Every infertile woman has been exposed to a plethora of stories of how there is some woman out there who tried to get pregnant for years and the moment she gave up, she finally conceived her rainbow baby. If it's not irritating enough to hear these tales, it's more frustrating to acknowledge that your friend thinks this strategy could be the answer for you. From her perspective, as it worked for someone else; it's a valid treatment method. (Brilliant observation from Annie at Sweetest in the Gale
"Although people mean well and are only trying to help, it's like someone who won the lottery handing out financial advice") When my lead physician shared her story of conceiving spontaneously just before her RE consultation, she commented that she definitely thought that stress played a role. "Isn't that anecdotal?" I countered "we only know about the cases where couples 'stop trying' because they do conceive. There are probably many more uncounted cases of couples who stop actively pursuing conception, but don't use birth control and don't conceive..."
Even before I experienced infertility, I struggled to accept that an infertile couple suddenly became more fertile if they were 'un-intending to conceive' at the time of coitus. Maybe it's my years of focusing on contraceptive services, where we teach that if you aren't preventing a pregnancy then you're pursuing one. Even if couples are not cycle tracking or continuing infertility treatments, if they're not contracepting, they are technically still trying for a pregnancy. In particular, hoping to be one of those stories; 'it happened when we weren't thinking about it!' At the basic biological levels, the endometrium, ovaries and sperm do not have any independent cognitive processes. It's not as if they can network together to plot, "Hey! They're not paying attention, let's make it happen and surprise them!" Finally, it's important to remember that correlation does not imply causation. Just because an event happens under a particular set of circumstances does not mean it was influenced by said circumstances.
I decided that I needed to examine the evidence. First, I referenced Clinical Gynecologic Endocrinology and Infertility. Although this edition was published in 1994, and the chapter on infertility evaluation was written before IVF was mainstream, the lead editor Leon Speroff is still considered to be the ultimate authority on gynecologic endocrinology. The following text is from a paragraph marked Myths and Appropriate Goals:
It is important for physicians and other health care professionals to dispel the myths that are associated with infertility. Women should not be told that they are infertile because they are too nervous. Unless anxiety interferes with ovulation or coital frequency, there is no present evidence that infertility is caused by the usual anxieties besetting a couple trying to conceive. Despite many anecdotes to the contrary, adoption does not increase a couple's fertility...
Turning to a source that is more Up To Date, I searched a database with that web domain (it's similar to PubMed, except others have already summarised the most current articles for you; yes, it's akin to using Cliff Notes) and found one article on Psychological Stress and Infertility. Here is her first paragraph:
As health care professionals developed the ability to diagnose and treat most cases of infertility, they began to view it as an organic condition. Some infertility patients were told that their stress level had nothing to do with their ability to become pregnant. hmm, I'm starting to sense some bias However, there is evidence that stress levels influence the outcome of fertility treatment, as well as contribute to patients' decision to continue treatment. Stress also affects patients' reactions to pregnancy loss during infertility treatment and pregnancy complications Ya, think? Moreover, physiological distress is associated with treatment failure and interventions to relieve stress are associated with increased pregnancy rates.
The article then defines stress and discusses how it is difficult to measure or assess baseline stress levels, but notes such a task is best handled by a trained mental health professional (psychiatrist or psychologist). She notes that stress tends to be higher in the partner "with the fertility problem" and references a study of 112 infertile women who were evaluated by a psychiatrist. 23% were diagnosed with an anxiety disorder and 17% with major depressive disorder -a rate considered to be 10-12% higher than the general population.
The author then discusses the impact of stress on 'drop out'. She notes that specialists presume patients stop treatment for one of two reasons -recommendation to discontinue due to a poor prognosis, or lack of finances. She then introduces a challenge to these notions and suggests that the psychological burden of the procedures appear to be the major reasons for dropout. To support her argument she reviews a few studies that examined women who had IVF funded by insurance programs. A researcher of one study concluded that attrition was due to emotional burdens, but did not ask the couples themselves and another large study of 2130 patients noted an observation of "enormous stress and frustration" but the participants were not surveyed. So why are these studies being referenced?
So far, if I'm following her argument correctly, she's advocating that stress contributes to fewer pregnancy rates as it is the main reason why patients stop fertility treatments. That's not the same things as stress being the cause of infertility... She presented one study that had some conflicting results. 148 women were followed through 2 IVF cycles. They completed a baseline psychological survey and patients with higher distress levels had higher pregnancy rates than those who were rated with low stress levels. However patients who were at moderate distress levels and went through mind/body interventions were more likely to conceive than their moderately distress counterparts in the control group. She references a comprehensive mind/body infertility program, which I think is her own clinic.
Finally she concludes with a review of 25 independent evaluation studies and summaries that psychosocial interventions could reduce negative affect and could produce positive changes. Yet none of these reviews found that psychological interventions impacted pregnancy rates. "It is unclear why psychological intervention might have a positive impact on pregnancy rates." Her final comments note that psychological stress of infertility patients should be assessed prior to treatment, and patients who exhibit signs of anxiety or depression should be treated. She offers relaxation techniques, stress-management, coping skills and group support as initial therapy, pharmacotherapy when indicated. Does blogging count?
Last summer after Todd Akin uttered the reprehensible words, "if it's a legitimate rape, the female body has ways to shut that whole thing down" the American College of Obstetrics and Gynecology (ACOG) issued a statement; "a woman who has been raped has no control over her ovulation, fertilisation, or implantation of a fertilised egg. To suggest otherwise contradicts basic biological truths." I thought his use of the word legitimate was worse than his lack of knowledge, as it demeans all women by perpetuating the notion that women lie about being raped. I cannot imagine how heinous that comment was to any woman who has been assaulted, let alone to the 32,000+ who experience a legitimate pregnancy as a result each year. I was pleased to see that ACOG took a position to correct the inaccuracy, and selfishly I thought it touched on the situation of infertility. We also don't have any control over our reproductive organs.
Also anecdotal, over the years I've seen many women become pregnant during very stressful times; financial hardships, academic pressures, troubled relationships, long working hours, drug and alcohol abuse and chronic health problems. Of course, these women are fertile and play by a different set of rules than the rest of us, but I feel it does refute some of the arguments that stress decreases fertility potential.
Last year when I attended the Infertility conference, I overheard two REs discussing the role of treating mild endometriosis. One commented, "I'll do a laparoscopy and note a few implants that I doubt are contributing to her failed cycles, but I'll go ahead and cauterise them and she'll get pregnant on her next transfer. Was it due to the surgical intervention, or maybe was it just her time?"
It was just her time. Such a brilliant and yet succinct explanation. One that is both comforting and yet scientific. For whatever reason and for every reason, at that moment, conditions were perfect and it was her time.
Last week our LVN presented a patient who was experiencing infertility due to male factor issues. They failed three IUIs and while deciding what to do next, they attended a destination wedding and conceived spontaneously. They didn't even consider the possibility that a pregnancy could occur and engaged in adventure sports and lots of alcohol. "It makes sense," she speculated "you let your guard down..." "Nope." I interjected and shook my head. "It was just their time."
Monday, 15 July 2013
Saturday, 13 July 2013
The Exception and the Norm
She was only 23 and wasn't planning a pregnancy, but she and her 25 year old boyfriend were very excited about the prospect for a baby. Naturally, they were devastated when her ultrasound revealed a blighted ovum. Her mother accompanied her to the follow up appointment and sat quietly as we discussed that a miscarriage is quite common, there wasn't anything she did or didn't do that caused it to happen, and there wasn't any reason to believe that she wouldn't go on to have a healthy baby. Her mother finally spoke, "Well, I just don't understand how this could happen." There was a slight smugness to her tone. "I had four pregnancies and four healthy children." My first thought: what a bitch! Nice to make your daughter feel even worse. My second thought: that is totally something my mother would say. I replied, "Then you are very lucky. To have four normal pregnancies without any complications is more of an exception rather than the norm."
That encounter occurred last summer, but I started to think a bit more about the exception and the norm more often. (Endnote: The patient conceived about 3-4 months later and gave birth to a healthy baby boy a few months ago) As Myrtle offered her advice of trying to conceive in Husband's childhood bedroom, as my in-laws slumbered in the next room, or recounted how she wore post coital socks during the two months she was TTC, I bit my tongue to prevent myself from saying what was really on my mind. "Do you want to know the reality Myrtle? You got lucky. For someone your age to conceive so quickly is the exception rather than the norm, so please do not think you have any wisdom to offer me." Although it would have be cathartic and may have been effective in shutting her up, I knew those words would be harsh to her ears; but I also knew I really needed to say it to myself. I needed to be reminded that she was the exception and not the norm, and I needed to stop comparing myself to her.
I often think about the exception and the norm when I hear pregnancy announcements. I can't be surprised when young seemingly fertile couples become pregnancy quickly and easily -that's the norm. I shouldn't expect similar success when I hear about other couples with moderate male factor conceiving spontaneously or with IUI -as they're the exceptions. However, this past week was a bit unusual as I saw a high number of cases that represented exceptions rather than the norms.
Case #1 I looked over her form and saw that she had a female partner and cautiously asked her how she conceived. The donor was an acquaintance of her girlfriend and lived in another state. He was visiting for only three days and during that time they did one at home insemination (yes, with a turkey baster). I asked her if she was doing any ovulation predictor testing. She didn't know what such tests were. They just took a chance as he was in town. 'Oh, to be 23 and fertile' I thought, but still acknowledged that her story was rather exceptional.
Case #2 A lovely couple in their mid-thirties. Infertility work-up diagnosed male factor and they failed three IUI cycles. As they were deciding their next steps, they travelled to Aruba for a friend's wedding, where they conceived spontaneously.
Case #3 I included this case as it was unusual. She was in her late twenties and had been diagnosed with unexplained infertility, this was her second pregnancy achieved with IVF. The nurse who did her intake commented that she had an odd affect and seemed really preoccupied with her four year old son and didn't seem that interested in this pregnancy. She seemed a little reluctant to talk about her IVF process, but when I asked her when her embryos were transferred (she went to an out of network REI and I didn't have any records) she didn't know the date! How do you not know your transfer date? She was also surprised that I would be doing a transvaginal ultrasound. Really, you're not used to being scanned via your hoo-ha yet? I started to wonder if she was really invested in this pregnancy (maybe it was her husband's urging) or maybe this was some form of self preservation.
Case #4 I first saw this patient over a year ago. It was her annual exam, she had just turned 40 and wanted to talk about fertility. Her first pregnancy occurred at age 37 and was unplanned, but very much welcome. When he was two, they started trying for a sibling and had come up on the year mark without success. I ran her labs; FSH 10.4 with AMH 1.22. I strongly urged her to seek an RE consultation if she wanted to optimise her chances to conceive. She came back to see me a year later this past March, feeling ready to proceed with an RE referral, although she did not want to pursue IVF. We rechecked her labs, FSH was 7.0 but her AMH dropped to 0.92, consistent with a declining reserve. You should have moved on this last year... I thought to myself. We completed her workup with an HSG (normal) and sent her husband for semen analysis. I called her to review the results; his count was low at 13.9 million with motility at 45%. I felt that their collective results still placed them in consideration for IUI, but discussed that success rates are low and prepared her that the RE would probably suggest IVF. The next day she started her cycle which led to a spontaneous conception. Tears of joy flooded her eyes as we saw a viable single fetus at 8 weeks and 4 days on the ultrasound.
Case #5 She is 26 and stopped birth control pills in August 2011. Her cycles were very erratic and irregular. She came in for her annual exam in April 2013 (the day of my BFN from IUI#1) I reviewed that she had some features suggestive of PCOS and ordered labs. We discussed the implications of PCOS and I suggested trying to induce ovulation with Clomid. (I know there is debate about the utility of unmonitored Clomid cycles, but our local RE's prefer us to try Clomid for 2-3 cycles in women with established anovulation) She just shrugged her shoulders and noted that it took her mother 2 years to conceive both her and her sister, so she wasn't too surprised and wasn't yet ready to intervene. Her period had started just a week before that visit and she conceived that cycle. She also mentioned they forgot about trying to get pregnant that month.
Cases #6-9 I included these two cases to illustrate that there are exceptions within the norms. #6 is 31 years old with two children. I removed her Copper IUD so she could try for her third and she had a BFP three weeks later. I think she literally conceived that night. #7 presented for pre-conception counseling (on the day of my BFN from IUI#2) before she removed her Nuva Ring. She conceived on the next cycle. #8 is a 26 year old who presented for a consult after 6 months of infertility (also on IUI#2 BFN day). She conceived right after her hystersalpingogram. #9 stopped breastfeeding as soon as her son turned one year. Three months later she still hadn't started a period, so she took a test and it was positive. "I was shocked" she told me "We've only had sex once this year..."
Cases #10-11 Case #10 is a 31 year old female with classic PCOS, but had three spontaneous conceptions. Case #11 had three normal healthy pregnancies and was diagnosed with multiple uterine fibroids. She was told that she wouldn't be able to conceive and was further instructed to stop her birth control pills as they could increase the size of her fibroids. Two months later, she had a positive pregnancy test.
Case #12 38 year old female who had a miscarriage at 10 weeks that was attributed to uterine fibroids. She had an abdominal myomectomy and needed to wait quite a length of time before she could attempt to conceive again. She finally conceived, but miscarried again at 6 weeks. A year and a half later she had a BFP after she and her husband went to Vegas for a weekend and decided "just to have fun".
Case #13 This one was included for comedic value. My medical assistant went into the room and introduced herself. "Hi, I'm Tammy-Lynn" the patient replied. She then quickly corrected herself, "Oh, sorry! That's my stripper name!"
While I feel it's important to pay respects to the exceptions and the norms, I also acknowledge that I'm applying to be one of the exceptions. My spontaneous conception was described by my RE as a 'fluke' and I feel that I've been giving my one and only pass to have a spontaneous conception prior to treatment. I'm estimated to have a 40% chance with IVF -that hardly seems like a norm. Myrtle and I are both exceptions -but on different ends of the spectrum.
That encounter occurred last summer, but I started to think a bit more about the exception and the norm more often. (Endnote: The patient conceived about 3-4 months later and gave birth to a healthy baby boy a few months ago) As Myrtle offered her advice of trying to conceive in Husband's childhood bedroom, as my in-laws slumbered in the next room, or recounted how she wore post coital socks during the two months she was TTC, I bit my tongue to prevent myself from saying what was really on my mind. "Do you want to know the reality Myrtle? You got lucky. For someone your age to conceive so quickly is the exception rather than the norm, so please do not think you have any wisdom to offer me." Although it would have be cathartic and may have been effective in shutting her up, I knew those words would be harsh to her ears; but I also knew I really needed to say it to myself. I needed to be reminded that she was the exception and not the norm, and I needed to stop comparing myself to her.
I often think about the exception and the norm when I hear pregnancy announcements. I can't be surprised when young seemingly fertile couples become pregnancy quickly and easily -that's the norm. I shouldn't expect similar success when I hear about other couples with moderate male factor conceiving spontaneously or with IUI -as they're the exceptions. However, this past week was a bit unusual as I saw a high number of cases that represented exceptions rather than the norms.
Case #1 I looked over her form and saw that she had a female partner and cautiously asked her how she conceived. The donor was an acquaintance of her girlfriend and lived in another state. He was visiting for only three days and during that time they did one at home insemination (yes, with a turkey baster). I asked her if she was doing any ovulation predictor testing. She didn't know what such tests were. They just took a chance as he was in town. 'Oh, to be 23 and fertile' I thought, but still acknowledged that her story was rather exceptional.
Case #2 A lovely couple in their mid-thirties. Infertility work-up diagnosed male factor and they failed three IUI cycles. As they were deciding their next steps, they travelled to Aruba for a friend's wedding, where they conceived spontaneously.
Case #3 I included this case as it was unusual. She was in her late twenties and had been diagnosed with unexplained infertility, this was her second pregnancy achieved with IVF. The nurse who did her intake commented that she had an odd affect and seemed really preoccupied with her four year old son and didn't seem that interested in this pregnancy. She seemed a little reluctant to talk about her IVF process, but when I asked her when her embryos were transferred (she went to an out of network REI and I didn't have any records) she didn't know the date! How do you not know your transfer date? She was also surprised that I would be doing a transvaginal ultrasound. Really, you're not used to being scanned via your hoo-ha yet? I started to wonder if she was really invested in this pregnancy (maybe it was her husband's urging) or maybe this was some form of self preservation.
Case #4 I first saw this patient over a year ago. It was her annual exam, she had just turned 40 and wanted to talk about fertility. Her first pregnancy occurred at age 37 and was unplanned, but very much welcome. When he was two, they started trying for a sibling and had come up on the year mark without success. I ran her labs; FSH 10.4 with AMH 1.22. I strongly urged her to seek an RE consultation if she wanted to optimise her chances to conceive. She came back to see me a year later this past March, feeling ready to proceed with an RE referral, although she did not want to pursue IVF. We rechecked her labs, FSH was 7.0 but her AMH dropped to 0.92, consistent with a declining reserve. You should have moved on this last year... I thought to myself. We completed her workup with an HSG (normal) and sent her husband for semen analysis. I called her to review the results; his count was low at 13.9 million with motility at 45%. I felt that their collective results still placed them in consideration for IUI, but discussed that success rates are low and prepared her that the RE would probably suggest IVF. The next day she started her cycle which led to a spontaneous conception. Tears of joy flooded her eyes as we saw a viable single fetus at 8 weeks and 4 days on the ultrasound.
Case #5 She is 26 and stopped birth control pills in August 2011. Her cycles were very erratic and irregular. She came in for her annual exam in April 2013 (the day of my BFN from IUI#1) I reviewed that she had some features suggestive of PCOS and ordered labs. We discussed the implications of PCOS and I suggested trying to induce ovulation with Clomid. (I know there is debate about the utility of unmonitored Clomid cycles, but our local RE's prefer us to try Clomid for 2-3 cycles in women with established anovulation) She just shrugged her shoulders and noted that it took her mother 2 years to conceive both her and her sister, so she wasn't too surprised and wasn't yet ready to intervene. Her period had started just a week before that visit and she conceived that cycle. She also mentioned they forgot about trying to get pregnant that month.
Cases #6-9 I included these two cases to illustrate that there are exceptions within the norms. #6 is 31 years old with two children. I removed her Copper IUD so she could try for her third and she had a BFP three weeks later. I think she literally conceived that night. #7 presented for pre-conception counseling (on the day of my BFN from IUI#2) before she removed her Nuva Ring. She conceived on the next cycle. #8 is a 26 year old who presented for a consult after 6 months of infertility (also on IUI#2 BFN day). She conceived right after her hystersalpingogram. #9 stopped breastfeeding as soon as her son turned one year. Three months later she still hadn't started a period, so she took a test and it was positive. "I was shocked" she told me "We've only had sex once this year..."
Cases #10-11 Case #10 is a 31 year old female with classic PCOS, but had three spontaneous conceptions. Case #11 had three normal healthy pregnancies and was diagnosed with multiple uterine fibroids. She was told that she wouldn't be able to conceive and was further instructed to stop her birth control pills as they could increase the size of her fibroids. Two months later, she had a positive pregnancy test.
Case #12 38 year old female who had a miscarriage at 10 weeks that was attributed to uterine fibroids. She had an abdominal myomectomy and needed to wait quite a length of time before she could attempt to conceive again. She finally conceived, but miscarried again at 6 weeks. A year and a half later she had a BFP after she and her husband went to Vegas for a weekend and decided "just to have fun".
Case #13 This one was included for comedic value. My medical assistant went into the room and introduced herself. "Hi, I'm Tammy-Lynn" the patient replied. She then quickly corrected herself, "Oh, sorry! That's my stripper name!"
While I feel it's important to pay respects to the exceptions and the norms, I also acknowledge that I'm applying to be one of the exceptions. My spontaneous conception was described by my RE as a 'fluke' and I feel that I've been giving my one and only pass to have a spontaneous conception prior to treatment. I'm estimated to have a 40% chance with IVF -that hardly seems like a norm. Myrtle and I are both exceptions -but on different ends of the spectrum.
Wednesday, 10 July 2013
It's the Little Things...
When our friends Norm and Vera wed eight years ago, Norm's older brother served as Best Man and read "The Art of Marriage" by Wilfred Peterson during the ceremony.
Of course, he tried to embarrass his younger brother on his big day, by strategically pausing and placing emphasis on the words little things. Referencing 'the little things' became the joke of the day among his University mates; as when the first of your friends is getting married, it's important to act like you're still twelve.
Oh, but the little things are the big things...
At least they are in InfertileWorld, where a simple event of my cycle starting a day earlier forced us to forgo an IUI attempt as Husband was out of town for part of the week leading up to the insemination. As I questioned the timing of my last cycle, which was scheduled around my business trip, it felt logical not to pursue a treatment that could be compromised in any way, and his return could be in time for scheduled coitus. It really felt like it was the right decision when I received a text from Husband informing me that he was going to be delayed overnight due to bad storms in Chicago (the ones that wrecked havoc for the dogs in the Non Sequitur Chica household). I was so glad we weren't anticipating his timely arrival to proceed with an IUI. He begged and groveled to be put on a later flight headed to the Bay Area, and considered telling the airline agent, "I have to get home tonight, my wife is ovulating!"
Actually, I wasn't. Left to their own devices, my ovaries are very unpredictable. I've ovulated any time from day 12 to day 19, but most often I ovulated on day 15, which I hoped would be the case this cycle (cue laughter). Thursday morning on Day 15, I was still at 'medium'. I was a bit relieved as I was quite knackered after the 0155 airport pickup the night before (he was able to get on that later flight). Husband was a bit randy after being away for a week, but as I wasn't yet fertile, coitus could be delayed and I was able to go to bed at 9:30. Friday morning -Day 16- still medium. I was annoyed with my ovaries. I really wanted to keep my cycle starting on Friday so I can schedule my monitoring appointments on Saturday. It's these little details that can be so important. However, after recently discovering that my colleagues are taking quite a bit vacation time in the upcoming months, I decided I would start taking the entire day or half day for my appointments. After exhausting possible excuses, as I why I need to run out for an hour, I concluded that it's easier to be out for an extended amount of time. I've only used 6 vacation days plus a handful of half days so far this year, and I think I could be facing a 'use it, or lose it' situation with my personal time off. Maybe I'll even do something cliché like getting a facial or a pedicure. Actually, who am I kidding? I could swim with the noon group!
For a couple navigating irregular cycles to achieve conception, the logical antidote would be to engage in more acts of intercourse, right? Well, here is where we run into one of our other challenges. Husband, like most males in England and Europe, is not cut. That stupid superfluous piece of skin gets irritated easily and can put him out of commission. Thus, it makes it even more essential for us to get the timing right. (Impassioned plea to those of you having boys: circumcise! Especially if you may want grandchildren one day.) At times I feel like we're in some sort of Special Olympics of conception.
That Friday night, as I was getting ready to leave work, I received a text from Husband: "Are we banging tonight or can I have a glass of wine?" I couldn't help but to indulge in one of those self pity moments. If we were a normal fertile couple, we would have banged the first chance we could, because that it what you do after one of you has been away for a while. A normal fertile couple would conceive that night; as if by magic, it would be her fertile time. I hated the fact that we were enslaved to my ovaries and his foreskin. I informed him that he didn't have to ask my permission to have a glass of wine. "Well, I have to check in with the plan." he replied. "You're the expert." "HA!" I retorted. When it comes to knowing when we need to schedule coitus, I feel as if I haven't a fucking clue. Additionally, at times it also feels that every decision I make seems to be wrong. I decided to say fuck it. Literally. The simple act of a husband and wife lying together in their marital bed can be considered a little thing, but flipping the finger to the process of trying to conceive, is most definitely a big thing.
Happiness in marriage is not something that just happens.
A good marriage must be created.
In the art of marriage the little things are the big things...
Of course, he tried to embarrass his younger brother on his big day, by strategically pausing and placing emphasis on the words little things. Referencing 'the little things' became the joke of the day among his University mates; as when the first of your friends is getting married, it's important to act like you're still twelve.
Oh, but the little things are the big things...
At least they are in InfertileWorld, where a simple event of my cycle starting a day earlier forced us to forgo an IUI attempt as Husband was out of town for part of the week leading up to the insemination. As I questioned the timing of my last cycle, which was scheduled around my business trip, it felt logical not to pursue a treatment that could be compromised in any way, and his return could be in time for scheduled coitus. It really felt like it was the right decision when I received a text from Husband informing me that he was going to be delayed overnight due to bad storms in Chicago (the ones that wrecked havoc for the dogs in the Non Sequitur Chica household). I was so glad we weren't anticipating his timely arrival to proceed with an IUI. He begged and groveled to be put on a later flight headed to the Bay Area, and considered telling the airline agent, "I have to get home tonight, my wife is ovulating!"
Actually, I wasn't. Left to their own devices, my ovaries are very unpredictable. I've ovulated any time from day 12 to day 19, but most often I ovulated on day 15, which I hoped would be the case this cycle (cue laughter). Thursday morning on Day 15, I was still at 'medium'. I was a bit relieved as I was quite knackered after the 0155 airport pickup the night before (he was able to get on that later flight). Husband was a bit randy after being away for a week, but as I wasn't yet fertile, coitus could be delayed and I was able to go to bed at 9:30. Friday morning -Day 16- still medium. I was annoyed with my ovaries. I really wanted to keep my cycle starting on Friday so I can schedule my monitoring appointments on Saturday. It's these little details that can be so important. However, after recently discovering that my colleagues are taking quite a bit vacation time in the upcoming months, I decided I would start taking the entire day or half day for my appointments. After exhausting possible excuses, as I why I need to run out for an hour, I concluded that it's easier to be out for an extended amount of time. I've only used 6 vacation days plus a handful of half days so far this year, and I think I could be facing a 'use it, or lose it' situation with my personal time off. Maybe I'll even do something cliché like getting a facial or a pedicure. Actually, who am I kidding? I could swim with the noon group!
For a couple navigating irregular cycles to achieve conception, the logical antidote would be to engage in more acts of intercourse, right? Well, here is where we run into one of our other challenges. Husband, like most males in England and Europe, is not cut. That stupid superfluous piece of skin gets irritated easily and can put him out of commission. Thus, it makes it even more essential for us to get the timing right. (Impassioned plea to those of you having boys: circumcise! Especially if you may want grandchildren one day.) At times I feel like we're in some sort of Special Olympics of conception.
 |
| Shall we shag now, or shall we shag later? |
I thought that we could at least stay in the game this cycle; just the simple act of successfully getting the P in the VG during my fertile time would represent such a significant accomplishment for us, even if it didn't produce a pregnancy. However as the weekend progressed, my monitor did not. Panic set in -was this an anovulatory cycle? Not only is it necessary to view infertility as a chess match where you need to plot two to three months ahead, but you also have to worry about the domino effect. One little decision can yield big consequences. Should I have used my Femara just to keep my cycle on track? Why did I think I could rely on my unpredictable ovaries? By Monday (day 20 and still no peak fertility reading) I questioned if my monitor may have been inaccurate. My suspicion was confirmed when my progesterone level measured 5.9. Did I ovulate around the time of our carefree bang? I'm doubtful, but trying to conceive spontaneously now felt like a little issue. Knowing that my ovies are still functioning is a big fucking deal.
Other little things that are actually big things: A went into for a three month check up after starting his diabetes treatment . His fructosamine level (which is essentially a kitty A1C level) was within normal limits. He is back to his normal weight and the vet says that he looks great. She told me that I'm doing an outstanding job taking care of him. Yay! I'm a good kitty mummy.
I recently injured my left shoulder as I crashed into the wall after miscalculating a backstroke turn, which delayed starting Cross-fit classes. I also had to stop swimming for nearly two weeks and I've been less motivated to run. After recently writing about breaking out of a mental block with my tennis stroke, I realised how much I miss playing. I used to play at a competitive level and participated in several different leagues and teams, but when we bought out house and renovation projects absorbed most of our time, I wasn't able to practice the 2-3 sessions per week that were required to maintain my current level. As a result, I haven't picked up my racquet in over a year and a half. A few clicks later, I was signed up for Cardio-tennis. It does give me a little pause to laugh; as when I was a competitive player, we ...kind of...made fun of the Cardio-tennis players. Okay, we made fun of certain Cardio-tennis players. There were two older women in the group who would shriek a la Maria Sharapova, despite the coach yelling "This is not the finals of Wimbledon! This is Cardio-tennis!" Anyway, I figured it would be a good way to get me out of my current fitness rut and get back on the court. I just never imagined I'd be participating in Cardio-tennis, but it's another example of finding myself somewhere I never expected to be...
Monday, 8 July 2013
Goodbye My Friend
I had just stepped out of the shower when Husband brought his phone into the bathroom to show me his Facebook page. As I tightened the tie on my robe and wrapped my hair into a towel, I prepared myself for a pregnancy announcement. Then I read the post and suddenly would have preferred to read that every woman on Fertilebook was pregnant at that moment.
Rest in peace, my love. My life now has an emptiness that cannot be filled.
Marie and Pierre were fellow chemists in Husband's lab. There was an instant attraction when they first met; but as they were both dating other people at that time, they insisted that they were "just friends". After a few months they realised they weren't kidding anyone -most especially themselves. As soon as they broke up with their now insignificant others, Marie and Pierre became inseparable.
Their personalities and interests were quite different, but they complimented each other so well. Marie was a 'type A' and was high strung. Pierre was very laid back and relaxed. Marie was an athlete, Pierre was content to be a spectator. Their other major difference is that Marie was adamant about not having children, while Pierre desperately wanted to be a father. A few years back, a mutual friend commented, "The only way Pierre will have children, is if they figure a way for men to get pregnant."
Last year, Husband and I ran into Marie and Pierre at the London Olympics. We hadn't seen them in about 5 years and we were shocked at the condition of Pierre. He was in a mobility scooter and appeared to have a facial droop. His speech was a bit slurred. We quickly engaged in hellos and pleasantries, but as they didn't offer any information regarding his health, we didn't ask any questions. Multiple Sclerosis, a stroke, early onset Huntington's disease...I started running a differential in my mind. Husband and Marie started chatting about their work, leaving Pierre and I to talk amongst ourselves.
It was an awkward moment, and I felt that I really didn't know what to say to him. Then I suddenly remembered that many years ago Marie and I were playing on the same hockey team. Pierre, as always, was there to watch Marie. I asked him if he would use my camera to take some pictures of our team in action. "How much film do you have?" He asked. (Pausing for a moment -remember film! -remember sending it off to be developed and waiting days to weeks to share your photos?) "I tend to go mad taking photos" he warned. "Are you still taking pictures?" I asked the now handicapped Pierre. His facial muscles couldn't completely express a smile, but he was beaming. "Yes I am!" He exclaimed "that was so sweet of you to remember."
When we met up with some other mutual friends, we received the details on Pierre's situation. Shortly after we last saw him, he started to feel poorly, but it was about a year and a half before he was referred to a neurologist. He was then evaluated by some neurology sub-specialists, who agreed that he probably had an atypical form of Amyotrophic Lateral Sclerosis, a.k.a Lou Gehrig's disease. Some commented that at times they felt that the disease affected his personality, but on his good days, they still found their old friend.
My first thought on learning of his passing was to acknowledge the blessing that he is no longer in pain and no longer suffering. It probably was a good thing that he and Marie didn't have children. As much as he would have loved every minute of being a dad, I'm sure if would have been agonising to know that he would never watch them grow up. As his level of disability increased, I'm sure he would have been more frustrated not to be able to engage in activities with his children. I imagine it would have been very difficult for Marie to care for her ill husband and for a baby. Yet, despite these silver linings; there's still no justice, it's still not fair. I'm relieved to know that he is now comfortable, but he shouldn't have been sick in the first place. I'm giving a double finger 'Fuck You' to the Universe right now.
I dug up my old photo albums (another blast from the past) and found the photos Pierre captured from our hockey match. He was really talented and I'm glad he could continue with his hobby despite his crippling state. I really treasure these photos, especially now as I realise that they represent our last connection to our friend. I'm so happy that we ran into them last year. I'm so glad that he was able to attend the Olympic Games, hosted by his home country, as he loves sports and has so much national pride. His last day was spent watching rugby, tennis and the Formula One qualifiers. I'm gutted that he passed the night before one of the biggest stories in British sports -Andy Murray's triumph at Wimbledon; but I like to think that he opted to have a better view of Centre Court.
Good bye Pierre. Your kindness and zest for life will never be forgotten.
Saturday, 6 July 2013
Infertiles Only
I started blogging when I realised that writing about my experience with infertility was really cathartic. I could have just started a hand written journal, but a blog just seemed more modern and Husband even described it as 'trendy' -a word seldom associated with me. I maintain that I only write my blog for myself and I never imagined that I would have any followers, let alone develop so many friendship with fellow bloggers. I was a bit nervous about divulging so many intimate aspects of my life onto the World Wide Web, but I figured that the only people who would be interested in reading my accounts would be fellow infertiles. I inspect the statistics provided by blogspot from time to time, as I'm always curious to see what key words lead people to my blog. My Thanks, Masturbation! post brought much traffic to my blog, but probably left a lot of viewers very disappointed. Despite the sexually laden themes, there is nothing sexy about infertility.
As recommended, I keep an eye on the spam filters, and I look out for new comments that show up on my older posts. Recently I discovered this note on a post I had published in February. I reported that my car sustained some structural damage and was written off by my insurance company. My essay explored how routine decisions about purchasing a car can be challenging to infertile couples, as we had to address whether to get a family sized car when we don't know if our family will expand beyond the two of us. This was the recent comment:
It's really disappointing when unexpected things suddenly came up, especially if it costs a lot. Good thing everything came out good. Anyway, how's your car now? Thorough inspection and good maintenance are always the key to make one's car extend it's life expectancy, and I hope that's what will happen to your car. x Bob Loblaw x @ XYZTransmission.com on The Foreseeable Future.
I have to admit I felt a bit violated. More so than thinking about the various perverts who may encounter my blog. Actually, I kind of feel badly for them. These would be wankers are just looking to jerk off to some erotic material (and they say no one reads these days...) but they stumble upon my blog and their libido is instantly depleted. Although this guy expressed some concern for my situation, he walked into the world of my infertility just to pursue his own agenda. My car itself wasn't really the focus of the post, but I'm not surprised that a guy who can't distinguish an adjective and an adverb didn't pick up on that. By the way, my transmission runs well despite the fact that I'm usually late for my oil changes and I'm overdue for my 125,000 mile inspection.
My blog is exclusively for my own needs to express my infertility journey through writing and I only intended to share my stories with others who can relate. I realise I can't control the traffic or the viewers who come to my blog, so I'll just issue this plea: Please don't feign interest in my story just to promote your own business.
As recommended, I keep an eye on the spam filters, and I look out for new comments that show up on my older posts. Recently I discovered this note on a post I had published in February. I reported that my car sustained some structural damage and was written off by my insurance company. My essay explored how routine decisions about purchasing a car can be challenging to infertile couples, as we had to address whether to get a family sized car when we don't know if our family will expand beyond the two of us. This was the recent comment:
It's really disappointing when unexpected things suddenly came up, especially if it costs a lot. Good thing everything came out good. Anyway, how's your car now? Thorough inspection and good maintenance are always the key to make one's car extend it's life expectancy, and I hope that's what will happen to your car. x Bob Loblaw x @ XYZTransmission.com on The Foreseeable Future.
I have to admit I felt a bit violated. More so than thinking about the various perverts who may encounter my blog. Actually, I kind of feel badly for them. These would be wankers are just looking to jerk off to some erotic material (and they say no one reads these days...) but they stumble upon my blog and their libido is instantly depleted. Although this guy expressed some concern for my situation, he walked into the world of my infertility just to pursue his own agenda. My car itself wasn't really the focus of the post, but I'm not surprised that a guy who can't distinguish an adjective and an adverb didn't pick up on that. By the way, my transmission runs well despite the fact that I'm usually late for my oil changes and I'm overdue for my 125,000 mile inspection.
My blog is exclusively for my own needs to express my infertility journey through writing and I only intended to share my stories with others who can relate. I realise I can't control the traffic or the viewers who come to my blog, so I'll just issue this plea: Please don't feign interest in my story just to promote your own business.
Wednesday, 3 July 2013
Business Time!
About five years ago, my friend H introduced me to the New Zealand folk duo Flight of the Conchords when she played a clip of their song, Business Time. I encourage everyone to watch it (especially if you need a good laugh) but basically it discusses how when you're married or in a long term relationship, sex seems like a weekly chore -just like taking out the recycling. Husband and I still refer to the fact that Wednesday is the day for business time (which is also our neighborhood recycling day and coincidently my swim team designated the day as "Sexy Underwear Wednesday")
The aspect of sex as a marital duty adopts an even greater obligatory feeling while you're trying to conceive. Scheduled coitus is just so un-natural and so awkward. In our very early days, I wanted to keep the process spontaneous, but soon discovered that Husband can't keep his hands off himself. More pressure was added to the situation when we learned of the issues with his sperm count and found that we needed to coordinate a three day run up with my erratic ovaries. Spontaneity continues to decline the longer you're trying to conceive, as it's inevitable that your partner will learn your cycles and can determine your fertile time. My medical assistant and I would often find it creepy when a husband or boyfriend answers the question "when was your last menstrual period?" and it's still a little weird, but I can understand why he knows the date.
It's so hard not to feel the pressure, and I can almost agree that the "just relax!" campaigners have a point here, but it's much easier said than done. Once the anxiety has been released, you can't put the toothpaste back into the tube. Not only does the process of procreation bring a sense of obligation, it changes the meaning of the act away from intimacy and pleasure. On that note, can we acknowledge much the modern male has evolved his focus to ensuring his partner's satisfaction? Although I did recently catch a very old episode of Friends in the one where Joey participates in a fertility study and can't conduct any of his own "research projects". As his new girlfriend is eager to jump in the sack, Monica encourages him to "be there...for her" -a concept he fails to grasp...
Now the tables are turned, and it's all about him. While not delivering a Meg Ryan from When Harry Met Sally performance, I admit that at times I've provided some false encouragement rather early to signify that I am sorted and that he is good to go. The longer things seem to take, means it's not a good sign. Two minutes in heaven is much better than thirty minutes or more. The nerves set in and I can sense his frustration. Even though he's a willing participant, it starts to feel a little creepy. Sort of like when you were at your first make-out party and let the guy you paired with get further than you intended...
I know it's merely a mental block. Many years ago when I was playing tennis, I was struggling with my forehand and my opponents were exploiting that shot. I signed up for a private lesson to correct it. The pro hit a few strokes with me and then started feeding exclusively to my backhand. I looked at the clock and was becoming annoyed. We were fifteen minutes in and not working on what I had specified. He just kept drilling the backhand and then randomly threw me a forehand. I ran over and hit a perfect clearcut winner. "There was nothing wrong with your mechanics" he informed me, "it was all between the ears". I hope that is the case once more.
Monday, 1 July 2013
2013 Challenge Update #3
Despite skipping out on painting that weekend, I only have two more batches of doors to do, which will each take about 6 weeks. I am starting to accept that my kitchen project is going to win the 2013 challenge and I will be finished with the painting before becoming pregnant. Although I will be happy to be done with this task, I think it will bring a little sense of sadness. I'll have completed painting every room, every piece of trim, every door and now every cabinet in our house. Not only will I not be pregnant, but it will some how feel unsettling not to have any more DIY projects in process. We still need to select the moulding for the cabinet trim and we need to coordinate borrowing my dad's laser level. Recently, he reported that he finished with it and could send it through the post. "Wouldn't it just be easier to bring it when you visit in September?" I asked "I know you're a little nervous about it getting damaged, and you know that as soon as you send it, you'll have a project where you need it..." He agreed with me. So, not only does that buy me a little more time, as the trim won't be installed before his visit, but I also think I can get him to mark the ceiling for us. Score!
This week also marks another anniversary. It was a year ago that we had the initial consultation with our RE. As he was rather optimistic at the conclusion of our visit, I didn't think we would still be in each other's lives 12 months later. I wasn't naive enough to think I would get pregnant after my first treatment cycle, and I never could have imagined the delays from Husband starting Clomid, a spontaneous conception and miscarriage, or discovering my uterine septum; but for some reason, I just didn't think we would still be here.
It wasn't so much the inevitable BFN with our last IUI that called our game plan into question; it was the fact that I was so certain of the outcome long before I peed on the stick. I know IUIs have a low success rate. Statistics show that they don't hold much advantage over timed intercourse, and other studies note that IUI may not be an effective remedy for male factor infertility. Since the very beginning of this process, Husband and I have acknowledged that we will ultimately need to do IVF. Shouldn't we just get this show on the road?
We had tickets to another ball game on the night of AF's arrival, so we re-visited our strategy between innings while sipping down some much needed beers. By the seventh inning stretch, we had decided to stick with the original game plan. If we're still un-pregnant after the in-law invasion and the Hawaii trip of family fun-ness, we'll start IVF in October. We both had different reasons. Thanks to my fellow bloggers, I have gained an understanding for the realities of IVF that is more accurate than anything I could have read in a textbook or absorbed in a lecture. We were already far too wise to entertain thoughts that we could start IVF now and deliver the good news to both sets of parents at the rare opportunity when we would all be together. We know IVF does not equal instant baby. Now we're savvy enough to know that protocols can be unpredictable, cycles get cancelled, retrieval rates can be low and fertilisation rates disappointing. Transfers can get delayed. It is best to prepare for the unexpected. Once we start this process, it's going to be a full commitment and we want to avoid all potential obstacles.
Husband's thinking is that if we stimulate and retrieve in the final months of the year, we can apply our 2013 Flexible Spending Accounts (FSA) to those costs and the we can use the 2014 FSA earmarks for our transfers. I so appreciate how he can view the plan of action so simply in terms of numbers and dates. For me, it's more of an emotional decision, although I'm reluctant to reveal that I'm letting my emotions consume so much of my thought process. I'm already feeling apprehensive about the visit with my parents and in-laws, but I feel it could be much worse after a disappointing cycle or failed IVF treatment. Not to sound co-dependent, but I am going to need alcohol and possibly some category 'D' anti-anxiety meds to get through these two weeks. I feel it's important for my body to be in an optimal state of health before starting IVF, so getting past the stress of the in-law visit is an important component. Although the Hawaii trip with my parents, in-laws, aunt, uncle and cousins, is not an ideal vacation, I feel we've earned the right to make the most of it and to find ways to have an enjoyable, relaxing and fun time. Oh, and I will collect $20 from Myrtle, who bet me that my in-laws wouldn't go and that I'd be pregnant by the time of the trip. At one point, I felt uneasy about turning my infertility into a bet, now I see it as contributions to my Mai Tai fund.
We're going to do two more IUI cycles in July and August, with an option for a third and final one in September. Mostly, because it's much easier and less stressful than scheduled coitus, and reasonably priced. My financial figure conscious Husband is still hoping to avoid the costs of IVF, while my personal figure conscious self is hoping to avoid the weight gain from hormone supplements. We're hopeful idiots. As we conceived spontaneously after seven meager attempts on our own, maybe it will only be a matter of time with professional assistance. We shall see...
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