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So this morning was a complete whirlwind and nothing was going right for the first couple hours of the morning (all of which related to things best n0t discussed on an infertility blog), but things eventually calmed down and I was working from home before leaving for my transfer (this was part of what didn’t go as planned – I had planned to be in the office for at least 2 hours before my appointment…). At some point, I looked at the clock and realized I’d been holding my breath all morning. Nine thirty. They would have called by now if everything had tanked and they were going to cancel. I hadn’t even realized that the thought was on my mind.

I set up a document to print at my office and grabbed a bottle of water, a pan of brownies, my keys, and my coat and went on my merry way. I stopped at the office to pick up the document I needed (a little light reading for the waiting room…whee!), and then headed up to Ye Olde Fertility Clinic. I called J, Marketing Supervisor Extraordinaire, as I was pulling into the parking lot. “So I’m early. Do I go upstairs and sit in the waiting room? Or do I bring you a brownie? You wouldn’t want to risk SuperDoc eating them all, would you?”

“You didn’t really bring brownies, did you?”
“J? Of course I did. I told you I was going to, and I always deliver!”

Needless to say, there was brownie delivery prior to waiting room waiting and document review.

And then my moment arrived… I was whisked back in to the transfer room. Asked to recite my name and social security number a few times, told to undress (waist down) and wait for SuperDoc. No problem. Except at some point I realized that my goal of a so-called “moderately full bladder” had, well, been exceeded. But I was good. Really. For a while. But the clock, it kept a-ticking. 5 minutes. 10 minutes. 20 minutes… Honestly what was worrying me the most was that they’d pulled out my little beauties and decided that they were all pretty useless after all and were trying to figure out how to break the news to a homicidal hormonal fertility patient. And finally SuperDoc walked in.

“So, did you pick a good one?”
“We might have more than one to choose from, but I know which one we’re going to use.”
“I’m just saying, you know, if you pick a good one, there might be some brownies in it for you, because I know that changes everything for you.”
“Well, in that case, we’ll be sure to pick the very best one. Since we weren’t going to do that anyway.”

We talked for a bit about which embryo he was going to transfer, and why.

He then reviewed the “Embryo Disposition Report.
“Okay, 10 retrieved, 9 fertilized, etc. etc. and we’re transferring 8, sign here.”

I. Lost. It.

I mean, all-out, completely hyperventilating, lost it. I told him I wasn’t signing that piece of paper (which CLEARLY said transferring 1) unless he TOOK THAT BACK. No even JOKING about that! Not with that timing.

“Don’t you remember my reaction when you told me how many heartbeats there were?”
“I think this reaction might be worse!”
“I think you might NOT get brownies!”

I made the embryologist get me a picture to prove there was just one. JUST ONE. (I have the picture, but haven’t been able to scan it yet. Will do so later. I assure you, it’s a cute little blastocyst. Early, and not totally perfect, but perfect enough for me. I mean, honestly, it was just a ploy to *get* a picture, but a girl’s gotta do what a girl’s gotta do, right?

(By the way, SuperDoc did note my “impressively full” bladder several times on the ultrasound. Rub it in, doc. Rub it in. See if I ever bring you triple-chocolate brownies again.)

I told SuperDoc after the transfer, “I swear to you, if this single blastocyst splits twice and I end up with monozygotic triplets -“
“-I’ll shoot myself,” he finished for me.
“You might have to fight me for it.”
“And if we only have one gun and one bullet, we might have a problem!”

After my allotted period of “rest” my nurse came in and looked at the picture of George (my blastocyst) and said, “Oh look, they transferred both of them! That’s great!” I almost decked her. Watch out there, or I might change your pseudonym from NurseAwesome to… well, something else. She went over my discharge instructions, and took some brownies (which I distributed all around, I took another for J (Marketing Supervisor Extraordinaire), and sent the rest to SuperDoc’s office (see? I don’t hold a grudge!).

I brought a brownie down to J’s office and bid him adieu. “I’m not back here until the 18th! What will I do without you, Marketing Supervisor Extraordinaire?”
“Oh, I’m sure we’ll be emailing.”
“Aren’t you sick of me yet?”
~dramatic pause~
“Of course not!”
(I’m kidding, there was no dramatic pause, but go with me here, it’s more interesting my way, right?)
“Well, maybe I’ll make my appointment for my beta late enough in the morning that I can bring you cookies.”
“Oh no! I don’t know how I can stay friends with you! I’m going to be 400 lbs!”

I’m thinking snickerdoodles… Yeah, ’cause those are low fat. Ahem.

I mean, there is the theoretical possibility that I’ll get pregnant this cycle and he’ll be rid of me. Right? RIGHT?

Yeah. Um. Seriously? I still can’t say that with a straight face.

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I know, I know, ever since my recent media appearances, it’s been hard to escape my adoring fans, the ruthless paparazzi, the constant phone calls, the text messages, the overflowing mailbox, the neverending emails… It’s a hard life, but someone has to live it, right? At least I can say that stardom has most definitely NOT gone to my head.

So you, my adoring fans, have questions. And, it turns out, I have a couple of answers. . .

Q: What time will your transfer be tomorrow?
Well, I’m glad you asked. Because I just got a call from my nurse answering that very question! I’m scheduled for 11:15 tomorrow morning. Be there at 10:45 with a “moderately” full bladder and instructions not to use the bathroom upon arriving at the office. Now, I find this incredibly hilarious. Have you ever tried to exactly provide a “moderately” full bladder? Yeah, it doesn’t happen. Either you end up with an empty bladder, or you’re sitting in the waiting room absolutely DYING and eventually a nurse says, “Okay, you can pee, but only THIS much.” And really, have you ever tried to pee just, say 30ccs with a completely overflowing bladder?? Yeah, it doesn’t actually work that way. So good luck with that. (I will say that the serious advantage of having had HOMs is that I never had to have bladder-filled ultrasounds in my pregnancy… that would have been sheer misery)

Q: But what about Shabbos preparations? How will you manage?
Fortunately, I’m not the only super-hero in my household. My husband, darling man that he is (see? I can say that now that I’m not on Lupron!), can totally handle Shabbos prep all on his own. That, and I’m going to cook as much as I can tonight so that it doesn’t ALL fall on him.

Q: How long will you be on bed rest?
My clinic, apparently, is “East Coast Conservative” on this issue. There have been several studies done on the benefits of no bed rest after transfer vs. 24 hours vs. 48 vs. 72 etc. So there’s some benefit to bed rest, but 72 hours seems to (maybe) be overkill. So we’re a 24-hour clinic. Look at me, referring to the clinic staff as “we”. Yeah, I’m there so much I feel like I work there. I assure you, I don’t. Though for all the free press I give them, I ought to be on the payroll.

Q: If you have 3 good embryos and they implant 1 and you freeze the other two and the first embryo takes and results in a successful pregnancy what do you do with the other two embryos?
Well, first I’m going to nitpick here a little – Doctors can’t implant embryos. They can only transfer embryos into the uterus and hope that it implants into the uterine wall. Implantation = pregnancy (though no guarantee of ongoing pregnancy). If doctors could implant embryos (and who knows? Maybe someday they will be able to!), they would always implant a single embryo in all IVF cycles – because it would be a 100% initial pregnancy rate. The media, for WHATEVER reason has never been able to keep these terms straight. For crying out loud, the frickin’ New York Times can’t even get the term right. If they can’t, who can we expect to get the term right? The problem with getting the term wrong is that it causes the general public to have a skewed view of the reality of fertility treatment. It makes the general public believe that IVF is more of a sure thing than it is. While IVF success rates have skyrocketed in the last several years, it is still not a guarantee. And when the general public perceives that every cycle is a guarantee that each embryo transferred equals a guaranteed baby, they think that women who come out of fertility treatment with multiple babies had it coming. And frankly? That’s unfair. So I’m on a mission to blot out the misuse of the term implant.

But I digress, because I didn’t actually get to the heart of your question, did I? You want to know what I’ll do with any leftover embryos should I have any frozen and should I get pregnant on my first go-round.

Well, I imagine the author of this article would have you believe that having any frozen embryos from this cycle would be an irresponsible consequence and rather poor planning on my part. And, further that the only morally acceptable choice for any remaining embryos that we have would be to enter into an embryo adoption program. But… that author probably never went through IVF himself. I daresay he actually never spoke with an actual IVF patient. And, further, probably never actually spoke with a reproductive endocrinologist or fertility science researcher. No, I’d guess that he never read beyond the abstracts of the studies he cited or the party lines of the political think tanks he references. Instead, he proudly waves the banner of prochoice moralism and dismisses any opinion other than his own, woefully uneducated one.

Right. Off soapbox now (but for a brilliantly written soapbox on this very article – I highly recommend Akeeyu’s post!)

Clearly, I didn’t have the luxury of telling my doctor to make sure to only create one embryo and make sure there were no others that survived. (I mean, that very well may still happen – but if it does, that’s Darwinism in action, not anything pre-planned). I certainly wasn’t going to tell him only to fertilize one egg and hope THAT one was the one that lived. (Don’t worry, I don’t think you, my reader, were suggesting that I should have done so. I’m just still so pissed off at that article… which, by the way, I read over a MONTH ago and my blood is still boiling). So, sure, I ran the risk that I would make more embryos than I needed for my planned single embryo transfer.

But, then again, we also knew that I wasn’t *quite* the ideal candidate for eSET… and so we knew that I wasn’t looking at the standard 67% odds on an eSET cycle that my clinic has. I was looking at 40-45% odds going in, which SuperDoc revised to…oh, 30% about halfway through my cycle. So clearly, having some back ups? Good thing. (again, still don’t know that I’ll have any back ups…)

So what if I get 3 blasts by tomorrow? We transfer one, freeze 2. And then, let’s say, I get a BFP? (Hah! I can’t say that with a straight face yet. But for the sake of argument…) What then?

Well, we’ll start with the knowledge that I’ve already had one late miscarriage, so a BFP for me does not necessarily equal an ongoing pregnancy. So I’m not holding my breath, first of all. But… if I do get and stay pregnant and deliver my (healthy? Please God) singleton baby (9? Please?) months later… what then?

Well, I’m not promising our family is complete with one more baby. Maybe it is. But I don’t know yet. We know that right now, we want at least one more baby. And that probably is it for us. But not because we want to be done, but because of the financial hardship of having more after that point… we’re already stretched financially, so one more? Sure. But two more? Probably more than we can handle. But option one is we hang out for a while until we are certain our family is complete. And that IS the current plan.

After that, our choices are between my husband and myself, and those decisions are up to us for the moment. We do have a plan, and they are documented in our consent forms with Ye Olde Fertility Clinic (though they’ll have to be revisited at the end of a specified period of time). But it’s our plan, and ours alone. (I will say that Jewish law is pretty complex in this area, so there isn’t a lot of choice involved, but regardless, our plan is documented)

Sorry for the long answer to a seemingly simple question.

Q: What happens to those embryos that don’t make it to freezing or transfer but are still considered viable?
This question came from an anonymous commenter. I’m not entirely certain that I understand this question. Honestly, if by Day 6 the embryos haven’t made it to a stage suitable to freeze, they aren’t really all that viable any more. I’ll check with Ye Olde Fertility Clinic, but I assume any non-suitable embryos are discarded in a respectful manner.

Q: All this fine-tuning seems sensible and makes me wonder how the Hatchery does those batches when obviously tailoring to individual response is needed.
This is from the same anonymous commenter. Yes, YOFC has been doing very sensible fine-tuning, which is fantastic considering that YOFC is an enormous clinic. Other clinics in the area accuse my clinic (without naming names, of course) of being a “revolving door of doctors” and tout themselves as being able to individualize care in a way that the “bigger clinics cannot”. I’m here to tell you – YOFC individualizes every patient’s care and treatment plan. They don’t just have one set protocol and squeeze each patient into it. They have been extraordinarily flexible with my protocol, recognizing that the fine tuning is where the success will come from.

As for The Hatchery – they do batch their patients for the start of their cycles (every two weeks), but they almost have to do so because they have one doctor and one doctor only. This gives him the ability to have one retrieval weekend and one transfer weekend per month on average according to his nurse. But he, too, has built in flexibility. And because he sees fewer patients, he’s able to individualize care plans very easily as well. For example – though they have never done an elective Single Embryo Transfer, and he wasn’t totally comfortable with the idea of having his hands tied on that issue (me saying that under no circumstances would I allow him to transfer two), he was willing to work with me on that. He never takes his patients to blast and always transfers on Day 3. Why? Because when he was doing blastocyst transfers, he found that he had a much higher pregnancy rate, but no more babies. His ongoing pregnancy rate didn’t change with blastocyst transfer. He couldn’t figure out why, either. However what he did say was that with me and me alone he was thinking that to do an eSET, what he’d probably do would be to take me to blastocyst before transferring. So he was definitely flexible in terms of the protocol and the timing, etc.

Obviously, with the batching, there is occasionally some overlap of patients, but it is kept to a minimum for him this way.

Any other questions??

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Day 6

No transfer today. Moving to a Day 6 transfer (tomorrow).

I, personally, think this is really all rather rude. I was waffling this morning about moving my afternoon meetings. If I moved them, for sure I was going to end up rescheduled, right? If I didn’t move them, I was going to end up with transfer staying on today’s schedule and having to cancel my meetings at the last minute. So, at 6:45, I rearranged my calendar, just in case.

And then, on my way in to work, my nurse called.

“Hi Perky One…”
“Oh this can’t be good.”
“We’re moving you to tomorrow.”
“Oh for the love of Pete.” (I admit I may have been, um, slightly less delicate than that)

Turns out, things are actually growing for a change (maybe we’ll even have something to freeze? Did I just say that?), but they’re growing slowly and unevenly and nothing’s made it to blast yet.

So… we’ll see what goes down tomorrow…

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I kinda left you all hanging about the embryology report didn’t I?

While I was at Ye Olde Fertility Clinic today, I ran into SuperDoc and he told me we are likely a go for tomorrow for transfer, but no promises. It will probably be a last minute call, but for the moment I’ll assume we’re a go for 1:15 tomorrow afternoon.

There’s at least one little embryo who could. Possibly another. Whether they’ll be blasts by tomorrow remains to be seen.

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Yes, people, I know it only takes one. I get that. But the cliche isn’t helping me right now. I have a right to wallow for a few hours in my less-than-stellar news, and that’s precisely what I’m going to do now, because today’s news was even less promising than yesterday’s news.

Let’s Review:

Going into Retrieval: We were expecting 4-6 eggs (not stellar news, but at least we were expecting not stellar news)

Retrieval Day: 10 eggs retrieved! (Double what we expected! A great number, all things considered)

Day 1 Fert. Report: Of the 10 eggs retrieved, 9 were mature (1 post mature) and all 9 fertilized and were 2 celled embryos (unbelievably good news! I was stunned and overjoyed by this news!)

Day 2 Embryology Report: 1 didn’t make it at all, 6 2-celled embryos still (1 with no change; not a good sign), 2 6-celled embryos (with 10-15% fragmentation, not good). Not a good enough report to warrant a 5 day transfer. Transfer scheduled for day 3 at 2pm. Disappointing news at best as with Single Embryo Transfers, they always try to go to blast in order to find the cream of the crop when possible.

Day 3 … (Today):

I’m on my way in to work and the weather is crappy, my head is pounding, my tushie is sore from the PIO shots, I’m cranky. You get it, right?

I’m walking out of my parking garage on my way into my office juggling my keys, my briefcase, a couple shopping bags (I bought candy to re-fill the candy jar I keep for people to snack on in my office), and my phone rings. I’m fumbling for it, but I have to pull off my glove (did I mention it’s snowing?) to get it open and turn it on; I almost miss the call. It’s my nurse at Ye Olde Fertility Clinic.

“Hi Perky One*, it’s NurseAwesome*. SuperDoc wants to talk to you.”
“Yeah? All right,” I sighed.
“You okay??”
“Yeah. Yeah, I’m fine.” I said, knowing that this just wasn’t going to bode well.
“Okay, hang on, here he is.”

Why the man couldn’t have just dialed the phone himself is beyond me. Because that introduction is exactly what gave me the anxiety I had, you know. But whatever. I do love him, and I know he has my best interests at heart. And for all I know it was NurseAwesome that wanted to make the call to me so that she could guage how I was doing, since she knows how pissy I’ve been all cycle. (Update: It turns out that SuperDoc did call me directly himself – but he called me at home and left a message at 8:45. Of course, I wasn’t home – I was on my way to work. NurseAmazing knows better, and she knows me well enough to know that I probably wouldn’t have been okay with just hearing a voicemail on my home number … which I may or may not have checked before I went in for my appointment this afternoon, by the way … so she probably said, “Yeah, no, we’re going to call her cell phone now.” That’s why I love her.)

So he said he took a look at the embryos with the embryologist this morning and what I’ve got is a 7-cell, a 6-cell, a 5-cell, and 2 four cells. If I were any other patient, with their normal criteria, he’d be recommending a two-embryo transfer today (day 3), but he does NOT recommend that with my history. With HOMs at home, and with my pregnancy history (e.g. not good) and with my need to ensure I do not get pregnant with twins (unless, you know, they’re monozygotic, in which case, we just had no way of controlling that risk), he is wholly opposed to a 2-embryo transfer. Which is good, because I am also opposed to it. My exact words were “absolutely not.” And he responded, “We are on the exact same page, don’t worry, I’m not recommending it – I would caution against it.”

My embryos look pretty crappy. They do not meet the criteria to go to a 5 day blast, but given the choice between picking a crappy single embryo for transfer today as planned or trying to grow one to blast by Thursday or Friday, he thinks our chances are better if we wait. He believes we are likely to have one at the blast stage if we wait.

So what happens if we don’t have any blasts by Thurs/Fri? We transfer whatever the best we’ve got is. And what if there’s nothing? We scrap the whole thing and start over. After all, we were all set to cancel this cycle last week before we got to retrieval, remember? It’s really no different, except that now we’ve been through a lot more hell than if we’d canceled ahead of time. But at least now we’ve got more information, right? What I don’t know is whether this would count as a full IVF cycle for insurance purposes if we don’t make it to transfer. My guess? Once you get to retrieval, it counts. That being said, my doctor is confident that we’ll have something to transfer either Thursday afternoon or Friday morning, it’s just a question of quality.

And so it goes.

*Note, she did actually use our real names… she doesn’t refer to herself as “NurseAwesome” though she’d be perfectly justified in doing so.

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