On to IVF

We have completed, unsuccessfully, our fourth IUI attempt, and so we will begin IVF shortly after the new year. We started with an initial round of tests and an IVF class at the new clinic. My blood tests had better results than back in February. There's no good explanation for that, but it does suggest that I should respond well to the IVF drugs. More interesting is that we had our third semen analysis, under more rigorous (and more reliable) criteria. The result was a normal morphology of 6%. Using these criteria, >15% is considered fertile, while <5% is considered infertile and not eligible for IUI. (It would have been nice if either previous clinic had run this test. We probably still would have been advised by the docs/required by insurance to try IUI, but our expectations would have been even more realistic.)

What this means for IVF is that we are currently scheduled for "traditional IVF," where the sperm and the eggs are combined in a petri dish to do their thing. But if day-of results are <5%, we will be converted to ICSI, a procedure in which a single sperm is injected into a single egg. Wild!

When is day of? Early March. I will start the first round of drugs (including one the infertiles on the interwebs call Loopyron for its tendency to induce irrational rages - fun!) in about four weeks. They will completely shut down my reproductive system for a month. Then, if all goes well, we'll begin stimulation drugs to grow eggs, hopefully 10-20. I will have minor surgery to retrieve them, around March 1, followed by embryo transfer (we hope!) 5 days later. And in the meantime, of course, I'll be teaching 5 days a week.

The IVF class was our first real exposure to our new clinic. We were pleased that we were very comfortable with the nurse and embryologist. Not surprisingly, we were the most informed couple there. (We were also the only ones who laughed at the jokes. Apparently other people have trouble seeing the humor in the infertility. But that meant we were a favorite of the nurse, which we always like.) We are also very blessed to have my continuing insurance; we were the only couple not paying a lump sum $12,000 out of pocket. (We are paying $12,000 to the insurance company, but in $500 bites, which is manageable. And if IVF #1 doesn't work, any more attempts in 2010 will essentially be free instead of an additional $12,000.)

I will call the clinic tomorrow to get on the schedule officially!

Just waiting

We're expecting lots of action in early-to-mid December: our final IUI, some additional tests for IVF, and our IVF class, where they'll tell us everything we already know and teach us how to give even more painful shots with even bigger needles. But for now, for the first time in 20 months, all things reproductive are quiet. I don't mind the break.

Another laugh

I had a consult with the second clinic in town last week; I'll post more about it soon. But my favorite part was when the doc said that there was probably nothing wrong with me; it's just the morphology issue. It's not what Brent wanted to hear, I'm sure, but it made me feel better! And coincidentally, Mo & Will's latest Hallmark reject is perfect for the occasion!

Isn't it ironic?

I'm actually feeling better, saner, happier in the last 10 days since going public and admitting that I'm *not* doing so well with all of this. Thanks for reading!

On the dark side

I caught Barbara Ehrenreich on Jon Stewart the other night, talking about her new book, Bright-Sided: How the Relentless Promotion of Positive Thinking Has Undermined America. I haven't actually read the book, so what follows is based on the Jon Stewart interview and the press release from her publisher. The book stemmed from Ehrenreich's breast cancer diagnosis and treatment, a period in which people told her to stay positive, visualize the cancer shrinking, repeat affirmations about her strength and health. Her theory is that "the relentless push for patients to maintain a positive attitude is often psychologically devastating."

I couldn't agree more, especially with regard to infertility. The bane of every IF's existence is someone saying "just relax." First, it's impossible, what with the constant monitoring, timing sex, giving up wine for two weeks out of the month, waiting to test, waiting to test again after the first BFN each cycle, popping pills or injecting shots, early morning trips to the doctor for ultrasounds that could reveal good or devastating news. There's nothing relaxing about any of it. Second, it doesn't work. Relaxing is not going to get me pregnant. Yes, we've all heard the stories about women who adopt a baby, only to discover they're pregnant and end up with Irish twins or women who, after multiple rounds of IVF finally produce a baby, suddenly get pregnant on their own. But in truth, it happens quite rarely. (And I suspect that the latter -- post-IVF surprise pregnancies -- result from the IVF finally shocking our systems into submission, an actual biological change, not from relaxation).

But is the "just relax" mantra (along with saying positive affirmations about my womb being a warm and welcoming place and visualizing the swimmers and eggies doing what they're supposed to do) actually, as Ehrenreich posits, "psychologically devastating"? Yes. Infertililty is a dark and lonely place. Despite knowing so many other women going through this right now, I often feel very alone. All the happy pregnancy announcements and adorable baby photos on Facebook crowd out the knowledge that there are others just like me. And when we are told to "just relax" and be positive, it feels like a denial of our reality, which is, frankly, "dark and twisty." It's okay that we are desperate and depressed. We feel betrayed by our own bodies; the one thing we are supposed to be able to do, we can't. Meet us where we are.

I think the positive thinking approach is really for the benefit of the "friend," not the patient. By telling us to remain positive and think good thoughts, the "friend" gets to avoid the dark and twisty. That's only more isolating for the patient. We're made to feel like we're wrong for feeling like we do.

But if you want to say affirmations and visualize for us, that's okay! I don't know if prayer works, in the sense that G-d hears our prayers and then intervenes in our lives. But I do know that circles of prayer -- as well as circles of affirmation and positive visualization -- can make us feel loved and supported. So feel free to pray or affirm or visualize for us; we'll draw on that strength. But don't expect us to do the same, and be willing to listen and accept it when we can't.

A tentative plan

It's amazing how helpful typing out the options is! Within hours of yesterday's post, we had a plan. We've got an appointment for a second opinion at the other clinic in town in two weeks. The biggest question we've got for both clinics is whether they would do the local bloodwork and ultrasound monitoring if we do a cycle at CCRM in Denver. That may well be the deciding factor, more than the stats of the respective clinics here. We're tentatively planning to do an initial IVF cycle here in town in February/March. If it doesn't work, we'll head to CCRM in May and cycle there over the summer, taking advantage of the flexibility that comes with our professorial schedules. In the meantime, we'll probably spend some time this winter thinking about our "Dear Birth Mother" letter to submit to adoption agencies. I can't imagine a more daunting task than writing a letter to convince a woman to let us raise her baby.

Choosing a clinic

Assuming our last round of IUI (whenever that happens) doesn't work, we'll need to choose an IVF clinic. We have four options:
*Our current clinic at the University. We really like the staff and find it to be a calming place that offers personalized attention. But it's a relatively new program.
*The other clinic in the city. It's a much bigger and older program, which means less personalized service but more experience.
*Colorado Center for Reproductive Medicine. It's the number one clinic in the country, according to Parents Magazine. I have a friend who had great success there. It's the place that all the IF bloggers go when all else fails. But it's out of network, which means meeting my deductible and huge co-pays.
*Presbyterian Hospital in Dallas. It used to be the number seven clinic, though the personnel has changed. And it's out of network. So this one seems easy to eliminate.

In patients under 35, all four clinics have roughly equal success rates: 57-65 percent. But in the 35-37 age range, the numbers vary wildly: our clinic had a 38 percent success rate in 2007; the other clinic in the city 51 percent; and CCRM 58 percent.

Technically, we have time for two IVF cycles before I move from the under 35 group to the 35-37 group. But my FSH levels suggest my eggs are old, so I wonder if I should just assume I'm going to behave like the 35-37 age group, which probably means switching clinics.

What's in a name?

Infertile:

1. Not fertile; unproductive or barren.

2. Biology

   1. Not capable of initiating, sustaining, or supporting reproduction.

   2. Not fertilized and hence incapable of growing and developing: infertile duck eggs.

3. Not capable of sustaining crops or vegetation: infertile land.

4. Unproductive or producing little: a path of research that proved infertile.

Barren:

1. 1. Not producing offspring.

   2. Incapable of producing offspring.

2. Lacking vegetation, especially useful vegetation.

3. Unproductive of results or gains; unprofitable: barren efforts. See Synonyms at futile.

4. Devoid of something specified: writing barren of insight. See Synonyms at empty.

5. Lacking in liveliness or interest.

The American Heritage® Dictionary of the English Language, Fourth Edition
Copyright © 2009

They mean the same thing; barren is, in fact, a synonym for infertile. But I prefer barren. Its old-fashioned sound takes the edge off the bleakness. Plus, good things happen to barren women in the Bible:

¹Now Sarai, Abram’s wife, had borne him no children.... [But God said,] "¹⁶I will bless her, and moreover, I will give you a son by her. I will bless her, and she shall become nations; kings of peoples shall come from her."
Genesis 16:1, 17:16

⁵In the time of Herod king of Judea there was a priest named Zechariah, who belonged to the priestly division of Abijah; his wife Elizabeth was also a descendant of Aaron. ⁶Both of them were upright in the sight of God, observing all the Lord's commandments and regulations blamelessly. ⁷But they had no children, because Elizabeth was barren; and they were both well along in years....¹¹Then an angel of the Lord appeared to him, standing at the right side of the altar of incense. ¹²When Zechariah saw him, he was startled and was gripped with fear. ¹³But the angel said to him: "Do not be afraid, Zechariah; your prayer has been heard. Your wife Elizabeth will bear you a son, and you are to give him the name John. ¹⁴He will be a joy and delight to you, and many will rejoice because of his birth, ¹⁵for ... he will be filled with the Holy Spirit even from birth. ¹⁶Many of the people of Israel will he bring back to the Lord their God. ¹⁷And he will go on before the Lord, in the spirit and power of Elijah, to turn the hearts of the fathers to their children and the disobedient to the wisdom of the righteous—to make ready a people prepared for the Lord."
Luke 1:5-17

What it's like

I've never been terribly self-reflective. I was a terrible journaler; psychotherapy, though incredibly valuable, was like pulling teeth. I don't often just sit down and think about how this feels. But I am contemplating a post about it. It sucks, not being able to do the one thing I've ever wanted to do. But there's more to it. And hopefully some day soon I'll write about it.

Awesome

Dark humor will get me through anything.


Hat tip: Mo and Will

Health care portability

I'm lucky to have always had good employer-sponsored health insurance, so I don't (yet) need a public option. But one of the big lessons of infertility for me has been the value of insurance choice and portability. Massachusetts requires insurance coverage of infertility, one of the things that has made universal health care in MA so expensive. So our two cycles of meds, two inseminations, and a multitude of doctor visits and tests cost us only my co-pay (and those ultrasounds in the basement didn't cost anything). Actual cost: at least $3200. Our cost: less than $100, plus my regular insurance premiums. Insurance: priceless.

My current employer, like most, does not cover infertility treatment. No problem, I thought, I'll just take advantage of COBRA and maintain my Massachusetts insurance. Even at $500/mo, it's cheaper than paying out of pocket. But then I realized that my Massachusetts insurance was only good in Massachusetts, and I couldn't exactly spend two weeks a month living at the Brigham. Panic set in, until I realized that old employer had an out-of-state insurance plan for it's out-of-state employees. And, thank goodness, moving out of state is a "qualifying event" that lets you switch insurance plans, even if you're no longer employed. Under COBRA, you're still entitled to take advantage of a qualifying event. So I am continuing to shell out $500/mo for Massachusetts-level coverage.

So far, it's probably been a wash: one complete cycle and one canceled cycle here in OK have probably not cost more than $2000, and I've now paid $2000 in COBRA premiums (though I've also used that insurance for other medical care, so I'm still a bit ahead). But if I maintain COBRA for the full 18 months, it will cost $9000, significantly less than IVF would cost if our next Clomid cycle doesn't work. And we should have time for two IVF cycles in 2010.

Regardless, I feel so lucky to have been able to bring my insurance with me. I'll gladly pay the additional premium for the infertility coverage. But in OK I don't have that choice. I should have been able to bring my insurance with me no matter what. And my medical records should have followed me, but they didn't. My current insurance carrier tried to deny my first OK IUI because it didn't have my records from Boston, even though I'd requested them from the B&W six weeks earlier. I think we've worked it out, but it shouldn't have been that hard.

So hard

March 2008: Brent has not landed a tenure-track job, but the dean has extended my contract for another year. Since we know we're not moving for at least 15 months, we decide to start trying to conceive (TTC). I'm quite certain that I'm ovulating and this will happen quickly.

April 2008-September 2008: Not pregnant, despite temperature charting and ovulation predictor kits and our very best efforts. I begin to suspect that I'm not ovulating as well as I thought. I also begin to suspect that I have fibroids.

September 2008: With six months of charts, we head to the OB. Mostly she tells us it hasn't been long enough and tells us to come back in three months. (Lesson number 1: if you're over 30 and know there's a problem, lie to the doctor about how long you've been trying.) At least she sends us for a semen analysis, which reveals mixed news: we've got lots of swimmers but they're shaped kind of funky. Dr. Google is not much help in telling me what caused the morphology issue or how to fix it.

December 2008: Second semen analysis shows the same results. This time a visit to the OB nets us a referral to the big guns down at the Brigham and Women's Hospital. (Of course, I think the fact that B&W has the best OB/GYN program in the country means that it has an equally well-ranked infertility practice. Not. But I don't learn that until much later.)

January - February 2009: Lots of tests, again with mixed results. Cycle day 3 blood work reveals a slightly elevated FSH (follicular stimulating hormone) level. Apparently my eggs are older than their years. Other tests come back fine. An HSG (contrast x-ray of my insides) reveals open tubes and a normally shaped uterus (I can see it - looks just like a textbook). No fibroids? I ask the doc. Not that I can see, he says. Hm. An endometrial biopsy shows the lining of my uterus is in good shape. After one more natural cycle with a little bit of post-O support from progesterone, we are on our way. But Brent gets a job in Oklahoma. We're moving in July; we're running out of time!

March 2009: 100 mg of Clomid on days 5-9. Beginning on day 11, I start going to the Brigham at 6 a.m. every other day for ultrasounds. I have no follicles developing. After a week or so, I demand bloodwork to figure out what's going on. I start going in every day. I am butchered and develop track marks on both arms. Spring break trip is canceled. Finally (finally!) a couple of follies grow, and eventually, after nearly two weeks of these mornings, the bloodwork and ovulation prediction kit shows that we're good to go. Back-to-back interuterine inseminations (IUIs) follow.

April 22, 2009: OMG, a positive pregnancy test! Am I really that girl who gets lucky on the first try? Maybe! I spend 24 hours floating on air.

April 23, 2009: Blood test comes back positive, but barely. The nurse is not optimistic.

Two days later: Still pregnant! Blood test shows that HCG (pregnancy hormone levels) are doubling. This could still work!

Two days later: HCG levels dropping; miscarriage is certain.

April 27-May 4: A very long week waiting for the miscarriage. This is the hardest thing we've done so far, the waiting. Lots of morbid jokes about dead babies ensue. But we do make a trip to the roller coasters at Canobie Lake Park to try to move things along.

May 4, 2009: Painful, exhausting miscarriage, but at least it's over.

May-June 2009: Two cycles off to recover from the miscarriage and find a house in OK. Meet with the doctor and decide to pull out all the stops: injectible meds. One theory is that the egg was "overripe" when it was fertilized, so we want to get me to ovulate sooner.

July 2009: Gon@l-F 150 injected into my belly every day starting on CD3; I discover I have no problem sticking myself with needles. Ultrasound on CD10 reveals we're ready to go. Brent manages to get through the injection of HCG to trigger ovulation (an intramuscular injection in the patootie). We have back-to-back IUIs. I've got lots of eggwhite cervical mucous; I'm convinced this one's going to work. But Aunt Flo (AF) arrives before I even get a BFN (big fat negative on a home pregnancy test). We move to Oklahoma.

August 2009: On our fourth day in Oklahoma, we visit our new fertility docs at OU. This is an entirely different experience: the doctor (not some tech in the basement) does the u/s and explains to us what we're seeing. Guess what? I do have a fibroid. Told you so. But he doesn't think it's the problem. We receive a (not terribly helpful) diagnosis: unexplained infertility with mild male factor. Since I got pg on Clomid, he wants to try that again, but starting on CD3 instead of 5.

September 2009: U/S on CD12 reveals good follicular development; U/S on CD14 shows we're ready to rumble. OU doesn't wait for ovulation to happen naturally; it's time for another HCG shot. But OU doesn't require IM injections; it's just a little needle in my belly. I can handle that. My one objection is that OU does a single insemination, not back-to-back. But beggars can't be choosers. Progesterone keeps AF at bay for a normal (>10 day) luteal phase, but both home pregnancy tests and the blood test reveal BFNs. I start Clomid again on CD3.

October 2009: I realize on CD7 that something's wrong; I feel like I'm ovulating or about to. But stupidly, I don't call the doctor. I've never ovulated this early before (on my own, I'm usually at CD18 and on Clomid, between CD14 and 23). I ignore it. Sure enough, u/s and blood work on CD13 reveal I ovulated about CD10. This cycle is a bust. And it's the most upset I've been so far. Now we're waiting for AF to arrive and wondering if we'll be able to squeeze in another cycle before the holidays, even though I'm traveling virtually every weekend.

Birthday party

My parents were here for the weekend. Saturday just happened to be the midway point between each of their August birthdays, so we threw them a little party. We started with flank steak with local seasoning; local tomatoes tossed with basil and olive oil; and roasted local red potatoes tossed with arugula.

For dessert, we had Wellesley Fudge Cake with Ina Garten's peanut butter icing.

The blog is back!

And featuring tomatoes, summer squash, and red potatoes from the Norman Farmers' Market. Recipes from the September issue of Real Simple.

All-American Girls

I joined flower girl Stella and her mom Maia at the American Girl store in Natick for a birthday brunch this morning. I thought about taking my first generation Felicity doll to the hair salon, but I refrained.

Star-shaped butter for Stella Bella!

How sweet it is

It sounded weird, but it was oh-so-good: sauteed chicken with a sweet potato-spinach salad, from the February 2009 issue of Real Simple.

Perfect breakfast

One of my favorite childhood treats: a dutch baby topped with strawberries and powdered sugar:

Real simple comfort food

The February 2009 issue of Real Simple was full of goodness. First, we had chicken pot pie:

Then pasta, with roasted broccoli and walnuts:

Then, from Cooking Light: brown-butter gnocchi with wilted spinach:

Hummus for dinner

It's so good, we had it twice this week: chickpea, lemon, and cumin stew over polenta.

Just another day in paradise

When we are visiting Brent's folks in Scottsdale, we love to eat at Paradise Bakery. Their cookies are fluffy and soft and delicious. I was thrilled to find their sugar cookie recipe online. They tasted just like the real thing!

Island flavor

I'm almost reluctant to post this, because it doesn't look very appealing in the picture. But Island Papaya chicken is one of our favorite dinners. It's comfort food around here -- chicken sauteed with papaya with a sweet and spicy marmalade sauce on top of coconut rice. I suppose it would look better sprinkled with cilantro, as the recipe calls for, but I can't bring myself to buy a whole bunch of cilantro for garnish. Trust me, it's so good. For the coconut rice, we make jasmine rice, substituting low-fat coconut milk for half the water and adding some sugar.

Cooking Light in 2009

Brent received the Cooking Light 2009 recipe collection. It's helpfully organized by month, so we can always stay in season. The January-February recipes include lots of dried fruit, which we paired with broccoli and sauteed spinach. Brent has just finished In Defense of Food and informs me that we need to branch out from eating brussel sprouts every night. We started with pork with orange-apricot sauce:

Rather than buy an entire pork tenderloin for the two of us, I substituted thin-sliced pork loin, which worked great. We then had Moroccan chicken with fruit and olives. I served it with pine nut couscous and spinach, which I sauteed with leftover onion and garlic from the chicken.

We'll be returning to this cookbook all year.

Winter feasts

We headed to the grocery store in advance of our first storm of the season in search of inspiration. We found lamb chops, which we grilled and served with roasted brussel sprouts and creamy goat cheese polenta. It wasn't quite my dinner at Tonto, but it was pretty close, at a small fraction of the price.

Then we pulled some whole wheat pizza dough out of the freezer and topped it with our favorites: roasted sweet potato, caramelized onions, cranberries and goat cheese. We used herbed goat cheese, rather than spending a fortune on fresh herbs. It worked great.

Color me Red

I needed to make dessert to take to some friends' for dinner tomorrow night. Ipso Fatto had recently made Red Velvet Cake for a Christmas party, and I remembered that Brent had brought me Red Velvet Cupcake mix many moons ago. Now normally everything here on the blog is from-scratch, but these are pretty darn close.

And with leftover roast chicken, we dined on chicken tortilla soup:

King Cake

To celebrate, Epiphany, I made King Cake for Godly Play. It was too lemon-y for many of the kids. It was beautiful, though! Next time, I think I'll make a pure cinnamon-roll type dough.