Thursday, 27 February 2014

How did she get pregnant?

It's the infertility Riddle of the Sphinx: why is it that so many women who aren't seeking a pregnancy, are able to conceive easily, unexpectedly and sometimes often, while others struggle with infertility?The answer is simple: they are fertile. We are not. Of course the larger question is why are they fertile at times when they can't appreciate it and why are we infertile? The only thing I can come up with is that life is unfair. Life is unfair in many ways.

There is a patient in our practice named Mary. She has been dealt some tough cards in her life and at times she seems like she's making strides to get her life in order, but her efforts often fall short. She's also smart enough to know how to manipulate the system and she can be a bit vindictive at times. I first met her about four years ago. She had a daughter five or six years ago and then seemed to have an annual abortion. As she hadn't had a period in months and felt nauseated, she suspected she was pregnant once again. Her pregnancy test in the office was negative, but as I noted that she seemed jittery and her heart rate was elevated, I ordered a thyroid panel. Her depressed TSH confirmed she had hyperthyroidism and I referred her to an endocrinologist who diagnosed Graves Disease. Fearing that she would gain with with treatment, Mary refused to take any medication.

A year and a half later, I saw Mary for an urgent visit. She called in complaining of pelvic pain and the front desk receptionist commented that she didn't look well. Her exam was suspicious for pelvic inflammatory disease (PID). An ultrasound noted the presence of bilateral hydrosalpinx. Concerned about the possibility of a tubo-ovarian abscess, she was admitted to the infusion unit for IV antibiotics. I spoke with my colleague who was on call for the weekend, he hoped she would respond, as he didn't want to perform a salpingectomy on a woman in her mid-twenties, but he also commented that she probably already has tubal factors present. Mary improved and was doing well when I saw her for a follow up two weeks later. However, she was back in the ER a month's time and was admitted for PID treatment again when her tests came up with the Gonorrhoea/Chlamydia daily double.

She kept coming back into the office for recurrent pelvic pain, likely residual adhesions from her recent bouts of PID. My colleague decided to perform a diagnostic laparoscopy to evaluate. However her procedure was cancelled when her pre-operative pregnancy test was positive. How? I asked my colleague. How is this possible? I noted that I wasn't asking as I felt I am more deserving or entitled. It was only a week or so after an au natural cycle where I thought I had implantation cramping and was especially devastated with AF's arrival. It was also a week before we learned the results of Husband's semen analysis. I clarified; I was asking HOW in the name of SCIENCE did she get pregnant?

My colleague just laughed and admitted that she couldn't explain it either. She reported that Mary herself was quite surprised. Oblivious to her own challenges, she thought her male partner was sterile as he was in his mid-thirties and had gotten anyone pregnant (to his knowledge). Mary has repeatedly declined any birth control methods as she describes that doesn't consider herself to be very sexually active (although there is evidence to the contrary; unless she selects really fertile and toxic bachelors). I was desperately trying to wrap my head around it. How? Hyperthyroidism increases sex hormone binding globulins which raises estrogen and LH levels and suppresses ovulation. What are the odds that she would engage in an infrequent act of coitus on the rare event of her ovulation?  How? The quick administration of strong antibiotics must have appropriately treated her PID and preserved the patency of her fallopian tubes. Studies have noted that even  subclinical infections can be severe enough to produce significant sequelae.

She had two episodes of clinically significant PID in a span of four months. I emphasize there is a distinction between true PID and presumed PID. I've noticed that many women who present to the emergency room with pelvic pain will be treated for PID as a diagnosis of exclusion. As the consequences of untreated infections are so significant in terms of fertility preservation, there has been a trend towards over-diagnosis and perhaps unnecessary treatment precautions. I once had to reassure a tearful virginal patient who had been diagnosed with PID in the ER that she was not going to be sterile from an immaculate case of VD, although non sexually transmitted bacterium can cause endometritis. There wasn't anything presumptive about Mary's presentation. She had the real deal. Twice.

Fast forward one year. It was the end of the two week wait after IUI#2. I was really optimistic that it may have worked. I had a good sized follicle and a decent endometrial lining. Husband had his first ever semen analysis where his total count was in the normal range -above twenty million. 8 million were selected for insemination. My RE had reported that 5-10 million was ideal; counts greater than 10 million don't necessarily have higher pregnancy rates. Yet, it was to no avail. My test was negative and I started cramping as I drove to work, indicating that AF's impending arrival would punctuate the BFN. I logged into our EMR and took a look at my schedule. There was an addition since I reviewed it before leaving the night before. It was Mary's name and she was coming in for an unplanned pregnancy consult. Oh Universe, you just really know how to rub it in my face...

It turned out to be a very busy morning and I barely had time to process the disappointment of my failed second cycle or the unfairness of Mary's unwanted fertility. I was finishing up with a patient when my medical assistant interrupted me to announce that Mary's pregnancy test was negative. I had her run another one, and for the second time that morning I was confronted with a solitary pink line and not a hint of blue. Mary was in disbelief and insisted that I do an ultrasound. Her uterus was as empty as mine. Her negative beta would preclude the possibility of an early pregnancy. Once again, I discussed the incidence of amenorrhea due to hyperthyroidism. Once again, I reviewed the dangers of untreated Graves' disease. Once again, I strongly advocated using an effective method of birth control as well as barrier protection. Once again, I suspect it all fell on deaf ears.

I had a smug sense of satisfaction. I felt as if science had prevailed. My world made sense. This was a win-win, as Mary did not want to be pregnant at this time. I wondered how long her luck would hold out, and I fear that someday she may want to become pregnant and will discover that fertility is not hers to command. As I called my RE to report my BFN and to schedule my baseline CD2 scan to start my next IUI cycle, I felt reminded that I will see many more cases that seem to defy scientific expectations. At least at that moment,  I felt that science was on my side.

Monday, 24 February 2014

It will happen...

I feel fortunate that some of our IRL friends maintain a respectful distance with regard to our infertility treatments. They check in to ask how we're doing, but don't ask for specific details. They figure we'll announce when we have news to tell. Recently, we went out to dinner with our child free by choice friends H+B and I gave them an update about our FET. She responded by saying, "We're really hoping that this works for you guys, but if it doesn't; life is still really good on our side..."

I really appreciated her honesty, and I was thankful for her willingness to address the reality that this may not work. It was also an encouraging reminder that we will be okay. Most of all, I preferred her words to the alternative; it will happen!

It will happen. Another cringe inducing phrase for infertiles. I once had someone tell me that it's not just a fluffy sentiment, friends really mean that it will happen. I do appreciate their underlying intention. What they actually mean is 'I WISH it will happen,' or 'I WANT this to happen for you'. No, they do not truly know if it will happen or not. Seriously, if anyone has the ability to see into the future, he or she may want to check out some winning Powerball numbers, rather than my uterus.

The other annoyance of the 'it will happen' platitude is that it can be dismissive, which is a bit insensitive. A fellow blogger once described that others figure if they tell us what we want to hear, we'll shut up and stop talking about this infertility stuff that makes them feel uncomfortable. It's not really what we want to hear at all. Such a statement is akin to the proverbial ostrich with its head in the sand.  It fosters a denial of reality, which is not necessarily helpful. The echos of such words only invoke more pain if it doesn't happen. If you go out on the limb with such a promise, there is a steep fall when the bough breaks.

Thursday, 20 February 2014

The Allure of Something Better

There have been some moments in my life that I wish I could do over. I keep thinking back to when I was sitting in my RE's office after he projected that the retrieval would only yield 6-8 mature eggs. Actually going back a little further, I wished I had asked more specific questions about what they were looking for with my estrogen levels. I knew it was a function of how my ovaries were responding to the stimulation, but I would have felt less blindsided if I had known that the peak levels (~1500) correspond to 200 points per mature follicle. I felt such an overwhelming sensation of doom. My RE grew quiet as he was studying my chart. This led to a long silence and very awkward pause. I was tempted to ask what he was thinking, but at the same moment, I was too afraid to hear the answer.

I know what I was thinking at that time. I was wondering if we should cancel the retrieval; even as I acknowledge that does sound a bit ridiculous as 6-8 mature eggs is a workable yield.  I was hoping that he would find a few hidden eggs during the retrieval. Maybe we would discover that none of the eggs would fertilise or progress into decent embryos and thus, we shouldn't waste any more resources in a second cycle. Of course, I was also hoping that we could get at least one good embryo that would come home as our baby. We just want one. We only want one. I never asked the question about cancelling. I figured my RE would reply that it was my prerogative, but it would be reasonable to proceed with the retrieval. We would have been out for the cost of meds and the monitoring, so roughly $4K for a mock stimulation cycle. I also feared that we could cancel, repeat a stim cycle and produce the same number of eggs or less, thus wasting more time and money. However, after hearing my RE discuss that there is room to adjust my protocol to generate better quality with my eggs (although I question if that is something they say to all patients repeating a fresh cycle). I now feel tempted to ask if he had any thoughts about suggesting cancelation.

New Girl shared some of my RE's notes with me at the start of my stimming. He was anticipating a possible over-response and was tentatively planning to trigger with Lupron. Knowing that it was forecasted that I could be a hyper-responder, it really resonates that I came up short. Personally, I think he had too many expectations from my ovaries and was a bit too cautious. As I had to hold and decrease my Menopur, I can't help to wonder if it would be a better strategy to start off on a lower doses and increase as we progress. I started fighting back tears as soon as I heard "6 to 8 mature eggs" as I felt I could predict everything that would happen next. Maybe half would fertilise, not enough to make it worth doing PGD testing. Need to do a desperation day 3 transfer. Discover on pathology report that the embryo was abnormal. Wash, rinse, repeat if desired with another fresh stimming cycle. The little voice inside my head is giving me so much flack. If I knew then that we would need to try to do better with a second cycle, why not proceed with it? Does anyone know the formula for ovarian aging? Is it like dog years, where six months could translate to two years?

The one unexpected variable was the two fro-yos that resulted from our first retrieval. Although, I've been regarding that we only have one, as the other barely met criteria for freezing. Even as I was receiving the beta results confirming that a pregnancy resulted from my day 3 transfer, I had regrets about not holding out to see if any embryos made it to day 5. Not only because I had compromised on the number to transfer and could potentially be pregnant with twins, but I felt that we missed an opportunity to use a higher quality embryo. As it turned out, I was right. Although I don't know for sure if our good looking blastocyst is euploid, hindsight confirms that we should have waited (and done the PGD testing). I'm truly glad the pregnancy ended as early as it did, as I wondered how much longer if would have thought about that other embryo if the pregnancy progressed. While we were holding our baby? Watching him or her grow into an active little toddler? Would my mind ever flash to the thought -I wonder how the other embryos would have faired?

Perhaps it's just my inner perfectionist. Always seeking to improve upon my previous effort. I'm falling into the allure of something better. The promise that the grass is greener in another pasture. If a fresh retrieval didn't have the pesky $20 K price tag, I'd start mixing the Menopur straight away. Thus, I've been trying to fight my initial skepticism and find some faith for this embryo.  Yet at the same time, I feel sustained by the belief that if this transfer is not meant to be, something better is waiting for us.

I went in for a visit on CD9. Dr Somebody that I Used to Know had recovered from the bug. I was a little concerned about how the patches would hold up with my swimming and running activities, but they seem to be doing their job as my lining was 10.7 mm. "Beautiful" my RE described, and it was, even if I say so myself. My progesterone level was 0.3, so my transfer has been scheduled in about two weeks. New Girl left me a voice mail confirming the day, but reported they won't know the exact time until a day or two before. When the date was still tentative, I had our office administrator hold any open appointments with a note 'provider may be out'. Recalling the experience from my last transfer, when I unexpectedly learned that we needed to do a transfer while I had three patients waiting in my rooms and an emergent D+C to coordinate...I decided to request to have the entire day off. I may be able to go to the gym, perhaps swim a double session if we're scheduled for the afternoon...Enjoy a leisurely day... At least there will be one aspect that will be better this time around.  

Monday, 17 February 2014

Whatever you're selling... I'm not buying

As many bloggers have described horrific fights with their insurance companies and others have no insurance coverage at all, I feel a bit badly complaining that my insurance is too keen to be helpful. The mere problem is that I don't need their services...

While we were discussing a natural cycle versus medicated FET, I suggested to my RE that transdermal estrogen patches may be a better option for me. In addition to my blood pressure issues, I had an episode of aura a few months ago. Aura is considered to be an absolute contraindication to any form of exogenous estrogen as it increases the risk for stroke. Data on post menopausal hormone replacement therapy has noted a lower thromboembolic risk with transdermal methods versus oral estrogens  (as they avoid the first pass effect of the liver), so I figured it would be a safer alternative and my RE agreed. After five days, my blood pressure has remained normal without medications and I haven't sustained a stroke. So far, so good...

My prescription was written to dispense a supply of twenty patches, which would be enough to get me through my transfer. As I anticipated, the pharmacy tech started explaining that my insurance would only pay for one month at a time. Now, if I were truly smart, the idea would have occurred to me much earlier, so that I could have stockpiled a box of four patches each month with only a $10 co-pay. "That's fine." I informed her that I was prepared to pay for the rest out of pocket. She offered to call my insurance company to see if they could grant an over-ride. Although I had limited coverage for my IUI procedures and meds; Healthnet made it clear that they wanted nothing to do with an IUI loser like me once we started IVF. I thanked her for her offer, but advised her not to waste her time.

Earlier today, I received a call from a representative from Healthnet. My first thought: holy shit! maybe they'll actually cover my transfer meds! Then I realised that I have never received a phone when my insurance has approved anything else...actually, there was only one other time when I received a call from Healthnet... Oh, fuck me, not again... "Congratulations on your pregnancy! We would like to enroll you in our Maternity Mentoring program. When is your due date?"

Maybe I was a little more sensitive from my estrogen patches. Perhaps I was a little tender after recently seeing a patient who was at the same gestational age that I would have been. Regardless of emotions, I was justified to be pissed that for second time, my insurance was offering me enrollment in a prenatal program when I am not pregnant. In a very angry tone, I informed the agent that I had a miscarriage over two months ago. As the representative started to issue an apology that nearly sounded sincere, I was tempted to hang up the call in a huff; but then I decided to do a little investigation.

"That's okay. I understand you are just doing your job. Can you tell me how you received information that I was pregnant?"
"We must have received a referral from your doctor..."
"That's bullshit. I miscarried very early and never made it to an obstetrician's office."
I also know that we never make such referrals to any insurance companies.
"Our computer generates a list of particular diagnoses. For patients who have been diagnosed with diabetes, they would be referred to our diabetes program..."
"So, you picked up that I was pregnant with the diagnosis code from my beta draws."
"I guess so..."
"No one noticed my diagnosis of a 'missed abortion', a CPT code for a D+C, or the fact that there haven't been any claims for prenatal care..."
"No, I don't have any access to your records. I just have your name on a list."
"Approximately one in five women will miscarry. Women may chose to terminate the pregnancy. I can't be the only upset phone call you'll face today..."
"No, you're not."
"Is it possible to opt out of this program? I'm going to be doing an embryo transfer next month, which may or may not work. I could miscarry for the third time. I don't want to be having this conversation again in another three months..."
"No problem. I'll remove your name from our database. If you do become pregnant, it will be your responsibility to enroll yourself in our program."
"That's fine. Thank you."

As I hung up the phone, I tried to determine if it is creepy that my insurance company is trolling through claims looking for certain diagnoses. I suppose it is benevolent that they are offering programs that help their members take steps to better health, but it also seems a little intrusive. I never asked specifically what this maternity mentoring program offered, but I feel I have no need to join. I shared this story with Co-worker, who started to chastise my pessimistic thinking. "Jay-ane... don't say that..." Then she stopped herself. "Oh. You don't need their program as you're already smart..."

Thursday, 13 February 2014

And so it begins...

I finally had a positive ovulation indicator on day 20, which happened to be the day Husband was leaving for a two week trip to the east coast. Ah, ovies, you must have read the calendar wrong; you usually wait until one of us had already left to release the LH surge... Anyway, we realised this was actually our first time since our spontaneous conception over a year ago that we would be actually trying the old fashioned way. In theory, a quickie before leaving for the airport should be fun; but for Husband, the pressure was just too much. Husband is one of those people who needs to arrive at the airport hours before his flight. As long as he can get online, he's content to sit at the airport bar and drink the over priced beer. He has caused confusion at times as he's shown up at the appropriate time window to check his bags for an earlier flight... In contrast, I once finished going through security just as it was time to start boarding my international flight, and I stopped to get some trail mix as I walked to my gate. (I love airport trail mix...)

Previously, I would have felt disappointed to have missed an opportunity. We turned to assisted reproduction as we really sucked at TTC; but oh yeah, we suck at IVF too... A mediocre IVF cycle offers so much perspective. Spontaneous conception now seems like a fairy tale. As if a touch of a magic wand could turn our gametes into a viable embryo. At least for a short while I was able to feel like Cinderella at the ball. Until the clock struck six weeks and the pumpkin carriage turned back into an empty uterus. If a highly skilled embryologist could only generate one decent embryo from eight mature eggs, we still wouldn't have had a chance, even if we had managed coitus. Nonetheless, I was excited just to have an inkling that my ovaries were functioning again, and more so I was happy to finally have a sense of when we might be able to start this process.

In the end, it was a easy decision to do a medicated cycle for my transfer. I noted that I've only had three au natural menstrual cycles in over a year.  All the others have coordinated with Femara and an HCG trigger and I'm also excluding the ones that occurred post procedures. Given that my cycles are inconsistent at their baseline and I have limited data, plus it took over seven weeks to have a "normal" period after my D+C; a natural cycle FET didn't seem too logical. Although my RE offered that he doesn't put much stock in ovulation predictor testing, AF arrived exactly a fortnight later. She launched right into full flow without any warning. Not just my version of 'full flow,' but the stains on my underwear would satisfy anyone's definition of full flow.

So it begins... I called to set up my baseline scan. Fortunately, I had a fairly light morning and was able to squeeze my last two patients into earlier spots, so the bean counters would be none the wiser about my absence. Heading into the mid-day traffic, it resonated that I was making the right decision with a medicated transfer. The office manager greeted me as soon as I walked into my RE's office. "I'm so sorry Jane, Dr Somebody I Used to Know went home ill. He tried to hold out for as long as he could..." As if she had to validate that he was truly sick, she added "He was throwing up..." My stomach started to sour at the thought of missing this window and needing to wait another month. Then she mentioned, "Is it okay if [the other doctor in the practice] does your ultrasound?" Oh, why didn't she lead with that? As long as we could proceed, I didn't give a fuck who was checking out my ovaries. I felt badly that my RE was sick, and it seemed that going home was the right call.

As I was preparing for my scan, I discovered that I has soaked a regular tampon in just under two hours. My inner thighs were covered. I had barely finished cleaning up before the other doctor and Misery entered the room. He introduced himself and asked what type of treatment I was doing. It's always a bit awkward to be filling in for someone else. When I worked in a community health clinic, I received a lot of patients from outside providers who didn't perform IUD insertions, and thus I dubbed myself the 'IUD bitch'. He proceeded with my scan and gave me a guided tour of my pelvis with a full explanation of the rationale. To my surprise, Misery spoke up, "She knows exactly what she's looking at..." she informed. "Ah, you've been at this for a while." he commented. For the first time ever, Misery's eyes made contact with mine while I was on the exam table and we shared a knowing smile. "Yes, I have." I replied. I didn't want to explain who I was or what I did. Many years ago, I needed some advice for a patient with recurrent pregnancy loss and I had emailed this doctor through the 'contact us' section on their website. I was quite impressed when he replied personally within a few hours. Once again, he was granting me a courtesy.

Actually, I was rather glad not to be seeing my RE, as I was a right bloody mess. I know it is out of my command, but I still felt embarrassed. I donned some gloves and cleaned the room, as I felt badly leaving it for Misery. Fortunately, I had a spare pair of undies in my swim bag, so I changed in the back seat of my car (not the first time...) before I raced back to the office in time to be twenty minutes late to a meeting and within two hours I had saturated another tampon. What the fuck? I was hemorrhaging! I actually had to open my box of super tampons. Oh, yes. Husband was due to return in a few more days. Our reunion was destined to be a sexless as his departure...

Monday, 10 February 2014

So, do you have any kids?

The intention is an innocuous attempt at engaging in small talk, but it opens a pandora's box of emotions. I tend to answer, "I have two beautiful cats." I think it throws people a bit, as I don't think many expect 'cats' to follow the adjective 'beautiful' (although, they are gorgeous). I've thought a bit about how my answer is perceived when it's one of my patients asking the question. If it's one of my pregnant teenaged patients, I wonder if it makes them feel more scared; OMG, this birth process must be really bad if even she won't do it! When I was in my late twenties and early thirties, the nods and gentle laughs that I received seem to convey, ahh, she's probably just too focused on her career right now... Now that I'm inching closer to forty, I'm starting to perceive a different thought process from the looks that I receive; maybe she's infertile...or just selfish...

Included among the many difficult aspects of infertility, is the fact that the alternative of living child free, is not widely accepted. Couples without children are sometimes viewed as being deviants. Heartless souls who are immune to the sweet nature and innocent whims of angelic tots. Self-centered bastards who would rather indulge in sports cars and exotic holidays. Child free families are often forced to defend their decision to the nosy naysayers who insist "someday, you'll change your mind" and criticise "your life just won't be fulfilled without having kids!" One of my friends in the empty womb club confessed that at times she lied about having infertility issues, in an attempt to stop the inquisition. That only led to the usual advice we all know too well... "Did you try [fill in the blank]? What about adoption? So-and-So tried for years to get pregnant, then they adopted a baby and now she's pregnant with twins!"

Additionally, from parking spaces to tax breaks, there are a variety of benefits granted to parents. I'm not saying they are not warranted or justified, I'm just asking that we [as a larger society] not pretend that they don't exist. There are times when child free couples are treated as second class citizens. It can be quite apparent in the work place. An RPL blogger recently wrote how her office had a staff meeting to discuss how to fairly allocate time off around the holidays. One of her co-workers commented in a bitter tone that "those of us with kids would like to be able to spend time with them." Thus, proclaiming that any parents in the office should receive priority status with their requests. There are times when it feels like child free employees are expected to pick up the extra slack and there seems to be two separate standards for parents and non-parents.

I'm also not claiming that as a child free individual that you can't use this to your advantage. Impress your boss by putting in the extra hours and maybe the nod for a promotion will go your way. While I was in my early twenties, I worked in an office and was the only employee without children. I signed up to work the early shift, as inevitably, someone would need to leave early to tend to a child and I would finish her shift. Cha-ching! it was overtime pay for me. One Friday I made plans to meet up with a friend after I finished my hours. My supervisor approached me to ask if I would cover for Brenda who got a call from the school nurse that her daughter had a fever. Hmmm, this supervisor didn't seem to notice that Brenda's kids seem to get sick almost every Friday. Monday too. When I explained that I had plans after work, she countered that Brenda had to leave as she has a sick child, but my plans were non-obligatory, and I could call my friend and arrange to meet at a later time. It was one thing when I was the eager beaver willing to pick up extra work, but I resented that it had become seemingly expected of me.

A few months later, I had to leave work early as I had left my laptop in the biology lab where I was taking evening classes. It was the day before Thanksgiving, the campus would be closing early and I needed to finish my application essays over the weekend. There was a skeleton crew working that day (including Brenda, who didn't have any available PTO) and I figured they could cover for me for a change. When I returned on Monday, I was written up for "abandoning my shift". The practice manager and my supervisor didn't accept the urgency of reclaiming a laptop. All the times I covered for others didn't earn me any credit either. As I needed the job, I just sat quietly and took my licks and I resisted asking 'would I have a mark on my file if it had been a sick child and not an inanimate object?' A few months later, I received an acceptance letter. Abandoning my shift paid off for me in the long run. Yet, fifteen years later I am still pissed about the fact that I have a demerit on my permanent record.

Perhaps this is why infertiles bond so deeply and the IF community is so strong. We're being rejected by the Mommies' club, but we're not water carriers with the child free crowd. We don't always resent some of the privileges that come with parenting, as it's what we're hoping for for ourselves. Yet, it just feels like another level of unfairness to also endure the burdens bestowed on the child free. The expectations that you can work late when needed. The implications that you prefer your lavish lifestyle over the pitter-patter of tiny feet. Relegation to the bottom of the pecking order for time off around the holidays. A fellow blogger who miscarried at the same time when her co-worker announced her pregnancy, described how she was later required to carry heavy stuff for her colleague as if she were an infertile mule.

"So, do you have any kids...?" I don't quite have an answer that explains, no I'm not afraid of child birth, but I am terrified about getting stretch marks and ruining my figure. Although, I'm probably not hot enough to be this vain, I work really hard to maintain what I have! Yes, I was too focused on my career for many years and probably missed any window for a natural conception, but ironically, if I hadn't been so driven, we may not be able to afford fertility treatments. Yes, I am infertile, but being selfish has at times become a coping mechanism. It may not be my choice to be child free, but it is my prerogative to embrace it. Isn't this all expressed with "Yes, I have two beautiful cats..." 

Friday, 7 February 2014

Survey Says!

One detail I discovered during my first IVF cycle, is that my RE uses the facility at XYZ Fertility Center for retrievals and transfers. I developed a certain distain for XYZ as they run really annoying radio ads. My RE vouched for the quality of their embryologists and their lab, but noted that he personally disagrees with some of the business practices at XYZ. I was really tempted to ask him to go into detail, but I figured it probably wasn't germane to our conversation. I quickly revealed my resentment that they give the impression that the RE will be delivering the baby, and scored a rare burst of laughter from Dr Somebody that I Used to Know.

Recently I received a letter with XYZ Fertility Center's logo in the return address. Fearing it could be a bill, I tore into the envelope immediately. It was an invitation to participate in a survey. If I submitted my responses within 30 days, I could receive a $5 Starbucks gift card. Although I'm not sure if you can get anything at Starbucks for 5 bucks, I decided to take a look through the survey. Allegedly, I was selected at random; which I believe as a lot of the questions seem to presume that I was an established regular patient at XYZ. I started filling in the Not Applicable (N/A) bubbles for inquiries about appointment scheduling. Then the survey asked about 'appearance of the waiting room'. Seriously? The waiting room has a breathtaking view overlooking the bay. Are they just bragging?

I gave high marks to the nurse who took care of me, as she was very sweet, and I issued good scores to the anesthesiologist as he didn't freak out over my blood pressure. The changing area and lockers met my satisfaction, as did the recovery space. I considered grading the surgical suite as N/A as I don't remember it too well, which I suppose reflects the good work of the anesthesiologist. I started to wonder if they would ask about... yup, that was the next section. The Gentleman's Room. Way to try to dignify it. They asked questions about the selection of pornographic materials and there was a space where your could write in comments. Husband noted that he'd have to reply N/A as he brings his own porn courtesy of his iPhone. We enjoyed a good laugh, but then reflected on the fact that this is someone's actual job to sort through the responses. Husband recalled his surprise upon the discovery that there was hard core porn available at my RE's office. He figured it would be more of the Channel Five porn variety. While we were at University in the UK, Channel Five was a new and low budget network that featured some shows with really poorly simulated sex scenes. We figured it's probably the librarian resembling, grandmother aged office manager at my RE's office who orders their materials. As she is probably the most outwardly caring person in the clinic; Husband reckons she'd be willing to lend a hand to a gentleman requiring assistance.

There were a few lines at the end of the survey for additional comments. My pen hovered as I contemplated sharing my thoughts about the radio advertisements. Then I remembered, if you don't have anything nice to say...

Tuesday, 4 February 2014

Life: On Hold

Myopia is another consequence of infertility. In this context, it is defined as the inability to see clearly beyond the next menstrual cycle. Often I'll receive a flyer for a medical education conference in a nice destination, or an out of state friend will suggest getting together some time in the near future. My mind immediately starts processing how far along I would be if I were to become pregnant, or what I would be doing if I were in a treatment cycle. I know I shouldn't be so preoccupied with such hypotheticals. I know I should just say 'oh, fuck it!' I have to live my life after all.

Unfortunately, it feels like we've been penalised so many times for trying to have a life outside of procreation. There have been four occasions when I've ovulated when one of us was away. It's most likely that it would not have made a difference, but we did have one spontaneous conception, so I think it's fair enough to claim that you never know. I travelled over Memorial Day weekend last year (as I was under the impression that my RE's office would be closed, but in fact they were open) and a compromised monitoring schedule missed my follicle's peak maturity. We delayed starting IVF due to our Hawaii holiday with the in-laws. I'm already fretting about the possibility of my trip to Memphis for the Women's Final Four conflicting with a fresh stimming cycle. At least for the time being, I feel I need to ground myself.

I have reached a new phase of planning a consolation event in anticipation of disappointing news. Actually it was Husband who initiated the idea. Last summer he suggested we take a cooking class together, as it's something we've wanted to do for a while. Unfortunately, we couldn't find any classes that were convenient to our schedules. Instead, we decided to join a Cross-fit gym as a treat to ourselves while we were benched for a month. If our transfer doesn't work, I've been contemplating seeking solace with some traditional approaches such as a spa treatment and/or getting intoxicated while dancing with H at our favourite gay bar... However, as I have been playing more tennis recently, I thought about returning to competitive play by entering a Spring flex league if this attempt yields a BFN.

Then, as if the Universe were reading my mind, I received an email from the captain of a local USTA team inviting me to play in the upcoming season. It was completely out of the blue, I haven't seen or spoken to this woman in over three years. Potential pregnancy concerns aside, I had some hesitation as I find the politics associated with USTA leagues to be rather irritating, but it is much more convenient than the individual flex leagues, where you have to contact all your opponents and schedule your own matches. At least with a USTA league match, all I have to do is show up and play.  Yet, that may not be so easy if this transfer actually works. What if I have hyperemesis with this pregnancy? What if I have a subchorionic hemorrhage and need to restrict activities? How do I respond, 'when do you need an answer? I may or may not be getting pregnant.'

It is much different when it is a team situation. I had planned to keep running races and competing in swim meets if I became pregnant, I would just adjust my pace. During our few months of TTC au natural, I was asked to do the swimming leg for a triathlon relay. I wheeled out the dates, if we were to conceive on either the next two cycles, I could have been either 9 or 13 weeks at the time of the event. I had to decline; I knew what time they would be expecting from me and I would feel badly if I couldn't achieve it. It's one thing to be competing for yourself, but another to know that others are relying on you.  I ended up cheering for my teammates from the sidelines, as someone else swam a slower time than I could do. Alas, I may be declining this invitation, I just hope I don't run into her during a flex league match...  

Sunday, 2 February 2014

The Point of No Return

I've written many posts addressing my frustrations with my friend Myrtle and her lack of understanding toward our infertility, but I found it really hard to process her reaction when I told her about my second miscarriage. She seemed to treat it as if I told her that I lost my iPhone and merely wanted to know how much time I had left on my contract. Husband thought it might be better if he were the one to try to educate her, as a fellow lay person. Apparently, I use too many technical terms...He texted Myrtle to arrange to get together during his trip east. "Is it okay that Husband meets little Myrtle before you do?" Myrtle wrote me seeking my approval. I reminded her that we both met her last year as I rolled my eyes. Sheesh, does little Myrtle have her own booking agent? Husband debriefed me after he had brunch with Myrtle and her husband. "They really don't know anything..." He had to explain the process of IVF in detail multiple times and it seems that the only thing they learned is how lucky they were that everything worked on their first shot. I spoke with Myrtle later that afternoon, but she didn't seem too much wiser. As little Myrtle was crying in the background, she asked "are you sure you want one of these?"

Ordinarily, such a comment would prompt a post about Myrtle's insensitivity, but this time it struck a nerve as I've been having similar thoughts myself. A few days earlier I had dropped Husband off at the airport. The next night I went to went to play tennis after work and came home late. The following morning I ran a 10 K and met up with some swimming friends for breakfast after the race. After doing a few errands, I returned home in the early afternoon and felt like taking a nap. Why not? I didn't have any responsibilities to anyone. As I stretched out of the sofa to indulge in mid-day slumber, I felt reminded that I wouldn't have so much free will with my time if we had a baby. Furthermore, shouldn't I be doing something more substantial with my time than napping?

Every now and then I'll encounter a patient in her late 30s or early 40s who presents to talk about infertility. Sometimes I suspect they're hoping I have an easy answer, rather than hearing it's now or never and the best option is to consult an REI. Some patients decline a referral. I can appreciate their reluctance. One of our medical assistants described that she thinks some couples can reach a point of no return. After waiting so long for a baby, they discover that they feel quite content with their current lifestyle and decide not to disturb the homeostasis. The thought of night time feedings and Saturday morning soccer practices seems overwhelming, while quality sleep and wine tasting trips sounds more tempting. They missed the window of ideal opportunity. Veronica went through this personally. She and her husband tried to conceive for many years, and when she failed to ovulate with Clomid, she declined to seek any further infertility treatments. A year later she came to me for an IUD insertion, noting that she would now be pissed if she were to become pregnant.

A week or so ago, Husband and I went out with some friends. Once a year, my friend H arranges for our group to go to a club in the city that features mashups. Yes, when a DJ combines two (or more) songs into one. It sounds rather lame, but is actually pretty cool. Boston and The Black Eyed Peas becomes "I've Got More than a Feeling." Snow Patrol and The Backstreet Boys yields "Chasing Cars That Way." We arrived just before the bouncer started imposing a cover charge. I recognise that for people 35 and older, getting to the club early is what going to the early bird special at the diner is to senior citizens. You and your friends own the dance floor, and you can just walk up to the bartender when you want another drink. Heck, at this point in the evening, we weren't even the oldest ones in attendance. Yet as the night creeps on, it unfolds like a reverse Cinderella story. More and more people file in and the average age drops rapidly. It gets harder to move; the dance floor becomes a mob scene. Ordering a drink takes at least a half an hour, and you just hope you don't need to use the bathroom. Oh, and to complete our status as crotchety old critics; we were disappointed as the evening was billed as 80s versus 90s, which would lead one to believe a mashup would feature a song from the 80s and one from the 90s. Not every third or forth compilation has at least an 80s or 90s song... Although the music of Miley Cyrus does blend with quite a lot...Confession time: I added 'Party in the USA' onto my running playlist...

When we first walked in, I took note of the 'you must have been born before this date in 1993 to enter' sign. Wow. I am biologically capable of being the mother to the youngest person in the room. Albeit, I would have been an episode of '16 and pregnant'. Still, that thought stuck with me as I saw all these young twenty somethings running around, I'm old enough to be your mother... The thought resonated further, I'm going to be an old mother (if it happens). I'll be in my 50s during the teenage years, and if he or she gets married after the age of 30, I could be 70 at the wedding. When I was in my earlier 30s, I would see first time pregnant patients at the age of 38 or 39 and thought, I'd never be having a baby at that age... This is why I had it all carefully planned out; start trying to conceive at age 35 and if it didn't happen after 2-3 years, then it just wasn't meant to be. After all, I'll never do IVF. Yet sometimes when you start down the TTC road, there seems to be another point of no return. The heart has grasped so firmly to this abstract concept that it's hard to let go.

Like Cinderella, when the clock struck midnight I was ready to go home. Dance clubs weren't really my scene in my twenties, so it felt more awkward to be at one in my (late) thirties. The proximity to so much youth made me feel so much older than I actually am. There was one bright spot to the night. As I was dancing with H and the girls, Husband and his friend were standing in the corner, scoping out the talent. "Ooh, look at her ass!"Husband pointed to his friend. The rear end in question belonged to yours truly. At least I've still got it to the guy who wants it. Get your coat Love, you've pulled.