Begin at the Beginning...

From: http://aliceinwonderland.wikia.com/wiki/King_of_Hearts

“Begin at the beginning,” the King said very gravely, “and go on till you come to the end: then stop.” 
~Alice in Wonderland

I feel so behind on blogging about what is going on.  Ok. Let's start at the beginning. Or at least the beginning highlights of IVF cycle #3.

Christmas Day I starting on my Viville-dot .1 estrogen patch. The instructions were to change it out every other day until I started my regular cycle meds. Once I began those, I was to leave the last patch on for 3 days. 

Day after Christmas I started my protocol of injecting Ganirelix 250 mcg for 3 days. 

Friday night (12/28) my period started, and that brought me into the ACRM office on Sunday morning to do our baseline ultrasound check: 11 follicles. 

Monday (12/31) I started my Bravelle (6 vials of 75UI) and Menopur (2 vials of 75UI). You can see my discussion about that process here.

Friday I had my ultrasound and was introduced to my new nurse. Our old nurse/third party coordinator was promoted to Director of Nursing (or some similar title) and I was a little apprehensive of having to start with a new nurse. Even though our old has frustrated me a few times. Both nurses were there on Friday and I was actually pleasantly surprised with our new nurse. My fear was that she was going to be a total noob, but I couldn't have been more wrong. Apparently she was the former Director of Nurses took 6 months off, and was coming back as the new third party coordinator. She instantly made me feel at ease with her knowledge and bedside manner. Brava because I was very irritated with my clinic that day. 

The ultra sound showed 6 follicles growing on my left ovary and 3 on my right. All in the 10mm category. She explained BEFORE the ultrasound (which was really smart in my opinion) that it was very early and the number we were going to see that day could change. Not to worry if we only saw a few. At 9, I was pretty happy. 

After the ultrasound, I requested to meet with the financial coordinator. She was supposed to have called me back on Wednesday after speaking with her manager about a mistake they made, but did not. This meeting ended up with manager joining us and I will save that for another post. Suffice to say, I was not pleased about a mess-up and I let them know. 

The rest of the day saw me at work, running around trying to get required IVF forms notarized, and finalizing the attorney items. A busy day indeed. The mountain of forms you have to go through is staggering. 

Saturday my GC had her ultrasound and mock transfer. All went well, but neither one of us was informed before hand that she would be having this mock transfer. I'm guessing it was a bit of a surprise for her. 

Which brings us to today. (Shew.) Another ultrasound and blood work. Lining (where I have it) is striped and at 7mm. There are 4 follicles on the left that are 10mm or greater, and 3 on the right. Several smaller ones that may still be recruited. We will know more at my ultrasound on Tuesday. Blood results came back this afternoon and estradiol is looking good in the 500s. As long as it was in the 300's that was a good sign. 

That pretty much brings everyone up to speed. Well, everyone that reads this anyway. Not technically "the end" but a good place to stop for tonight. :-) 

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. 

Egg total = 4

Less than I thought for 12 good follicles, but still twice as many as last time.

Today we go and see if they fertilized. Already my stomach is a tad in knots. 

Day 9: 12 are good to go!

12 follicles are between 16-21mm and 1 is at 14mm. YAY YAY YAY. This is so much better than last time (and with the original 5 we thought we were starting with). I'm still on the antagonist protocol, but with extra meds that Dr. P says has recently shown really good results in poor responders. Now let's just hope everything else goes well and that the follicles are filled with good eggs, that make good embryos, that make BABIES. It would really suck to feel so positive this time to have it all go to crap.

We are going to retrieve on Thursday. My husband has switched his travel plans and it taking an earlier flight into Vadodora, where the hotel car will be waiting for him. We nixed the train idea. That should shave a few hours off his time, so maybe he will make it before I go under. I hope so.

My husband wanted me to ask the doctor if we could do the retrieval in the afternoon, but she said she doesn't want to take the chance and compromise everything. I knew that would be the case. If we don't time things exactly right, then we could miss our window, especially with my larger follicles.

So Thursday it is. Right now my husband should arrive around 8:30AM and I am scheduled for retrieval at 9:30am. With any luck he will be there to hold my hand before I have to go under. Hoping that Dr. P is able to retrieve many and that they are good.

While we are waiting, here are some pics of a small local temple nearby.

Day 8: Yay! and try not to freak out.

Had another sonogram today, more shots, met the surrogate, and went over some preliminary paperwork.

Sonogram showed 13 follicles (yay!). 5 really good size, 6 average, and 2 small. Hopefully we will get some good eggs and then embryos out of these. Right now we plan on extracting on Thursday, but Dr. P said she will confirm after my sonogram tomorrow. 

Starting to get a little worried with the timing of my husband's arrival. I recall when we were planning this trip that I commented we didn't have much buffer room for mess-up (time wise), but I didn't think much more of it. Don't think I even thought of the timing for HIS arrival at all. Saturday I realized how short we were cutting it with his arrival. He gets here on Thursday - right now I'm tentatively scheduled for egg retrieval that day. That means he will not be there when I go under, something I am NOT happy about. Think "scared" is more the word I am feeling around for. In case of emergency, we do have 2 backup samples from last time, which is  good to know, but still don't like the idea of possibly having to use them if ANYTHING goes wrong with his travel. 

Try not to freak out, Try not to freak out. 

Last time we had to go a day earlier than expected. We expected 10 days of shots (not including the trigger) and ended up with only 9. If I go on Thursday, this will mean that I only had 8 days. I think the average person goes 9-12 days. I'm hormonal and irritable at my husband right now. Even more at myself for not looking at his schedule more closely and insisting on better buffers. 

Try not to freak out. Try not to freak out. 

Ok, got that out of my system for now.

On a different note: met the surrogate today. The surrogate is 28 years old, 121 lbs and 5'3 (I think she's 5'2 1/2). She has a brightness to her eyes and is ready with a smile. Sadly, she is going through a divorce and wishes to have enough money to get her own house and have some left over to go towards her son's education. 

When people talk about exploiting the poor, I really wonder if they think of things like this. Many months ago I looked up Gujarat house/flat prices and I remember being amazed how low they were. A surrogate in the USA could NEVER buy a house for what a woman could here in India. Sure, it may be a small house/flat compared to what we are used to, but so are most of the homes I have been to here. Even in very well to do homes. A woman could not earn the equivalent of 10+ years salary for surrogacy in the USA and they could not have left over funds to educate their children. When you see the lives here that have had such a positive impact due to Dr. Patel and surrogacy, it's easy to see why she does not let her critics affect her. 

Ok, got that out of my system for now.

Please let this take this time. I don't think we could come back again for another try with my eggs. Please please please. 

Hopefully this cow gave me her blessings. I gave her and a baby cow some of my leftover Malai Kofta and rice. Actually I gave it to the calf, but then she came and took it over. I'm ok with that. Maybe I'll get double blessings. 

Boss cow

Baby cow eating bushes after a few bites of delivery

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. 

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) 

Plus 2 Minus 1

Yesterday we were given the good news that the two tiny follicles were responding well to the increase in meds. That means we were up to 6! Today we were told that I have 3 on one side (responding well) and 2 on the other. Down to 5. :-(. On a good note, we'd probably be down to 3 had we stayed the course as the 2 on my left side were the tiny ones.

On a separate issue, we are going to have to retrieve on Sunday instead of Monday. Normally the doctor is not at the clinic on Sundays, but one follicle has grown so large (23mm!) she fears we will lose our chance if we wait. So a Sunday retrieval it is.

We met our surrogate yesterday and she is quite lovely. 34 years old with 2 boys and had a successful surrogacy 4 years ago. She is a half inch shorter than me and is the weight I was when I was pregnant so long ago. In my IVF book, with the exception of 38-40 IP mothers, gestational carriers have a higher rate of pregnancy for all ages. Sometimes over 10% higher. For 38-40 it's about even. This sounded pretty interesting to me even though it currently doesn't apply. Here's a pic of the chart (keep in mind the picture and blog post is from my phone. The darker line is for those who used a surrogate / gestational carrier.)

A New Day

Yesterday sucked. Really really sucked. We had our Day 6 scan and it revealed only 4 follicles maturing on one side and 2 tiny ones on the other one. Basically I'm a poor responder.

If you're keeping score, at my original appt in the US, I had 16 follicles. 16 put me right at the next level of a better success rate. Not the highest, but still fairly good. On our first appt here in India, my initial scan only revealed 3 and a big cyst. Aspirating the cyst revealed 14. 14 put us in the fair range, but it was a hell of a lot better than 3. I don't know if they'd even go through with 3. Crisis averted.

But now we are down from 14 to only 4 responding. I expected 70% (as that is what is the norm) and thus 4 is crushing. 4 combined with my age drops us down again. Immediately I started ferociously pulling up stats I have saved to my iPhone, and then I stop. I don't want to know anymore. Neither my husband nor I am religious and it is times like these that I wish I could be. For the moment, hope has left me and and the realist in me wishes I had not let the excitement of the process overcome the knowledge of the likelihood of success.

How do women go through this roller coaster over and over? I'm not sure how many times I can, knowing every month our chances decrease as I age. I'm not sure how many trips to India we can do with me not working. I'm not sure if I can get an exception to my visa to return in a month (I have a 10 year tourist visa from 2008) or instead try for PIO cardholder status (husband is still considered Indian citizen). I'm not sure of so much.

If this seems early to have lost all hope, then realize these were my thoughts and feelings of yesterday. Today is a New Day. The doctor has doubled my dose and I am cautiously optimistic.

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.