Friday, August 19, 2011

IVF Journey - Part III, frozen cycle II -

My ivf clinic is not rated at top in any category, but it certainly is one of the best in town. In fact, even my ob/gyn who has produced first test tube baby in town recommended us to use this fertility center. However, after two aborted cycles, I began to be in doubts of our choice. It did not seem to be a medical necessity to me to abort both my previous cycles. "A high risk of OHSS" was more like a risk of messing up the holiday long break of my ivf clinic. "Dominant egg" sounded like laziness. Could a HCG trigger shot get rid of it? They had the ultrasound machine to follow the egg precisely, did not they know that the first test tube baby Louise Brown was produced by following Lesley Brown's natural cycle? IVF by following a natural cycle is still a common practice nowadays in the Europe, my REs were either too conservative or too incompetent to do something uniquely fitting each patient's need, I suspected. Or better yet, they just wanted to keep me coming back for more cycles so that they could make more money out of me.

Once one is paranoid and anxious, she/he is also unreasonable. I started to shop around for new infertility clinics in town. I lined up with the REs that I would like to consult with while I was waiting for the start of my third ivf cycle. Every new RE sent me right back to where I came from. Don't get me wrong, they all liked me as a great responder to ivf drugs but they did not believe that they could do any better than my fertility center. "Change clinics at this point is not a good idea, especially you have already 19 embryos collected." They sounded like as long as I had one cycle completed, I would bring home a baby for sure. At least, that was what I believed.

There I was. Continued to be with my old clinic, I started my third ivf cycle in Feb. 10, 2006, by taking 21 days of BCP. This time, again, was a frozen cycle. If you have ever done ivf procedures yourself, you know what's like. An ivfer generally needs to visit the clinic every other day once the stimulation (of follicles) starts. However, if it is frozen cycle, meaning transferring frozen embryos, it only needs to prepare the endometrium of your uterus to become competent to accept incoming embryos, your visits to the ivf clinic can be quite sparse, which is good and bad. The good is that you don't have to "disappear" from work frequently; the bad is you feel like lost since you are taking BCPs, injecting Lupron, putting on E2 patches, and taking E2 pills, but you really don't know whether they work or not. At Feb. 27, 2006, after 17 days of BCP, I went back to the clinic. The E2 was measured at 2 and one egg at 4.8 mm but no additional cysts in my ovaries were found in sonograph. I was then given the order to start Lupron on Feb. 28th, which would overlap with the last 5 days of BCP to make sure my ovaries suppressed. "This time, make sure use the right dose!" I was told since in the last frozen cycle I had used mini-dose of Lupron that might have jump-started my ovaries instead of suppressed them!

One week following the last visit, I was back to the clinic again. This time, the E2 rose to 10 but no cysts found, great! "Everything looked okay and go ahead to start the E2 patches on 3/8. In the mean time keep taking Lupron until 3/13." I was told. The nurse/RE wanted to make sure that my ovaries did not make mature follicles this time, they overlapped the initial stimulation of E2 patches with Lupron suppression. Progress was made! I had not reached this stage in the last frozen cycle. I was happy. I also felt confident. This is common among us ivfers, you know. Each new ivf cycle, one always begins with confidence, hopefulness, and excitement, then moves on to anxiousness, worry, and doubtfulness, finally progresses to spectacular disappointment, sadness, and hopelessness. We call it "roller coaster ride". At least that had been what happened to me, twice already, so far.

In fact, at the third cycle, I was feeling like a veteran. I had enough time to surf the Internet for information about ivf. I had enough time to consult other REs, and I was getting used to the ivf clinic, and most importantly, I was getting to be known by the nurses, sonograph technicians, and receptionists, by the first name. Although they still did not like to make any eye contact with me, I adapted to enjoy being just a number to the clinic - Later I figured out why the clinic staff generally don't like to smile or to talk much to me or their patients. They simply cannot afford any emotional connections with us. Imagine that, most of us come with high hope and go with great sadness. How can they be happy seeing our dumping all the money to the drain... I understand now also why the REs seem to be always hiding from us. They stay behind the scene, just check our charts and give orders based on what they read from the blood work and sono graphic reports. In this case, they can get their job done. Otherwise, they could be eaten alive consumed by their angry or emotional patients! They know keenly that most of their patients cannot afford multiple ivf cycles yet ironically a live baby almost always requires multiple ivf cycles. I had naively believed that all I needed was ONE ivf cycle, which was also predicted by my ob/gyn. She liked my low FSH (follicle stimulating hormone) and she liked the fact that I was pregnant before (at age 24). But now, I was already at my third cycle.

Okay, back to my cycle. Everything looked perfect this time so far. At march 20th, 2006, 38 days from the start of the cycle, I was back to the clinic, for the third time of this frozen cycle. The E2 rose a lot (263) and endometrium grew close to 8 mm's thick. "This time will work." I thought. "Take 2 mg estrogen pill per night and come back again three days later." I was sent home and wait. Apparently, they wanted thicker endometrium and higher estrogen level. Three days later, on March 23rd, the E2 rose to 414 and I was told good enough, the embryo transfer (ET) could be scheduled. Yahoo!!!

To prepare the ET, one needs to take antibiotics and immune suppressants (tetracycline and methyl prednisolone, in my case) for few days to prevent infection and immune rejection of the incoming embryos. And one also needs to take progesterone in oil (PIO) shots, which is the most scary and awful hormone among all the other hormones for ivf cycles, because others ones need only subcutaneous injections with tiny insulin needles, you can hardly feel them. Yet PIO requires intramuscular injections with long (1 and 1/2 inches) and big needles, 18 gauge (G) ones for drawing out the medication and 22G ones for injections. Unlucky for me, the local pharmacist from whom I often got my medications ran out 22G needles, so he sent me home with bunch of 20G needles. "Draw and inject PIO with the same needle and push all the way inside of the top quarter of your buttock." the pharmacist instructed. Those were some scary looking needles. At the first, I asked Fabrice who does intracardiac injections in the lab often to his experimental subjects (rats and mice) to perform this horrible task. As masculine as any man in the world can be, he could not inject his wife with these long and scary needles. Now you know why surgeons usually do not operate their own wife and kids. After two painful injections that Fabrice did on me, I took over. I was tired of pretending that did not hurt. That hurt like hell! Progressively though, I learned how to look at mirror to find a good spot, I learned how to twist my body to give myself a shot on the top of my butt, I also learned how to find new locations and then rotate from left side to right side of my buttock, from left thigh to right thigh to avoid forming lumps at those injection sites.

The ET was scheduled on March 30th, 2006. Two days before the ET, the embryologist thawed 6 precious embryos, 5 of which survived and thrived to become 5- to 10-cell morulas after two days in the incubator. The quality of them were great, as I was told. On the day of ET, my RE sat Fabrice and me down. He told us that he planned to transfer all 5 back into my uterus. "5?" Fabrice and I were shocked. "What if they all implanted?" we both questioned. The RE patiently explained to us that he had not experienced many multiple pregnancies in his practice with 43-year old eggs. "Not every 43-year old woman can make 24 eggs at each ivf cycle, either." I reminded him as if he had not been the one who had read my chart every day and directed the whole process. "Plus, we had a friend that she had to do selective reduction to sacrifice two implanted embryos. She had transferred 3, but one of which divided and separated to become two." I naively argued with a white lie - I only heard this story from our MD friend who likes to exaggerate to make his point. He suggested us not to transfer more than 2 embryos the day before our ET day, when we asked him how many we should put back.

Having sensed it would have been a total waste of time to continue this discussion, my RE said, "If I were you, I would at least transfer 4 of them. We could leave the 10-cell embryo out since in our experience, fast growing embryos rarely give rise to live babies."... "you think about it." Then he left the room to get himself preped. Fabrice and I looked at each other and it did not take that much of a discussion for us to decide to listen to the man who was doing this everyday for the last decades. When the RE returned, both Fabrice and I answered simultaneously "Four" to his questions of "how many have we decided on?" And then we (mainly, I) spent the next of the two weeks worrying about multiple pregnancies.

The ET process was bit of nerve wracking, since it almost did not happen. Because my RE almost lost them in the air! When the embryologist brought in my embryos in a petri dish, she announced, "We are going to transfer the following 4 embryos: 1 at 8A, 2 at 6B, and 1 at 5B." Meaning one grade A embryo of 8-cells, 2 grade B embryos of 6 cells, and so on. Then she went back to load them into a thin and long plastic tube (catheter) and handed the catheter to the RE. The RE somehow did not hold the top of catheter tight enough, that top is important since it prevents the embryos inside the catheter to leak out! I saw one small drop of liquid (medium) at the tip of the catheter. He saw that too, so he handed the catheter back to the embryologist. She left the ET room to the embryo lab next door and returned promptly. I guess she had checked it under the microscope to make sure none of those precious embryos escaped along with the medium. So, the RE proceeded to send my precious embryos inside of my uterus through the catheter, with the help of the ultrasound machine. It took sometime for him to push them one by one out of the catheter. The room was quiet, we all held our breath and stared at the ultrasound screen. Then the handed the catheter back to the embryologist. She left and came back again promptly. I guess she went to examine whether all the embryos were out. I remember seeing she handed the catheter back to the RE, but I could be wrong. What I do remember was that I was not too impressed by my RE. I remember thinking that he was not young enough to have a pair of steady and meticulous hands for such sophisticated procedure.

I had done ivf and ET with my own hands in the lab to my poor subjects, mice, a while ago prior to my own ivf cycles. I knew that it could be very difficult to get those embryos inside the catheter - they float in the growth medium and I always worried about hurting them, even though I knew it took a lot to actually damage them since the medium protects them from mechanical damage. When we load them into a catheter, we also load a bit of medium in between each embryo so that we can easily control the transferring process. One must have steady hands for this job. Otherwise, the embryos could be lost in the half way! Let's assume this did not happen in my case, shall we?

On April 5th or one week after the ET, I came back to the clinic to get blood work done and was told later on that day that my E2 was 385 and P4 was 42. I did not know what that mean. I was told that just to make sure that my E2 patches and P4 (PIO) work well. In some of the ivf clinics, this mid-term check is omitted.

I did home pregnancy test (HPT) every other day after that. And at day 12, on April 12th, 2006, just before I went to the clinic to have the blood drawn for the official pregnancy test, a faint positive line showed up in the HPT stick, which I picked up at CVS store on the way home from work the night before. I was excited and told the phlebotomist confidently, "I saw a faint line on the HPT this morning." "Oh, good," she answered indifferently. She must have heard that a lot, I thought. "Is it often that a urine HPT tells you positive but blood test tells negative?" I pushed my luck. "No, it usually is the other way around. Blood test is more sensitive and accurate." she answered, reluctantly. Then she gave me the signal to leave so that she could move on to the next person in line. 

In the early afternoon on the pregnancy test day, a nurse with lovely voice from the clinic called me at work. She informed me the pregnancy test was negative. A dreadful BFN (big fat negative)! "What was the number?" I asked her, pretending that I did not hear what she said. "Zero." She answered. "What, not even a chemical pregnancy? Why the HPT showed a positive line? Where could those embryos go?" I asked as if she did not know what she was talking about. "A negative is a negative, there was nothing vague about it. I am so sorry." she must have said she was sorry many times. She sounded very sincere and sympathetic so I trusted that she was sorry. "Oh, don't apologize, you must have done this job for sometime now and I am sorry for you instead for having to break people's heart more often than you would like to." I sounded like her boss, I guess. It was the very first time that I was formally informed to have a negative pregnancy test. To be honest, I was not nearly as devastated as I later became at that moment. I did not know what I was doing, but I was sure that I felt sincerely sorry for the nurse who had to call me for such disappointing news. It must have also been the very first time that she heard someone who said sorry back to her, since I had not heard her speaking until a good a minute or two later. "Please make sure that you stop all the meds and wait for the next period. And oh, do not have intercourse before your next period!" 

For the third time, I was told to stop all the medications to wait for my next period to call the office back to arrange for the next cycle.

The faint line is a line, there was nothing vague about that. That would at least suggested few picorgrams of the pregnancy hormone, HCG (Human Chorionic Gonadotropin) in my urine. Maybe the pregnant test that the clinic used was not sensitive enough to detect so low level of HCG! I told myself and continued few more days of the progesterone and HPT. I did not believe the hospital pregnancy test. It was the first time that my ivf cycle went far enough to finish a cycle. It was the first time that I had few embryos transferred back to me. I could not give up so quickly. 

I was clearly in denial, because the line I saw the other day disappeared mysteriously, no matter from which direction that looked. My period showed up at the exact predicted day, April 18th, 2006, 6 days after the pregnancy test, one day after I ran out of the progesterone suppositories. I failed once again, spectacularly!
Stay tuned, in my next post, I will tell you how to cope with ivf failures. Just between you, my dear hidden readers, and me, those techniques guarantee you a live baby! 


  1. I hate cliffhangers... when will you post again?

  2. By Sunday night, promise! Thanks for stopping by.