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Sunday, July 5, 2009

What happened?, part dos

OK, so I'm finally typing up the second part of the wtf appointment.

Here's the continuation..

Me: Any chance my body has trouble absorbing or producing progesterone? (Side note to blogosphere: This is something that I have been very conflicted about. I chose not to do the PIO because I was scared of 6 inch needles. I chose this before I did any shots, and at that time I was extremely nervous, so nervous that we considered hiring a nurse when Carlos was out of town. Now I know they are no big deal. But at the time I asked for alternatives and was prescribed endometrin. Since then I have had questions about what "would have been" if I had done the PIO.

Dr H: Very unlikely that your body didn't absorb it.
There are 4 options for progesterone:
- Vaginal suppositories (compounded locally into glyceryn and estrogen is added)
- tablet - endometrin
- creme

For natural cycle, I recommend suppository - 1 per night. And your body will produce its own progesterone since we are doing a natural cycle and not putting you on BCPs or anything.

Me: When do I start the progesterone?
Dr H. You will start the suppositories 3 days after HCG shot. Then transfer 4 days after that
PIO rarely done with natural cycle.

Me: Oh yeah, HCG. Will I take Ovidrel or HCG? What is the difference?
Dr. H: Ovidril : recombinant DNA drug, easier to give, more expensive.
HCG : human drug, has to be mixed, less expensive. HCG longer acting and tighter binding.

Me: (reaching for anything that would make any sort of difference.) I read about labs that do embryo culturing in my own endometrial lining. Is that a good idea? You know just do an endometrial biopsy a few weeks before.

Dr. H: Well, we are beyond that now. And your embryos didn't have any trouble growing. We have no reason to believe this would help. The data on this is not very convincing. Success rates not better. Plus there is greater risk for contamination. The studies indicate a very modest increase in success rate EVEN if it's true.

Me: Again I'm searching for a reason why this didn't work. Remember how high my estradiol was. You probably don't. Look it up in your computer. Dude, it was seriously high. Like 79hundred something. What does this mean?

Dr. H: There are lots of pregnancies when this is high. Your ovaries were hyperstimulated, but you did not have symptoms of hyperstimulation syndrome. Yes, your estradiol was very high. You will not have it that high during your frozen cycle because you won't be stimulated.

Me: I read a lot about studies. Do you do any experimental studies here?
Dr H: No, generally no, we are not a research center.

Me: I've been reading about other top centers. Some are highly rated and have high success rates and do PGD. If I have to do another fresh cycle, is there any benefit to doing transfer and PGD onsite?

Dr. H: Onsite doesn't matter. You're not transferring the embryos. Only the genetic material that you had biopsied. It doesn't really matter. That's not a reason to chose a clinic.

Me: Oh yes, Biopsy. That reminds me of another question. I read about Polar Body Biopsy. Coudl we do that instead of PGD?

Dr. H.: Some clinics do that, not a large number of clinics. You have to remember that the more manipulation of the egg and embryo, the greater the chance of problems. There are low pregnancy rates with these cases. Oh and, it's not either, or. You are still doing PGD in these cases also.

Me: Why do these top clinics do better than other clinics?
Dr. H. I really think the embryology lab has a lot to do with it.

Me: What do the clinic do that is so different? Should I go fly to Colorado for a month?
Dr. H.: There is not really an answer for that. But if you choose to do that, you don't have to go for a month. We could do all your monitoring here and work with the other clinic.

Me: Thank you, that's really nice. By the way, next topic. Should I use ovulation predictors this month?

Dr. H.: It won't hurt, but it won't tell you anything about next month's ovulation. You could do your BBTs. That would be free.

Me: Free, yeah, By the way, you know what's not free? Condoms. You don't think birth control pills are a good idea? Did I mention that I really want to have sex with my husband, and sometimes we don't have condoms handy, and I think its really really really weird that we want a baby really really really bad, and I have to freak out and remember to get the condoms.

Dr H. Nah, not good. It could affect pituitary cycle.

Me: Ok, the biggest, most important question.. What *biologically* happened? What could have happened? I need to understand logically.

Dr. H.: You did implant, prob just one embryo. It grew for a short time. Most likely the embryo itself just stopped growing.

Me: WHY?

Dr H. It could have been the environment / could not.

Me: Environment, like what? My uterus? My high e2 level??

Dr. H: Well, we dont' know. Very low probability that there is a problem with the environment. But yes, E2 level will be taken out of the equation for frozen cycle.

Oh yeah, one more. Why are all the doctors against HPTs? I might be out of twon for my Beta dates this time. Why don't I just take a test on my own?

Dr H: I'm not against HPTs. I just know we can have false positives, and we need to know the levels.

Me: Yeah, I get it. But if I get negative, I'm not going to go crazy and drink a bunch or anything. I won't get some majoe wild hair and go get my nails done. And I won't go even crazier and go swim in the ocean or have some deli meat. If i promise not to have deli meat if it's negative, can I take an HPT?

Dr. H: Sure, of course, or you could just enjoy your vacation and come afterwards to test.

Me: I so knew you were against them! Knew it!

Me: Thank you Dr. H. I really appreciate your time and ansering all my questions. I'll see you in August!


Well, that's it. Thanks for bearing with me.

Reults of WTF appointment

Wow - I have been a really bad blogger.. It's not that I have nothing to say, because I've written a thousand blog posts it seems in my head in the shower, but they have never made it to my Mac. I'll get better, I promise.

(Would someone please invent a device that will transcribe my thoughts from my head in the shower to my computer, and then I can just edit and hit Publish? Thanks, that would be very helpful.)

So, I had been reading blogs that talked about this WTF appointment. For those who don't know, this appointment is the one where you and partner, (Carlos, in my case) basically get a chance to talk to the RE, all three of you fully clothed and say,

"Ok, I took all my shots and pills as instructed. We had almost 30 follicles, 22 beautiful eggs, 17 of which were fertilized by the best of the over 50 motile percent of the 42 million per liter hunky sperm. We produced and our amazing embryology staff took care of 14 gorgeous embryos, and we spent 8 thousand additional dollars to have them tested for CF and other chromosomal disorders. On transfer day, we had 6 gorgeous, highly rated embryos waiting for us, alive and growing on Day 5. I had a lovely transfer (I am pretty sure I even used the work lovely to describe it.) And I took all my pills and shots and progesterone and didn't even go within walking distance of a sushi restaurant, oh yeah, AND, I even took off my acrylic nails for like the first time in 10 years and I am not pregnant. So, yo Doc.. what the fcuk?

(Please excuse me, I am not one to curse at all.. But that's the name of the appointment. I won't say it again.)

Unless the need arises. Just kidding. Sort of.

So, I didn't feel like I really had any questions, but I felt like I wanted to have the appointment, thanks to the amazing IF community that have written about theirs. My appointment was with the RE that did my retrieval and transfer. He's is the Christian man who made me cry at my retrieval, then gave me his email address. He also hugs me and Carlos every time we come in. I'll call him Dr. Hugs.

I knew I could dredge up some questions, and I felt like "when do you really get an hour to spend with a qualified specialist to ask all your questions?" Like, never. So, I made the appointment. And then started gathering my questions. I like to understand things, so, honestly, it was not that hard to come up with questions. And, honestly, I read a lot of other blogs to come over with, "they did this, why didn't I do that" kind of questions?" It was pretty easy. And the questions get you talking. And I had I knew I'd learn something if I got three smart people in a room talking. Oh yeah, and I had some dumb questions, too, because I wanted to eliminate potential paths.

So, on to the questions. I took a little liberty transcribing Carlos's notes.

Ok, here we go.

Me: So, how were my four embryos frozen? I hear some labs freeze them in "twos," so you thaw both at the same time. In that case, if we thaw 2 and one does not survive, we have to thaw the other two same time, and either transfer all three.. or what? I want two cycles (and two babies, but of course, I'm willing to settle for two cycles and one baby!) out of these embies.

Dr. H. Let me look. Plays with one of the four computers in his office, while I think "This is just like our office at home!) The are frozen individually.

Me: I love you. Next question. Should I do a fresh cycle now, and keep these frozen ones for later? I ain't getting any younger.

Dr. H: No, you're young! Let's go ahead and do the two frozen cycles - hopefully you'll get two babies, one at a time, and you'll never have to go back to a fresh cycle.

Me: Great. Let's do it. Glad you are optimistic.

But, really dude, I'm sure you haven't done them before, so I'm here to tell you the shots are not. That.Bad. Really, they are not. I will do fresh cycles anytime, if there was a better chance of a baby! And yes, on that topic of shots, I'm serious, I'll do them. (Wow, do i sound like a junkie, or what?) You really think natural frozen cycle is the way to go?

Dr. H. Yes, natural. You ovulate on your own. There is no need for shots. You'll do the OPKs and we'll take a look at your lining and do that transfer. Much less stress on you and your body. And a lot cheaper.

Me: I don't care about money. I'm 35. Been working for 13 years. Carlos too. We have pretty much been saving money our whole careers for this. I mean, not that we knew this would happen. We didn't even know each other. But I think God knew we were going to need the money for babies, so he made us have great careers and live beneath our means. We are not going for cheap, we want what works. OK, next question. Tell me about the quality of my eggs.

Dr. H. I have no concerns about the quality of your eggs. Your embryos are of high quality. There are many things we can't test or see, but I'm confident that they're high quality.

Me: I was kinda looking for a number on a scale of 1-100. And if it wasn't 100, a list of things to do to get it there. I'm all about the metrics. But whatever.

OK, the little swimmers. Is there any actual scientific way to choose the best sperm to do the ICSI with, since we have to do ICSI (actually I'll get to asking about why we have to do ICSI later) I know all about the spinnin' and all that, but part of it seems sorta subjective to me.

Dr. H: Well, there is a test. Hypoosmotic swelling test is the only test that can be done. Typically only done when ..(oh shoot, Carlos missed this part. I'll ask him or research later.) And then there is the DNA fragmentation test: looks at DNA integrity. Not really helpful. There are tests that can be done, but not on the actual sperm sample that you are using for ICSI.

Me: Even though we are theoretically picking the best sperm.. Is exercise, vitamins, toxins, etc. of concern for sperm with IVF?

Dr. H.: Carlos should keep taking the fertility vitamin. L-carnitine is beneficial, and that is in the Fertility for Men vitamins DH is taking.

Me: Ok, I asked the PGD lab, but the answer I got was not clear. It was clear that we HAVE to do ICSI, even though it would not normally be indicated because my husbands sperm are beautiful, so why do we have do do ICSI? Do we have to do ICSI?

Dr. H.: THe PGD lab requires it. Here's why. Normally sperm coat the egg and one gets through. But the other dudes might hang around the egg and they may have additional genetic material there. During the biopsy, this adds additional genetic material that could distort the testing. It's a cleaner and more reliable process with ICSI. This is especially true when single gene testing is being done. Magnification process used during testing magnifies any DNA (including contaminant sperm).

But, problems associated with ICSI are just a small fraction higher in babies than IVF with no ICSI, so it's not much of a concern.

Me: Yes, right. I'm not too concerned about the whole fraction higher thing, because that might be caused by the fact that typically the patients that do ICSI have something indicated in the sperm that is causing the need to do ICSI. I'm just saying, if we could do natural selection, that might be cool. But I totally get it now. Thanks for explaining. By the way, I've been calling Carlos's sperm gorgeous and beautiful, but I never really asked, did they test the sample the day of retrieval?

Dr. H.: Yes. His stats:
5.6 ml volume
counts in 1ml
34 million count (> 20 million normal)
53% motility (> 40 normal)
They did not test for morphology. They don't normally do that.

Me: Ok. (Note to self. If we have to do another fresh cycle, ask them to test that. I just want to know. A woman can ask, right?)

Me: Any reason to do another fresh cycle instead of moving forward with frozen? (Sometimes I like to ask questions twice, to see if I get the same answer. You know, throw them off. I should so be in FBI interrogator.)

Dr. H. See above. (Carlos refused to type the answer twice, even though the sweet doctor answered it again. I recommend moving forward with frozen. OK, cool. Like I said, beautiful. By the way, still wanting to know why this didn't work. Could I have endometriosis?

Dr. H: Yes.


Dr. H. But it's not likely. You woudl have pain with your period, intercourse. It requires
lapropscopy to diagnose.

Note to self: If this goes on much longer, ask for more tests.

Me: Could I have PCOS? (I know all you smart IF bloggers out there are laughing at me, but I'm just trying to rule things out here.)

Dr. H.: Yes. (Dude, is he just trying to cover himself, or what?) But you have normal cycles, so not likely. In truth, there are a myriad of variables... most of which we can't test for or account for. There are a few key things we look at. In practice, it's often a combination of many small problems.

Me: New topic. After this frozen cycle. Can I swim or take a bath afterward? We're thinking about going to a beach in South America the last weekend in August.

Dr. H. Swimming is an issue is for a few days. We don't want you to get an infection.
- Not in a lake or an ocean
- But swimming pool ok after 5-6 days

Dr. H. With your Frozen IVF this time, I think we will also do an insemination at the same time. There is some evidence that combining implantation and insemination can increase chances of success because it causes ovulation.

Me: What? are you kidding? and then risk that that sperm and egg make a baby? And then it has CF? I'm not convinced that we can't get pregnant with SEX, much less IVF. If we could do IUI, I might be out to here by now.

Dr H. Oh, yes, I forgot. Can't guarantee that some sperm won't hang around and introduce the possibility of a baby with CF. Bad idea. You're right. Yeah, we won't do that.

(but I left that part in for you women that are doing IVF. Might be something to ask about. I'm cool with the doc forgetting. He has a lot of patients. And, honestly a lot of patience too. At this point, we're already at least 40 minutes in, and I'm still on the first page of my questions.

In fact, I am thinking I'll make this two blog posts. Stay tuned for the rest.