As I walked into the break room to refill my water bottle one morning, two medical assistants were chatting about where they take their dogs to be groomed. One I have already introduced. Betty confided to Co-worker that she failed to conceive on her own, and by the time she went to an RE, she had a depleted ovarian reserve. It took her a long time even to acknowledge Co-worker's pregnancy and she revealed that even years after embracing her child-free status, she still found baby showers and other children-related events difficult to attend. When I joined the practice nearly five years ago, a few staffers revealed that Veronica was trying to conceive. Two years later, she disclosed to me that she failed to ovulate with 100 mg of Clomid and she decided not to pursue any further treatments. Her husband had a teenaged daughter from a previous relationship, and she had accepted her role as a step-mother. A year ago, she approached me and asked for an IUD, noting that she'd be pissed if she became pregnant at this time. I could appreciate her desires and understood that it was a painful process to arrive at that place.
Michael Scott, the office busybody, walked in the room and started listening to their conversation. "You spend how much on your dogs?" she gasped (as if she didn't engage in any frivolous purchases ahem, purses!) "That's ridiculous" she criticised. Betty was quick to react, "My dogs are my children!" she exclaimed as Veronica nodded in agreement. Michael Scott just rolled her eyes, "No they're not. You should have had real babies."
I nearly dropped my water bottle. While I would never actually resort to violence; on any given day, I could fantasize about hitting Michael Scott. Now I was imagining myself putting my weight behind my punch. I'm pretty sure Co-worker is the only one who knows about Betty's infertility history, but Michael Scott certainly knew about Veronica's story.
Her words stung like a slap in the face. They may not have been directed toward me, but I felt their effects. Such is the solidarity of infertility. Make an insensitive comment to one of my sisters and you hurt us all. I wanted to speak up. I wanted to say something to put Michael Scott in her place. Alas, I cannot. To do so would expose their skeletons as well as mine. Members of this sorority vow to honour each other's secrets. Such is the solitude of infertility. Alas, I'm cringing in silence.
Friday, 20 September 2013
Wednesday, 18 September 2013
Numbers and Figures
As we were wrapping our initial REI consult last July, my RE commented, "I think you have a good chance with IVF." "Forty percent" he estimated off the top of his head. I wasn't quite prepared to hear that we would need to consider IVF at that moment, let alone to comprehend that a forty percent success rate would be accepted as 'good'. I couldn't think of any other situation in medicine, or in life for that matter, where a higher failure rate is satisfying. It truly reflects the unique and precarious nature of infertility. "So, that means there is a sixty percent chance that IVF will not work..." I immediately countered. "Well Jane, that depends if you see the glass as being half full or half empty..." He replied, sounding a bit like my mother. "No. That all depends if you are drinking or pouring." I retorted with a saucy tone.
I hadn't intended to be a smart-alec, although it was an added bonus. I did have a point. I've always hated that simplistic test used to determine if one is an optimist or pessimistic, as it entirely depends on the situation. One cannot make an evaluation without any context. A mother who is trying to feed her baby is happy when the bottle is half empty. A pregnant woman taking her glucose challenge test is annoyed when the bottle is half full. A bartender is optimistic when he sees a half empty glass, as it means that the patron may order another. I become irritable if the night is getting late and Husband's pint glass is still half full as I want him to finish up so we can go the fuck home. As it is with so many things in life, it's not black and white.
The 40%-60% split stood out in my mind for another reason. Years ago, when I was talking a colposcopy training course, the instructor referenced a retrospective study from New Zealand. The researchers collected data on women who had high grade lesions on a Pap smear, but failed to comply with the recommended evaluations and treatments. Twenty years later, 40% were eventually diagnosed with cervical cancer. "Isn't it more impressive that 60% did not progress to cervical cancer?" I asked earnestly. The instructor chided that I could not view the results with "Pollyanna thinking." Thus, implying that 40% was still a significant cancer rate, and was irrespective to the fact that 60% did not develop cervical cancer. Maybe it reflects the fact that it's a difficult comparison between infertility and cervical cancer, but on the surface it still seemed odd. In one situation fewer patients gets cancer, but it's still considered bad; in the other, fewer patients get pregnant, but that's considered good? I suppose it helps to frame with ideals and realistic expectations. Ideally, one wants to have a zero percent cancer rate, and I think my instructor was trying to emphasize the role of intervention and treatment in this situation. Ideally, one would like all infertility patients to become pregnant, but unfortunately it's not realistic at this time. Forty percent becomes a significant number when you compare it to the fact that very few patients would be able to conceive without intervention. I also appreciate that 40% is a higher rate compared to couples with more challenging diagnoses.
If we were to take the laize-faire approach to conception, I would estimate our chances for success to be 0.1%. I am somewhat making these numbers up as I go along, with a preference for whole numbers to make my maths easier. I am basing that figure on the fact that even with my Clearblue Monitor, it is still difficult to determine when I will ovulate, and being able to schedule coitus during that time is another obstacle. Perhaps with proactive efforts, our chance of spontaneous conception would be around 1%. Thus IVF increases our chances by 40-400%. It is projected that an IUI only has a 15% opportunity for success in ideal conditions. My RE noted that the sperm count should be between 5-10 million (in the absence of male factor issues, there doesn't seem to be an increase in pregnancy rates when the count is higher than ten million). As we had less than half of the desired sperm count and if you round down a bit to adjust for my old age, we probably had a 4% chance for pregnancy. IVF increases those odds ten-fold.
The diagnosis of infertility really starts to hit home when you approach the data that way. Modest success rates are still preferred to the alternative of doing nothing. It's also helpful to frame your expectations. There is a greater probability that this won't work. It is statistically anticipated that I won't get pregnant with these treatments. Two out of three couples leave their REI clinic heartbroken. I haven't asked my RE to re-estimate our chances for success, and I don't plan to do so. I already know they're probably lower that what he conjectured last year. Just as I dismiss the platitudes proclaiming it will happen! as merely being meaningless words; statistics are only numbers, and they don't necessarily mean anything.
I hadn't intended to be a smart-alec, although it was an added bonus. I did have a point. I've always hated that simplistic test used to determine if one is an optimist or pessimistic, as it entirely depends on the situation. One cannot make an evaluation without any context. A mother who is trying to feed her baby is happy when the bottle is half empty. A pregnant woman taking her glucose challenge test is annoyed when the bottle is half full. A bartender is optimistic when he sees a half empty glass, as it means that the patron may order another. I become irritable if the night is getting late and Husband's pint glass is still half full as I want him to finish up so we can go the fuck home. As it is with so many things in life, it's not black and white.
The 40%-60% split stood out in my mind for another reason. Years ago, when I was talking a colposcopy training course, the instructor referenced a retrospective study from New Zealand. The researchers collected data on women who had high grade lesions on a Pap smear, but failed to comply with the recommended evaluations and treatments. Twenty years later, 40% were eventually diagnosed with cervical cancer. "Isn't it more impressive that 60% did not progress to cervical cancer?" I asked earnestly. The instructor chided that I could not view the results with "Pollyanna thinking." Thus, implying that 40% was still a significant cancer rate, and was irrespective to the fact that 60% did not develop cervical cancer. Maybe it reflects the fact that it's a difficult comparison between infertility and cervical cancer, but on the surface it still seemed odd. In one situation fewer patients gets cancer, but it's still considered bad; in the other, fewer patients get pregnant, but that's considered good? I suppose it helps to frame with ideals and realistic expectations. Ideally, one wants to have a zero percent cancer rate, and I think my instructor was trying to emphasize the role of intervention and treatment in this situation. Ideally, one would like all infertility patients to become pregnant, but unfortunately it's not realistic at this time. Forty percent becomes a significant number when you compare it to the fact that very few patients would be able to conceive without intervention. I also appreciate that 40% is a higher rate compared to couples with more challenging diagnoses.
If we were to take the laize-faire approach to conception, I would estimate our chances for success to be 0.1%. I am somewhat making these numbers up as I go along, with a preference for whole numbers to make my maths easier. I am basing that figure on the fact that even with my Clearblue Monitor, it is still difficult to determine when I will ovulate, and being able to schedule coitus during that time is another obstacle. Perhaps with proactive efforts, our chance of spontaneous conception would be around 1%. Thus IVF increases our chances by 40-400%. It is projected that an IUI only has a 15% opportunity for success in ideal conditions. My RE noted that the sperm count should be between 5-10 million (in the absence of male factor issues, there doesn't seem to be an increase in pregnancy rates when the count is higher than ten million). As we had less than half of the desired sperm count and if you round down a bit to adjust for my old age, we probably had a 4% chance for pregnancy. IVF increases those odds ten-fold.
The diagnosis of infertility really starts to hit home when you approach the data that way. Modest success rates are still preferred to the alternative of doing nothing. It's also helpful to frame your expectations. There is a greater probability that this won't work. It is statistically anticipated that I won't get pregnant with these treatments. Two out of three couples leave their REI clinic heartbroken. I haven't asked my RE to re-estimate our chances for success, and I don't plan to do so. I already know they're probably lower that what he conjectured last year. Just as I dismiss the platitudes proclaiming it will happen! as merely being meaningless words; statistics are only numbers, and they don't necessarily mean anything.
Monday, 16 September 2013
Initial Instincts
"Trust your initial instincts -they are usually correct." I recall many teachers offering those words of wisdom, but mind you those same teachers also advised you to "read every question carefully" and to "review your work." Often many exams were not necessarily testing your knowledge, but were evaluating your ability to find the best answer that fits a particular question. In which case, your initial instincts could be misleading.
When I first moved to California, I was planning to keep my Connecticut plates and my CT driver's license in order to maintain my New England identity. I had always done so when I lived in other states for schooling and training. However, my Dudley-do-right husband pointed out that California highway patrol is strict about making new residents register their vehicles, and I would need apply for a California driver's license in order to facilitate voter registration. Still not able to let go of my Connecticut roots, I kept my old mobile phone number. My RE is one of the few who recognises the area code, as a reflection of the fact that ten years ago we lived in the same town on the other side of the country.
I had to take the written exam in order to obtain a California driver's license, and I was rather surprised at their primitive testing process. When I took the test as a teen in Connecticut, it was computerized. Each question actually showed you a little video and you judged your answers based on what you thought was appropriate in that situation. There were only 16 questions and you needed 12 correct responses to pass. I got my first question wrong, but then aced the next twelve and the computer stopped the test after I submitted my 12th correct answer. Fifteen years later, the much larger state of California simply issued a double sided sheet of paper with multiple guess questions and I think we had to supply our own pen. There was a designated testing area, which was merely a large counter and no one proctored the exams. One could easily cheat off a neighbour.
I thought that 15 years of diving experience and reading the California driving handbook the night before would be enough preparation, but I was wrong. I was truly struggling with the questions. The temptation to cheat was overwhelming, but I felt I had to maintain some integrity. I re-read one question and changed my answer by placing an 'X' though the box I had filled in and coloured in the one for my new answer. Later, I reviewed it once more and thought about what they say about your initial instincts. I placed another 'X' though that box and circled my original answer. Just to make my intentions clear, I added the words 'Yes' and 'No' next to my responses.
I handed in my test and watched as my paper was hacked with a red marking pen. "Five incorrect. FAIL!" pronounced the DMV employee as she signaled to the next person in the queue and handed my exam back to me. Humiliated, I walked out of the DMV as quickly as possible. I was devastated. While I can't say that I never failed a test in my academic career, it was a rare event. Now I had just failed one of the most fundamental exams in one's life. I got back in my car to drive home after failing my driving test and I looked over my paper. She had marked the question where I changed my answer twice as being wrong, but indicated that my original response was correct. I stormed back into the DMV, drew another number and waited to confront the disgruntled DMV grader. "How do I know you didn't just mark this now?" she demanded. I was tempted to mention that if I wanted to cheat I could have done so while I was taking the test... Instead, I pulled the "May I speak with your supervisor?" card. I plead my case and he believed that my initial intention selected the correct answer. "Always trust your initial instincts" He advised me. "They are usually right."
When I went into hypertensive crisis after consuming birth control pills for ten days, I expressed concerns to my RE about what this would mean for potential IVF protocols. He noted that he preferred to use microdose Lupron, and more recently when we started IVF discussion, he commented that a Lupron agonist protocol is standard. However, when he proposed my tentative schedule, he described that after giving it some thought, we could stimulate with a natural cycle. This makes me question which suggested protocol truly reflects his initial instincts?
I know my initial instincts were correct when we decided to pass on the original proposed time table. In addition to coinciding with the in-law invasion, it would have been really difficult to be out of the office while I've been trying to tie up loose ends before my vacation. There was one more disconcerting aspect about that possible retrieval date. It would fall on little Myrtle's first birthday. I know that I need to move past the fact that Myrtle conceived naturally on her second attempt while I am infertile... However, to be going through a procedure for assisted reproduction at the same time when everyone is celebrating the day her relatively easy pregnancy led to a textbook spontaneous vaginal delivery on her fucking due date and produced her gorgeous daughter; would be filed under the heading: Not Helping.
The easy solution would be to wait for my next natural cycle in October, but my RE will be attending the ASRM annual meeting during the approximate retrieval time. If we look toward November or December, we could be conflicting with the holidays. I don't want to wait until 2014, as when we met with my RE for a postmortem after my miscarriage, he recommended starting before that date. I'll be 38 that year, and success rates start to drop. Sooner is better than later. After trying to avoid IVF for over a year, I don't want to delay any longer. So we're back to the (original?) plan of a lupron agonist protocol. He's targeting a retrieval date of 30 October, so I'd start stimming around the 20th (Interesting that he picks the retrieval date and works backward). Husband has no travel plans during this time, I may run a half marathon on the 20th, but then my competition schedule is clear until my 80s run mid-November. Not that it would be critical, but just an added bonus that my calendar happens to be free, and it seems nice to have some aspect working in my favour.
Husband couldn't resist pointing out the irony. Just before we started trying to conceive, we signed up for this holiday time share so that we could take family vacations with our little one. Not only is a trip with both our parents, my aunt and uncle, cousins and their estranged significant others not what we had in mind, it created a barrier for us to achieve the dream of having a little one. Alas, a reminder not to count your chickens before they hatch, but it also reflects how one decision can affect circumstances in the future. Yet, which ones are pivotal? Would the difference between the two protocols be akin to picking six of one or half dozen of another? Calling 'heads -I win; tails -you lose' on a coin toss? Or could this be a game changer? Whose initial instincts will be validated? Only time will tell...
When I first moved to California, I was planning to keep my Connecticut plates and my CT driver's license in order to maintain my New England identity. I had always done so when I lived in other states for schooling and training. However, my Dudley-do-right husband pointed out that California highway patrol is strict about making new residents register their vehicles, and I would need apply for a California driver's license in order to facilitate voter registration. Still not able to let go of my Connecticut roots, I kept my old mobile phone number. My RE is one of the few who recognises the area code, as a reflection of the fact that ten years ago we lived in the same town on the other side of the country.
I had to take the written exam in order to obtain a California driver's license, and I was rather surprised at their primitive testing process. When I took the test as a teen in Connecticut, it was computerized. Each question actually showed you a little video and you judged your answers based on what you thought was appropriate in that situation. There were only 16 questions and you needed 12 correct responses to pass. I got my first question wrong, but then aced the next twelve and the computer stopped the test after I submitted my 12th correct answer. Fifteen years later, the much larger state of California simply issued a double sided sheet of paper with multiple guess questions and I think we had to supply our own pen. There was a designated testing area, which was merely a large counter and no one proctored the exams. One could easily cheat off a neighbour.
I thought that 15 years of diving experience and reading the California driving handbook the night before would be enough preparation, but I was wrong. I was truly struggling with the questions. The temptation to cheat was overwhelming, but I felt I had to maintain some integrity. I re-read one question and changed my answer by placing an 'X' though the box I had filled in and coloured in the one for my new answer. Later, I reviewed it once more and thought about what they say about your initial instincts. I placed another 'X' though that box and circled my original answer. Just to make my intentions clear, I added the words 'Yes' and 'No' next to my responses.
I handed in my test and watched as my paper was hacked with a red marking pen. "Five incorrect. FAIL!" pronounced the DMV employee as she signaled to the next person in the queue and handed my exam back to me. Humiliated, I walked out of the DMV as quickly as possible. I was devastated. While I can't say that I never failed a test in my academic career, it was a rare event. Now I had just failed one of the most fundamental exams in one's life. I got back in my car to drive home after failing my driving test and I looked over my paper. She had marked the question where I changed my answer twice as being wrong, but indicated that my original response was correct. I stormed back into the DMV, drew another number and waited to confront the disgruntled DMV grader. "How do I know you didn't just mark this now?" she demanded. I was tempted to mention that if I wanted to cheat I could have done so while I was taking the test... Instead, I pulled the "May I speak with your supervisor?" card. I plead my case and he believed that my initial intention selected the correct answer. "Always trust your initial instincts" He advised me. "They are usually right."
When I went into hypertensive crisis after consuming birth control pills for ten days, I expressed concerns to my RE about what this would mean for potential IVF protocols. He noted that he preferred to use microdose Lupron, and more recently when we started IVF discussion, he commented that a Lupron agonist protocol is standard. However, when he proposed my tentative schedule, he described that after giving it some thought, we could stimulate with a natural cycle. This makes me question which suggested protocol truly reflects his initial instincts?
I know my initial instincts were correct when we decided to pass on the original proposed time table. In addition to coinciding with the in-law invasion, it would have been really difficult to be out of the office while I've been trying to tie up loose ends before my vacation. There was one more disconcerting aspect about that possible retrieval date. It would fall on little Myrtle's first birthday. I know that I need to move past the fact that Myrtle conceived naturally on her second attempt while I am infertile... However, to be going through a procedure for assisted reproduction at the same time when everyone is celebrating the day her relatively easy pregnancy led to a textbook spontaneous vaginal delivery on her fucking due date and produced her gorgeous daughter; would be filed under the heading: Not Helping.
The easy solution would be to wait for my next natural cycle in October, but my RE will be attending the ASRM annual meeting during the approximate retrieval time. If we look toward November or December, we could be conflicting with the holidays. I don't want to wait until 2014, as when we met with my RE for a postmortem after my miscarriage, he recommended starting before that date. I'll be 38 that year, and success rates start to drop. Sooner is better than later. After trying to avoid IVF for over a year, I don't want to delay any longer. So we're back to the (original?) plan of a lupron agonist protocol. He's targeting a retrieval date of 30 October, so I'd start stimming around the 20th (Interesting that he picks the retrieval date and works backward). Husband has no travel plans during this time, I may run a half marathon on the 20th, but then my competition schedule is clear until my 80s run mid-November. Not that it would be critical, but just an added bonus that my calendar happens to be free, and it seems nice to have some aspect working in my favour.
Husband couldn't resist pointing out the irony. Just before we started trying to conceive, we signed up for this holiday time share so that we could take family vacations with our little one. Not only is a trip with both our parents, my aunt and uncle, cousins and their estranged significant others not what we had in mind, it created a barrier for us to achieve the dream of having a little one. Alas, a reminder not to count your chickens before they hatch, but it also reflects how one decision can affect circumstances in the future. Yet, which ones are pivotal? Would the difference between the two protocols be akin to picking six of one or half dozen of another? Calling 'heads -I win; tails -you lose' on a coin toss? Or could this be a game changer? Whose initial instincts will be validated? Only time will tell...
Friday, 13 September 2013
Oh, Yes...I did.
Shortly after AF's arrival announced the failure of our final IUI, I sent a text to Myrtle.
20 bucks. In-laws set to arrive in ten days and I'm still not pregnant. It's contributions to my Mai Tai fund.
Her response: Ughh ok I will begrudgingly pay!
I wanted her to know that I didn't forget about her bet. A year ago, just before little Myrtle was born, we were texting about whether my in-laws would actually make the trip. "I'll bet you $10 they don't come" she offered. Then she added, "Actually, I'll be collecting $20 from you. $10 for your in-laws staying home and $10 for you getting pregnant." I was less than a year into my TTC and infertility journey, but it just seemed inappropriate to be wagering on my uterus.
I truly know that she means well and doesn't quite know what to say in this situation, but it just resonated that she's been wrong with so many predictions. When I first disclosed that we were getting off to a slow start, she confidently assured me "it will happen!". As I was still naive at that time, I didn't feel I had much cause to doubt her. After I informed her of Husband's diagnosis of moderate male factor infertility; she proclaimed, "I still think you'll conceive on your own." Her blind faith astounded me, but I couldn't help read into her emphasis on a spontaneous conception. Was she some how implying that there would be something inferior about a pregnancy achieved with assisted reproduction?
After I flew out to Connecticut to host her baby shower, she sent me a thank you card and included a note, "I know in my heart that I'll be throwing a similar event for you soon." Yeah, more than a year later is not exactly soon... although it's a moot point as I wouldn't want her (or anyone) to arrange a shower for me. Finally, on her Christmas card she wrote "...and now we ring in 2013 which will be your year!" To be fair, I think she sent it after I received my BFP and before my miscarriage. Her experience found that positive pregnancy test equals baby. She didn't know that you have to hold your breath for a few serial ultrasounds. Although 2013 has been my year to achieve some personal best swim times, complete two more half marathons, start cross fit classes and return to the tennis court; not that Myrtle ever asks about those events.
I wanted to prove a point. That predictions based only on hopeful thinking are not only irritating at the time the words are spoken, but they add to our ever present disappointment when they don't come true. Additionally, there is some concern that I could also be forced to hear her say 'See, I told you so!' if I were to become pregnant; you know as if she truly had psychic powers to back up her insight. Although I'd be willing to take one on the chin in that situation. It's simple; don't make empty promises -especially ones with a time frame.
Thankfully, Myrtle didn't point out that I did in fact spontaneously conceive, so technically she was correct with two of her assertions. I didn't want to counter that a pregnancy that didn't even make it to the first ultrasound appointment is not what either of us had in mind. A few minutes later, she sent another text asking if I had received an email from the Commish. A few years ago, a friend of Myrtle's husband invited us all to join an NFL elimination pool. Participants must pick a winning team each week (can only select a team once) to remain in the draw and the last person standing wins the pot. I don't have much interest in American Football, but I enjoy the strategic aspect of the challenge. Myrtle is actually much better at guessing NFL winners than she is at forecasting my fertility and usually stays in the pool the longest out of me and our die-hard football fan husbands.
I confirmed that I did receive his email and intended to participate this season. In his message, the Commish announced that this year's contest is brought to you by the letter 'O' and the number '3'. "As in, Oops! We now have 3 kids!" Sheesh, not even an NFL elimination pool is safe from someone flaunting his fertility. Myrtle offered that she could pay my $20 entry fee. "Thanks, that would be great." I accepted, mentally thinking that I would be applying that earning on to a chance to win $4,000. That's the cost of my stims, GPD testing or a FET! Infertility treatments themselves are a gamble, is it so far fetched to be gambling for them?
20 bucks. In-laws set to arrive in ten days and I'm still not pregnant. It's contributions to my Mai Tai fund.
Her response: Ughh ok I will begrudgingly pay!
I wanted her to know that I didn't forget about her bet. A year ago, just before little Myrtle was born, we were texting about whether my in-laws would actually make the trip. "I'll bet you $10 they don't come" she offered. Then she added, "Actually, I'll be collecting $20 from you. $10 for your in-laws staying home and $10 for you getting pregnant." I was less than a year into my TTC and infertility journey, but it just seemed inappropriate to be wagering on my uterus.
I truly know that she means well and doesn't quite know what to say in this situation, but it just resonated that she's been wrong with so many predictions. When I first disclosed that we were getting off to a slow start, she confidently assured me "it will happen!". As I was still naive at that time, I didn't feel I had much cause to doubt her. After I informed her of Husband's diagnosis of moderate male factor infertility; she proclaimed, "I still think you'll conceive on your own." Her blind faith astounded me, but I couldn't help read into her emphasis on a spontaneous conception. Was she some how implying that there would be something inferior about a pregnancy achieved with assisted reproduction?
After I flew out to Connecticut to host her baby shower, she sent me a thank you card and included a note, "I know in my heart that I'll be throwing a similar event for you soon." Yeah, more than a year later is not exactly soon... although it's a moot point as I wouldn't want her (or anyone) to arrange a shower for me. Finally, on her Christmas card she wrote "...and now we ring in 2013 which will be your year!" To be fair, I think she sent it after I received my BFP and before my miscarriage. Her experience found that positive pregnancy test equals baby. She didn't know that you have to hold your breath for a few serial ultrasounds. Although 2013 has been my year to achieve some personal best swim times, complete two more half marathons, start cross fit classes and return to the tennis court; not that Myrtle ever asks about those events.
I wanted to prove a point. That predictions based only on hopeful thinking are not only irritating at the time the words are spoken, but they add to our ever present disappointment when they don't come true. Additionally, there is some concern that I could also be forced to hear her say 'See, I told you so!' if I were to become pregnant; you know as if she truly had psychic powers to back up her insight. Although I'd be willing to take one on the chin in that situation. It's simple; don't make empty promises -especially ones with a time frame.
Thankfully, Myrtle didn't point out that I did in fact spontaneously conceive, so technically she was correct with two of her assertions. I didn't want to counter that a pregnancy that didn't even make it to the first ultrasound appointment is not what either of us had in mind. A few minutes later, she sent another text asking if I had received an email from the Commish. A few years ago, a friend of Myrtle's husband invited us all to join an NFL elimination pool. Participants must pick a winning team each week (can only select a team once) to remain in the draw and the last person standing wins the pot. I don't have much interest in American Football, but I enjoy the strategic aspect of the challenge. Myrtle is actually much better at guessing NFL winners than she is at forecasting my fertility and usually stays in the pool the longest out of me and our die-hard football fan husbands.
I confirmed that I did receive his email and intended to participate this season. In his message, the Commish announced that this year's contest is brought to you by the letter 'O' and the number '3'. "As in, Oops! We now have 3 kids!" Sheesh, not even an NFL elimination pool is safe from someone flaunting his fertility. Myrtle offered that she could pay my $20 entry fee. "Thanks, that would be great." I accepted, mentally thinking that I would be applying that earning on to a chance to win $4,000. That's the cost of my stims, GPD testing or a FET! Infertility treatments themselves are a gamble, is it so far fetched to be gambling for them?
Wednesday, 11 September 2013
Last Ditch Attempt
Oh, Gametes... if ever there was a more opportune moment for you...
This was our last ditch IUI attempt before moving forward with IVF. There were two co-dominant follicles and 4 million sperm with 75% motility and a progression score of 4. We led you to the Fallopian tube; all you had to do was fertilise, find your way to the uterus and implant. Is that really so hard? Have you seen some of the people getting pregnant out there? Did you watch Jersey Shore?
There were so many distractions in our lives during this 2WW that our gametes could have been happily doing their thing without us obsessing about them. The day after the IUI we jumped on the plane to head to Arkansas. A long weekend with the ex-pats (none seem to be planning for children at this time) provided a perfect distraction. The only trouble with spending a weekend away is that you don't get any chores done, so when we returned, our evenings were filled with laundry and cleaning. I was working 11 hour days to try to catch up after taking a couple of extra days out of the office.
As we're less than two weeks away from the in-law invasion, we've been getting the house into dress-to-impress mode (which is also operation hide everything procreation and infertility related). We had the hall carpet professionally cleaned a few months ago, but the beige colour still exposes the heavy traffic in that area, so we decided to replace it with a darker colour. This also gave us the opportunity to fix a defect in the subfloor. There was an 1/8th of an inch gap between two boards, which may not seem that significant, but if your foot caught it in the right place, you could feel yourself sink a little. A few applications of filler made it even. I can add "leveled subfloor" to my list of DIY skills. I also touched up all the trim paint. Additionally, we got around to hanging up some artwork on our bare walls.
We finally gave some attention to our much neglected gardens. We have to keep the front of the house neat, or else we'll be reprimanded from the Homeowner's Association, but the back garden hasn't seen a rake all summer. Husband pruned the way overgrown bushes, while I power washed our deck. It's still in a very sad state, but as Aramis would describe, at least it no longer looks like we're drug dealers.
When we first moved into our house and were still in the process of renovating, we didn't have the extra funds for a proper bed for the guest room. I purchased a double level air mattress from Target for $45 and left it up full time. For more than three years it has served as a decorative purpose, and many of our guests found it surprisingly comfortable. It would not be suitable for my in-laws who each have artificial hips, and as we've had the same mattress for just over ten years, we decided to get a new bed and move ours to the guest room. Husband had been complaining about our mattress for years, and while I thought it was fine, I didn't realise how bad it was until our new bed arrived. Additionally, I have a patient who works at Macy*s, who hooked us up with a sale on linens and bath towels. We also purchased a new sofa and loveseat, as ours were looking rather tattered. Love stores with the no interest financing plans!
My 2013 Challenge to see what would occur first -getting pregnant or finishing painting the cabinet and trim in out kitchen- became skewed toward the kitchen goal. Apparently, it became a deadline to finished the cabinets before the in-law arrival, and their visit led us to delay starting IVF. I completed a batch of five upper cabinet doors, and I've been painting in the evenings to try to finish the final two doors. I'm hoping my father can install the upper moulding for us during his visit. Then, I'll still need to caulk and install some side pieces of trim, which will need a touch of paint; so depending on how motivated I am, there may be a chance that a conception could win the challenge.
I had also been so busy at work that I barely had time to go to the bathroom, let alone to text Husband with quarterly updates. Finally, it dawned on me. Oh yeah, my IUI was two weeks ago... I hadn't been inspecting the toilet tissue, but there was no obvious sign of AF. I pulled my hair down and put the tie around my wrist. I was starting to hear some echoes from my patients:
"We had given up thinking we could become pregnant and lo and behold!" Snap.
"We were so busy, I had forgotten when my period was due!" Snap.
"We were going to start IVF next month!" Snap. Snap.
As Husband had to umpire a high school hockey match, I was on my own that night. I left the gym late and AF still hasn't made her presence known. It was 8 PM, if I could go another 12 hours, I'd be in uncharted territory. Then, whilst I was in a queue at Safeway, I had the feeling that she was imminent. When I arrived at home, my intuition was validated.
Oh Gametes, you failed to seize your moment of opportunity. As we're proceeding with IVF, I won't be as forgiving. You better be ready to perform. End of story.
This was our last ditch IUI attempt before moving forward with IVF. There were two co-dominant follicles and 4 million sperm with 75% motility and a progression score of 4. We led you to the Fallopian tube; all you had to do was fertilise, find your way to the uterus and implant. Is that really so hard? Have you seen some of the people getting pregnant out there? Did you watch Jersey Shore?
There were so many distractions in our lives during this 2WW that our gametes could have been happily doing their thing without us obsessing about them. The day after the IUI we jumped on the plane to head to Arkansas. A long weekend with the ex-pats (none seem to be planning for children at this time) provided a perfect distraction. The only trouble with spending a weekend away is that you don't get any chores done, so when we returned, our evenings were filled with laundry and cleaning. I was working 11 hour days to try to catch up after taking a couple of extra days out of the office.
As we're less than two weeks away from the in-law invasion, we've been getting the house into dress-to-impress mode (which is also operation hide everything procreation and infertility related). We had the hall carpet professionally cleaned a few months ago, but the beige colour still exposes the heavy traffic in that area, so we decided to replace it with a darker colour. This also gave us the opportunity to fix a defect in the subfloor. There was an 1/8th of an inch gap between two boards, which may not seem that significant, but if your foot caught it in the right place, you could feel yourself sink a little. A few applications of filler made it even. I can add "leveled subfloor" to my list of DIY skills. I also touched up all the trim paint. Additionally, we got around to hanging up some artwork on our bare walls.
I had also been so busy at work that I barely had time to go to the bathroom, let alone to text Husband with quarterly updates. Finally, it dawned on me. Oh yeah, my IUI was two weeks ago... I hadn't been inspecting the toilet tissue, but there was no obvious sign of AF. I pulled my hair down and put the tie around my wrist. I was starting to hear some echoes from my patients:
"We had given up thinking we could become pregnant and lo and behold!" Snap.
"We were so busy, I had forgotten when my period was due!" Snap.
"We were going to start IVF next month!" Snap. Snap.
As Husband had to umpire a high school hockey match, I was on my own that night. I left the gym late and AF still hasn't made her presence known. It was 8 PM, if I could go another 12 hours, I'd be in uncharted territory. Then, whilst I was in a queue at Safeway, I had the feeling that she was imminent. When I arrived at home, my intuition was validated.
Oh Gametes, you failed to seize your moment of opportunity. As we're proceeding with IVF, I won't be as forgiving. You better be ready to perform. End of story.
Monday, 9 September 2013
You Can't Tell by Looking...
Although, I've been hopeful; I always tried to remain realistic about the low success rates with IUI treatments, especially with male factor issues. I especially felt that I wasn't naive enough to believe that it could work on our first treatment cycle. Nonetheless, after being sidelined for a few months, there was a certain excitement just to be back in the game, and the BFN after my first cycle definitely produced some disappointment. As soon as I got into work that day, I saw that my first appointment was a new patient, scheduled for an annual GYN exam and to discuss infertility. Personally, this was going to be tough as the last topic I wanted to discuss was infertility. Professionally, this was going to be tough as I was already behind schedule, and needed to cover a lot of ground without being rushed.
Fortunately, she was very prepared and had detailed answers for my questions. I always start by asking patients to describe their TTC efforts. I've learned not to make any presumptions, as I've noted over time that many people do not know how to anticipate when they ovulate. Some couples copulate too frequently and others not enough. A former colleague once had a particularly shocking case. They were a highly educated couple in their late thirties, and had been trying for two years before they presented for evaluation. They were convinced something was seriously wrong and pushed for a comprehensive work up. Multiple semen analyses were normal. Serial day 3 and day 21 draws indicated good ovarian communication and ovulation. Although her HSG showed patent tubes and no obvious cavity defects, she had a laparoscopy and hysteroscopy performed. When she came in for her post-op visit, the front office staff noticed she needed to update her health history form. A medical assistant reviewed it and discovered that she was listing 'condoms' as her method of birth control. "Why are you using condoms when you're trying to get pregnant?" The patient answered that she found semen to be "icky" and they didn't think condoms were effective as a friend become pregnant while using condoms. Rather than refer her to an RE, my colleague encouraged her to get over her "ick factor" and ditch the condoms. She conceived a few months later.
My patient had been tracking her cycles, which were very regular and was having unprotected sex at the correct times with appropriate frequency. She briefly used OPKs and received consistent results, but stopped as they didn't seem to be helping her get pregnant. Her history was pristine, and I couldn't identify any red flags for concern, so I thought there could be male factor issues or they could fall into the unexplained category. I reassured her that she was doing everything right, and it was time to evaluate. Knowing all the stupid 'tips' I received, I thought those were important words for her to hear. I placed all her orders, but as I needed to move on to my next waiting patient, I asked my medical assistant to review the timeframe her her labs and HSG. I still felt that I had rushed her, so I sent her a message on our online system encouraged her to let me know when she goes for her testing or to ask any further questions.
Three months later I saw an FSH and Estradiol for an name I didn't immediately recognise. She finally went for her testing. Her results (FSH 9.8 (E2 35) and FSH 1.08) gave me concerns for her ovarian reserve. She needed to see an RE now. A week later, I received her HSG results and was not prepared for the findings. Neither tube was patent. Without any risk factors present, she had a significant tubal factor to accompany her concerning ovarian reserve. Her husband is insured though Kaiser, so I didn't have any access to his results, but I hoped for their sake that his semen analysis was normal.
I felt reminded about how hidden and secretive infertility is. I used to counsel patients regarding the lurking threats of STIs, as most affected carriers have no symptoms. "You can't tell just by looking at someone" I warned. This situation feels very similar, you can't tell by merely looking at the surface and you won't know what you'll find until you look deeper. Thus, the recommendations to "relax" or "take a vacation" and "stop trying so hard" are not only inappropriate, but potentially detrimental, as they could delay a someone who is closing in on a narrow window of time.
I reviewed her results with her, describing a somewhat 'bad news, good news' situation. No one wants to hear that an abnormality was found, but sometimes it's comforting to have an explanation. I emphasized the positives; she is ovulating and IVF is a treatment to address tubal factor. She took the news rather well and quickly scheduled an appointment with an RE. I asked her to email me after her consult. A few days later, she replied that they would be starting IVF in somewhat of an excited tone.
There is a part of me that wants to reach out to her as a fellow IF sister. I want to let her know I personally know how much it sucks to need infertility treatments when your friends and family members conceive spontaneously. I know the difficulty of attending baby showers and birthday parties. There is so much more I could say to her, but I don't want to overstep my professional bounds. I wished her the best of luck and asked her to keep me posted. She replied "Thanks :)"
Fortunately, she was very prepared and had detailed answers for my questions. I always start by asking patients to describe their TTC efforts. I've learned not to make any presumptions, as I've noted over time that many people do not know how to anticipate when they ovulate. Some couples copulate too frequently and others not enough. A former colleague once had a particularly shocking case. They were a highly educated couple in their late thirties, and had been trying for two years before they presented for evaluation. They were convinced something was seriously wrong and pushed for a comprehensive work up. Multiple semen analyses were normal. Serial day 3 and day 21 draws indicated good ovarian communication and ovulation. Although her HSG showed patent tubes and no obvious cavity defects, she had a laparoscopy and hysteroscopy performed. When she came in for her post-op visit, the front office staff noticed she needed to update her health history form. A medical assistant reviewed it and discovered that she was listing 'condoms' as her method of birth control. "Why are you using condoms when you're trying to get pregnant?" The patient answered that she found semen to be "icky" and they didn't think condoms were effective as a friend become pregnant while using condoms. Rather than refer her to an RE, my colleague encouraged her to get over her "ick factor" and ditch the condoms. She conceived a few months later.
My patient had been tracking her cycles, which were very regular and was having unprotected sex at the correct times with appropriate frequency. She briefly used OPKs and received consistent results, but stopped as they didn't seem to be helping her get pregnant. Her history was pristine, and I couldn't identify any red flags for concern, so I thought there could be male factor issues or they could fall into the unexplained category. I reassured her that she was doing everything right, and it was time to evaluate. Knowing all the stupid 'tips' I received, I thought those were important words for her to hear. I placed all her orders, but as I needed to move on to my next waiting patient, I asked my medical assistant to review the timeframe her her labs and HSG. I still felt that I had rushed her, so I sent her a message on our online system encouraged her to let me know when she goes for her testing or to ask any further questions.
Three months later I saw an FSH and Estradiol for an name I didn't immediately recognise. She finally went for her testing. Her results (FSH 9.8 (E2 35) and FSH 1.08) gave me concerns for her ovarian reserve. She needed to see an RE now. A week later, I received her HSG results and was not prepared for the findings. Neither tube was patent. Without any risk factors present, she had a significant tubal factor to accompany her concerning ovarian reserve. Her husband is insured though Kaiser, so I didn't have any access to his results, but I hoped for their sake that his semen analysis was normal.
I felt reminded about how hidden and secretive infertility is. I used to counsel patients regarding the lurking threats of STIs, as most affected carriers have no symptoms. "You can't tell just by looking at someone" I warned. This situation feels very similar, you can't tell by merely looking at the surface and you won't know what you'll find until you look deeper. Thus, the recommendations to "relax" or "take a vacation" and "stop trying so hard" are not only inappropriate, but potentially detrimental, as they could delay a someone who is closing in on a narrow window of time.
I reviewed her results with her, describing a somewhat 'bad news, good news' situation. No one wants to hear that an abnormality was found, but sometimes it's comforting to have an explanation. I emphasized the positives; she is ovulating and IVF is a treatment to address tubal factor. She took the news rather well and quickly scheduled an appointment with an RE. I asked her to email me after her consult. A few days later, she replied that they would be starting IVF in somewhat of an excited tone.
There is a part of me that wants to reach out to her as a fellow IF sister. I want to let her know I personally know how much it sucks to need infertility treatments when your friends and family members conceive spontaneously. I know the difficulty of attending baby showers and birthday parties. There is so much more I could say to her, but I don't want to overstep my professional bounds. I wished her the best of luck and asked her to keep me posted. She replied "Thanks :)"
Friday, 6 September 2013
It's a Different World
In a previous post I described how the woman who is casually TTC is nearly oblivious to the 2WW that is such a dreaded experience for patients going through infertility treatments. It's more fodder for fertile envy, but it doesn't reach the same level as frustration as the 'I didn't know I was pregnant!' woman. This situation truly demonstrates how it is such a different world...
Our LVN approached me, a patient received a reminder that she was due for her HPV vaccine and scheduled an appointment. When the LVN asked about her last period, she replied "Oh, I think it was a few months ago..." She explained that she had a lapse in her insurance and stopped her birth control pills during that time. Her coverage was recently re-instated, so she wanted to get her shot and to restart her pills.
"Have you been using anything else for birth control?" the LVN asked
"Like what?"
"Condoms, spermicide, withdrawal, abstinence..."
"Oh....no."
"Do you think you could be pregnant?"
"Oh....no."
The LVN handed her a urine cup and briefed me on the situation. "It's going to be positive" she assured. "Maybe she has post pill amenorrhea." I countered, recalling my own experience of a delayed menstrual return after stopping birth control pills, although AF returned in less than two months for me and she was closer to four. We watched the test together -the blue test line lit up immediately. She measured fourteen weeks when I scanned her. "Maybe she should sign up for email messages reminding her when her period is due" I joked.
Except there was an aspect that it wasn't funny. I thought about all my patients with recurrent pregnancy losses or those experiencing infertility who hold their breath each day waiting to make it out of the first trimester. Here she was in the safety of the second trimester without experiencing any awareness of what those prior thirteen weeks represented. As she was young and this was her first pregnancy, maybe her obliviousness could be explained. Although I questioned if she did suspect she was pregnant and used the rouse of needing the HPV vaccine as a way of getting into the office. If that was the case, then she's a lot smarter than I previously thought.
It's fairly common that patients can't remember the exact day of their last menstrual period, but can produce an approximate range. I find that I often can't remember mine, as it becomes eclipsed by other dates, monitoring appointments, trigger time, the IUI itself and testing day. Maybe I'm not so different from unsuspecting fertiles. Often, I'll be satisfied if they can narrow it down to the beginning, middle or end of the month. This next patient would not be one of those cases.
I received report from our LVN "This is her fourth and it was an Oops!" she informed me "She wanted to have her tubes tied with her last pregnancy but her papers weren't signed in time.' I suddenly recognised the name "Bullshit. I signed her consents myself." I quickly checked her chart and my suspicion was confirmed. She went into labour before her scheduled C/section date and the on-call doctor didn't notice her sterilization intentions. "She thinks her period may have been sometime in May or June. You have your work cut out for you..." she warned.
"So, you're not quite sure when your last period was, but it may have been in either May or June?" I began
She just looked at me blankly for a few seconds and then offered,
"You see, my family is all girls and my sisters noticed I didn't have a period in July"
Oh, imagine having others who track your cycles for you! Oh wait -our partners and the staff at the REI clinic all do!
"So when did you suspect you were pregnant?" I asked
"Well, my mom looked at me one day and said 'I think you're pregnant'"
Oh, imagine having someone else spot your symptoms!
"When did you have a positive pregnancy test?"
"At the beginning of this month. But then I got my period."
"What do you mean..."
"I started bleeding for a week -just like my period"
You should have mentioned that earlier!
"That wasn't your period." I informed her "A period signals the absence of a pregnancy during each ovulatory cycle. You experienced a bleeding episode in your pregnancy."
The sight of blood would strike fear into the heart of a woman whose pregnancy was achieved with fertility treatments, one with recurrent losses or even an excited first time spontaneously conceived mom-to-be. The moment I spotted light pink blots on the toilet tissue, I knew that I was doomed. Yet a woman with an unintended fourth pregnancy can bleed for a week and merely attribute it as "her period". Didn't feel it was necessary to call or even to mention it earlier in the interview. I quickly proceeded with her scan. There was a viable single intrauterine pregnancy at 9 weeks without any visible explanation for her bleeding. Once we were done, I reviewed some of the causes for bleeding in pregnancy and explained why it was important to be evaluated during those situations. She reminded me that she doesn't want there to be a next time and asked again to have her tubes tied. I promised her that I would ensure it happens.
I've often commented how fertiles have no idea what it is like to walk in our shoes, how they can never appreciate what we experience trying to start a family. What is so elusive to us, is effortless to them. It's a different world, and just as they can't relate to our situations, we'll never understand what it's like to live in theirs.
Our LVN approached me, a patient received a reminder that she was due for her HPV vaccine and scheduled an appointment. When the LVN asked about her last period, she replied "Oh, I think it was a few months ago..." She explained that she had a lapse in her insurance and stopped her birth control pills during that time. Her coverage was recently re-instated, so she wanted to get her shot and to restart her pills.
"Have you been using anything else for birth control?" the LVN asked
"Like what?"
"Condoms, spermicide, withdrawal, abstinence..."
"Oh....no."
"Do you think you could be pregnant?"
"Oh....no."
The LVN handed her a urine cup and briefed me on the situation. "It's going to be positive" she assured. "Maybe she has post pill amenorrhea." I countered, recalling my own experience of a delayed menstrual return after stopping birth control pills, although AF returned in less than two months for me and she was closer to four. We watched the test together -the blue test line lit up immediately. She measured fourteen weeks when I scanned her. "Maybe she should sign up for email messages reminding her when her period is due" I joked.
Except there was an aspect that it wasn't funny. I thought about all my patients with recurrent pregnancy losses or those experiencing infertility who hold their breath each day waiting to make it out of the first trimester. Here she was in the safety of the second trimester without experiencing any awareness of what those prior thirteen weeks represented. As she was young and this was her first pregnancy, maybe her obliviousness could be explained. Although I questioned if she did suspect she was pregnant and used the rouse of needing the HPV vaccine as a way of getting into the office. If that was the case, then she's a lot smarter than I previously thought.
It's fairly common that patients can't remember the exact day of their last menstrual period, but can produce an approximate range. I find that I often can't remember mine, as it becomes eclipsed by other dates, monitoring appointments, trigger time, the IUI itself and testing day. Maybe I'm not so different from unsuspecting fertiles. Often, I'll be satisfied if they can narrow it down to the beginning, middle or end of the month. This next patient would not be one of those cases.
I received report from our LVN "This is her fourth and it was an Oops!" she informed me "She wanted to have her tubes tied with her last pregnancy but her papers weren't signed in time.' I suddenly recognised the name "Bullshit. I signed her consents myself." I quickly checked her chart and my suspicion was confirmed. She went into labour before her scheduled C/section date and the on-call doctor didn't notice her sterilization intentions. "She thinks her period may have been sometime in May or June. You have your work cut out for you..." she warned.
"So, you're not quite sure when your last period was, but it may have been in either May or June?" I began
She just looked at me blankly for a few seconds and then offered,
"You see, my family is all girls and my sisters noticed I didn't have a period in July"
Oh, imagine having others who track your cycles for you! Oh wait -our partners and the staff at the REI clinic all do!
"So when did you suspect you were pregnant?" I asked
"Well, my mom looked at me one day and said 'I think you're pregnant'"
Oh, imagine having someone else spot your symptoms!
"When did you have a positive pregnancy test?"
"At the beginning of this month. But then I got my period."
"What do you mean..."
"I started bleeding for a week -just like my period"
You should have mentioned that earlier!
"That wasn't your period." I informed her "A period signals the absence of a pregnancy during each ovulatory cycle. You experienced a bleeding episode in your pregnancy."
The sight of blood would strike fear into the heart of a woman whose pregnancy was achieved with fertility treatments, one with recurrent losses or even an excited first time spontaneously conceived mom-to-be. The moment I spotted light pink blots on the toilet tissue, I knew that I was doomed. Yet a woman with an unintended fourth pregnancy can bleed for a week and merely attribute it as "her period". Didn't feel it was necessary to call or even to mention it earlier in the interview. I quickly proceeded with her scan. There was a viable single intrauterine pregnancy at 9 weeks without any visible explanation for her bleeding. Once we were done, I reviewed some of the causes for bleeding in pregnancy and explained why it was important to be evaluated during those situations. She reminded me that she doesn't want there to be a next time and asked again to have her tubes tied. I promised her that I would ensure it happens.
I've often commented how fertiles have no idea what it is like to walk in our shoes, how they can never appreciate what we experience trying to start a family. What is so elusive to us, is effortless to them. It's a different world, and just as they can't relate to our situations, we'll never understand what it's like to live in theirs.
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