Infertility Diagnostic Testing

I've wanted to write this post for about six months, but I keep running out of time to sit down and write it!

After about a year of trying to conceive without success, most doctors will concede that it's possible that you may be facing infertility, but it's very difficult to get the doctor to recommend that you see a specialist. In our case, Brian was seeing his general practitioner and an endocrinologist and neither would come out and directly say that we should see a fertility specialist. I'm not sure why, but I assume it's because they don't want you to go off and see another doctor and never come back to their practice! Pretty ridiculous. We asked for recommendations and never received any help, so we took matters into our own hands and researched various clinics.

I highly recommend that if you think there's an issue that you go see a fertility specialist as soon as possible. There is quite a lot of diagnostic testing for infertility and many of the tests have to been done at certain points during the menstrual cycle, so it's possible that it could take several months from your initial appointment before any procedures are done for conception.

When you're watching all your friends and family members announce their pregnancies, that can be a very, very, very long time period to wait.

Some of the diagnostic testing is a little unnerving, so I thought I'd review the various diagnostic procedures that we experienced. Of course, every person and body is different, so what's painful for one person, may not even be an annoyance for another.

Men

Semen analysis: In our case, most of the semen analyses were conducted by Brian's endocrinologist while Brian was on testosterone medication in hopes of improving sperm counts. It takes about 6 weeks for the body to make sperm, so you can expect that if you are on testosterone medicine that you might have several analyses over several months. (Note, if you have low testosterone and are also trying to conceive, you must make sure your provider knows this because gels to increase testosterone will also kill sperm and destroy your counts.)

Pain factor: -3/10
Embarrassment factor: 400/10
Recovery time: Negligible

Women

Blood tests: 
If you have infertility, I hope you have good veins because you're going to have your blood drawn a lot. I had my blood drawn at least 13 times from September 2012 to January 2013 (plus two more draws in February for my pregnancy tests). Your doctor will be checking your AMH, LH, progesterone, prolactin, and estradiol levels. If you decide to do IVF, you'll also have your blood drawn for infections disease testing (as required by the FDA). I had recently had my annual physical, so I also already had results for cholesterol, glucose, and other typical checks, which your doctor may also do if it's been a while.

Pain factor: 1/10 (for me); 4/10 (for Brian, who also had infectious disease testing)
Embarrassment factor: 0/10
Recovery time: Negligible

Diagnostic ultrasound: 
You will also have a lot of ultrasounds throughout the entire process. The diagnostic ultrasound looks at the shape of your uterus, the location/size of your ovaries, and if you have any cysts in your ovaries and fibroids in your uterus. The parts of your body that they're looking at are very small, so the only ultrasound that works is a transvaginal ultrasound wand. (The good news is that you do not have to have a full bladder like you would with an abdominal ultrasound. The bad news is that the vaginal wand can be a bit uncomfortable at times.) These become less painful as time goes on, but they are definitely uncomfortable, especially if the doctor has to manipulate the location of the wand to get a better look at things.

Pain factor: 2-4/10
Embarrassment factor: 2/10 (but after the 3rd one probably 0/10)
Recovery time: Several hours to a day. You will likely have some internal soreness and possibly some spotting.

Hysterosalpingogram (HSG) test:
There is a lot of information about this test on the Internet and I was pretty terrified going in. The purpose of the test is to check to make sure your fallopian tubes are clear from any blockages. The test is done by a radiologist. A speculum is used and a tube is inserted into the tip of your uterus, just past your cervix, and a fluorescent dye is sent through the tube while the X-ray machine takes a series of pictures. My doctor recommended that I take Advil a few hours before the test.

Pain factor: 9/10 (Though during the test, it very much feels like 10/10; I almost yelled aloud and in the moment, I wasn't sure if I could take the pain. Fortunately, the worst part was very quick. The other bad thing is that because there was an x-ray involved, Brian was not allowed in the room with me. But I was very glad that he was there to drive me home.)
Embarrassment factor: 5/10 (I was not pleased with the radiology clinic we used and did not like the facility, nurse, or radiologist.)
Recovery time: A day or so. I was sore for several days. For the hours immediately following the test, there is also some leakage from the dye, so a good pad is necessary.

Saline ultrasound:
In my case, my HSG indicated a small "doughnut" shaped indention in my uterus, so the doctor suggested a saline ultrasound to look at it more closely. Saline is inserted into the uterus and the doctor looks around with a transvaginal ultrasound wand. This was slightly uncomfortable, but nothing like the HSG test.

Pain factor: 5/10
Embarrassment factor: 4/10
Recovery time: A day or so. Again, I experienced some internal tenderness and some slight spotting for a day or so afterward.

Endometrial biopsy:
Before our first IVF cycle, my doctor strongly suggested an endometrial biopsy to ensure the mass in my uterus was gone, so that it wouldn't affect any embryo transfers. This procedure, for lack of a better phrase, "vacuums" out your uterus so that any masses or tissues are forced out. A speculum is inserted and a vacuum aspirator is inserted into the uterus to force everything out. Any tissues removed are also sent to lab for abnormal cell growth. Again, my doctor told me to take Advil a few hours before the test.

Pain factor: 10/10
Embarrassment factory: 4/10
Recovery time: Quite a lot longer than expected. I was quite sore. My doctor told me that I could have spotting for a few days. In my case, it was more like a two weeks and it was very similar to medium-flow period.

So, that's pretty much it, but the good news is that if you do end up pregnant, then nothing (in at least the first 27 weeks) will be nearly as painful as the tests. Also, the pain from running a marathon is still worse. :-) So, if you've done that, you'll be golden.

Still TBD if labor and delivery + recovery is worse. ;-)

"Why Don't Y'all Just Adopt?"

Or, "Well, there's always adoption!"

For some reason, that question and statement seem to be said a lot when a couple explains that they are struggling with infertility. (For the record, if you say it to someone facing infertility on a particularly emotional day, you're likely to get knocked upside the head.)

Children who need a forever home is a major problem. It is an impossible problem. It is a gut-wrenching problem. And it is a problem for which all of society is responsible. 

Infertility is a medical condition. If you can be "cured," it requires medical treatment. 

In no other situation do we ask people who are sick to "fix" a societal problem.

Although it seems awfully convenient that people facing infertility are the perfect solution for these parentless-children, it isn't. In some situations it may be the perfect solution; in many others, it isn't.

The decision to stop pursuing the conception of biological children is an extremely emotional decision. It requires a grieving process and each couple has to come to that decision at its own pace. Once that grieving process has occurred, then it is possible to consider the possibility of adoption, which comes with its own challenges and opportunities.

So...why didn't we decide to adopt?

Well, we thought about it. A lot. In fact, last summer while we were waiting to see if a medicine was working we spent a lot of time looking into adoption. We first became aware of North Carolina's foster care system at our annual, statewide church assembly in June. At a session focused on how churches can support foster parents or those looking to adopt children out of the foster care system, we learned that there are not massive fees or monetary requirements to adopt a child who is a ward of the state. And we learned that if just one family from every church in North Carolina adopted one child approved for adoption from foster care that there would be no children available for adoption in North Carolina. What a wonderful thought!

We were incredibly intrigued. So we got the paperwork. We looked over it and over it. We signed up for an information session with Wake County (all foster care and adoption-from-foster-care in North Carolina is done at the county level). We went to the session. We found out that "our" child could still stay on Medicaid, we would receive a stipend from the state, and, most importantly, we would be able to give a child a home.

We looked at the website, where, yes, you can see children available for adoption. It's heart-wrenching. They say stuff like "I just want someone to love me." "I just don't want to be separated from my brother." "I just want my own room."

We prayed about it. We went on a road trip to Montreal and talked about it on the way up and the way back. We talked to friends. We talked about how we felt about adopting a child of another race. How would I learn to do a black female child's hair? I read a book about how to best assimilate an adopted child into a new home and how to deal with the unique challenges. Would we pass a home study? Do we have enough fire extinguishers? Would we want a sibling group?

There are so many questions and things to consider.

But there were two very nagging, major questions:

• Were we really ready to stop pursuit of a biological child?
• At age 30 and 31, could we start our parenting with an 8 year old child (the average age of a child in foster care)?

When it came down to it, we had enough doubts about our answers to those questions that we felt it was important to pursue assisted-reproductive technology. And we knew that if there was any doubt, that we shouldn't pursue adoption right then. When it's someone's life, you have to be sure.

So that's what led us to our reproductive endocrinologist.

However, we still feel very connected to the adoption process and we hope our life leads us to a point where we're able to pursue it.

At some point. When we're ready.

Baby? Baby!

So, when we last left off, Brian was excitingly telling you that we had 11 eggs retrieved. And then two months of silence. Because, well, it worked! We are having a baby in October!

So, let's see...

Our egg retrieval was on a Saturday morning (there are no weekends in IVF). And, not just any Saturday morning, but the Saturday morning after a lovely snow and ice storm on a Friday afternoon. We watched the weather for like a week in advance and were like "You've got to be kidding me." By late Friday morning, we realized that the roads were going to be pretty bad all afternoon and that they would freeze over into the night and present a problem for our 7 a.m. appointment that's about 30 minutes away. So, we got our stuff together, hopped in the CR-V, and drove across town in snow and ice to spend the night in the Hampton Inn that was right by our doctor's office (2 min. drive). This was absolutely the right decision because were able to relax the night before and got to sleep in. 

When we got there Saturday morning, the office was buzzing. There were at least 3 procedures that morning and tons of nurses and doctors. Brian and I were so grateful at the incredible care we received. All of these people were working on a Saturday morning and traversed incredibly slippery roads to get to the office. They were all so friendly! Our doctor even spent the night in the office the night before so that she didn't have to deal with the ice! If you know anyone who needs a fertility doctor recommendation in the Raleigh area, please, please get in touch with me.

The egg retrieval process requires that the egg donor (that's me!) be under anesthesia, so Brian and I had a lot of time to sit around and check Twitter while I got lots of IV fluids and anti-nausea medicine. When it was time to go, they wheeled me off to the procedure room, but this time it was a bit different. Because one of ovaries sits really high and behind my uterus, the doctor wanted to keep me awake for a bit while she checked my positioning to make sure she could reach all the follicles. At that point, I knew that I still had follicles (remember last month I had ovulated early and there were no follicles). And then the nurse turned up the anesthesia and the next thing I remember they were wheeling me back down the hall. In the middle of the hall I said "DID IT WORK?" and they said yes and that they had retrieved 11 eggs. I was so overcome with emotion. I couldn't believe we got through the retrieval and that they had that many eggs. The doctor had been thinking 8 eggs would be fantastic! Afterwards, I recovered for a bit and then we were able to leave. The roads were clear so we stopped at KFC and had takeout fried chicken, mashed potatoes, and slaw. It was soooo good.

And then we took a nap. :-)

In the middle of the afternoon, the doctor called to check on me and let us know that out of the 11 eggs retrieved 9 of them were mature and all 9 were injected with sperm.

The next morning we were at church when I realized I had missed a call from the doctor. I don't think I've ever not heard a word ever said at church like during those 20 minutes. Brian was serving as the assisting minister so he was sitting at the front of the church and I kept trying to get his attention. I kept mouthing DOCTOR-PHONE over and over and he was not getting it. Until, eventually he did and he was like GO TAKE THE CALL. I bet the people at church thought we were crazy. So as soon as it was time for the offering, I hopped up and ran out into the hall. And then I decided to go to the bathroom in case the doctor had bad news. So, I stood in the stall with my phone and listened to her message: 

"Hi Laura, it's Dr. Copland. I'm calling with good news. Actually, 100 percent good news. All 9 of your eggs have fertilized and are growing." 

I was so ecstatic and when I came out of the bathroom, Brian was pacing nervously, in his robe, in the narthex. We were so overjoyed (and texted our families as soon as church was over).

The next few days were a waiting game. At day 3, we heard that five of the fertilized eggs were growing right on target, three were a few days behind, and the last was another day behind. (This is pretty typical growth, which is why the more eggs they can harvest, the better the chances.) We scheduled our embryo transfer for day 5.

At our embryo transfer, we found out we had two "almost-perfect" blastocysts and a couple other embryos that were lagging a bit behind. The embryologist recommended that we transfer the two blastocysts to increase our chances of pregnancy (and, of course, multiples)! Brian and I asked them to step out for a bit and we talked it over for about 2-3 minutes. We decided to go ahead and transfer both blastocysts. If we ended up with twins, we would figure out a way to handle it! :-)

The transfer itself was really cool. I was completely awake and Brian was able to go back in the procedure room with the doctor and the embryologist. The doctor explained to us what was happening and we were able to see her transfer the blastocysts. (It looked like two dashes of white on the ultrasound screen.)

Our two sweet little blastocysts, one of which is now a little fetus! I think they look more like Brian. (Isn't it amazing that each one contains the complete DNA for an entire human being?)

And then we waited. With nothing to do.

That is the hardest part. Until the two week wait, we were actively doing something every day (injections, phone calls, appointments, etc.)

But, for two weeks, there is nothing to do except analyze every twinge in your body. Compounding this, the trigger shot that induces ovulation contains a synthetic version of the human pregnancy hormone (HCG), so you can't even obsessively take home pregnancy tests with accurate results.

Friends, all I did was read message boards and then I couldn't take it anymore, I took a pregnancy test at 4 days past my transfer (4DP5DT). It was positive! But was it real? So, I took another pregnancy test (many times multiple tests on the same day) for the next 7 days. And then I started consulting pharmacological sites to detect the half life of my trigger shot. I created a spreadsheet to calculate the half life!!  

Every single pregnancy test was positive. OMG! But there's always that fear that it isn't real and or will be a chemical pregnancy or a very early miscarriage. 

Fifteen days after our egg retrieval (on my sister's birthday), I had my blood test at the doctor. And then another test 48 hours later. All positive with increasing HCG.

We've also had ultrasounds at 6 weeks, 8 weeks, and 9.5 weeks. At each ultrasound, we saw the baby (just 1!) and saw/heard the heartbeat! At 9.5 weeks, the baby was kicking up a storm. It was pretty amazing.

So, that's where we stand now...just a few days short of 12 weeks. I've had nearly constant nausea, lots of exhaustion, and plenty of other annoying symptoms, but all-in-all it has been a pretty good first trimester. We are incredibly grateful and excited to see what the next six months bring!

The dog is very excited about the baby. The kitties hate everything.

That'll do.

Much more to come later, as I'm posting this from the fertility clinic, but: egg retrieval this morning, 11 retrieved and they all look good. We'll know in a day or so how many fertilized and how many (and when) they'll be transferred.

For all the crappy days we've had, today almost makes up for it. Things couldn't have gone much better. Thanks for all of your prayers and well-wishes, and since they worked well this time, keep it up that the eggs fertilize and they're able to transfer a couple of them.

Whew.

Science!

(Source: Know Your Meme.)

As a former chemistry nerd (I was a chemical engineering major at NCSU, until I realized that I'd much rather sit around and write papers), one of the most interesting things about going through IVF is learning about all of the medical procedures and how the medicine works.

At the beginning of each cycle, I have my blood checked to measure my Estradiol levels and have a baseline ultrasound to ensure that there are no cysts in my ovaries and to ensure that everything looks OK. After I've been on stimulating hormones for several days, then I go back for an ultrasound and a blood check every other day until the egg retrieval.

I have had 11 ultrasounds since mid-September, which I think is more than are conducted during 9 months of pregnancy!

The first time Brian and I saw an ultrasound screen, it looked pretty much like a bunch of static. Today when I looked at it, I could actually see the discrete follicles and could understand exactly what the doctor was describing. It's fairly amazing how much practice helps. :-) (The ultrasounds also confirm that my uterine lining thickens for implantation as the Estradiol levels rise.)

I am very, very, very fortunate that I have really good veins, so blood draws are not an issue. I could never understand why people didn't like needles, until I witnessed Brian get his blood drawn last month. As it turns out everyone is very different, it took the nurse several times to eventually get his blood, whereas she has just done mine on the first try! (I've never had a nurse *not* get it on the first try.)

Before our first round of IVF we had to have our blood drawn and run through a panel of tests (as required by the FDA). The good news is that neither of us have

• hepatitis,
• HIV, or
• Syphilis.

I also received confirmation that my blood type is, indeed, O+ and that I've had the chicken pox and have received my rubella immunizations. (Separately, we've also both received a booster for Tetanus, Dyptheria, and Pertussis.) And before our IUI, I had my Prolactin and several other hormone levels checked.

Because I ovulated early for our first round of IVF, with each blood draw this time, they check, in addition to my Estradiol level, my LH and progesterone levels. The goal is for the Estradiol to rise and for the LH and progesterone to stay low. (A spike in LH/progesterone would indicate that my pituitary gland is telling my ovaries to ovulate.) So far it's working! In particular, I think it's incredible how my Estradiol levels rise (over the course of 11 days): 48.4 -> 435.4 -> 757.4

So, how does all this happen? Well, that's where the chemistry comes in!

(Source: Our kitchen table.)

A few days into a cycle, I start injections twice a day (just under the skin with a very thin needle in my stomach) of a drug called Lupron, which suppresses my ovaries (by telling my pituitary gland to dump out all the LH and not tell my ovaries to ovulate). 

After a few days of Lupron, then I add in two drugs called Follistim and Menopur. These drugs stimulate my ovaries. The Menopur is powder in a vial, so I'm able to inject the Follistim (which is a liquid in a needle) directly into the Menopur vial. Then I take the Lupron injection and inject it directly into the Menopur vial. THEN I take 0.5cc of NaCl (saline solution) to finish dissolving the Menopur powder. Then I draw all the liquid up into a needle and do one injection. I could live without giving myself the shots, but I love mixing up all the medicine. It reminds me of chemistry lab!

If you're interested, this is a neat video by another fertility clinic that shows how most of my medicines are mixed. I watched it a lot in December to make sure I didn't mess up!

(Source: Carolina Conceptions.)

I do this twice a day for approximately 10 days. The injections usually sting for about 20 minutes, but they really aren't too bad and because none of them are injected in a muscle, it doesn't hurt once the stinging stops.

Now, as extra insurance to make sure I don't ovulate early, after several days of stimulating medicines, I add another drug called Ganirelix, which also tells my brain to not ovulate. This injection comes in a pre-filled syringe and I have to inject it separately each night. Last cycle, I was able to mix it in to the Menopur vial, but this month I'm not supposed to because I'm also on Lupron. 

The goal during all of this is to get my ovarian follicles to grow and produce as many mature eggs as possible, so that they can be retrieved by the doctor, while also telling my brain "no, don't ovulate yet!" It's really quite miraculous!

Once the doctor sees on my ultrasound that the follicles are the right size, I'll stop taking all of the previous drugs and do one final injection of a drug called Ovidrel, which tells my brain "OK, NOW. GO!" and if this is timed exactly right (36 hours after the injection), the doctor can go in, while I'm under "waking anesthesia," and retrieve the eggs out of each follicle to start the in vitro part of IVF. :-)

If you're curious, some of these drugs make people really crazy because of the hormone changes. I have been very, very fortunate with few side effects. I've had a few moments were my temper has been really short, but, in general, I'm not too crazy. (At least I don't think.)

Ugh.

Pretty much all you can say after today.  I know it's been a while since either of us posted anything here, so here's a Cliffs Notes version of where we've been over the last month or so:  we decided to start IVF this month, which meant two weeks' worth of medicine for Laura - injections, medicine mixing, you name it; it would have made a pharmacist blush - and we scheduled an egg retrieval for this morning.

At which point a problem appeared: there were no eggs to retrieve.

This, in the words of our doctor while Laura was still recovering from anesthesia and had no clue where in the world she was, isn't good.

One of the medicines Laura was taking is supposed to suppress ovulation.  Basically, each egg grows in its own follicle, and when it matures the follicle ruptures and the egg(s) start making their way down the fallopian tubes.  For IVF, you have to beat the clock, because the procedure involves pipetting out the stuff inside the follicle and retrieving the egg in the process.  After ovulation, it's impossible to retrieve the egg - and the medicine wasn't strong enough to keep ovulation from occurring.

The doctor said that this happens about once a year.  Lucky us.  That'll be $Texas, please.

So we'll regroup and try again at some point.  The timing is totally up to us, but will need to wait for a menstrual cycle to complete, so no earlier than early January or so.  And this time, they'll change up the medication to the extra-strength model, which will hopefully do the trick.

Going through this today reminded me of how important it is to have two partners walking hand in hand on this journey.  This morning, I was a wreck.  I mean, doing everything I could to just keep from breaking down and bawling with the doctor in the room.  It's really the first time in this whole process where I've come close to losing it.  But Laura, bless her, was generally OK - broken up and upset, yeah, but strong enough to prop me up.

Yes, the roles have been reversed at times.  I've had to be the stiff-upper-lip type more than a couple times during this whole process when she was really upset.  Today, it was her turn.

You never know when you're going to need a shoulder to lean on.  But without question, you'll need one at some point.  Having that around makes all the difference in the world, and today it made what could have been a super crappy day only a sorta crappy one.

The Party Bus (Or: ICSI Is Not The Number That Identifies A Commercial)

(Warning: this post talks about rather graphic stuff.  It's way easier to just type it out rather than dance around it in endless euphemisms, so if you don't want to hear rather frank discussions of what happens in fertility treatments, you might want to go elsewhere.  But then again, if that's the case, why are you reading this blog?)

So, we did our first IUI treatment a couple of weeks ago on a really damp and gloomy Friday morning.  Suffice it to say that the weather should have served as our first clue on how the day was going to go.

In a nutshell: not well.  My washed sperm count was 500,000; for the highest probability of success, it needs to be above 1 million.  Not surprisingly, it didn't work.

Back up a second.  What's a "washed sperm count"?  In order to inject the sperm into a uterus, they have to remove the sperm from the, ahem, produced specimen.  (In blunt terms: the semen in the collection cup.)  Otherwise, the uterus will reject the semen, since it's never supposed to get in there; the cervix usually handles that job, but since IUI bypasses the cervix, the sperm need to be removed from the semen before they're injected.  Sperm washing is the process by which that happens: basically a big centrifuge separates the components, then an embryologist isolates the best-performing sperm and prepares those for injection.  The sperm count after that preparation is the washed sperm count.

(Total aside here, but worth mentioning simply for comic relief: fertility clinics are likely the only doctor's offices with subscriptions to porn-on-demand services.  Hey, you gotta do what you gotta do, and there is serious business to be attended to, right?)

So, my washed sperm count was too low, and it seems like it probably won't get any better.  My total count was 13 million per mL, which isn't too far below normal but hasn't moved much since the last time it was checked, in July.  In other words, they've corrected about as much as they can, and where I am now is probably where I'll stay, with some minor variance.

So we'll probably move onto plan B (C? D? I've lost track), which is something called IVF with ICSI.  You probably know what IVF is, but ICSI is something new-ish (last 10-15 years or so) that corrects for the problem I have.  Most IVF is focused toward female infertility: PCOS, irregular cycle lengths, that sort of thing.  Until ICSI (which stands for intra-cytoplasmic sperm injection; you'll understand in a second) came along, guys with non-swimming sperm pretty much had no option other than crossing your fingers and hoping it works.

ICSI replicates the process of the sperm fertilizing the egg, courtesy of a microscopic pipette that takes one sperm and sticks it into the egg, which in theory should get the ball rolling.  It corrects for sperm that can't find their way around the female reproductive tract, and it is also a godsend for low sperm counts; you only need as many individual sperm as you have eggs, so instead of needing a million you might need five or six.

Even in my low samples, they can find six sperm that could fertilize an egg.

Unsurprisingly, the success rate for ICSI is astronomical: our doctor told us that it usually is around 60% effective.  In fertility, 60% is as close to a sure thing as you're ever going to see.  The only complications are if they can't find any perfect sperm (that could cause trouble for fertilizing the egg and getting the embryo development process going) and whether or not the egg implants.  Considering traditional IVF usually has a 35-40% success rate - and likely lower for us given our situation - this is a very good thing.

And in the meantime, ultrasound pictures and pregnancy announcements continue to pop up on Facebook about as much as political posts and lolcats.  The more things change, the more they stay the same.

At this point I kind of feel like I'm standing at a bus stop where three or four routes make stops.  I'm waiting for one route, which hasn't come yet, and meanwhile 30 buses have stopped for the other routes and picked up the other folks waiting.  After a while you get really tired of waiting, but what else can you do?

The one thing that I'm sure of: when our bus does show up, there's going to be one hell of a party on it.

(In regards to the title: every commercial on TV and radio has something called an ISCI - Industry-Standard Commercial Identifier - code assigned to it; it's almost like a barcode to identify the commercial and make sure the correct one is running.  I just thought it was interesting that the acronyms are so close, even though they have absolutely nothing to do with one another.)