we've had two mutual patients. I inherited one patient from a colleague who transferred to a different office. She had classic PCOS and my colleague was giving her a trial of Clomid for 3-4 cycles before referring to an REI. After the fourth cycle was unsuccessful, she sent me an email asking for a referral to my RE' office, as he participated with her insurance. I carefully drafted and signed her referral letter (which was not awkward at all...) and noted to myself that I hadn't actually met her in person. All our correspondence was by email. I had no idea what she looked like, and unless she looked up my on-line profile, she wouldn't recognise me. Fortunately for her, she started her third and successful IUI cycle just after I was in the office for my miscarriage.

At the end of last year, I saw another mutual patient for her annual GYN exam. She revealed that her primary care provider referred her to an RE after her husband's workup confirmed male factor issues. Curious, I looked into the computer database, and discovered that she had been referred to my RE. I was still fueled with the 'at least you can get pregnant' optimism and thought I'd either be pregnant soon, or maybe she wouldn't have too much recall after meeting me only once. However, she's had a few other GYN related issues and I've seen her a few times this year. Recently, I asked her how things were going with her treatments. "We did two IUIs that didn't work and we're saving up for IVF" she informed. Then she added "We didn't like the doctor, so we won't be going back there."

I have to confess my first thought was a sense of relief. One less potential encounter. I also have to confess that I wasn't too surprised. Perhaps it's easier for me to navigate his personality, but I can definitely see how he could rub someone the wrong way. Immaturely, I felt a little smug. Although he's brilliant and highly educated, he failed to connect with this patient.

At the end of each day, I always try to look ahead at my schedule for the next day to familiarize myself with the patient load. I came across a name that looked really familiar, although she was entered as a new patient. I ran her name through the database, just to see if there was another account for her. Nope, she had no prior visits to our office. I walked in and introduced myself. She looked vaguely familiar, but I didn't have any immediate recall. Then I looked through her patient history questionnaire. She listed 'Wax Specialist' as her occupation. "Do you work at the salon in town?" I asked, as she nodded. Bingo! That was it. She waxed my bits on at least one or two occasions. I started to wonder if she was the one I informed that my waxing appointments are scheduled in accordance with my infertility treatments. It was a little un-nerving to acknowledge that she is perhaps my only patient who has seen my hoo-ha, but as she didn't seem to indicate that she recognized me during the visit (or was being very professional) I guess all her clients and the many VGs all blend together.

Out of sheer curiosity, I logged into my online profile through the salon's website and looked through my service history. I had seen her on two occasions, and she was the one who offered 'Congratulations!' when I informed her about my infertility treatments. Thus, although you never know when someone may be watching you, it doesn't necessarily mean they're paying attention.