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Archive for July, 2009

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Last week, I met up with a bunch of Stirrup Queens (Mel, LJ, Murgdan, Barren, N, J… am I missing anyone?) for ice cream.  Since it fell on a Thursday, my typical day to get to see Barren, but also a day when I was feeling particularly antisocial, the lovely Ms. Barren convinced me that it would be good for me to get out and go hang out with these lovely ladies for the evening.  So hang out I did, and she was right, I had a lovely time, as I knew I would, antisocial status and all.  (Nothing against anyone else – I just get into my little funks and I have a hard time getting out of them and when I’m there, I get antisocial – don’t take it personally).

But after we finished ice cream and we were disbanding, I told Barren I’d drive her home (it’s not entirely altruistic, mind you, it’s a selfish way to get to spend quality 1-on-1 time with her, but don’t tell her that!  It can be our little secret, okay?).  But first she had to run over to the bookstore with me to pick up a book that my therapist wanted me to read called: Stop Walking on Eggshells which was located in the section on “Personality Disorders.”

While perusing the shelves in search of my book, I stopped short, because this is what we saw:

Infertility Personality Disorders

What I found particularly humorous was that there wasn’t just one fertility book there – that could have just been a filing error (but, um, hello?  That’s one HECK of a filing error!) – but there were two!  The Fertility Diet AND Taking Charge of Your Fertility!  (Now, admittedly, I so despise TCOYF that I think it kind of does belong in the “personality disorders” section… or at least maybe I belonged in the personality disorders section after having read it, but I’m sure that was a bit of an overreaction on my part. )

Well, I always knew we were a little bit crazy.  It’s all those hormones.  Or maybe just the waiting.  Or the stupid things people say to us.  Yes, I think it’s that last one.  Like, “Just relax” or “if you just stop thinking about it or adopt, you’ll get pregnant.”  Or “Have you tried propping your hips up?”

Yes, those things would give anyone a little bit of a personality disorder, don’t you think?

 

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Now that I’m all set up in my new home, I guess I ought to mention…

Ask and ye shall receive, I suppose.  All that whinging I did about my absent period must have done me some good, because it did arrive, and I have started my BCPs.  There won’t be any other suppression with this cycle, so I’ll just be going in for monitoring on August 11th, and starting stims on August 14th.  Currently, the projection is that retrieval will be August 25th and transfer will be sometime August 28-30th.  Retrieval and transfer dates are highly hypothetical at this point, of course.  Who knows if we’ll even get that far.

If we do get that far, I’m betting on a Day 3 transfer.  No bets on whether it’ll be a 1 or 2 embryo transfer – that’ll depend on embryo quality and whether the antagonist protocol changes anything in that department (I’m not counting on improved embryo quality).

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A comment today on this post reminded me that there’s a bright side to being at the last resort after all. I mean, the last resort is Ganirelix. Which means? No Lupron.

Admittedly, I don’t know a lot of women who’ve done an antagonist protocol, and even fewer women who have done a Lupron protocol followed by an antagonist protocol (most women I know who’ve done ganirelix have simply started out there), so truthfully, I don’t really know how the side effects are going to compare. Maybe they’ll still suck. But I’m guessing that I’m not going to be describing headaches that slice through my head like a piece of broken glass. I mean, that was pretty graphic and gruesome, wasn’t it? Ick!

It’s bound to be better than that, right?

Admittedly, starting the Ganirelix protocol requires me getting my period at some point. And my dear, sweet period is still MIA, which, I must say, is definitely not amusing.

Honestly, there simply *must* be something interesting to say about waiting, but there just… isn’t.

Hey, so, have any of you out there used Ganirelix? More importantly, have any of you who have used Ganirelix also used Lupron in the past? How do they compare (specifically with regards to side effects)? I’m thinking of posting this question to the LFCA in my copious spare time, but, um, you all know about me and my copious spare time. I’ve got so little copious spare time that I haven’t even managed to put one of those handy dandy little buttons in my sidebar that says “post my news in the LFCA” which would make it super easy to just go and do it now, wouldn’t it? And in the space of time it took me to type this little paragraph about how I don’t have time to go post this in the LFCA, I could have popped it into Mel’s google spreadsheet. Or picked up the phone and called Mel and told her I’m too lazy to post it in the LFCA and could she please do it for me? But no. I’m not as industrious as Mel. I, as they say, am lazy.

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I took Provera over a week and a half ago for five days and… nothing. Well, nothing except some really visciously bad PMDD-like symptoms. And now I wait.

At the end of this week, in all likelihood, I’ll call Ye Olde Fertility Clinic back and ask WTF is going on and they’ll tell me to come in for bloodwork (you know, to make sure I’m not pregnant – don’t worry, I’ve already POAS’d to make sure, and well, I’m not… duh). And after the bloodwork I imagine they’ll give me more Provera. Which theoretically will induce a period, at which point I can start BCPs.

And if it doesn’t induce a period… well… I don’t know what then.

And I’m tired of waiting. I’m tired of the schedule changing. I’m tired of recalculating when stims might start and, consequently, when my hypothetical retrieval and transfer could be. I’m tired of thinking things like, “Well, as long as we start by X day, it shouldn’t interfere with Rosh Hashana.” For heaven’s sake we had an extra month’s lead time to avoid the High Holidays! This was not supposed to be a problem this time. You know, just like Passover wasn’t supposed to be a problem. Or Shavuos. Or, you know, Shabbos last cycle.

I get it. I get that I’m not in control. I don’t need to be reminded of it at every turn.

As I wrote to a friend this morning I’m having a hard time looking forward with a lot of optimism…

“Even SuperDoc doesn’t seem particularly optimistic about this upcoming IVF cycle. It’s pretty disheartening when the doctor is the one that isn’t super optimistic.

He said if I’d asked him in January what he thought my odds would be going into my fourth initiated cycle (which is essentially where I am right now by HIS count… my count is a little different, but I know where he gets his number)… he said he would have given me about 80% odds of a successful pregnancy back then. But now that he’s seen the outcome – two failed cycles, and one canceled due to low response (he’s not counting the one that didn’t get to stims)… he doesn’t have that kind of optimism. He said he’d maybe give me about 30% odds on this cycle.

He said, “I definitely think we’ll learn a lot from this cycle, and it’s going to be key to your ultimate success.”

I paused, took a deep breath, and thought about the implications of that statement.

And he said, “I mean, of course hopefully you’ll just be pregnant at the end of this cycle…”

Right.

I’m not trying to be a negative nelly about it – I just… with the IUI cycles even though I technically had more at stake (having never had a successful pregnancy before), none of my negative cycles hit me the way these do. These cycles? No matter how much I prepare myself for the failures, no matter how much SuperDoc himself prepares me for them to fail? They’re devastating. Even though I have four beautiful children at home. Maybe because of it.”

I admit, I much prefer his honesty to meaningless platitudes. I don’t want to hear him just blindly say, “I know this is the one” without scientific basis for saying so. But I admit I’m growing weary. I’m beginning to wonder if I’m the patient that keeps going despite a doctor who secretly thinks there’s really no point. I don’t think I’m there yet. But … will I be there soon?

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On Friday, I received two pieces of mail from Ye Olde Fertility Clinic. The first was a statement detailing my deposit due for IVF#3 (they call it IVF#4, interestingly). I had already paid the deposit that morning, but they couldn’t have known that when I put it in the mail, so no biggie.

The second piece of mail was slightly more annoying (and that’s saying a lot – because any piece of paper that’s more annoying than a piece of paper asking for a large sum of money? Well, that’s pretty annoying, don’t you think?)

It was my embryo disposition report from IVF#1… which was in Jan/Feb of this year! So just a lovely little reminder that:

I had… 10 eggs retrieved.
I had… 9 eggs fertilized normally.
I had… 0 eggs fertilized abnormally (e.g., with more than 1 sperm)
I had… 1 eggs unfertilized and discarded.
I had… 1 embryos transferred. [with zero resulting pregnancies]
I requested… All remaining embryos to be cultured and that any that reached the potentially viable blastocyst stage be cryopreserved.

And…. (drumroll please)

As a final result of embryo culture… 0 embryos were cryopreserved this cycle.

Presumably, that last line was the whole reason they sent this copy to me – since I didn’t have a copy that actually said that before, and I’d merely been told over the phone what the final result was (and it took several days for me to be told that result, too, btw).

Thanks for the reminder. It really… um… helped give me closure?

er…

I wonder how long it will be before I get the embryo disposition report from my May/June cycle and I’ll get to be happily reminded of that hell of a transfer day with the evil doctor when I look at the embryo disposition report and see several signatures that aren’t mine, but are, instead the witnesses who signed in my place. Fun times to look forward to. Hopefully by the time I receive that report, it will be irrelevant and I won’t care, because I’ll just be happily pregnant.

Right.

I almost said that with a straight face.

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I would like to say that I met with SuperDoc today and he said, “Well, it’s obvious that the problem is X, and therefore, we simply have to do Y, and voila! You will be cured and you’ll have a baby in 9 months.”

I would like to say that I met with SuperDoc today and he said, “I absolutely know that this next cycle is going to work for you.”

I would like to say that I met with SuperDoc today and he said, “You are the most straightforward patient I’ve ever treated – clearly textbook diagnosis X. I know just what to do next.”

I would like to say that I met with SuperDoc today and he said, “I know this has been a long and frustrating road, but with this new protocol, I believe you have an 80% chance at achieving a successful pregnancy.”

I would even like to say that I met with SuperDoc today and he said, “If you look at all the things you have going for you in Column A and all the things you have working against you in Column B – Column A clearly outweighs Column B.”

I would like to say a lot of things, but none of those things would be true. So what really did transpire? Well, honestly, it’s a bit late now, and I’ve got a fair bit of pain medicine in me right now, so I’m not sure I’ll do it justice, but I’ll do my best.

First, I noted that he had a lovely new desk for his office. I told him I’m clearly paying him too much, and that we simply must cut that out. I brought him fudge, for which he thanked me, and I said, “well, we’ll see – I’m not sure you deserve it.” He agreed. “I don’t deserve it – I’m not at all happy about what we’ve failed to achieve for you.” I told him to stop being so hard on himself – after all, that’s my job, and it’s fun for me. He wouldn’t want to take away my fun, would he?

SuperDoc is definitely frustrated. He acknowleged that I’m a “challenge” and said he knows that I don’t want to be the “interesting” patient. Oh please. Who wants to be the “boring” patient, anyway? If I were boring I wouldn’t get to spend so much quality time with such a wonderful person like him! Um… He talked through all of my cycles (including my response to stims in my IUI cycles) and he put the items in my favor into one column, and the items against me in another column:

Good Bad
Age Average to low response to stims (luteal phase lupron protocol)
(some good) Mixed embryo quality (majority poor)
successful triplet pregnancy 5 failed IUIs; 3 failed initiated IVFcycles

He said if he were only looking at the response that I’ve had to the initiated IVF cycles that I’ve had this year (in other words – most of the second column), and he didn’t know my history (in other words, most of the first column) – he’d probably be talking to me about egg and embryo quality issues. But the fact that I have had a successful pregnancy before, and the fact that I’m (relatively) young-ish does change things a bit for him. But on the other hand (there were many “other hands” in today’s consult), he said that there’s still the question of why did it take so many IUI cycles to conceive the triplets in the first place? And why triplets after so long and so little success? (There were, by the way, a lot of unanswered, rhetorical questions asked in today’s consult)

When we were cancelling IVF#2, Take 2 I had asked SuperDoc about considering an Antagonist Protocol (Ganirelix). He said then that he felt that Ganirelix would give me a lower quality cohort of embryos, and that he didn’t think there would be an advantage to changing the protocol at that time. At the time, he said he wasn’t opposed to trying an antagonist protocol if he was forced to – but that it would be a last resort.

Today, he talked through some of my history and my options for moving forward. It seems clear that I no longer respond like a woman with polcystic ovaries, which, he says, is extremely unusual – apparently this doesn’t normally just “get better”. Still, all signs point to me maybe not really having PCOS right now. He does still want me to stay on metformin, on the off-chance that it’s doing me some good – but he said he doubts that it is. It can’t hurt, though. In IVF#1, they treated me like someone with classic PCOS (lots of Lupron, low stims) – I didn’t stim particularly well, but I did have a reasonable outcome with the retrieval. Fertilization was fine, embryo quality was terrible, I had one good quality blastocyst, nothing to freeze. IVF#2, Take 1 was canceled before I got to Stims. IVF#2, Take 2, they treated me with less Lupron, more stims but still pretty conservative – and had to cancel for under-response. Clearly, I wasn’t behaving like a PCOS patient. IVF#2, Take 3 I was treated like a typical average-to-low responder, very low Lupron dose, moderately high stim dose. Good retrieval numbers, reasonably good fertilization, great Day 2 embryology report compared to IVF#1, everything went to hell on Day 3.

He said that there are a very small number of women (about 5%) who simply make crappy (my word) embryos with Lupron, for whatever reason. So he could consider doing a “Lupron Stop” protocol where they just stop the Lupron on Day 1 of stims (no suppression after that), but he doesn’t want to go there, because he thinks the Lupron could be partially responsible for my crappy embryos. (He’s not discounting the likelihood that I simply make crappy embryos – three beautiful babies snoozing in their cribs notwithstanding).

He would, instead, like to move to an antagonist protocol. Shocking! Compared to the 5% of women who make crappy embryos with Lupron, about 20% of women make crappy embryos with Ganirelix. He said that with Ganirelix, you run the risk of a certain amount of unevenness in the cohort, which is something he’s particularly concerned about with me, given my propensity to have lead follicles in my cohort -but he’s hoping that without any Lupron on board at all, we’ll see a different trend than we’ve been seeing. He believes that we have a 30% chance of seeing a lower quality cohort with the Ganirelix and a 50% chance of seeing a better quality cohort. I believe we have a 100% chance that this is all a crapshoot no matter what.

As for his overall recommendation – he said this is really about my personal stamina – and what I think I can handle. He said that he thinks he knows me well enough by now to know the answer to that, but that it’s really up to me. We talked around the insurance issues a bit and I told him that I have one covered cycle left in my insurance and that after that my husband’s insurance covers us, but only at The Hatchery. Interestingly – the Hatchery is merging with Ye Olde Fertility Clinic in the next few months, and this may seriously impact whether we’d be able to pursue additional cycles after this one. It was actually quite comforting to know that we may not be as limited in options as we thought after this cycle. I thought about it for a few minutes and told him that my husband and I were both committed to wanting another baby. But that most likely what we would do is do this next cycle and then take some time to re-group and consider the insurance implications of continuing on with another couple cycles under his insurance. Even with the merger – which would mean taking away the logistical nightmare of forcing me up to a city an hour away in the wrong direction at all the wrong times – my husband’s insurance still isn’t as good as mine, and the upfront cost is still significantly greater than mine, so that’s still a lot to swallow. But … I do like knowing that we’re not at the end of the road come August if we don’t choose to be.

SuperDoc said pretty clearly that “this cycle is going to be very telling – we’re going to learn a lot from it…. of course, hopefully you’ll simply be pregnant at the end of it.” It wasn’t lost on me that the pregnancy possibility wasn’t the immediate thought, and was more of an… afterthought. Just as it wasn’t lost on me that SuperDoc’s recommendation to move to an antagonist protocol – once his “last resort” – was now his next step.

I asked about whether I should be considering a 2 embryo transfer on Day 3 – rather than continuing to dig my heals in about the Day 5 blast eSET transfer. He said that we need to look at what the embryo quality is with the antagonist protocol – if there is an improvement in embryo quality, he would still encourage me to transfer one embryo (Day 3, Day 5 – we’ll see when we get there). But if we’re still looking at the same embryo quality issues – then it’s a matter of talking through the statistics and making an informed choice when the time comes. With embryos of the quality I’ve been looking at on Day 3 these last couple cycles? He’d have put me at 5-10% odds of having a twin pregnancy – odds I can live with. If we were looking at transferring 2 high grade blastocysts, the twin odds would be closer to 50% – odds I could not live with.

And so… Friday I’ll be getting my progesterone drawn to see if I’ve ovulated on my own (my period was 14 days ago- if I am, we’ll wait for my period to come. If I’m not, I’ll start progesterone for five days. When I get my period, I’ll start birth control pills for 21 days – go in for BW and U/S, and start stims 3 days later.

He’s starting me at 375 units of Follistim, 75 units of Luveris. Once I start the Ganirelix, this is going to mean 5 shots per day. Awesome.

He doesn’t sound super optimistic, and I’m not either. He and I are both realistic about the fact that nothing with me has gone quite the way we’ve expected. He’s been doing this a long time and has never quite been able to predict what’s going to happen with me, and that … is frustrating, and a little worrisome. I’m beginning to realize that I’m … not the boring PCOS patient I always figured I was.

We did, by the way, talk briefly about the shabbos incident with Dr. Hate. I may write more about it later, but the long and the short of it is that SuperDoc handled it appropriately, and with the care and sensitivity that I needed. He assured me that he would do everything he could to be the doctor who was present for all of my procedures no matter when they are, but that if he can’t be there for whatever reason, he will ensure that whomever is on call will be well-versed ahead of time in what needs to be done to accomodate the religious restrictions that I have on Saturdays, should it come up again. I assured him that I don’t expect him to be at all of my procedures – it’s a big practice, and I know how the practice works – different doctors are on call for procedures on different days, and I know that.

“After all you’ve been through, the least you can expect is that I’ll be there for your procedures. I will always do my best to be there for you,” was SuperDoc’s reply.

Take that all you ridiculous competing clinics out there with your radio commercials calling Ye Olde Fertility Clinic a “revolving door of doctors” – implying that my clinic is impersonal, without contact from individual doctors. Take that!

And this, my friends, is why I love SuperDoc. Why I love my clinic. Why I sing their praises. Why I’m willing to put myself on television and in print media for them. Why I refer patients to them consistently and frequently.

Because they care.

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