Day 1.5

Yesterday Santa brought me a nasty cold. Wee! I managed to make it through the morning's festivities, but alas, was couch bound for the rest of the day. (On a separate note, the movie Mulholland Drive sucks - don't let anyone tell you differently.)

Nevertheless, I began my pre-cycle meds as described in my RE schedule. Namely I started the Vivelle-dot 0.1mg patch (estrogen), which I take every other day. Tonight I will add on to the patch and start a 3 day course of Ganirelix 250 mcg injections. Double wee!!!

I tried to think of a time in my life when I gave myself a shot and came up empty. Even with my couple year course of allergy shots as a kid. Even with my 2 previous IVF cycles in India. Ugh - I guess I should have checked for extra practice needles in my box, although now that I think about it, who the hell wants to take extra shots, practice or not.

Next step is "Await period Day Of Cycle 1 = First day of continuous menstrual flow (spotting is NOT day 1)". Great. Many times my periods are only spotting (due to my previous cryoablation surgery.) How should I determine that? So in typical "omg" last minute panic and realization that I have new questions, I sent the below email to my nurse. Hopefully they will get me some answers today.

UPDATE: rather than write a separate post on my nurse's answers, which were prompt, I'll just type them in red by each one. Nurse ended up calling me directly when I was at work, so my responses are just a quick summary.

P.S. Clearly I don't know how to count...But at least I caught it before she did. 
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1.) Started the vivelle-dot today. Do these have to be changed out the same time (every other day) or can I change it out with my nightly shot (I put it on in the afternoon)? -->yes - that's fine

2.) It looks like I am suppose to start the Ganirelix tomorrow, but I am not positive because the date is wrong on your documentation (I think we may have previously discussed this on the phone, but I'm not positive now.) Please verify and send an updated copy. Also, please let me know if there is anything special I need to do/know regarding the shots. For some reason I thought we were going to have training on it, but we never did.-->tonight. around the same time. 

3.) I have been battling a very minor cold the last 2 weeks, but yesterday it took a turn for the worse. Today it is in full fledged mode. Please notify the doctor and let me know if there is anything I should or should not take for it. -->Take lozenges, any Tylenol line, robitusson but no DM, sudifed

4.) Last week I wrote you regarding an approximate drop-dead date for when the surrogate's cycle could start (and thus you would have to have a contract in hand.) Haven't heard back from you on this - please let me know. The lawyer has submitted the rough draft to us. --> earliest Friday. You have 2 1.2 weeks before her injections start. If she hasn't by Friday, call Mikesha on Friday. 

4.) Dr. Carpenter approved my taking supplements for the last few months. I need to know if and when I need to stop taking these. In particular the DHEA (75mg per day) as it is a hormone and I don't want it to interfere with the other hormones I am now taking. -->yes --continue taking all

5.) My 2 previous cycles I had cysts prior to the start of cycle. The first IVF cycle, we had to aspirate the cyst as it was interfering with my hormone levels (and consequently would have ruined the cycle.) I need to know if we need to do an ultrasound or blood tests to make sure this isn't occurring again. Dr. Carpenter is aware of my previous history with this. -->will come in on day 2 or 3 for ultrasound and bloodwork. Check it then. 

6.) My blood tests are complete. The FDA ones should be faxed to you directly from Quest. The remaining ones were done at Emory. Please let me know if I need to sign a release for you to get them. I believe you already have it on file, but since it is a new doctor, I am not positive. -->need to fill out a record release for emory to send over to ACRM. She will email. Email back to her or fax.

7.) The ACRM email system appears to remove emails after a certain period. This is very confusing and I worry that I might miss some documentation. It is also difficult for me to log on to the ACRM email system when I am in the office. If possible, I would prefer to use regular email rather than your website email system. Please copy my husband on return correspondence as well (his email is included in the CC line.) -->yes - that's fine. 

Thank you and I hope you had a great holiday.

You have questions...We have answers

Actually I need your answers, so if any of this sounds familiar please post your experience/knowledge in the comment section.

On Tuesday night, I attended a seminar at my old clinic ACRM, here in Atlanta. I described some of it here and also pinky-swear promised to post the questions I posed to the new doctor during the Q&A session. (Ok, I didn't really pinky-swear, but I wrote I would, which is almost like the same thing.)

So here are the questions I asked.

1.) Can endometriosis affect the outcome of an IVF cycle if the woman is using a surrogate?
A.) Yes it is possible. [Sadly I have forgotten the reason behind it. I believe she did mention that there could be an effect on the eggs in a follicle and thus less eggs retrieved, but for the life of me I can't remember if she said certain things or if I am confusing it with stuff I have read.]

2.) Besides cost, what are some of the downsides of using ICSI?
A.) There have been studies done of the offspring conceived by ICSI and it was noted that the male children had a higher rate of sperm problems. Whether this is a cause of the ICSI or due to genetics (ie, the father having sperm issues thus ICSI was used) is unknown. 

[This one I already knew the answer to, but I wanted to make sure there wasn't anything else I didn't know about. Primarily because our clinic in India uses ICSI as a default with no extra charge (unlike here in the States).]


3.) How long after a laparoscopy, do you need to wait to start an IVF cycle?
A.) Generally the recovery time is short and we like to do the next cycle as soon as possible. Especially if the woman is older.
[I know they can't do it the same month as IVF, so I'm guessing that means you just have to wait until the next month.]

I'm getting conflicting statements about #1 and I'm a little concerned about it. Everything I read regarding endometriosis and IVF revolves around the woman carrying the baby, there is very little info for women using a surrogate.

My new OB/GYN did not seem to think that endometriosis would be a problem for me (with regards to lowering my IVF success rates) since we weren't using my uterus. In fact he thought there was a low likelihood that I had it since some of my symptoms were relieved with my cryoablation. He advised for me to find out if the cyst I had aspirated during my first IVF cycle was a chocolate cyst. He did mention at the end of our lengthy consultation that he did not specialize in reproductive endocrinology, so I'm guessing that was his out if he was wrong. The only surrogate cases he probably has is if someone walked into his office who IS a surrogate and already pregnant. Also this WAS before they locked me in the bathroom.

Conversely, Dr. GS on SIRM's forum indicated endometriosis could cause a problem in my case, but it was hard to tell if he understood that I would not be CARRYING the child. Even though I definitely mentioned it. (I am awaiting on a response for that clarification.) He mostly pointed me to articles that either talked about the problems in the woman's lining (and toxins activated in it) or in one case a long article he wrote with one tiny sentence that suggested a gestational surrogate would be a better option. That seemed to contradict his reply to me. Anyhow, I've awaiting clarification.  [UPDATE: Dr. GS did reply and state he missed the part about gestational surrogacy. He said that in the case of immunologic implantation dysfunction, it wouldn't apply to me, but an endometriotic cyst would affect egg quality.]

The REASON I'm even asking is because I don't know if I should be tested for it. We have decided to cycle again, but this may be my last one and I want to optimize my chances. If endometriosis can affect my eggs pre-aspiration, then it seems like a good idea to be tested and get any problems fixed. On the FLIP side, scheduling and doing a laparoscopy  plus recovery time could add a couple of months to the process - thus lowering our chances. PLUS some doctors advise against laparoscopic surgery for poor responders as it can further lower your ovarian reserve and raise FSH levels.

What to do, what to do. Time to go have a real one-on-one with our ACRM doctors again.

As I said at the beginning, feel free to chime in. 

Days are flying by: Day 6 - Part deux

Good and bad.

The bad was the AMH results, but for reasons I will not go into right now, I don't have absolute confidence in the results from the blood peeps. That could be a preserving mechanism, could be erroneous results, maybe my cyst threw it off, or maybe the results were simply wrong. Whatever. I'm not going to focus on that either way. PLUS, from what I understand, AMH is a direct reflection of follicle/egg count and if that's the case then it doesn't make sense that....


MY FOLLICLES ARE WAY UP! I have 11 that are growing. 7 of them are good sized. The 4 smaller ones can always potentially catch up, but I'm very happy about the 7 follicles. That's much better than last time.

(pic my send friend sent me during my 1st cycle)

I realize that 11 follicles isn't earth shattering news for some, but it's great news for me. Let's just hope that they have good eggs inside and that will grow into great embryos. 

Day 1 and 2 with the doc

Some of my meds

Yesterday was my first visit with the doctor. We thought we were going to have to aspirate my cyst, but Dr. P thought we should check my hormone levels first. We would only aspirate if the hormones were off.

 Last cycle I had a 3cm cyst and my estradiol was way off. I only had 3 follicles and we had to aspirate in order to proceed and get my hormones back in line. Once it was aspirated (general anesthesia - ACK!), we saw 14 follicles. Not exactly sure how that works (were they hiding???, why were we able to see more later on the unaffected ovary?), but that made the initial panic of 3 follicles easier to deal with.

This time I knew I had a 5cm cyst walking in. Turns out it had reduced to 2cm, but I only have 5 follicles currently showing. 4 and 1. My hormone levels came back normal, so we opted not to aspirate. Dr. P ordered an AMH test, and I get the results back tomorrow. Truthfully, I am a bit horrified to get the results back from that one. The follicle thing I can not worry about and simply hope more "appear", but a bad AMH right off that bat will crush me.

We are starting off with a stronger course of meds this time, though the Gonal F is at the same range we started last time (we increased it halfway through last time). 4 shots to the belly right now. Here is the breakdown:

gonal f - 375 IU

luveris/lutropin - 75 x .2

lupride/ leuprolide - 1. mil IU

human chorionic gonadotropin (hCG): HOCOG - 1250 IU

I started researching some stuff yesterday and then I just stopped. It was too depressing and I don't think it is doing me any favors right now. Hopefully my AMH has not tanked (it was 1.7 in February) and then I can be cautiously hopeful. Not even sure if cysts can affect AMH, but I'm too afraid to keep looking. 

Today I'm ok. Got shots in the belly and then socialized a bit with some other patients. For some reason, buying dog food to leave for homeless dogs (I especially worry about the lame ones) made me feel better. I don't know why, it just did. Maybe because it gives me a little bit of control or maybe it's because I feel like I can do a little tiny something to help. Right now I need a super simple way to make myself happy and that did it. I'm sure there are plenty of more laudable things I could be doing right now, but that comes with such complications at times and often tons more stress. 

I'll confess that in the last few weeks, I have, on occasion, semi-prayed. Given my atheist/agnostic ideology, this is quite complex to me internally. Not posting this because I want I bunch of comments regarding religion (quite the opposite), I just thought since it is part of my journey that I better fess up. If you are religious and are reading this, feel free to send your prayers, good vibes, or whatever else my way. I need all the help I can get. :-)

That's it for now. 

Another day...

Hormonal.
Sore.
Moody.

Woo hoo! Off to Indian by myself on Thursday. Can't wait for the general anesthesia to aspirate my ginormaous cyst right off the bat.

Yea, it's like that today.

Spot Check Part 2: Calming down

Right now I've calmed down enough to realize my spotting yesterday may  have been caused by the sonogram on Thursday. It has happened before with a sonogram. I don't know why it didn't occur to me till this afternoon when I was at a baby shower and was relieved to see no blood on a ladies room break. (Sorry to be so graphic.)  Or it could have been a minor nick on the cyst. I think if it had burst at 5cm, then there would have been a lot more blood.

Must have been pale as a ghost last night and my wonderful hubby helped calm me down. All I could think of was how I had some how messed up my last chance. I'm still a little worried, but not massively freaked out like I was last night. Tiny, tiny spot this morning, but then no more blood today. I was so freaked out last night I took an extra BCP. I may take extra ones till the 5th just to be sure.

Thinking that my side effects (like dizzy) may be merely from the cyst itself. (Or the freak out!) Not surprised that I had one as I had started cramping on occasion. I'm not bleeding today, so I'm hoping and hoping that the sonogram caused it. If I'm ok till Monday, then I will be able to breath a sigh of relief. If I'm not, I will contact Dr. Patel in India. As long as I am not bleeding, I will try not to worry.

In other news, if all goes well, I will have my cyst aspirated in India. Not ideal (will be alone initially and I will have to undergo general anesthesia), but I don't have much of a choice. Was able to confirm that my OB/GYN had been talking about laparoscopy and Dr. Patel said that she would have to cancel the cycle if I did that. Dr. I's staff (and he) were using laparoscopy and aspiration interchangeably (they most certainly are NOT) and after a series of confusing discussions with his staff, I was finally able to clarify with him on Friday morning. Apparently he DOES NOT aspirate, and told me that an infertility clinic would have to do that.

We have a really good infertility clinic here (ACRM) that we have used for all of our initial tests, but the chance I would be able to get an appointment in time are very slim. Not to mention that it most certainly WOULD NOT be covered under insurance. My old company insurance covered some things, but my husband's BCBS covers next to nothing for infertility. The mere fact something is done at an infertility clinic usually means they won't pay for it. The money we have spent at the infertility clinic does not even go against our yearly deductible.

Just as well. My husband did not have a warm and fuzzy about my having it so close to international travel. And my travel to India is not direct - it usually takes about 36 hours of travel time. I don't sleep well on planes, trains, or automobiles (all of which I have to take), so it's best to do it in India. Dr. Patel said she would do it and she did it last time. Pretty sure she didn't even charge us extra. Hopefully it doesn't affect the cycle.

Please keep your hopes/prayers/warm wishes for me that it was just a result from the sonogram and that I will have a successful cycle in Anand. 

Spot check

I started bleeding tonight. Not good. It's only very light, barely spotting, but then again that's how my periods start.

Have no idea if my cyst burst or if my period is starting early. Will a burst cyst cause problems that will cause an infection? What if I missed a pill? Or was late? Is my whole cycle for India screwed now? My head is spinning and it is taking everything not to freak out. 

Simple Cyst

When I woke up this morning, I wondered if I should just stay in bed. Was trying to get 8 CONTINUOUS hours of sleep, which is nearly impossible in my house due to the fact that I stay up too late and my husband gets up early. A bad dream woke me up after 6 1/2 hours. I tried to go back to sleep until my husband's 7am alarm, but I never really did.

I should have just stayed in bed the rest of the day. Already I felt weepy.

At 9:20 am I had a followup appointment at my OB/GYN's office (Dr. I) to check for cysts. I didn't even have to ask this time, the big black space on the monitor told me everything. Then I met with the doctor, where he informed me that I have a minor "simple cyst" and not to worry. Except I do worry. And then I asked the size... 5 x 4.1 cm. Look, I may not be a doctor, but that's not small. I think the one that threw off my cycle last time was smaller than that and that we had to aspirate before proceeding.

I reminded Dr. I that I was starting IVF in September and that a cyst was a problem last time. He said we could check in a few weeks, that it would probably burst on it's own. Without losing my shit, I explained I would be on a plane next Thursday. He still seemed mighty casual about it all and said that if we wanted to PUSH to remove it, then I would have to undergo GENERAL anesthesia. Still keeping my cool (I'm not sure how), I informed him that I had to have general anesthesia in India to have it aspirated anyway and that I would much prefer doing it here, then letting it mess up my cycle. He was nice about it and all, but hellz balls I'm frustrated.

Initially I thought I would ask my doctor in India (Dr. P) what to do (which I did), but I also wanted to go ahead and schedule my appointment here. In India they immediately gave me anesthesia and aspirated, in the USA you have to have appointments way ahead of time. After returning home, it occurred to me that he had really been saying laparoscopy removal when he was talking about general anesthesia. I have NO IDEA why he didn't just suggest aspirating it as that is what I told him we had to do last time.

Months ago I had asked my Indian Dr if I should get a laparoscopy to check for endometriosis or just get some sonograms to check for cysts. She only wanted me to do the sonogram and distinctly said no to the laparoscopy. When I called Dr. I to schedule it (had to calm my mind down and go home first), I asked to have it aspirated. If Dr. P wants me to wait till I get there, then I can always cancel. I don't even know if it will be covered on insurance here.

When I come back from India, I will be having a laparoscopy to test for endometriosis. After today, I may want to try to find a different OB/GYN. I miss my old one (had him since I was 15!) and his small practice ways. There is something to be said about a doctor and his staff knowing you every time you walk through the door and remembering everything you tell them.

Waiting for the flood gates to open. If I cry now, then I may be ok when I see hubby later.

I guess the myo-inositol didn't work. 

Special Lady Cocktails

When I first was swept up by the internet infertility tornado, I remember reading forum posts from other hopeful women. Falling on a theme (as I often do), I obsessed over the ridiculousness of women taking all kinds of crazy pills - usually without having a doctor recommend them. OMG! DO YOU JUST TAKE ANYTHING YOU FIND ON THE INTERNET??? Some posts swore by the helpfulness while others confessed that they worried it may have hurt. Once discovered, some doctors gave full-on lectures how it was not appropriate for the poster's situation, only to find out that someone else (usually another doctor) in their clinic had told them to take it. Truthfully, I was personally affronted that such naivety and desperateness could drive women to arbitrarily take anything in an attempt to conceive.

The picture above is from MY house. That's right, Ms. Holier-than-thou is ...well, the same as everyone else.

At first it started small. My first pill was THE PILL, and I was told I would have to take it by my Indian doctor to make sure I was synced properly for my IVF treatment. Fair enough. I called my OB/GYN and promptly got a prescription. Let me mention here that I do not like taking birth control pills (bcp) as not only does it make me gain weight and experience occasional nauseousness, but sometimes I experience additional glum side effects (depending on the brand). Fine - whatever - I set my alarm on my phone to give me a daily reminder; particularly because my history of remembering to take medicine on a daily basis is pretty dismal. Especially BCP. Our local IVF doctor also advised to add a pre-natal vitamin (another item bound to make me nauseous) and I immediately relented as I ran to our local Publix.

Baby aspirin and acupuncture were added to the regime - the latter being something I normally would have scoffed at a year earlier. Doctor semi-recommend it and so I shelled out the cash. My husband gave me the big-eye, but I'm guessing he recognized my fervent look and said nothing. 100 bucks a pop for 6 weeks = not cheap. What can I say except I wanted no regrets.

IVF treatment #1 was dismal. 2 eggs retrieved, only 1 fertilized. Even that 1 took a damn long time to fertilize.

Now I am prepping for treatment #2. In typical fashion, I have been obsessively researching similar cases. Not just blog posts, but academic papers and any type of current research I can lay my grubby little eyes on. A clinic in India recommended 25mg of DHEA for 3 months. I rush to pull up the scientific documentation and realized all of the research is really based on a tiny Tel Aviv study. The study showed a significant difference in live birth rates with women who were poor responders and took 75mg of DHEA for 40 days vs women who did not. A follow-up study had additional encouraging results. Screw the 25mgs -I only had about 40 days till cycle, I was going to go full boat - 75mgs it is! [I would like to make a note here that I was not able to take the full 75mg initially because of side effects. I had to build up and even now I have minor side effects.]

Next I read how melatonin could also help woman with poor ovarian reserve and immediately I was hunting down more articles and recommended amounts. 3mgs seemed to be the magical number, but that amount knocked me on my butt. Still 1-2mg was doable and thus it was added. Combining it with the DHEA means I sleep really well, but I'm groggy as all get-out when I wake up. Heaven help me if I don't get a full 8-9 hours. Oddly enough, my friend says she takes 10mg all the time and it barely helps her sleep. What can I say? I'm a lightweight.

Did I stop there? Heck no! I was on a search that day and after reading some articles (which I can not find at the moment) regarding myo-inositol, my amazon shopping cart increased. Among other things, myo-inositol was suppose to help women with cyst issues and a giant cyst almost caused a no-go last cycle. My OB/GYN found a cyst last year and I began to wonder if some of the pain issues I had felt over the last year were cyst related. GIVE ME MYO-INOSITOL NOW!!!

There were a few other things on the list, but these 3 new items had good scientific data to back them up and they applied to women with similar (if not exact) conditions. The other pills I noticed my fellow women-at-arms were taking were either less scientifically regarded or didn't apply to me. Besides, as I mentioned before, I'm a light weight and I wanted to see how I was going to handle this new concoction.

Which brings me to last week. I'm not quite sure HOW I ended up at the Rainbow (read: hippie) Grocery store - but all of a sudden I found myself at the cashier's stand with CoQ10, some fancy fish oil supplements, and yes even some Royal Jelly that was well hidden in a jar of honey. And some awesome low-sugar dried mango. And a yummy nut mix. And Activated Charcoal that I told myself would be good to have on hand if my dogs ever get into something they shouldn't. Somehow I think my subconscious was trying for an easy excuse to get some for me. You know. Just in case.

"Just a spoon full of sugar..." (or honey) 

First day jitters

Our nice A/C waiting room is for IVF peeps only. We waited only a short time (by universal doctor standards) to have our initial consult and then blood drawn. After which, we grabbed some lunch at The Rama Hotel's Thalis restaurant. Both my husband and myself enjoyed it very much, although it was on the sweeter side of his preference - typical of Gujarati cuisine according to him.

After lunch, we came back to the clinic as directed. After another short wait we were able to see Dr. Patel. She was concerned about a high estradiol level and we went over the dreaded "you're 40 speech". I appreciate the honesty, but that is one "tut-tut" I've grown weary of, regardless the source. We followed up with a scan that gave us more bad news: only 3 follicles and a 2cm cyst. The cyst would have to be aspirated to insure the highest chance of success. Come back at 5:30pm. Eat or drink nothing.

"Ok!!!! Wait what?" We had 3 hours to burn in the heat of Anand (currently at 104 F) and I was instructed not to drink. Fine. We took a rickshaw/tuk-tuk (my first ever!) to the famed Big Bazaar (BB) where even the girls in Bedazzled burkas stared at me. The BB here is like a really tiny Walmart with food items. Even though the drinks were in a refrigerated area, the want to drink was too much and I walked back over to the skin lotion aisle. The Nivea whitening lotion I bought is a testiment on how well marketing works (I've seen the commercial 30+ times now, and it has convinced I'm covered in spots from skin damage, even though I'm not positive that's what the Hindi spoken commercial says.)

After BB, we return to the hotel for an hour, and then back to the clinic. At the clinic, in a not so A/C area, I'm handed a consent form to sign. I ask what it is for and I understand it is for the anesthesia; it's at this point I realize I will be getting GENERAL anesthesia and not local. Ask my husband to confirm this and he does. Crap. I'm not known for doing well under general anesthesia. I prepare myself (and others) for the liklihood of puking.

Fortunately, I did not puke when they woke me up, but my husband was asking me what the class of antibiotics was that I have a problem with. Once we figured that all out, an older lady in a white sari added a yellow liquid filled syringe to my empty IV. They let me rest till I was good and ready to come back downstairs.

Dr. Patel informed us that once the cyst was aspirated, she could see 14 follicles. Yay!!! I had to confer with my husband that I understood correctly. Not because any language barrier, but because I still felt a little loopy. He said yes and I was jubilant, if not completely dexterous.

That pretty much was the end of our first day. We went back to the hotel for me to rest, which really turned into me going to bed for the night. My poor husband missed dinner for the second night in a row.