Holy cow. We're having twins!!!!!!!!!!!!!!!!!

Shock and awe.
Complete and utter amazement.

Is this really happening?!?! Yes, I do believe it is. :-)
Two gestational sacs, two yolk sacs confirmed.
We go in next Thurs, Sept 10 for our second ultrasound and to see the Tweedle's heartbeats!!

GOD IS SO GOOD!!!

Anxiously awaiting our first US!

Tuesday, Sept 1st, is "the" day!! I am both more excited that I can ever imagine being AND equally just as scared to lay eyes on that ultrasound screen.

Let's not elaborate on that last part though. I mean, really. At this point that does no one a bit of good. I'm staying positive and focused on the fact that a Tweedle, or two, have by now camped out very nicely, deep inside my lining and are leasing my uterus for the next 8+ months. I'm also very excited that the official countdown to holding baby(ies) has already begun!!

What we might see!
On Tuesday, I will be 5 days and 4 weeks along. I believe Dr. Ahlering will be performing an internal ultrasound, so that he can see as many teenie tiny details as possible. Let's face it. At this point, teenie tiny is pretty much all that would even exist. I was amazed that the book my mom just gave me on pregnancy said the baby would be about the size of a the letter "o" in the book, or that of a mustard seed, currently.

I am fascinated about what we might expect to see at this point, so I did a little googling (surprise, surprise :P) and found a smattering of things. As AmericanPregnancy.org states, "The gestational sac(s) is often the first thing that most transvaginal ultrasounds can detect at about 5 weeks. This is seen before a recognizable embryo can be seen. Within this week, at about week 5 ½ to the beginning of the 6th week, a yolk sac can be seen inside the gestational sac. The yolk sac will be the earliest source of nutrients for the developing fetus."

Details on each of these, and more, is outlined below - all taken from this site, which I found to be a wonderful resource! Usually I summarize my sources, but it was all so interesting! (to me anyway!)

Gestational Sac: The gestational sac is the earliest sonographic finding in pregnancy. The gestational sac appears as an echogenic (bright echoes) ring surrounding a sonolucent (clear) center. The gestational sac does not correspond to specific anatomic structures, but is an ultrasonic finding characteristic of early pregnancy. Ectopic pregnancies can also have a gestational sac identified with ultrasound, even though the pregnancy is not within the endometrial cavity. The gestational sac first appears at about 4 weeks gestational age, and grows at a rate of about 1 mm a day through the 9th week of pregnancy.

Twins?: Twins and other multiple gestations can usually be identified fairly early in pregnancy. They may be seen with two separate gestational sacs (diamniotic, dichorionic twins). They may be seen as two fetal poles occupying the same gestational sac (monochorionic twins). It is useful to identify twins early as the prognosis varies, depending on the chorionicity and amnionicity of the twins. A "vanishing twin" occurs in about 20% of twin pregnancies. In these cases, one of the twins fails to grow and thrive. Instead, its development arrests and it is reabsorbed, with no evidence at delivery of the twin pregnancy. It will prove useful to advise patients of this phenomenon who are found to have twins early in pregnancy.

Yolk Sac: As the pregnancy advances, the next structure to become visible to ultrasound is the yolk sac. This is a round, sonolucent structure with a bright rim. The yolk sac first appears during the fifth week of pregnancy and grows to be no larger than 6 mm. Yolk sacs larger than 6 mm are usually indicative of an abnormal pregnancy. Failure to identify (with transvaginal ultrasound) a yolk sac when the gestational sac has grown to 12 mm is also usually indicative of a failed pregnancy. Yolk sacs that are moving within the gestational sac ("floating"), contain echogenic material (rather than sonolucent), or are gross misshapen are ominous findings for the pregnancy.

Fetal Heart Beat: Using endovaginal scanning, fetal cardiac activity is often seen even before a fetal cell mass can be identified. The fetal cardiac muscle begins its' rhythmic contractions, and that rhythmic motion can be seen along the edge of the yolk sac. Initially, the fetal cardiac motion has a slower rate (60-90 BPM), but cardiac rate increases as the fetus develops further. Thus, for these early pregnancies, the actual cardiac rate is less important that its presence or absence. Sometimes, with normal pregnancies, the fetal heartbeat is not visible until a fetal pole of up to 4 mm in length is seen. Failure to identify fetal cardiac activity in a fetus whose overall length is greater than 4 mm is an ominous sign. It can sometimes be difficult identifying a fetal heartbeat from the background movement and maternal pulsations. You may find it useful in these cases to scan with one hand while taking the maternal pulse with the other. This makes it easier to identify sonographic movements that are dyssynchronous with the maternal pulse.

Fetal Pole: A mass of fetal cells, separate from the yolk sac, first becomes apparent on transvaginal ultrasound just after the 6th week of gestation. This mass of cells is known as the fetal pole. It is the fetus in its somite stage. Usually you can identify rhythmic fetal cardiac movement within the fetal pole, although it may need to grow several mm before this is apparent. The fetal pole grows at a rate of about 1 mm a day, starting at the 6th week of gestational age. Thus, a simple way to "date" an early pregnancy is to add the length of the fetus (in mm) to 6 weeks. Using this method, a fetal pole measuring 5 mm would have a gestational age of 6 weeks and 5 days.

Crown Rump Length: This term is borrowed from the early 20th century embryologists who found that preserved specimens of early miscarriages assumed a "sitting in the chair" posture in both formalin and alcohol. This posture made the measurement of head-to-toe length impossible. Instead, they subsituted the head-to-butt length (crown rump length) as a reproducible method of measuring the fetus. Early ultrasonographers used this term (CRL) because early fetuses also adopted the sitting in the chair posture in early pregnancy. Today, the crown rump length is a universally recognized term, very useful for measuring early pregnancies. The CRL is highly reproducible and is the single most accurate measure of gestational age. After 12 weeks, the accuracy of CRL in predicting gestational age diminishes and is replaced by measurement of the fetal biparietal diameter. In at least some respects, the term "crown rump length" is misleading, because during much of the first trimester, there is no fetal crown and no fetal rump to measure.

Symptoms few, but still present
I woke up Friday morning to a bit of spotting. This was the second occurrence of this, actually, but the first time it was so tiny it wasn't worth mentioning. This go-around, I wasn't super freaked out about it, but obviously a little concerned. It was just enough to tinge the Endometrin discharge that occurs, but nothing more, and it didn't continue throughout the day, nor did I experience any serious cramping. Although, I did wake up to some type of cramping in the middle of the night. It's not unusual for me to get up one to two times each night to pee (good thing I can easily fall back to sleep, right now anyway), but this night I woke up to a bit of either cramping or maybe what were slight uterine contractions. Either way, it was somewhat noticeable, but seemed to go away after I went the bathroom and lied back down. As for tonight, I have been having some mild pinching in my uterus again, which I'm taking as a way for the baby(ies) to let me know they're in there, growing away!

Looking forward to delivering some more good news soon! Please pray that our baby(ies) are cooking away and growing at a healthy rate for a very young 5 weeks, 4 days of age! Thanks again, everyone, for the many congrats and well wishes. We have loved each and every one of them and are still so very thankful for all of your kindness!

No frozen embabies :- (

We just found out that out of the other 6 embryos that were grade 3 yesterday (which was day 6 of embryo development), NONE of them matured any farther and therefore could not be frozen.

That's right. We had a ridiculous number of eggs retrieved, thought nothing could touch us for a mere moment and now everything is riding on the two embryos that are inside me right now.

I know it only takes one to make a baby. I know that God can work miracles.

I pray that *that* miracle is had in this fresh cycle. My heart is trying to stay positive. I have to be positive. At the same time, I am openly admitting that, in the back of my mind, I wonder if these two little ones will make it, seeing as how all of their other siblings around them didn't. It just isn't a good sign to me that our grade 1, day 5 embie dropped off and all of those other grade 3s didn't perk up. Given our age, this just doesn't rest well with me.

Having said that, I am not going to try to think too hard about it over this next week. There will be plenty of time to over-analyze the "what-went-wrongs" if we find out this cycle didn't work.

Please, please continue to keep us in your prayers. We are far from out of the woods and our hearts are VERY much still wrapped up in this cycle. Wrapped up in the hope that we might be expecting 9 months from now, right around the day my husband was born.

I introduce to you: Our little tweedles!

We made it!
Two embabies are nested all snuggly inside me
and I couldn't be more happy!!

We got the call this AM telling us we should be there at 10:30. Overall, it was super quick and simple. Undress from the waist down, climb onto the table, legs in stirrups, ultrasound on belly, speculum, catheter, babies in pipette... that's where it got really interesting! We were in awe as we watched Dr. Ahlering find the *perfect* spot in my endometrial lining (which he said looked great) and then a little "woosh!" on the ultrasound screen as he released each one into their new home. It was AMAZING!!

There was a bit of discomfort when he was digging into my lining so that he could burry them nice and deep, but It wasn't any more than a mild period cramp. Perfectly managable and worth it! What was probably the toughest was fighting off the tears as we watched everything unfold. I could feel them welling up, but I refused to get all worked up and not be able to see each and every move he was making on the screen. When we were finished, they moved me to a cot and wheeled me back into the recovery room to lie for 30 minutes, wheeled me out the car and that was that. Transfer was here and gone before we could blink an eye.

The SIRM ladies were so sweet today. Penny, the woman who called us yesterday with our news, called today regarding the transfer and asked how I was doing. You could honestly tell she felt concerned about the whole thing. Then, the woman who wheeled me out the the car gave me a big hug as she told me they were all sending us good thoughts going into next week. I have always felt so good about dealing with that office and, even though during the fertilization process I wish they would have been more forthcoming with info prior to it being requested, they have always been very sensitive, timely and respectful. I'm so happy we decided to go with them and am extremely thankful we have made it this far. Feeling very positive going into our beta countdown!



The final details on the blasts they transfered is that they were both grade 2 blasts - one was fully expanded and the other way in the pre-expansion stage. Of course, in my mind they are perfect in every way - see the top-most pic! Our little "tweedles" as Jay has us referring to them. I just think that's so cute! I've modified the previous names a little though. One is tweedle and the other tweedle dee. I just can't have my kids being referred to as "dum".

I just found some info on our little tweedles (ok ok, embryos) that I thought was very neat. According to this site, "Keeping the embryos in the laboratory for almost a week, allows us to observe them growing through the morula and blastocyst stages. The cells compact together to form a morula, and then begin to pump fluid to the center of the morula forming a cyst. As the cyst inflates with fluid, the cells of the embryo organize themselves into 2 distinct groups. The inner cells are the first cells of the fetus, and the outer cells will become the placenta. (neato!) The size of the embryo increases as more and more fluid is pumped into the cyst, and the blastocyst bursts out of its shell. (Our are expanding and will be getting ready to hatch out of their shell soon!) Once out of the shell, it is ready to implant in the uterus."

The other is a pic of them both nestled tightly in my uterus. This one is just too cool to me! The embies are the little white blobs (as indicated by the arrows) and the dotted line represents my endometrial lining. The lining one is a bit harder for me to wrap my head around, but as Jay said, it's the perspective that's throwing me off. Anyway, if the doc knows what he's seeing, then I belive it!

We are still waiting to hear about the fate of our other embryos. As of this AM, Dr. Ahlering spoke with the embryologist who said that our grade 1 blast did arrest and is no longer with us, exactly what they were thinking might happen because it was compacted, and the others (not sure how many at this point) are still growing . They want to watch them the rest of the day to see how much more they mature. Only then will we know how many, if any, we have to freeze. I am trying not to get my hopes to high, but of course it would be wonderful if we had at least two to freeze. Don't get me wrong though, I am thrilled about today's blasts. To make it to transfer is something I will never take for granted. So many things had to line up perfectly in order to even get to this point! As so many of you have pointed out (thank you so, so much by the way!), the grade of our blasts aren't a very good indicator of the possbilities. It's a human's guesstimation and that's about it. As far as we are concerned, I am pregnant until proven otherwise. That should be more than enough to get me at least half way to my beta ;)

Our first beta (HCG blood draw) is next Tuesday, 8/18; our second which will confirm pregnancy is Thursday, 8/20. At SIRM-St. Louis their practice is to not notify patients of the outcome of the first beta. The thought is that it's not really a perfect, or totally accurate, indicator of a BFP. However, the second is. It should, ideally, double from the first number. The paperwork said that we could inquire about the first number if we wanted to know, but I think we'll probably just wait.

We'll also wait on the HPT tests. I don't want to get my body all tied up in a knot if I can help it. And, really, the second beta is just one week from today. That's really not that long at all. Afterall, we've waited SOOO long to get to this point. In retrospect, this is a piece of cake!

As for me, it's total bedrest. I'm laid up on the couch, laptop and tv close by until mid-day tomorrow. Dr. A said that the minimal discomfort I'm feeling down low still from the ER is normal. My ovary still looks fairly enlarged, but there is no extra cause for OHSS alarm, especially since I'm not really having any other symptoms. It could get a bit worse if we get a BFP, but all is on track for now. I was very happy to hear that.

Now, let the dreams and big plans begin! Trying not to get too excited, of course, but how can you not let yourself be just a *little* bit happy!!

I'm triggered and ready for Friday!!!

It's is so totally official now! Yay!!

Today's US was phenomenal. Dr. Alhering was smiling from the minute we started. He immediately saw lots of follicles and started measuring the big ones.

16
18
16
22
18
and so on...

At this point, he actually says that he's not going to even bother calling them all out. He already sees exactly what he likes. There are many others that, he said, are also within range and will hold eggs as well, which is great, but there are plenty of big ones too which is what they like to confirm.

He reiterated that my estradiol numbers do in fact look great (exactly what you said Fran!) - they are high, but not too high, and they aren't continuing to go sky high, so that's what they like to see. How nice, because I had to go in to get blood work AGAIN this morning and it sucked. They stuck me in the same vein they did yesterday (said it actually looked better than the arm they did the day before) and gosh darn it if it didn't hurt. I was dreading slightly what they might do tomorrow. Ah, not to worry. It was minor to begin with and now it's not even a concern!

As he was wrapping up with the US, he said, we'll definitely be doing a Friday ER and we can definitely expect to get 15+ eggs at retrieval!!! It just doesn't get better than that!! I couldn't stop smiling the entire time he doing the US. And then, after leaving the office, total permagrin the rest of the afternoon. I screamed in the car. I, of course, called Jay and then my Mom. I am so very thankful and blessed by every milestone we overcome in this. God is so good!

Looking back, today was pretty surreal. Still is. It's so funny how you envision something working out in your head and then, when the time comes, it just feels a lot different than how you imagined. I know that's not a new concept, but it definitely describes my day and many of the steps in our IVF leading to this point.

Before I left the office, I was given a set of instructions for tonight. Trigger and start the ZPack basically. And, I was also given instructions for ER - what not to do, what to do. I wasn't told exactly when those two things would happen though. That, they said, they would call me about later in the afternoon.

Then, just as planned, we got the call:

Peggy said: "You have come about as close as you can to winning the lottery!"

Your trigger will be at exactly 6:45 pm tonight (Wednesday)
Egg Retrieval will be at 8:45 am on Friday

This evening, after work, what did I do? Ran home, decided to go out for a celebratory all-you-can-eat Chinese dinner with my husband, drove super fast back to my office to pick up our latest set of instructions, drove back, threw the car into park and at precisely 6:45pm on the dot received my final tummy shot of Ovidrel (HCG). For a split second, I was like "it did say 6:45, right?!?" I just hate how cruel the mind can be. What a awful, awful trick.

And There you have it. I'm all triggered up and waiting for the big day!! Please pray that these eggies stay where they belong, ripen fully and beautifully right at picking time and that our ER goes smoothly and recovery is a breeze.

Whew! Good thing there's not a limit on the amount of things you can pray about. :)

Who needs two of 'em anyways? :-D

First and foremost, thanks everyone for your sweet comments and for all the support and prayers. We wouldn't be making it through this without them!

Before I get on to the great news about our US today, I'll mention that our second, and looks to be last, Luveris (LH) injection last night went MUCH better than the first night. Thank goodness. By the end of yesterday, I was definitely feeling quite tender and bloated. I weighed myself right before bed and I had gained about 4 lbs! Luckily when I did it again this morning, most of that must have been water weight, because I was back down to only about 1lb from where I had been. Whew! Don't need any early signs of OHSS!



So... onto the good stuff: Our CD 9 US Results!
Can I just say that I'm oh so proud of my single, solitary ovary (and what remains of my right). The tender little thing is definitely doing double duty. Thank you ovary! In a nutshell, Dr. A thinks we should expect to get in the upper teens for retrieval count. Yay, Yay, YAY!!

In he walked with a nurse - I just knew that meant business! He cut right to the chase and started measuring all the ones worth measuring (mentioning there were still a decent amount of smaller ones that we wouldn't count). I'll be real honest, I started counting up in my head each one as he called out "12 mm", "14", "16"... but I lost track right when it mattered the most. I knew I should have pulled out the pen and paper. I did, however, play back the voice recorder I took along and I'm pretty sure the below is fairly accurate.

So, as of CD 9, here is our count, according to measurement:
12mm - 8
13mm - 8
14mm - 5
15mm - 1
16mm - 2
18mm - 1

He summed up the scan by stating most are currently in the 12-14 range, with a couple outliers and that we won't need much additional stim; tonight he had me do 75 IU, with the idea of keeping them going and nudging the size up a bit. As of my appt this afternoon, they still hadn't received my estradiol level from the lab. He said they will look closely at that when they get the results and want me to go for another E2 draw tomorrow AM.

As for my uterine lining, it is measuring at 12, which he said looks very nice. This site states, "There is some ongoing debate as to "how thin is too thin", as well as to "how thick is too thick". In general, 8-13 mm is good, less than 6 is potentially a problem, and greater than 15 or so might possibly reduce chances for a successful pregnancy. During IVF treatment, the uterine lining starts at about 3mm thick at the end of the menstrual period. After the estrogen levels rise sufficiently, the lining of the uterus then thickens by about 1mm each day during IVF."

I have another scan for Wednesday at 1pm to assess where things are at. For some reason he felt compelled enough to say that he has a feeling ER will be Saturday, vs Friday, and that they'll have "no problem getting upper teens on ER day". Yippee!!! Go ovary go!!

I am supposed to hear back from their office by tomorrow afternoon regarding how my estradiol numbers are looking (from today and then again tomorrow). In going back and rereading a passage from the book "The A.R.T of Making Babies", by Dr. Geoffrey Sher, it appears as though "a woman who is optimally stimulate will, in our opinion, usually demonstrate a continuing rise or at least maintain a sustained level of blood estradiol while receiving gonadotrophins. This would confirm that the follicles and eggs are continuing to develop optimally. It has been demonstrated that a large drop in the blood estradiol level after gonadotrophins are discontinued is often associated with poor-quality eggs." With that said, I guess we won't really know the latter (because I'm not off the stims yet), but we should be looking for the numbers to be high or slowly climbing still. At least that is how it sounds.

FWIW, his book also states, "The optimum time for ER is about 34-36 hours after the final gonadotrophins injection is administered. (aka trigger shot). The average number of eggs retrieved varies from program to program. We average between 8 and 15 eggs per retrieval attempt, and can usually successfully fertilize about 70-80% of the mature eggs retrieved." He goes on to say "while the level of hormones and the US findings roughly correlate with the chances of retrieving a large number of eggs, this doesn't always hold true. Sometimes the follicles don't want to give up the eggs, or scar tissue may prevent us from reaching the ovary. And just because we retrieve an egg doesn't mean it will fertilize or that a fertilized egg will produce a "good-quality embryo". If we get a lot of eggs, that's great. I always emphasize that we have had many pregnancies result from the transfer of just one embryo." It'd been awhile since I read that and I feel like now it's a good overview for what's to come.

Ok, back to my E2 levels... depending on how those look, it could change when my trigger shot is or if we do another night of stims, which he didn't really mention today, but I suppose isn't out of the realm of possibilities. When I was making my appt for Wednesday afternoon, I was thinking to myself, "but what if I end up triggering before my 1pm Wed appt?" I asked the woman at the desk that and she said that if I wasn't given specific instruction today, that it wasn't a concern (timing of the two I guess). So, we'll see what happens!

Sorry this post is all over the place. I am so freakin excited that my mind is just racing!! Thanks again to everyone who is following our progress - for your prayers, words of encouragement and good vibes! I'm not too proud to say, keep them coming :D

Still stimming, eagerly awaiting our next scan!

Hooray for the weekend! And for the fact that Friday marked exactly one week, or right around there, until egg retrieval. Time has F-L-O-W-N by!

We had our second US scan on Friday
And thank goodness! It was hard to tell at first what Dr. Ahlering was thinking... we were all looking at the monitor, seeing lots of follicles, but his reaction just wasn't what I thought it would be. That's because I think he expected to see something other than what was there. This time around, he measured some of them, with the biggest coming in around 11 or 12 mm. He said that, come next week, we'll be looking for them to be anywhere from 16-20 mm in size. He did point out others that were there, but weren't as far along in size yet. In total, he said I had around 12+ follicles, but I didn't really get the impression that he counted one by one.

He said that, overall, there really isn't much to say at this point. Monday is when we'll have our next scan and, at that time, is when he'll be counting, measuring and deciding where I'm at in terms of meds and such. Before he left the room he also said my uterine lining is looking good and that he was going to take a peek at my calendar and check to see if anything needs to be adjusted.

With that under our belt, I went back into the waiting room and Jay went to "produce" (hahaa! I love it when our coordinator calls it that) his back-up sample. As I was waiting, a friend who's doing her cycle in September came in the office. Such a small world! We chatted for awhile and then before long, out came Peggy with a new calendar in hand.

Dr. A decided to change our stim dosage again!
We're back up to practically where we were when we first started. Friday was supposed to be the first day of our stims going down in dosage, but he kept us at 225 every day except the last day. That day we go down to 150 IU. I guess that while things looked good, they didn't look as good as he thought they could. Jay's theory is that he wants to try and get the other follicles that aren't quite as mature yet to catch up. I've heard follicles do mature at different rates, so this definitely seems logical, but I'm sure there is more to know than that, so this is one area I definitely want to do some more reading on over the weekend.

In the end, I'm glad we went yesterday. I would hate to have just waited until Monday to possibly find out that the one ovary wasn't producing as much as we hoped... though I think that 12+ for one ovary is pretty good. The thing is, at SIRM, they don't typically see patients until the Monday before ER, during stimming. We were seen only because we asked specifically, due to concerns we have since I have only one ovary. The good thing is that when we expressed a concern in our calendar review, there was no hesitation whatsoever to add in the extra appointment. Thankfully we asked! It definitely made me feel better going into the weekend knowing what is going on down there.

Thursday night we did our first injection of LH - Luveris
Boy did that suck. The needle was the same as the micro-fine you use for Lupron, but the medication itself stung and had a slight burning sensation the entire time he was injecting it. I, being the one pinching my skin, had a really hard time cooperating. When something stings like a bee you want to react and pull away from it, not stand there and take it. I accidentally moved a little just as we were finishing and looked down to see my skin had instantly swollen a semi-hard bulge appeard. It took about 15 minutes for the lump to go away, even with a hot washcloth over top.

Since we elected to do that first, we had to follow it up with a separate Follistim. The last time we did this, the 225 IU seemed to pool up under my the surface of my skin for awhile. It didn't hurt, but it was sorta freaky! Last night it wasn't near as noticeable and the injection itself went pretty smooth, thankfully. Tonight we'll do another vial of Luveris, perhaps our last (let's hope!). This morning it occurred to me that we're running out of spots to give injections, or at least it feels like it anyway. I do not, however, have any desire to explore giving them in my thigh or the back of my arm, so we'll just have to make do!

Tomorrow is CD 9: That means another E2 check and US
I am really anxious to see what this ovary has been up to. On Thursday I noticed some light twinges, on Friday during the US I could tell things were definitely more tender and yesterday it was pretty obvious that I have started gaining a little extra fluff in my tummy. Today I'm markedly more sore when I sit or put pressure on my stomach. "Just how big are those things getting?!" is all I can think. So we wait with lots of anticipation. Depending on what Dr. Ahlering sees determines if I'll stay on stims longer, when my next appointment will be and even when he thinks I might do the trigger shot prior to ER. Speaking of trigger shot, I just realized last night that I'm not sure if that injection has been ordered yet or not, or what injection I'll even be doing to trigger. All it states on my current calendar is "HCG shot" and there are several different types. So, that will for sure be asked tomorrow.

This has been a wonderful weekend full of things-not-planned: lazy days of board games, movies, afternoon naps and snuggling with the three loves of my life (my pups and my husband, of course). It has been VERY stress-free and a much needed way to begin a new week full of lots of things yet to be determined. And, of course, there have been tons of things on my mind. Each night before I drift of to sleep I've seemed to grasp onto some scenario surrounding IVF or pregnancy and imagine us in the middle of it all. Your mind races when there is so much that lies ahead! Things like the excitement of getting our final beta in just a few short weeks and those darn PIO intramuscular shots that I have been sorely dreading, both of which deserve their own post. More to come!

Gearing up for Operation Human Pincushion!

Ok so last week, week number two of our IVF cycle, was just flat out exhausting. Not so much because of the meds or any one thing about IVF specifically... it was more that it was extremely stressful. Stress which I want to keep at a minimum more than ever right now.

As with the rest of the U.S. economy in the past year, profits are down significantly for the company I work for. Since there are only about 12 of us here, there's not a lot of room for variance. We were told last Friday that things had to change immediately just so that we all have a chance at keeping our jobs. The biggest change that affects me is that my boss will now not be doing any creative design work from this point forward. In the past, we're nearly shared the workload. As you can imagine, this could, and most likely will, affect me in a big way. And here is where the stress comes in.

On Tuesday, I saw my first official side effect of being on Lupron. It seems that it makes a stressful situation about 80x worse than it normally is. I could feel my blood pressure rising and was *this* close to saying "WHATEVER!"and just walking out of a meeting - total out of body experience. Luckily, we broke for lunch which gave me the chance to run home, get a bite to eat and do some yoga and deep breathing. I honestly don't think I would have been able to make it through the afternoon (with a job anyway :P) otherwise.

My plan with work is to just try taking things day by day and not to get consumed by the long, long list of projects on my to-do list. I cannot let this work stuff affect our success. I will not!

Now for the fun stuff!
Tuesday, I woke up early and made my way to have my E2 blood drawn before 8am, as instructed. Then, Thursday, AF showed up, as anticipated, and I was due for my baseline ultrasound scan at 11 am. Both turned out wonderful! My E2 was nice and low, meaning no functional cysts present. Apparently, if one of these were to exist, all of the FSH/stim drugs that we will be injecting next week would have went directly to that functional cyst, instead of to devleoping healthy follicles. Didn't know that and found it very intersting, even though, thankfully, it doesn't apply to me.

Onto good news number two: The scan revealed, as Dr. Ahlering put it "Lots and lots and lots and lots of follicles" on my ovary. By his expression, I think he saw more than he thought he would because he said he was going to primitively step down the dosage of Follistim that begins next week. Instead of it being 225 IU for each of the 6 days, it will now start out at 225 IU for 3 days, then go down to 150 for two days, and only 75 on the final day. If he kept me at where I was at, we'd end up risking severe hyperstimulation, which we don't want.

He also commented that it looked like my left ovary and what remains of my right ovary appeared to be on top of one another (further confirming things are all jacked up in there!), but didn't seem concerned about it - just made the observation. I asked him if it still looked as though the left ovary was glued to my uterus and he said for sure. You could see the follicle filled ovary and the curvature of my uterus right up next to each other and it didn't budge a bit when he poked it with the ultrasound wand. I asked if it would be a concern once I did get pregnant and he said no - that sort of thing isn't super uncommon.

All in all, I left that office feeling so darn good!
When he walked in, he greeted me with a warm smile and a tone of calm. The first thing out of his mouth other than "hello, good to see you" was "are we ready to get you a big round belly?" That just put a huge smile on my face. Totally unexpected, but you could tell it was a tone of excitement that mirrored why I was there that day. And then, a simple thing that I've had no other doctor do before during an exam... After the scan was complete - me still lying on my back totally exposed (we all know how fun that is) - he extended his hand as a gesture to help me sit back up and regain my dignity. Usually, I'm left feeling like "ok, we're done, but you're still down there talking to me and this is awkward". :) Simple things like that go such a long way for me!

Follistim, here we come!
Going into this next week, I'll continue doing the Lupron injection in the AM, keep taking dexamethasone & my prenatal, and then on Tuesday, we'll add the Follistim injection in the evening. I'll be well on my way to becoming a human pincushion! :)

Will it be Bravelle or Follistim?

Anyone who has gone through, contemplated or will soon go through IVF knows just how important your protocol is. While is not the entire determining factor of success, it is a HUGE part of it.

A protocol should be specifically designed with the woman's infertility factors in mind: any and all conditions or family conditions, past surgeries, current blood work, ultrasounds, any past incidents of miscarriages, and probably many other things I'm forgetting. Point being, your protocol shouldn't be out-of-the-box. Everyone's body is different and in order for you to get to the outcome you desire (yes, a BFP!), your protocol should be one that is custom-fit for your issues in mind. Even then, there is no exact science, but it's a great place to start.

Count my issues, and blessings, one by one
Luckily, I have age on my side. My ovarian count, or FSH level, appears to be good and my AFC is good (15+). What I'm working with is the fact that I have only one ovary (appears to be slightly damaged due to surgical scarring) which means they may get less eggs and I have PCOS. At this point, it might be good that I have PCOS to some extent because it likely means I'll still produce a good number of follicles and eggs during IVF. The problem is, however, those eggs may be of lesser quality than your average woman.

Along with most other PCOS women, my FSH to LH ratio is out of whack
Normal values should be a 1:1 ratio, where as PCO women have an LH that is more like 2 to even 3 times as high as their FSH. Mine is 4.5 times as high!! This means that my body is ultra sensitive to LH. If there is too much, this can cause an over-production of androgens (male hormones), which can have a negative impact on the quaility of the eggs the retrieve. Poor quality eggs can sometimes lead to a lesser potential that they will fertilize well and turn into healthy embryos for transfer. No healthy embroys, means no BFP.

So, how does this relate back to my IVF protocol?
Well, I am - for certain - going to be on the Long Lupron Protocol. Lurpon is designed to suppress your pitutiary so that your body doesn't make it's own LH or FSH. The idea behind this protocol is that between BCP clearing up most cysts and by taking the Lupron for an etended period of time, my body's hormones and natural androgen production should be at a minimum. Once the ovaries are quiet, then they'll add in the drugs stimulate the ovary(ies) to do it's thing and from there the idea is that we'll recruite between atleast 8-15 healthy eggs, or more if we're super lucky. Yes, the time before stimming is critical for someone with PCOS, but stimming itself is JUST as important.

This brings me to the concern that came about in our calendar review.
As we were handed out calendar, we saw a familiar, but unexpected stim with our name on it - Bravelle. We had read about this drug in many places, including Dr. Sher's book (wow, I still haven't reviewed this...) and SIRM's Dr. visited forums, but couldn't for the life of us think about what the difference between this drug and Gonal F or Follistim were. We knew for certain that the latter two were 100% FSH because, in truth, that's what we expected we'd see on our calendar.

Instead, it was six days of Bravelle (3 vials each day to be exact). To be sure I understood before we went any further, I asked our coordinator what the difference between that and Follistim was. She started by explaining that everyone is given specific protocols and that our doctor wouldn't put us on something if he didn't think it was "the" way to go. Ok - I buy that. Afterall, we think Dr. A is swell and he has wonderful success rates. No need to be convinced on that one - it's one of the main reasons we chose him. Ok, so after being assured our protocol is custom and carefully selected, my husband mentions that we were just surprised to see it on our calendar and that we happen to have been gifted Follistim. Now... give me a little "eeeeerrrrr" breaks sound effect and spin your little car around into a 360. "Oh, you have Follistim. Well if you have Follistim, then we'll use that for sure."
Wait just a sec. A minute ago Bravelle was "the" stim for us that had been specifically selected from a host of drugs. We both say to her in unison, "If Bravelle is what Dr. Ahlering things will be best for us, then we, by all means, want to use that instead. Even if it means having to buy different drugs. We're ok with that." To which she assures us it's no problem to substitute an equal amount of Follistim for the units of Bravelle we were supposed to be on. Again, I ask - what is the main difference between Follistim and Bravelle (half of me wished I'd brought our book with us, but I can only imagine how that would have come off), to which she replied something like "they're the exact same thing". I really wasn't up for arguing and I was putting my trust in the fact that she does this nearly every day. So, we continue on.

Back at work that afternoon, I decided to do one last inquiry on the matter and low and behold, it is what I suspected. While Follistim and Gonal F are the same thing (FSH only), Bravelle is FSH + 2% LH. With my body's natural sensitivity to LH, my instant reaction is to think that an FSH only stim would be the way to go for me. Additional research also seems to support this. However, even so, I want to keep an open mind. Afterall, I DO trust my doctor. He really does seem to put his all into each and every cycle. Knowing we're all human, I don't expect my coordinator to remember every little fact there is surrounding IVF. So even that I'm willing to keep an open mind about. I do think, though, that the doctor should always give the final OK, even in situations where it seems safe to switch something up.

In an effort to stay on the same page with our coordinator, I sent her an e-mail asking that we better understand the "whys" behind the protocol that was selected for us. I also brought up our concern about having too much LH given my circumstance. In the end, we are really just seeking peace of mind. To know that we're going into this cycle with a game plan that feels, within our depths, like "the" protocol is sooo extremely important.

Our doctor's been on vacation this past week, so we hope to hear back sometime this week about what lies ahead for our stim. In the meantime, we start Lurpon next Wednesday!

From a high level, here's what our IVF protcol looks like, currently:

• Continue BCP. When I come to the sugar pills, I'll skip those and start a new pack.
• On 7/15, begin daily prescription prenatal vitamin, Dexamethasone in the AM (a low dose steroid that enhances the implantation process by positively impacting the immune receptivity of the embryo; I was told this can cause insomnia. Let's hope not... I think I'll be needing all the sleep I can get during this time) and start the first of our daily Lupron injections in the AM (Lupron is designed to suppress the pituitary which produces your body's own key hormones - FSH & LH).
• I should get a period around 7/22-7/24.
• 7/23 I go in for a baseline ultrasound to check out my ovary
• Still on Lupron, on 7/28 I'll add in my injectable stim of FSH in the PM- actual stim type still TBD. Hmm... TBD? Yep. I'll expand on this in a sec.
• Still on Lupron and stim, on 7/31 add in a 3rd injection of LH (Menopur).
• Skip a day of Menopur and on 8/2 add in another dose of Menopur (LH).
• On 8/3, I'll go in for an US and E2 check. This is, what they consider to be CD9 and it marks the last day for Lupron. It's also the last of the true concrete part of this calendar.
  

I will scan my updated calendar, once we here back regarding our stim. It really is crazy to see it all mapped out in one solitary calendar.

As for what's not on the calendar yet... the rest is still very much up in the air. Generally speaking, the first week in August I will likely be in my RE's office for a daily ultrasound and perhaps blood work. Our coordinator thinks that I'll respond nicely to the stims (I guess since I'm PCO?) and that I'll probably do the HCG trigger shot during the mid morning on 8/5, which would put my retrieval sometime Friday. The trigger time and retrieval procedure will be precisely timed and I might not have too much advance notice as to when we'll trigger. If, I do in fact, have that sort of timing on retrieval, and they get a good number of eggs and then embryos to fertilize, she is guessing I'd do a 5 day transfer of two embbies on Wed 8/12. Even still, all of the stuff just mentioned is a total guess at this point.

Ah, the suspense! And we're not even in the thick of things yet.

The What & How: Recapping our IVF Calendar Review

The first big step into the land of IVF - the Calendar Review. Yes, I believe this must make it even more official, than the last official thing I posted. :-) Even though the full payment hasn't been made, or we haven't started pumping the heavy meds into my system, this is the foundation for the weeks to come.

We were the first appointment of the day. I should stop here to make a mental note that even though we left the house at 7:45 for our 8:45 appt, we arrive unnervingly early - 8:15 to be exact. Full steam ahead we walked through the doors and were soon greeted by our coordinator, Peggy. After greeting us with a smile, she asked if we wanted any coffee (umm... no thanks, we're trying to get pregnant :D) and showed us to an empty office. Things were a bit disheveled there that day; they recently experienced a water leak on the 3rd floor of the building they occupy, so lots of men were scattered about putting new drywall in and getting the place back in order. We didn't mind, though she apologized repeatedly. Later she was sure to mention that none of the fancy equipment was harmed (whew!)

Going over the "playbook"
Once in the room, Peggy started by breaking down "the playbook", otherwise known as our IVF calendar. This thing comes complete with a rainbow of what to inject, when and how much, all squeezed tightly into a month's time frame - and this doesn't even cover the entire process. Apparently, we'll receive additional, super critical information during the first and second weeks in August via phone and e-mail. Lord help us if there is a power outage or major disaster. I'll be pumped full of meds with no one to release my precious eggs to.

That aside, the first set of instructions seems pretty straightforward. Peggy took the "you might not know much about IVF" approach (which I fully appreciated) and took the time to explain every step in great detail. It was nice to have us all on the same page going into each phase of the cycle. Along the way, I stopped to ask if they would allow us to replace the intramuscular injection of Progesterone in Oil (PIO) for vaginal suppositories. While the latter doesn't sound fun, it has to be better than super deep shots in the butt, right? No, they don't like to do that. If come two weeks after a BFP, they are just too much to handle, we can consider switching it up then, but the first approach will be to stick it out and take one for the team. At the end of the day, if that truely is what's best, then I suppose I'm up for it. Luckily those don't start until the day of the transfer and they are every three days only (+ suppositories), so it could be worse. She did mention the trick of using ice to numb if we needed to. I even asked about the numbing cream. She said that yes, we could use it.

At this point, she must have detected a little "internet forum" speak or something, because it was then that she gave me a small lecture on how it has been their experience that most patients only seem to get stressed out by them. In some ways, I needed to hear it, I really did. She had the unique ability to be "mother-like", when my Mom wasn't able to be present. The other part of me wanted to let her know that I really only make a practice of going to SIRM's forum or keeping my nose in good, reputable books like the one written by Dr. Sher, but I just couldn't get the words out in time. We were onto the next line of business. Which was...

Learning how to self/spouse-inject
This part made my stomach turn just a wee bit. As Peggy rightly pointed out most of these particular type of needles are made for those who don't work in the medical field. They are super thin and not very long; basically the same type that are used for insulin shots. At least that's the speech I was given... I think I bought it! :P I'm sure that after the first one or two, it won't be too big of a deal, but it's getting over that hump that's the hard part. We were able to use a test dummy - a wonderful invention of fake flesh on a portable pod that I could hold up to my stomach and pinch the "fat" of, similar to what we'll do for the real injections. I went first, pretending to look like a natural. She called Jay the "back-up". Right. How about he'll be the go-to guy on this one - at least at first. I'm not sure how I'll feel about shoving that thing into my body willingly. We both had a good laugh because when he did it, his needle almost stabbed my thumb that was holding up the dummy. She was like "you might want to stand to the side when you actually do it, and hold it a bit closer." When she told him to hold it like he was holding a dart, I think he thought that meant to "throw it" like he was throwing a dart too. Yeah, not so much. This, folks, should be quite interesting!

Ending our injectable conversations, she mentioned which ones will come pre-primed and which ones we'll have to mix and prime on our own. I just hope we don't get confused and inject the wrong dosage. Let's not think about that for now... The only other injection she didn't go over much was the PIO shot. She said they'll show us how to do an intramuscular (IM) when I have my first one on transfer day there in the office.

Things you never think you'd decide
After all the talk, it was time for some paperwork. Of course you can't do something this major without having to sign your life away. Some of the questions we were totally prepared for... How many eggs do you want to have fertilized. All. What do you want to do with any excess embryos. Freeze. What we didn't expect was - What do you want us to do with those extra embryos in the event both parties dies. Ok, so even though it was creepy, the answer was obvious. We'd want to do an anonymous donation. The one that was super weird was, what do you want to do if just one of you dies. That was so uncomfortable to think about. Peggy said that she has had to walk out of the room before because couples have started arguing back and forth trying to come to a resolution. Luckily we were able to talk it out and decide that really in any event like that that we'd want the other to have the power to decide to keep or to donate anonymously. I mean it makes sense that they would ask these questions, but talk about super creep factor. That is the farthest thing from your mind when you're at this point and it, for a split second, it was sorta like a little dark cloud surrounded by a sea of wonderful possibles. Blah. Out with the bad vibes, in with the good. Out with the bad, in with the good.

Touring babyland
After finishing awkward paperwork, we had the opportunity to take a little tour of the clinic. With it being a slow, out-of-the-ordinary Friday, we had a fun surprise of being able to meet the soon-to-be "man of the hour". No, sorry sweetie, I don't mean you. I mean one of the embryologists. He probably thought I was one odd duck when I said "thanks for everything in advance" or something Corny like that. Hey, he's talented and this was, quite possibly, our one chance to suck up. You would have done it too :-P AND, what's even cooler, is that we were able to peek our heads in the embryology lab. I'm not sure if he was referring to just himself or the lab too, but he said he'd been on the Discovery channel twice. Pretty high-tech stuff!

What I loved about the clinic is that it doesn't feel very "hospitally" at all. Warm, soothing colors on the wall. The space, overall, wasn't very big, which made it feel more approachable. The procedure room where they'll do the retrieval and transfer was right next to the lab and they have this little window they slide the important stuff through when it's go-time! The recovery areas were small, but seemed to contain all of the important stuff. Bed for relaxing, guest chair and a small TV for taking your mind off everything.

Everyone has a role
Our coordinator was really good about explaining what she does in all of this. She specifically said "Don't worry. That's what I'm here for. I'll do the worrying for you." Anytime I have a question or concern I am to call her directly during business hours, or the exchange line during after hours. She assured me someone will be there to answer any question. Then, when it comes time for retrieval, she'll be present in the room assisting Dr. Ahlering in immediately labeling the egg filled pipettes to the lab where they will inspect and count each egg that is retrieved. I believe she said that before we leave we should know about how many were retrieved and later that day she will call us to give us a fertilization report. Then, that next week will be filled with getting updates from her on how they are progressing -which ones make it through ICSI and mature into little embryos. For a 3-5 days we'll watch their progress to see which ones divide and continue to blossom, ideally hoping for 8-10 celled embryos by day 5 for a two blastocyst transfer. She's thinking we'll stim quickly and be ready for retrieval on Friday 8/7 and things we will make it to a day 5 transfer, which would put that on 8/11. Each of these we won't really know until the day or morning of. Those first two weeks will be filled with so, so much. I'm glad to know Peggy will be there every step of the way.

My OhMyGoshThisCouldREALLYHappenMoment
Oh, and how could I forget to mention. The "moment" I had while we went through our calendar. Following all of the meds, all of the procedures, there will be the wait. At this point in the conversation, Peggy started using words like "when we find out you are pregnant," I started to loose it. I don't generally allow my brain to get too far down that path. It just isn't safe. It was all too much when she started saying around the time when we'll be able to hear a heart beat(s) and find out if there is more than one sac - more than one baby!! At this point, I was looking around like a scared puppy dog for a box of Kleenex. Peggy could see it in my eyes and felt really bad that there wasn't anything to be found in the office we had borrowed (hers was being worked on). Moments like that are few and far between, but it was crazy to think that in less than two months from now we would not only find out if we were pregnant, but how many we were having. Totally crazy. I am so ready for this!!!!!!!!!!!!! Bring on the shots!

Ok, so on and on I've went and I've not gotten into the protocol or dates one bit. I'm going to pause and go get some sleep, but I'll be sure to write soon, complete with a pic of our very bright and color laden calendar. The first time I saw one of these I did second take. Lots of instructions, lots of meds and the biggest concern that came out of our appt. More of the really important stuff to come - promise!

Wake up and smell the coffee... Decaf, please ;)

Today began by checking my blogroll to catch up on what everyone had been up to the past couple days. AF just arrived for my friend Fran and she outlined what was ahead of her over these next few weeks for her IVF protocol. Fran and I will practically be cycle buddies (though she's a week or so ahead of me), which is neat. (By the way, Fran: I tried commenting to your latest post, but had no luck... the darn comment button just doesn't appear to be functioning. Anyway, just wanted to say "Hooray for starting!")

After reading her post, my progression of thoughts went like this:
Fran knows what's ahead of her, which is awesome!
I wish I knew.
... I know.
I'll see what Dr. Google has to say.
Then, with limited knowledge of what type of protocol I'll be on,
I type: "how does a typical lupron ivf cycle work?"
To which I stumble on a site and find this:
Gulp. If this DOES represent what my protocol will look like, then I'm starting even SOONER than I thought with injectables (Lupron could begin around July 2nd!!). The only thing I've been told so far about my protocol was what Dr. Ahering said in our last appointment with him back mid April. He said at first glance he imagines he'll put me on a "classic" Lupron protocol, or L3C (as it's referred to at SIRM). What you see above is considered a "classic" Lupron protocol, according to that particular clinic; I would assume my clinic's would be nearly identical.

Without confirmation from my clinic, here is what COULD lie ahead for me. These conclusions are based on the above chart/clinc info noted below and a sample calendar from another clinic. My thoughts are in blue.

1. Menstruation starts. (Should be around June 16 for me.) Baseline labs such as FSH can be drawn on day 3. (Around June 18 for me?)
   
2. Birth control pill (Begins on CD 3?) is used to suppress the pituitary and to resolve any residual ovarian cyst from previous cycles. The pill also allows flexibility in IVF scheduling. Women who start menses at different times can have their cycles synchronized by the pill in order to start IVF treatment as a group.
3. Lupron, an injectable medication, is started near the end of the pill cycle to further suppress the pituitary. (This could be around July 2 for me!?) The pill is eventually discontinued while Lupron is continued into the next phase to maintain pituitary suppression. Ovarian stimulation is initiated once there is sufficient suppression of the pituitary, as evident by a low estradiol level and quiet ovaries on the sonogram. (Based on this sample calendar, from yet another clinic, it sounds like I might just continue Lupron up until the time everyone else starts their stims, so July 15... I guess there's no harm in "over" suppressing my ovary, especially since I have PCOS?)
   
4. Ovarian stimulation is initiated once there is sufficient suppression of the pituitary, as evident by a low estradiol level and quiet ovaries on the sonogram. The injectable medications used to stimulate the ovaries (Bravelle, Follistim, Gonal-f, Repronex - I believe I'll be doing Follistim or Gonal-f) are actually LH and FSH, the same hormones normally produced by the pituitary. Close monitoring of the ovaries with blood works and sonograms is essential during this period to ensure optimal egg development and avoid complications.
5. Human Chorionic Gonadotropin (HCG) injection is given when the follicles reach mature sizes. HCG induces the eggs to undergo the final maturation. It also causes the eggs to be detached from the wall of the follicles to facilitate their removal.
6. Egg retrieval is performed about 36 hours after the HCG injection. The procedure takes 20 minutes and is conducted under IV anesthesia. A long needle is introduced into the pelvic space through the vagina under ultrasound guidance. After their aspiration, the eggs are inseminated or injected with the sperm in the same day. (ER for my cycle will be on or around August 3.)
   
7. Embryo culture typically takes 5 days after the day of retrieval, the same duration an embryo takes to travel from the tube into the uterus under natural condition.
8. Embryo transfer usually takes place on the fifth day of culture (otherwise known as the blastocyst stage). Two best blastocysts are transferred into the uterus using a soft catheter. The procedure is similar to an IUI and requires no anesthesia. The remaining embryos, if there are any, can be frozen for future use.
9. Endometrial support with progesterone and estrogen supplements is important to prepare the uterine lining for implantation. Progesterone is started on the day after the retrieval. Progesterone transforms the endometrium into a rich environment to prepare for embryo implantation. Progesterone is usually administered in oil (PIO) form by deep muscular injection into the buttocks. (Our patients use progesterone vaginally instead of by injections. Our decision to use vaginal progesterone is based on numerous scientific researches that showed the superiority of the vaginal route over the intramuscular or oral route in endometrial maturation. I think my clinic normally recommends PIO, but I'm going to ask about suppositories or Endometrin inserts instead.) (Estrogen is added back to maintain hormonal balance within the endometrium. The estrogen level usually drops after egg retrieval since many estrogen producing cells are also removed along with the eggs. Estrogen can be used as a patch or as tablets. (I don't know if my clinic gives Estrogen supplements like this.)
10. Pregnancy test can be performed 12 days after embryo transfer (Not sure if this is the typical number of days my clinic likes to test on). Once the test is positive, progesterone and estrogen are continued until the 11th week. A vaginal sonogram is performed at the 7th week to confirm the pregnancy.

In short, that's a lot of "what if's," but it definitely tells me that I need to get thoughts in order and begin to ask questions to my clinic. I am a prefer-to-know type of girl so I know I'll feel better once everything is confirmed. I also want to find out what supplements/vitamins we can be taking in order to help my husband's sperm and my egg quality, due to PCOS. Need to start that regime ASAP I'd imagine. Lots to do and learn!

Also, it's time to cut out caffeine and alcohol. Not that I was ever a big consumer of either, but I ought to eliminate this just to be safe. This weekend was full of enjoying a little of both. My mom came over on Friday to visit (we had a wonderful time!) and we bought some Teavana tea - very expensive, but it was so unique it will be a nice little treat from time to time. I bring it up for those who are undergoing, or about to undergo IF treatments. Their Tarocco Ruby Orange Herbal Tea/Apple Lemon Pomegranate Rooibos Tea combo is completely caffeine-free and is absolutely AMAZING! It tastes exactly like super yummy fruit juice and is fairly thick, for an iced tea. If you're looking for something different and IF friendly, I'd highly recommend it.

All in all, it was a great weekend. Lots of time spent with family and friends, which I always love. I even got to celebrate our upcoming IVF with my husband on Saturday and then with my good friends Sunday. What more could you ask for!! Going into a new week, please pray that we get good news back about our loan situation. This is the last big nail biter in terms of something that would be able to hold us up from starting. We applied last week and should know early this week if we'll be able to get the financing we need to pay for our upcoming cycle. We've gotten ourselves excited enough already that it would definitely be tough to let go of our hope now.

You see... there's this list and WE'RE on it!

My heart was racing. Palms sweaty. Me, my phone and a small notebook stepped away from my desk this afternoon and snuck off to an empty suite where I would make "the" phone call. The call that makes it officially, official.

When the time came, I was happy and fully prepared to relay my CC # to my clinic; today was "down payment day." Refundable if something happens and we need to back out; otherwise it will be applied to the lump sum. Even that I've learned to accept. By now I've come to the realization that no company health insurance will be there for us in our time of need. It's up to us to turn over hard earned cash accumulated over the last year and will be up to us to pay off the remainder owed during the next several months. It's worth it because THIS - August IVF at SIRM St. Louis - is OUR chance. Our long awaited shot at having OUR baby. I was pumped and ready!

What I was not prepared for was what came next.
I was told final payment would be due July 8. I doubted that in and of itself will be a problem, but it did make me curious. The clinic cycle calendar I was given in early January of this year said final payment would be due July 22 - approximately one week prior to starting meds. My next natural thought was... so, is the August cycle date still August 17th (like my previous post stated)?

To which she said "No. No it's not. The new, correct date is now August 3rd." However, even that date isn't when I'll start meds. That date is for the actual retrieval.

Come again. Retrieval on August 3? Yep. "And you'll start meds around July 15th." :-|

Basically what you're telling me is the entire August IVF process is ONE MONTH SOONER than I'd originally expected?! It was then that my blood pressure sky rocketed, a wave of heat came over me and then cold sweats. THIS IS IT! It's really happening! And SOON!

To celebrate I first did what must have looked like the stupidest happy dance ever (good thing I was in a room by myself :P) and then I told a few close friends and relatives. I don't think the high left me for several hours. I'm not sure I've ever felt this type of combined excited and totally scared in my life!!


That's all fine and great, but what's next?
I was told to call Mary on Day 1 of my next cycle. Since I'm a very irregular cycler, I asked what if I didn't start my cycle by a certain date and she said I should e-mail her to find out what to do in that situation. So, that e-mail will go out tonight.

On a related note, Dr. Ahlering just so happened to e-mail me yesterday to see if everything had been addressed properly during our last meeting, which I think means he had an old e-mail of mine in his inbox and noticed he hadn't seen me come up on any of the recent IVF cycles. I'm just glad he saw my name and thought of our situation, especially for being as busy as he is. I did let him know I will be coming his way soon! I feel so fortunate to be able to cycle under his care!

For tonight, I will rest better knowing that somewhere there is a list with OUR name on it, and that list is titled "August IVF". For the time being, that alone makes me beyond happy.

We're a go! Doing IVF with SIRM in August!

It's official, though I'm not sure if it's quite set in yet! Our appointment with Dr. Ahlering on Monday went well, as I anticipated, but I don't believe we learned all that much new. Prior to our appt, I made a list of questions that were slightly different than what I posted previously. I find that when I make the list it is a chance for me to run down the conversation in my head, with the goal that I don't forget any major points. By the time we actually get to the appt, I pretty much have the list memorized, but it's nice to have in front of me so that I don't get caught up in the conversation and leave something out. As you'll see, I do need to learn how to set-up my questions better so that, hopefully, they are answered a bit more on target... oh well, there will be plenty more appts for me to try this out on, I'm sure. :-P

Our final list of questions were:

1) What is positive that we have going for us, and what will be our challenges?
As I look back on how this question was answered, I don't think we had a definite clear answer on this from the doctor. Not because he was trying not to answer it. I should have framed my conversation better. After I asked the question, he was like "well that depends..." and then I backed up and stated IVF and he took time to elaborate on how he thought that really was the best approach for us, given our IF issues, and from a monetary standpoint and controlling multiples standpoint. When it comes right down to it though, I do feel fairly confident that I know what we're up against. My husband's issues can be "fixed" via HRSS (high-res sperm selection) ICSI. My issues will be a matter of getting a good number of eggs from the one ovary and then getting them to fertilize into embryos, all the while trying to avoid OHSS. Right now, age is on our side and the fact that my one ovary has so many follicles is a good thing. We won't really know how I'll respond to stims until we try it.

2) Are there any other tests we can do to gauge how I'll respond to meds, besides my FSH (5.5), Estradiol (55) and antral follicle count (15+), which are all within good, normal ranges.
When I framed this question I, again, was wayyy too wordy. I tend to do this sometimes when I get nervous. As a result, it's too much for the other person to remember and they end up not answering everything in the manner I'd hoped. So, scratch that question. From what I'm finding online, there isn't really a way to tell this, other then the above things already mentioned. I think they just begin a protocol that they feel will best address your issues and then adjust throughout the cycle and, if no BFP, further adjust in the next cycle. Not the best scenario possible, but it is what it is. If anyone is reading this and knows of any additional things they can test for, please comment and let me know!

3) Regarding the issue of hydrosalpinx tubes, is the FUS (fluid ultrasound) enough to rule this out, or should we do an HSG? If we ended up needing to do a laparoscopy, would that only cause more pelvic scarring, thus risking further damaging my ovary?
Ok, so this is the point in the appt that I must have woke up (about time, don't ya think!). I remember this answer quite clearly and even took notes on it. He basically confirmed that, yes, he doesn't feel we should be worried about a hydrosalpinx, because our FUS didn't show signs of an enlarged tube. He said that, yes, we could do a laparoscopy and that he would for sure if he thought there was a real cause for concern, but as of now we'd be don't it just because and since I have had a previous abdominal incision (a long vertical one), it makes it more challenging to do a laparoscopy and increases the risk for bowel injury. He said that at this time, it's not a risk that would be worth taking.

4) What about our personal infertility issues lead you to believe we should only purchase a 2-cycle package?
Honestly, he didn't form an answer that was extremely directed to our situation. Rather, he focused on their success rates and the fact that a majority of their BFP cycles happen within the first or second transfer. Based on that, he said he believes that would then be the most cost-effective path for us would be the 2-cycle. We did want a more direct answer, however, we're realistic and know it would be difficult to give a highly pinpointed answer (I don't believe they ever truely know how a cycle will turn out).

5) Should we consider CGH, given that PCOS are high responders and tend to have a disproportionate percentage of eggs which are chromosomally abnormal (or aneuploid)?
He said he doesn't recommend this for us at this point in time. The PCOS isn't cause enough to do CGH as a first line approach. He said he would do it if we asked for it, but he doesn't think it's the best way to spend our money right now. That it wouldn't tell us all that much more, other than the exact one we should put in, vs. transferring 2 embryos. He did say though that in rare cases were tons of eggs fertilize, it can be challenging to determine which 2 of the bunch to put back in. Typically, there may only be one or two babies in the entire group, so it's difficult and often becomes a trial of elimination. CGH, in that situation, would be helpful. I'm guessing we would cross that path if that ended up applying to us.

6) IVF Protocol - What is the likely path for my circumstances?
Dr. Ahlering said that he would most likely start me out on the the "classic" Lupron protocol, or L3C Protocol, as they refer to it as SIRM. More to come on that. I don't know specifics from SIRM yet, but you better believe I've been googling my heart out :-)

So... good news!! August will be here before we know it I'm sure!

Diagnostic test follow-up appt made!

This is a long time coming. Having had our tests done all the way back in late December, I just finished marking our calendar for Monday, April 13 as the day. Boy does it feel good to be moving forward. We both agreed we would prefer to have a face-to-face with Dr. Ahlering to go over our collective tests that were run. Yes, I already did this once, but hubby was unable to attend, and truthfully it was a phone follow-up so I didn't feel like everyone was entirely focused. Now that we have a lot of the other things nailed down, we're ready to get down to business!

At our appointment, we hope to have the following answered...

1) Specifically what about our personal infertility issues lead him to believe we should only purchase the two-cycle package?

2) Are any other tests or things they can do to gauge how I'll respond to meds, besides antral follicle count?

For example, what about the Clomid Challenge Test? We want to know this because if there ARE other test we can do BEFORE making a decision on how many IVF cycles to purchase, we should do pursue them. I wonder though, if a test came back as questionable, would they still allow us to buy the 3-cycle Refund Package? I would assume not, if it goes against what is in the agreement you sign when you purchase that package. So, given that, is there any point to doing the tests? Wait, did I just answer my own question? :) Better ask the professionals at least!

3) What unique approaches will he recommend for our IVF protocol, taking into consideration PCOS, one ovary and sperm quantity and abnormality issues?

More about the Clomid Challenge Test
I just ran across a write up on IVF1 Infertility Clinics's website and wonder if I might be a good candidate for this as a pre-IVF test, given that I've had an ovary removed and therefore may have egg count issues. The article does say that "There is one concept that must be stressed above all else. A normal clomid challenge test tells you nothing. It does NOT prove that your ovaries are working well. It simply fails to prove otherwise. The clomid challenge test is not a sensitive enough test to identify every woman with decreased ovarian reserve. Some women with very poor egg quality (this may apply to me because I have PCOS) are going to be missed."

However, according to their website, "an abnormal clomid challenge test has specific predictive value. These predictions are very accurate and have been confirmed by a number of different studies from a large number of investigators. It is well documented that women with an abnormal clomid challenge test: *Respond poorly to injectable fertility drugs (gonadotropins), *Have higher cancellation rates in IVF, *Have fewer eggs retrieved in IVF, *Have much lower pregnancy rates in IVF and IUI, *Have higher miscarriage rates and *Increased risk for chromosomally abnormal embryos."

If we did this test (which would be fairly inexpensive to do) and found out that it was abnormal, while we may still have to buy a 2 cycle simply because we may then be disqualified from buying the 3-cycle Refund Package, it might tell us if we need to pursue other things like CGH testing on our embryos. I also wonder if it will help inform my RE as to how he should structure my injectable protocol.

In the end, maybe Dr. Ahlering won't tell us anything that we haven't already discussed, but either way, it will be nice to get his undivided attention and hear everything coming directly from him. Following our appointment, our plan is to be equip enough to make a final decision on how many cycles we'll buy at once and exactly when we'll start!

More from our RE regarding IVF

Following up to my two most recent blog posts, I wrote Dr. Ahlering on Saturday with three questions (yes, he does answer his own e-mails... not always as thorough as I'd like to receive, but they are coming from him, so I'll take what I can get for now).

My questions were:

1) Knowing that we had testing done in Dec '08, do you feel it would be detrimental to our IVF success for us to wait until next January to begin IVF?

This was left unanswered. My feeling is that, no it probably wouldn't impact us that much, given our ages and health issues. However, there is always the small *chance* that something could happen to my only ovary. This past week I have been having soreness near where my ovary is located (like soreness when I push on my stomach from the outside). Who knows what is going on... maybe I'm actually going to ovulate on this 90 day (and counting) cycle I've been on since the beginning of January. Anyway, taht type of thing always gets my nerves jumping thinking "what if" some gianormus cyst is forming on my ovary and will forever kill my only chances at conceiving. I try to block this out of my mind and pray for the best.

2) Without us knowing how my one ovary will respond to fertility drugs, what is your professional opinion as to if should purchase the 2 cycle or 3 cycle package?

To which he answered "I think the 2 cycle plan is best for your situations."

3) I also asked him about the CGH plan I mentioned in my last blog post. My question, specifically, was: Can you tell me, would this be something you would think our situation (one ovary, PCOS and male factor) could greatly benefit from?

His answer: "CGH is something to consider for anyone that has RPL (Recurrent Pregnancy Loss), or IVF failures and decent ovarian response. Or, if someone is looking at fertility preservation/egg freezing. The thing that people do not like sometimes is that one has to freeze the embryos for later transfer."

It's worth mentioning that RPL or IVF failures doesn't apply to us (not at this time, and hopefully never) and we don't yet know how my ovaries will respond, since I've never undergone a cycle with injectables. I'm not sure how the mandatory freezing of embryos would affect our situation. I know they have improved the freezing/thawing techniques so that fewer are lost in process, but if we don't respond very well and get a lot of embryos, it may hurt if we loose even one. I suppose something to think about is that they stated if you don't produce at least 5 ovarian follicles, you could opt out of the CGH plan and covert your cycle to a fee-for-fee service, which is basically like going with one of the plans we'd already been considering. I'm assuming that if you had to convert, you would be converting at the single cycle cost (not the "buy in bulk costs" of the 2 or 3 cycle plan), which would mean it would cost more if you had to do another fresh IVF cycle.

I'm still digesting all of this. I can't help but rethink things a little, knowing Dr. Ahlering is thinking about our health situations and recommending the 2 cycle to us, vs. the 3. I would think that he feels pretty positively about us getting pregnant in 2 cycles or less, otherwise he wouldn't have said it.

Not wanting to be pushy, I brought it up again with my husband via IM today at work. As you can imagine, IM isn't the best way to talk about these things, but sometimes it just has to be that way. Our conversation starts by him commenting on something else entirely, that happened to mention us in relation to IVF... (sorry sweetie, but I'm putting our convo in my blog!)

[14:25] cathy@thinktpi.com: "as we prepare to start IVF in January"
[14:25] cathy@thinktpi.com: that means that Dr. Ahlering's comment from yesterday didn't change anything, did it?
[14:26] Jay: I thought we were waiting on pricing information
[14:26] Jay: I'm all for starting sooner if it's cheaper for the risk
[14:27] cathy@thinktpi.com: well, yeah, i mean there were two things. 1) this whole CGH thing... we are waiting on pricing for that package 2) but then there's the thing where he said "with your situations, i would recommend the 2 cycle", which is seperate from the CGH.
[14:28] cathy@thinktpi.com: i mean that's his opinion and we just have to consider how much we want to factor it into how we feel
[14:28] Jay: sure, but we'd already gone over how two cycles this year leaves us in a bad spot financially if we do somehow end up with multiples.
[14:29] Jay: we can do a two-fer in january to save even more money, but that's about all that his comment really changed.
[14:31] cathy@thinktpi.com: oh... see it thought it may have changed the timing. especially if he's recommending 2, and that, or less than that really does work. (which i would assume he's betting it would, otherwise he wouldn't recommend it, but who knows). anyways, i just wanted to see how you felt about it. i still feel that if we did 2 this year, we'd have to agree to wait until some time next year to do another 2... and we haven't really even played out that scenerio financially, so who knows. i just wanted to make sure we thought about it enough, since he did give us his opinion, that's all.
[14:32] Jay: His comment basically makes me feel good that, were we to do it this year, we'd probably be successful.
[14:32] Jay: The other stuff I mentioned is really unchanged by his comment.
[14:38] cathy@thinktpi.com: i just hope you can see where i'm coming from... the idea that he believes we could be successful with less tries, just makes me wish all the more that it was happening sooner than later. i just wonder what it would look like if we got pg on the first cycle and had twins... i mean, less money towards IVF, so more money left over if i had to go on bedrest... i suppose it seems that it could even out somewhat, but i don't think we've done the numbers for that. sorry to open the can again... just want to really make sure we've thought this through.
[14:39] Jay: Doing a two-fer this year becomes viable if... a) The cost goes down substantially, b) the probability of multiples drops substantially, c) we find a way to make substantially more money.
[14:40] Jay: If CGH comes back as a reasonable option, I can see us strongly considering this year since we'd have a dramatically lower chance of multiples.
[14:41] cathy@thinktpi.com: k
[14:41] Jay: *kisses*
[14:41] cathy@thinktpi.com: :(
[14:41] Jay: Kisses are good things...
[14:56] cathy@thinktpi.com: fwiw, CGH doesn't really have an impact on multiples for us, since the most we'd ever put in are 2 (at least right now anyway, because of my age and no failed IVF history). Where it cuts down on multiples is when women have a hard time getting pg so their Dr puts in a handful, just hoping one takes. the only way it could impact us is if we did CGH and had one embryo that was "perfect" so we only decided to transfer that one. doing so, though, in and of itself lowers our chances because you're lowering the odds, so to speak.
[14:56] cathy@thinktpi.com: so yeah, i think i just shot myself in the foot
[14:56] cathy@thinktpi.com: whatever

Based on that, unless I sit down and run the numbers again and want to rehash this all, it's probably still that we're waiting until January, because we know the cost for IVF most likely won't go down and there really isn't a way for us to make more money, given our economy right now. Unless of course I win the lottery! (that I don't play, but hey, you never know!) And I don't see how this CGH thing will be cheaper, but we'll see. I'm still waiting on financial numbers for CGH cost from SHER.

Sorry for the long winded post, only to find out we're back at square one, but it helps me to write it all down, for sanity sake.