Tuesday, August 9, 2011

IVF Journey - Part I, first cycle

IVF or in vitro fertilization, is one of the most effective ARTs (assisted reproductive technology) that many infertile couples or fertile women at advanced age rely on to get themselves pregnant nowadays. If you are trying to conceive but not able to in a year or two, you may know exactly what I am talking about here.  I belong to one of the these normal women who is fertile when young but infertile when aged.  I don't really know when I had become infertile.  What I know for sure is that I used to be fertile at age of 24.  I also know that my mother had my little brother at age of 40, although that was the third child my mother had.  I discovered painfully that I was too old to get myself a baby or two at age of 43 and started to go through ivf process in last quarter of 2005.

At the first try, we, like many other ivf newbies, were quite confident and optimistic.  The reproductive endocrinologist (RE) had us started right away since I was very close to the cut-off age - the clinic we went does not take any woman who is older than 44 if she wishes to use her own eggs.  So, I was instructed to get started immediately.  The protocol that my RE used on me was the most effective one for women of advanced age called mini-dose flare protocol, which involves taking regular birth control pills (BCP) for 14 to 21 days - depending on where you are at your cycle - to make sure that the ovaries don't produce any eggs.  Following this so-called suppression period is a flare stage, which involves to take mini dose lupron to jump start the ovaries.  After 3 days of lupron, one needs to take FSH (follicle stimulation hormone) to stimulate follicles (eggs) to grow in the mean time of continuing the mini-dose lupron for entire course of FSH stimulation, which lasts 7 to 10 days, depending on how fast your eggs become mature.  Just in case some of my readers here are from the ivf message boards or undergoing ivf at the moment, here is the detailed protocol and progress in my first and the only ivf fresh cycle:

10/17/05 ~ 10/31/05: BCP, for 14 days

11/4/05: E2 = 23, egg = 3.5 mm
8 pm, Lupron, day 1, 20 U (diluted, 50 mcg/ml, 0.2 ml)

11/5/05 ~ 11/7/05:
8 am, Gonal F (FSH), 300 U + 20 U Lupron
8 pm, Repronex (75 IU FSH and 75 IU LH per vial), 2 vails + Lupron, 20 U

11/8/05: E2 = 706, eggs = L10 + R15, 7.7 mm
8 am, Gonal F (FSH), 300 U + 20 U Lupron
8 pm, Repronex (75 IU FSH and 75 IU LH per vial), 1 vail + Lupron, 20 U

8 am, Gonal F (FSH), 225 U + 20 U Lupron
8 pm, Repronex (75 IU FSH and 75 IU LH per vial), 2 vails (a mistake, was told to use only 1 vail) + Lupron, 20 U

11/10/05: E2 = 2344, Eggs = L14 + R11, 9.6 mm
8 am, Gonal F (FSH), 225 U + Lupron, 20 U
8 pm, Repronex (75 IU FSH and 75 IU LH per vial), 1 vail + Lupron, 20 U

8 am, Gonal F (FSH), 150 U + Lupron, 20 U
8 pm, Repronex (75 IU FSH and 75 IU LH per vial), 1 vail + Lupron, 20 U

11/12/05: E2 = 3000, eggs = L18 + R18, 11.2 mm
8 am, Gonal F (FSH), 75 U + Lupron, 20 U
8 pm, Repronex (75 IU FSH and 75 IU LH per vial), 1 vail + Lupron, 20 U

11/13/05: E2 = 6328
8 am, Repronex (75 IU FSH and 75 IU LH per vial), 1 vail + Lupron, 20 U
9 am, HCG, 5000 U
8 pm, Lupron, 20 U

11/14/05: E2 = 6772; HCG = 156
8 am, Lupron, 20 U
8 pm, Lupron, 20 U

12 pm, egg retrieval, 24 mature eggs collected.

No transfer due to hyperstimulation!

As you can see, this mini-dose flare protocol worked extremely well.

During ultrasound exams, I found many black holes in my ovaries.  They looked like a grape bunch and those grape-looking follicles were becoming bigger and bigger with time.  The ultrasound technician carefully measured the sizes of each of them and then reported to my nurse, who was quite happy at first, then she became less happy and finally nervous.  Of course, she tried her best to hide her emotions, but my professional sensitivities allowed me to detect her panicking state of mind.  At the 4th day into FSH, I was told to decrease the FSH dose, two days after that, I was told again to decrease the dose even more!  My crazily growing follicles seemed to become more and more of a concern than of an excitement!  I did not know why the nurse was nervous at all, because I thought the more follicles, the better.  The increased number of growing follicles also raised the estrogen (E2) level in my blood stream, which caused severe fluid retention.  My lower abdomen felt very bloated but I did not know it was fluid retention - a side effect of high estrogen!  I was jogging every other day for 5K each time!  I could have died from stroke!

At the day of egg retrieval (ER), Fabrice was sent to a small room to make his contribution to the baby producing process.  After a short while, he came out and handed a brown bag to the nurse, who was waiting outside with me then she immediately disappeared from our sight after receiving the brown bag.  She must have gone to store the bag in a cold and safe place because inside that bag hiding a plastic cup filled with Fabrice's little swimmers.  "That was quick, did they allow you to watch pornographic movies in there?" I joked to Fabrice once we were left alone.  He gave me an evil look and said, "I wish."  Later that day, he told me he was seriously thinking to suggest the clinic to make some effort so that small sperm-collection room could be more exciting.  I wanted to be sarcastic but I could not since I was quite sympathetic of him.  I have to admit even though that was the only contribution he had to make in this whole ivf business, I would not have traded anything I have done for that 1 minute or two that he had to spend in that room.  I could not imagine how awkward that he must have felt while being confined within a strange and small room masturbating.  Yuck!

After that, Fabrice followed me into the ER room.  I was drugged up with an by someone who looked familiar but I could not recall where I saw her before - Few days later I met her again in the same building, I suddenly remembered that she was the same anesthesiologist who knocked me off few months ago for my ob/gyn who was performing laparoscopy to find out what happened to my female organs then - The RE was chatting and asking how I felt. Then slowly I could not hear him anymore. It felt like merely seconds later I woke up, I heard that the nurse was telling me that the RE collected total of 24 mature and beautiful eggs excitingly. I, on the other hand, was not exciting nor happy because I was expecting 36 or so. So, I asked, where were the rest of these eggs? "Oh, the RE was too exhausted to collect them all since they were still small." REs usually collect as many eggs as possible if ivfers do not produce enough eggs since they can mature them in the incubator. But in my case, there was no need to go this route. The nurse then hand us some instructions and told us to wait for another 15 min to leave. On our way out, the RE stopped us and told us that the sperms were being prepared (washed, centrifuged, cleaned?) and they would check the quality and quantity. If more sperms needed, they would call, he said to Fabrice. "my office is right across the street and just call me." Fabrice showed, for the first time from the start of our ivf cycle, some enthusiasm. 

However, we did not receive any phone that afternoon, nor next morning. Everything must have been fine, Fabrice told me, when I was bugging him with all my suspicions. The Clinic finally called in the next afternoon. "We have some good news." She said. I knew it. Something must have been terribly wrong. Because of it was only good news, she would not start her conversation like this. None of my eggs were fertilized? Survived? I started to imagine the worst scenario. "The good news is that 20 out of the 24 eggs matured and fertilized well and 19 grew to 2-cell stage." "Wow, that sounds very good. I am do glad that you had enough sperms for the in vitro fertilization." I said to her with some kind of suspicious tone. "Oh no, we had to do ICSI (intracytoplasmic sperm injection)." She told me but this made me upset, because that would cost us additional $1000! "Why did not you call to ask my husband for more sperms! We were just here waiting for your call." Now I was bit upset that our clinic did not keep us informed and did a procedure without our consent. She probably gave me tons of reasons to explain why ICSI was necessary, but I was worried about that did not select the best quality sperms ti do the job. Based on what I learned from text book, only the strongest and healthiest sperms can make their long journey to meet and enter the egg. How could they omit this important natural selection step? "Oh, ICSI has better fertilization rate." She explained.

I am sure she said something more, but whatever she said, it did not matter anymore. Finally, she continue to tell me what I did not like to hear, "The bad news is that you now need to stop all the medications and wait for next cycle to call us back." "What, why?" I asked her to repeat and made sure what I heard. "I won't come back tomorrow for the embryo transfer?" I asked. "No, just stop all the medication. And it is important that you and your husband won't have intercourse in the next few days."  I was so upset for not being able to continue the ET step and must have been shouting in my end at this point. "Your have 19 good quality embryos, don't worry." She tried to calm me down. She explained to me that the estrogen level in my blood was too high, which was a indication of over-stimulation. If we proceed the next ET (embryo transfer) step, I would have a high risk of OHSS (ovarian hyperstimulation syndrome). I did not want to listen to her for all these reasons. I argued, complained, and begged that she would talk to the REs and let me come back for the next step. "But all your embryos have already been kept frozen." She tried to end the long conversation. "What will it be next cycle?" I asked with disappointing tone. "Sometime next January." She said. I could not believe my ears. Now, I was very upset. Not only I could not proceed for the next step, but also I had to wait for longer than expected. "We would not have enough time to start and finish your next cycle, since we will close in week of Thanksgiving and 20 days of Christmas and New Year." I was speechless, I was shocked. I never knew that Americans had real holidays for more than a long weekend, let alone it was 20 days!

That was a long phone call and possibly the most difficult phone call my nurse had to make on that day, if not in her entire nursing life. I thought that I reached the end of the world. I had to let her know how I felt until I finally realized that she was merely doing her job as my nurse. She was not paid as my psychiatrist. "Okay, I will call you when my January cycle comes." I let her go on her life, finally.

I am not an easy customer. I admit. I demand every penny's worth of service. 

The next of the few weeks, I sent my lovely husband Fabrice to hell and I will tell you how in my few posts. Stay tuned!

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