infertility Archives » Alina Avery

Final Fertility Update – Our FET

September 29, 2018 by Alina Avery Leave a Comment

After our first IVF cycle failed, we met with our Reproductive Endocrinologist to follow up on how the cycle went and what our next steps were.

We were very much on the same page, we were happy with how our cycle went right up until the negative pregnancy test. My response to the medication, egg retrieval, fertilization and maturation of the embryos was all pretty much textbook. We feel very lucky to have had such a positive experience. It was obviously going to be emotional and difficult and the fact that we weren’t one of the lucky unicorns who find success after their first cycle was upsetting, but not world ending. We did have 6 more frozen embryos and nothing about the cycle raised any red flags that indicated we would need to change treatments or do more testing.

So the next step for us would be an FET, a frozen embryo transfer. Compared to the stim cycle, this would be a walk in the park. There were two options for us, a “natural” cycle, or a medicated one. During a natural cycle, you’re monitored similar to how you are for a stim cycle to pinpoint your natural ovulation. Then 5 days later, a 5-day old embryo is thawed and transferred when your uterus is receptive. The pros here: little to no medication. The cons: lots of visits to the lab for monitoring, less control over timing. Since I prefer more control and less poking (blood draws) and prodding (internal ultrasounds), I opted for a medicated transfer. What that meant was that at the start of my next cycle, I would start taking oral estrogen pills as well as using estrogen patches to both suppress my natural ovulation and begin to build a uterine lining. After two weeks of that, I would go into the lab for a lining check where they would do just one blood draw and ultrasound in order to make sure the estrogen had done its job. They were looking for low progesterone, meaning I hadn’t spontaneously ovulated, and high estrogen. I believe for the uterine lining, they were looking for something over 8mm and mine was 9.5mm, so all signs pointed towards go. And that’s when I started the most tedious point in the process: Progesterone In Oil injections, or PIO.

PIO is an intramuscular shot. Meaning that instead of a tiny, short little subcutaneous needle into your belly like the stim injections, it’s a massive long 1.5 inch needle that goes into your bottom. I needed to do one injection every day around the same time every day. It’s nearly impossible to do yourself and after daily injections, even after switching sides, your butt gets bruised and sore.

The progesterone injections are intended to simulate ovulation. It changes the quality of the uterine lining to be sticky and holds it in place so that the embryo can implant in it. In a natural cycle, progesterone is produced by the follicle left behind on the ovary once the egg is released. Since I wasn’t actually releasing an egg this cycle, I had to supplement my progesterone. So after 5 days of progesterone injections, we went in for the FET.

It was very similar to the process for a fresh transfer. I needed to have a full bladder again, but this time I overdid it and was told I could try to partially relieve myself so I wasn’t in pain. I had to do that at least twice and still when the ultrasound tech came in the first thing she said was “whoa, good job with that bladder!” Matt commented that he could see a lot more definition on the ultrasound screen looking at my uterus this time. It was pretty clear to see the outline of the organ, the lining, and where the little embryo ended up. After the transfer, they gave us a photo again, told us to come back in two weeks for a pregnancy test, and to continue the progesterone injections and estrogen pills and patches.

I had a minor freak out a few days later when we got about 6-8 inches of snow. Matt injured his back at the gym, so digging the car out was up to me. I thought maybe I’d over done it shoveling snow, even though I hadn’t gotten out of breath and was careful not to lift any too heavy shovel loads. I was a bit paranoid that I’d managed to dislodge our precious embryo. Some incessant googling calmed me down though.

Two days after that, we boarded a flight to London. Remember when I said the PIO shots had to be done around the same time every day? Well we’d started doing the shots around 9pm eastern time, which meant that 1. we had to do a shot at the airport and 2. we’d be doing the shots at 2am while we were in London. The shot at the airport was difficult for me. The only private place we found to do it at Logan Terminal E was a breast feeding/pumping pod, which felt ironic and a little like adding insult to injury. The code to get in was 80085 though (BOOBS) which I found funny at least. Also in case you’re curious, needles and syringes are totally fine to pack in your carryon. We had a note from the doctor that they were medically necessary, but no one gave us a hard time about it. The 2am shots in London weren’t actually as bad as we thought they might be. The nice part was that we were always back in our room and not out-and-about doing tourist-y things. We just prepped everything before we went to bed, set a phone alarm for 2am, and when it went off, sleepily drew up the injection and administered it.

We had a fantastic time in London. It was a great way to distract myself from constantly wondering if the transfer had worked or not. We flew back to Boston on a Sunday evening and my pregnancy test was scheduled for early Tuesday morning. Monday morning I woke up around 3am to pee and probably a bit due to jetlag. Since I was up and going anyway, I decided to take a home test, fully expecting it to be negative so I could brace myself for the next day’s blood test. I think you could have knocked me over with a feather when two dark lines showed up almost immediately. Once I convinced myself I wasn’t actually dreaming, I ran back into the bedroom to wake Matt up and make him look at the test. He was definitely still very much asleep but similarly excited to see our first ever positive pregnancy test.

My HCG level on Tuesday was around 1500. They scheduled another draw for two days later to make sure the levels were rising appropriately. That one came back at 2800, which the nurse described as “perfect”. A final draw a week later came back at almost 16,000 which pretty much meant that I was definitely pregnant and it was looking viable. Slow rising or dropping HCG levels can indicated a chemical pregnancy, where the embryo implants but fails to grow shortly after, or an ectopic pregnancy where the embryo manages to find its way out of the uterus and implant somewhere it shouldn’t. They’d have me in for an ultrasound to confirm placement two weeks later. Those two weeks CRAWLED by. Like I said… lots and lots of anxious waiting in this process!

Our ultrasound was scheduled for when I was 7 weeks and 6 days pregnant and our little embryo measured exactly on track with a strong heartbeat. At that point we were released from the fertility clinic and were transferred to an OB for standard prenatal care. That was obviously the good news. The bad news was I was still required to continue the PIO injections and would need to keep doing them until I was 10 weeks pregnant.

Looking back, my “symptoms” while we were in London could have been due to the progesterone or the time change, but I was exhausted. Especially towards the end of the trip, I couldn’t keep my eyes open. I thought my sense of smell on the plane home was a bit more sensitive than usual, and I completely lost my taste for wine. We planned a little wine tasting with our friends one of the last evenings there where we bought a few nice bottles and wanted to taste them side by side and compare notes. Every glass tasted awful to me. I was completely disinterested in drinking any sort of wine, which is very unusual for me!

The IVF Process Part II: Egg Retrieval and the Hunger Games

July 4, 2018 by Alina Avery Leave a Comment

At the end of your stim phase, you’re given a different medication called a “trigger shot”. This is administered exactly 36 hours before your egg retrieval is scheduled and lets your ovaries know that it’s time to mature the eggs and prepare them for release. Before they are actually released, the procedure is performed to aspirate each of the eggs out of their follicles. The follicles have grown to be about 20mm at the largest, and usually at least 14mm if they are containing a mature egg, and they’ll continue to grow after the trigger shot, but the eggs themselves are still microscopic. Essentially what they do for the surgery is administer a general anesthesia and go in and suck out the fluid from each follicle, including the egg, and then observe the fluid under a microscope to see how many eggs they were able to collect. So roughly, the number of follicles correlates to the number of eggs you can expect, but some eggs get stuck to the side of the follicle, some follicles are empty, some eggs are released sooner than expected, and some immature follicles will mature by retrieval time, so it’s not exactly 1-to-1.

At the time of my trigger shot, my left ovary had 5 follicles measuring (in mm) 19.6, 19.1, 18.9, 18.4, 17.2, and my right ovary had 18, measuring from 21mm to 11mm. It’s pretty normal to have one ovary more active than the other, and it varies from cycle to cycle. During a natural cycle, only one ovary matures and releases an egg, so logically to me it seems like that side might have a leg up, but I haven’t had that confirmed by a doctor or anything.

The day of the surgery, I arrived about an hour before my scheduled retrieval time. I was told not to eat or drink anything after midnight, no makeup or perfume or contact lenses, and no jewelry. I was given a gown to change into and a warm blanket and some socks. A nurse administered an IV and that was the most uncomfortable part of the whole day. I met the anesthesiologist and the fellow who would be performing my retrieval, and they went over what I could expect, how long the operation would take, things like that. I might have signed a consent form but I don’t really remember. I was pretty nervous, even though at that point, everything was out of my control. I was mostly paranoid that I had ovulated all of my eggs already and they’d go in and find nothing left. That was not the case, and is very rare, although it does happen.

Matt left me on my own for a few minutes to go produce his sample that they would use for fertilization and when he was back with me, it was time to go into the operating room. I used the rest room (awkwardly as I had an IV in my arm and a fluid bag with me), and walked into the room and got up onto the table myself. They had me get into position while I was still awake so that I would be comfortable and not pinch any nerves or lose circulation, and then they replaced the IV fluid with whatever drugs they used for the anesthesia and the next thing I knew I was being wheeled into the recovery area about 25 minutes later.

The anesthesia can sometimes make you nauseated, so they give you some crackers and ginger ale while you wake up, and a nurse comes by with a little slip of paper to tell you how many eggs they were able to retrieve and give you some post op instructions. Basically, no driving, no strenuous exercise, call if you notice anything unusual. Once I felt strong enough to use the bathroom by myself, I could change back into my street clothes and be on my way. I did need to have a ride home as I couldn’t drive, and a nurse actually walked me out to the car, probably to make sure I didn’t fall and also to make sure I wasn’t driving.

We got 24 eggs, from what seemed like 23 mature follicles two days before, so pretty much what was expected. Generally, this is a lot of eggs for an IVF patient. The “sweet spot” is around 15 eggs to balance quality and quantity, but a lot of patients who are older get fewer, and patients who are younger without any ovarian issues get more. We went home and spent the rest of the day on the couch essentially, watching movies and napping. My recovery was very easy, which isn’t always the case. I had a very easy go of it and I’m very thankful. I was back at work the next day and did not have any lingering nausea, pain, or side effects from the anesthesia. I consider myself very lucky.

Then, the hardest part of all of this started. The waiting. No one prepares you for how much waiting you have to do, and this was just the start. Twenty-four hours after the surgery, the clinic will call you to let you know how many of the retrieved eggs fertilize naturally. We opted to do something called ICSI, where instead of just putting the sperm and eggs together in a dish, they inject a single sperm cell into each egg, which helps with fertilization rates. Waiting for that phone call was nerve wracking, but I was happy to hear that we had 16 eggs fertilize. Generally, you’ll lose 25-30% of your starting egg count with each stage of growth, which is very normal and mostly due to chromosomal issues with the cells or something along those lines. IVF message boards and support groups sometimes refer to this as the Hunger Games, as it is kind of a survival test of strength for microscopic groups of cells. Some clinics will give you an update on the growth of your embryos on day 3, but many will prefer to leave them undisturbed until day 5, when most patients will have a “fresh” (as opposed to “frozen”) embryo transfer. So we went from day 0, retrieval and 24 eggs, to day 1, fertilization and 16 embryos, and then we wouldn’t hear anything more about our embryos until day 5, transfer day. Those four days feel like an eternity, but it was really just the beginning of all of the waiting we’d be doing throughout this process.

The IVF Process Part I: Baseline, Stims, and Monitoring

June 1, 2018 by Alina Avery 1 Comment

First, our medication arrived from a special fertility pharmacy. It arrived in an insulated box I could almost fit in. Needles and syringes and everything. The nurse warned us that the box would be big when she taught us how to administer the medication at our last appointment. It was still pretty overwhelming.

Our box had several medications in it, some of which needed to stay refrigerated. According to my research, the first IVF cycle can be “diagnostic”, meaning the doctor will see how you respond to a standard dose and if you need to change dosages or protocols in a future cycle, you can adjust to try for a better outcome, meaning more mature eggs that fertilize normally. I was on a standard “antagonist” protocol, which means that my ovaries were stimulated to grow more eggs and then we used an antagonist to prevent them from ovulating until the doctor decided they were ready. The injectable medications I was prescribed were Menopur and Gonal-F to stimulate the ovaries, Cetrotide as the antagonist, and Pregnyl to trigger the release of eggs when they were mature enough to be retrieved. Along with these were a number of syringes and needles to draw up and administer the medication, an empty sharps container, and some alcohol wipes and sterile gauze. The non-injectible medications included in the box were for after the retrieval, to support my body hormonally after we hopefully transferred an embryo back into my uterus. For that I was given an estrogen transdermal patch and a progesterone suppository gel, which was honestly the worst part of the whole ordeal, but I’ll get to that later.

Once my next period arrived, which is day 1 of my cycle, I went in for baseline monitoring. The objective is to make sure you’re ovaries are suppressed before you start stimulating them to produce more follicles, which contain eggs. This is done using an internal ultrasound, which is pretty uncomfortable but you get used to it after undergoing several. They also do a blood test to make sure your progesterone and estrogen and other hormone levels are appropriate for the beginning of a cycle. All of my levels came back within range and my ovaries looked nice and quiet, so I received a call from the nurse that I would start stims that evening.

The nurse confirmed my dosages, gave me a few instructions on timing, and scheduled my first monitoring appointment for four days later. I’d do nightly injections of Menopur and Gonal-F and then they’d check and see how I was responding with another ultrasound and a blood draw. She also reminded me that unprotected sex was not allowed during this time, as there was an increased possibility that I could release multiple eggs while stimulating my ovaries, resulting in a high-risk high-order pregnancy.

Matt did my injections for me, and they really weren’t so bad! They were subcutaneous, meaning they just need to go into the fatty layer right beneath your skin, and they go right into your belly. I will say, there is nothing less flattering than pinching a handful of belly fat for your husband to stick a needle into. But we made the process a bit of a ritual and by the end of the stim period, I kind of enjoyed our few moments together. We’d sit together and have a cup of tea after. The process was really emotional for me, so it was nice to have a few quiet minutes together to decompress.

After my first monitoring session, thing were going well, so I was told to continue the same dosages for three more days and go back again. The second monitoring appointment was when things had started to take off, so they decreased the dosage of one of the stimulating medications and started me on the antagonist. I went in again two days later and was told that we’d reached the point the doctor was looking for and we were ready to trigger! The trigger shot is administered exactly 36 hours before the retrieval procedure, so I was told to do the injection that evening at 8:30pm exactly and then enjoyed a full injection free day before heading in for my retrieval appointment at 8:30am the following day.

Overall, the injections weren’t so bad, but you do get uncomfortable towards the end. Your ovaries are normally the size of grapes, but by the time your ready to trigger, each follicle can grow up to 2 centimeters wide and you can have up to 15 follicles or more on each side, meaning your ovaries swell up more like the size of grapefruits. One of the reasons you’re so closely monitored is to prevent OHSS, Ovarian Hyper-stimulation Syndrome, which is very unpleasant and can result in hospital admission. Doctors may keep your dosages lower to be on the safe side and avoid OHSS. I stimmed for 9 days total and was lucky enough to avoid it.

Next up: the retrieval and fertilization process!

Fertility Update — Blood tests, Ultrasound, HSG

November 8, 2017 by Alina Avery Leave a Comment

I left off our fertility story after we made our first appointment for a visit to a Reproductive Endocrinologist to figure out why we weren’t having any luck trying to conceive and what our possible options are moving forward.

We chose Boston IVF/IVF New England, which used to be two separate organizations, but have merged into one. It’s honestly a bit confusing since there are so many office across Massachusetts, New Hampshire, Rhode Island, etc. and they all have different names. We chose our doctor, Dr. Wright, based on the recommendation of a friend of Matt’s sister. Her office is a bit farther away, but honestly there were an overwhelming number of options so it was nice to have a little guidance. And to me, feeling confident and comfortable with our doctor is worth the longer drive. When we were making the initial appointment I also made sure that we could change to a different office or a different doctor if we felt things weren’t working out, since our first appointment would also be our first conversation with our doctor.

Luckily, Dr. Wright was great and answered all of our questions. We didn’t feel rushed or belittled or judged and she took our history, listened to our concerns, gave us more information on our options, both short and long term. She was also knowledgable about our insurance and what would or would not be covered. I appreciated that, since a lot of times it seems like doctors don’t concern themselves with insurance and let the billing office handle it, which can lead to a disconnect between what treatment you can afford and what you are given. Especially since fertility treatments can be so expensive, it’s nice to know that everyone is aware and conscious of cost. We spent about 45 minutes discussing our case and then met with an admin to go over the suite of tests that Dr. Wright had ordered and how and when to schedule them.

For me, I was told to call the office on the first day of my next period to schedule blood tests and an ultrasound for day 3 of my period. Then sometime between day 5 and day 12 of my cycle, I’d go back in for an HSG or a “dye test”, where they’d inject a contrast dye into my uterine cavity and then use an x-ray machine to make sure my tubes were open. For Matt, he’d do a second semen analysis and also a blood test. My period wasn’t due for another 3 weeks, so it was back to waiting. I don’t think I’ve ever been so excited to get my period and probably never will be again.

I’ve always been (weirdly) totally fine with needles, so the blood draw was the easiest part. They did an STI panel, tested my hormone levels, and sent some off for genetic testing. The genetic testing is to determine if Matt and I are both recessive carriers for certain genetic mutations or diseases, so if we end up doing IVF, they’ll be able to screen the embryos to make sure they aren’t affected. In my opinion, it was a little early to be concerned about that, especially since we don’t have a family history of any of the issues they’re screening for, but if they’re taking blood anyway might as well tack that on.

The ultrasound was slightly less comfortable. It’s an internal test, so they have a wand they use to measure your organs and count antral follicles, which is a way of measuring ovarian reserve or the number of eggs you’ve got left. They also make sure there aren’t any ovarian or uterine cysts and that the lining of the uterus looks appropriate for where you are in your cycle.

Finally, the HSG a week later was definitely the least comfortable, and definitely the weirdest. I told Matt after that it was kind of bizarre to see an x-ray of my pelvic bone. I mean, I know I have a skeleton, it was just strange to see it projected on a monitor! The whole procedure only took about 60 seconds, but a very uncomfortable 60 seconds.

For Matt, it was very straight forward, all he had to do was go into a special room to “produce” into a cup. . We scheduled our visits so we could go in at the same time. I thought that the HSG would take longer and Matt’s specimen production would be relatively quick and he’d end up waiting for me, but my test was actually super speedy and we had to wait a while for a room to open up for Matt.

The initial results are mostly posted on our patient portal, and from my compulsive and incessant Googling, all the numbers seem normal, and both my tubes are free and clear. The genetic testing takes longer, and we don’t have Matt’s results yet, but from his first test back in 2015, we know at least roughly what we can expect. Our next step is to schedule a follow up visit with the doctor, but the next availability isn’t for a few weeks, so we’ll have to be patient. The waiting is definitely the worst part, especially since we’ve made the decision to go ahead and seek intervention. I wish I’d known that sooner so I could have prepared myself for the timeline. It seems obvious now, but I thought that it would be relatively quick between our first appointment and starting treatment, even if the treatment itself took a while. It’s a special kind of torture. When I brought this up to Matt he was surprised that I was surprised at how spread out everything is. He (rightly) expected a much more drawn out timeline.

So I guess the next post will be any news from the follow up and what our course of action will be. I also might do a quick update on the cost we’ve incurred so far, since I know that’s a factor for a lot of people. Luckily we have excellent insurance, but I’m still bracing myself for a bill.