Thalia's fertility journey: hopefully more comedy than tragedy

The big guns

The appointment with Dr Candour was good. Not good as in: I had a good time, we laughed, we shared a glass of wine; but good as in he listened, he said sorry, he gave us honest opinions. He wants to share the letter I wrote describing our experiences this cycle - good and bad - with his staff. He told us he thought they had lost our trust, and that if we wanted to go elsewhere he'd understand. I immediately decided that he was trying to fire us as patients. He insisted he wasn't, just trying to give us an out if we wanted one. Cynical bitch that I am - H. saw no such subtext!

Eventually I decided to believe him. He told me that if at any point in the next cycle I have questions that his staff aren't answering, I should just call his assistant. If he is around, he will take the call. If he is not, he will call me back that evening. He had even found me some additional research papers to look at to complement what I'd read. It's the paper that justifies their clinical practice, I'll post the title some other time.

We came out with a game plan, which is to do IVF. He didn't recommend it, but when I asked about it, he eventually, after much prodding, agreed it was probably the right choice at this point. Since IUI, as he put it, "will not be straightforward for you," I don't see any point in messing around with it any more. At 38.75 I don't feel like waiting around, particularly since they will not do IUI two cycles in a row. That he was most definite about - he insisted that after producing four follicles my left ovary would be twice as large as it should be and it needed time to recover. Of course they could do an IUI with no drugs, but I think he thinks that is quite pointless. I'll ask him. Not because it will change our course now, but because I'd like to know.

So we're booked in for the set-up appointment on 7 September where we get to answer all sorts of questions about our preferences for our embryos, and presumably learn even more about injections, get our prescriptions sorted out. My clinic doesn't do the sniffy Synarel, so it's injections for me from the get go. But no progesterone injections - they use progesterone pessaries. Rectal pessaries. Anyone else do those? Oh, and hand over £1,900. How silly of me to forget that.

I should start a new cycle about 2 weeks after that. Suppression starts on day 21 of that cycle, all things being well and me not being cystic or high FSH, yada yada yada. So we'll be doing retrieval some time in the last week of October. Assuming we don't get cancelled. Fuck. The last week of October. Until I just sat and calculated it I had no idea how far away that was. That's a really really long way away. Damn my clinic and their concern for my health. Why can't we get started now????

I have another post brewing about how I feel about the decision to go for IVF, but it's a post on its own, so I'll work on it tomorrow and post it separately.

Thanks again to you all for your comments on the last post. If I wasn't so fat I'd be baking this weekend and at least able to post pictures of the cookies you requested a few weeks ago. But I gained three pounds in the last month, and am now 10 pounds heavier than this time last year. Enough is enough. I'm not going to kill myself, but I am going to get back into proper, minimum three times a week exercise and eating a lot less crap. I know I feel better when my clothes fit. I know I do.

One batch of brownies wouldn't hurt, though, would it?

What ever made you think there might be even a slim chance of this being in the bag?

I'm bleeding. Yes, it's the 10 day luteal phase again. Almost precisely as it's currently 30 minutes past midnight in the UK. That's the second time my period has destroyed all hope on the stroke of midnight. Considerate, don't you think?

My temperature crashed this morning, our last morning on holiday, so I did know this was coming. Kind of put a damper on our last day of the holiday. But you know how you persuade yourself that of course your temperature could climb 0.6 degrees centigrade in one day? Yeah, I did that a bit today. I didn't really convince myself but I did do it. Because it's never over til it's over, even when you know it's over, right? I'm a moody cow at the best of times, this really really doesn't help. But now, with this blood, I have no choice but to believe that it's really really over.

We have an appointment with Dr Candour tomorrow, now this, morning. I'm going to ask why he's so convinced I don't need progresterone support given this crappy luteal phase I have, as well as going over everything that happened this cycle. Then we need to decide on a game plan. I'm unconvinced that it's worth trying IUI again. We might as well pull out the big guns. I'm also fairly sure that we won't be able to do IVF this cycle as I don't have the drugs ready to go and I'm sure we'll have to have another one of those bloody stupid induction appointments at the clinic before we can even get a prescription.

I'm so very very angry that they didn't do the insemination that it's hard for me to stop being angry long enough to type this. We had FIVE follicles! FIVE! And three days worth of do-it-yourself sperm deposits outside my cervix didn't do any good. So, either my eggs are crap, or there's a problem with my cervix, or the endometriosis has come back faster than expected, or there's a problem with implantation. That's four reasons why it might not have worked, but there were FIVE follicles! Couldn't we have had just one? Five months worth of trying in one go, and it didn't work. What hope do we have of this ever working?

I know you're all going to tell me that there's much more that we can do, not to give up hope etc. And I know that others have gone through so much worse than this so this is going to seem incredibly self-pitying and insensitive. I do know that. But right now I can't feel anything but hopeless. If I couldn't get pregnant with five follices and a two week holiday to do nothing but eat good food, relax, do yoga and swim a lot, what chance do I have of ever getting pregnant at all?

It's either in the bag, or it isn't

After another deposit last night, and a truly stupendous temperature rise over the last two days which I'm assuming is due to the drugs, there's nothing much more we can do. We leave tomorrow for a week of sun, sea and...whatever else you can imagine. I'm very definitely not taking the computer with me, so I will check in with all of you when I return.

Deposits are on their way

Good for H. We had a great romp in the hay tonight, at pretty much the perfect time - ~28 hours post detecting the LH surge and post the HCG shot. Although he did get tense he handled it really well, just chilled out, then tried again. He's getting better at this! We'll try again tomorrow night, just to be on the safe side, but I feel like we're already in good shape. Or as good shape as we can be in, given we didn't get to do the IUI.

I wrote a very long letter to the consultant (Dr Candour) detailing my concerns with our treatment. I found his email address via a research paper he wrote and sent the letter through electronically today. I didn't expect to hear back, since we have an appointment to see him on the 19th (the day after we get back from holiday). But when I logged on just now there was a response from him saying he took our concerns very seriously, and did we want to come to see him sooner as my points were too complex to discuss over email. We can't do the dates he offered since they are when we're on holiday, but I really appreciated him getting back to us. I was nervous about sending the letter since I thought it might label me 'trouble patient' but so far he seems to be taking it exactly in the right way - seriously and with respect. That's a relief.

The other thing I did today was acupuncture. Never done it before. I got a recommendation via a newspaper journalist who went through IVF very publicly last year and gave birth to her daughter a month or so ago - NB daughter was conceived on a rest cycle between IVFs! I enjoyed the experience. The therapist was very respectful, and listened well to me. He didn't half go on about the 'relaxation' thing, but also told me that things like cooking or gardening might help - nurturing exernally helps the yin energy, apparently. Nothing like confirming female stereotypes through chinese medicine, is there? I'm actually quite open to this in a way that my 25-year-old self would have laughed at, cynical scientist that she was, but it has left me wondering if societal attitudes to women came first, or if the medicine did? Anyway, I enjoyed the deep relaxation and laughed at myself for the slow pace I was walking at on the way home from the appointment!

Let's hope those sperm know where they're going. My ovaries hurt, and have been doing so on and off all day. Never felt that before. In a way, it's encouraging to know that something is going on there, and more so than in a usual cycle. Reminds me to keep focusing on doing good things with my body. Yoga tomorrow, and more sex. This might actually be fun!

The fruits of my labours

I've realised that I need to change the category on these posts, since the IUI isn't happening. Something to do later.

Well, the amount of research I've done in the last 48 hours has surpassed the intensity of many days when I was writing my PhD. Funny how things are different when you have 'skin in the game'. I thought it would make sense to write it up here so someone else can benefit if they find themselves in the same position.

Where indicated with a star, the full article can be read for free by going to Pubmed. Where not marked with a star, just the abstract is available on Pubmed, unless otherwise indicated by the link.

IUI and multiple follicles

1. A multifollicular ovarian response to clomid/HMG (ie FSH) resulted in better treatment success than a monofollicular response. Other factors contributing to success included female age of less than 40, infertility duration of less than 6 years, and no evidence of endometriosis. Nuojua-Huttunen et al. Human reproduction 14.3, 698-703, 1999. *
2. Risk factors for higher order (ie more than twins) implantation after FSH stimulation and IUI are serum oestrodiol >=862 pg/mol, female age =<32, and total number of follicles. For a woman over 32, with 4-5 follicles and eostradiol >862, the risk is 13%. If oestrodiol is <862, the risk is 4.3%. I was in the latter category (although only just). Tur et al. Human Reproduction 16.10, 2124-2129, 2001*
3. More recently, Tur et al have applied the methodology indicated above to manage the cycles at their clinic. Application of these three variables has resulted in an 8% reduction in pregnancy, but a 290% reduction in higher order multiple pregnancies. Tur et al, Fertil. Steril. 2005 (don't have the rest of the info)
4. For patients 35 or older, pregnancy rates in hMG and clomid+hMG cycles doubled when six or more follicles were =>12mm, or E2 levels were >1000 pg/mol, but incidence of higher order multiples was not increased. In women under 35, the same conditions did increase the incidence of three or more implantations. Dickey et al. Fertil. Steril. 75.1, 424-426, 2001

IUI in general

1. A good summary of all the factors contributing to IUI success, too much info to summarise here. Duran et al, Human Reproduction Update, 8.4, 373-384, 2002 *
2. Another overall summary, not as good and I had to pay $35 for it - won't do that again! Email me if you want to know more about it. Balasch, Reproductive Biomedicine online: 9.6, 664-672, 2004

Use of HCG versus LH to trigger ovulation in IUI
To decide what to do today after Pamplemousse's comment on the last entry, I looked into this in detail. Sadly, the evidence is not conclusive. Here are the better articles that I found, you'll see they have somewhat contradictory results. After reading this, and realising from an OPK this afternoon that the LH surge was beginning, I went ahead and gave myself the shot. Let's see. The downside some authors have mentioned is that HCG may have an effect on the receptivity of the endometrium. However, it's not clear and I wanted to give every chance to those 5 (or 4, realistically) follicles.

1. Across a wide range of stimulation protocols, administration of HCG (whether with an LH surge or without) leads to increased pregnancy rates. In most cases (although they didn't get statistical significance with all the differences) the LH surge plus HCG shot was the most effective method. When FSH is used in the stimulation protocol, an HCG shot was beneficial. Mitwally et al, Reproductive Biology and Endocrinology, 2.55, doi:10.1186/1477-7827-2-55, 2004* (this seems to be an online journal so usual page numbers don't apply)
2. No statistical difference between LH-timed IUI (measured through urine) and HCG-timed IUI. However, many authors have commented that urinary monitoring is v inaccurate and will miss the LH surge in about 35% of women, so this study is probably not well designed. Zriek et al, Fertil. Steril., 71.6, 1070-1074, 1999. Several other studies published, all the ones I've seen say no difference between the two methods
3. Possible effect of HCG on endometrial receptivity. This relies on the longer half life of HCG in the blood than that of LH, as well as a slightly different effect on endometrial physiology. Fanchin et al. Seminars in Reproductive Medicine, March 2001. I had to sign up for medscape access to get this, but I didn't have to pay. I just said I was a doctor. Hell, if all this googling isn't good for something...

I hope that helps someone. I will make sure we have sex tomorrow night, which will be 28-ish hours after the HCG shot and LH surge. This all feels like such a mess, I have no idea whether we have a chance. But we have to try, right?

I've also used this research to write a long letter to Dr Candour, describing what went right and what went wrong from our perpective with this cycle. I'm going to email it through and hope he doesn't just see us as trouble-makers. Let's see.

Thanks again for all your support.

I feel just like a lesbian

Wow. Thank you so much for yesterday's comments. Your ideas were gratefully received. Last night, we tried fooling around for a while but H was just getting more and more tense. I offered him the cup and syringe method, and he at first declined as he felt like a failure for doing so. After 30 minute or so he gave in and went away and did the deed, returning with what he called a 'special delivery'. As I injected the sperm (5ml syringe, no needle), I thought of our lesbian friends, T and S, and how they'd done something like this for a few months each before conceiving their son and daughter (2 years apart).

I haven't yet had an LH surge, so we have time for more tries after H can get the drugs on Monday. Blood on Friday said my LH level was 3.0, and I've been peeing on OPKs ever since, and they are all clearly negative. I bought the wrong brand unfortunately. I've always used the digital ones, although I take them apart afterwards and examine the lines. This time I picked up the basic ones by mistake, which was a bit irrirating. But the test line is clearly shadowy - almost invisible until 5 mins or so after I've taken the test, so I'm pretty sure I'm reading them right. Should I give myself the ovitrell shot? I thought I might as well wait to have my own surge.

Re wessell's question on H and ambivalence. No, he's not ambivalent about having a baby. He is, however, messed up about the impotence. He's seen a counsellor on and off about this problem for nearly 2 years, and I've also gone with him on a few occasions, but once it starts working for a few tries he stops going. Then the problem recurs - which might be ok if he could just forget it and move on - but instead he freaks out and the problem is back to stay. That's happened twice now. The counsellor got very cross with him the first time it happened, because he had told H to keep coming and discussing the issues, but H had heard: "You're fixed, don't come back". The counsellor said that H was a lazy thinker who just wanted the difficult things to go away, and so heard what he wanted to hear.

I discussed that issue with H last night and he agreed. Every time I try to discuss what's going on with him and this issue, he tells me he doesn't want to talk about it - that this is not a good time. But it's never a good time, that's the problem. On the occasions we have been able to talk about it I've said so much to him about this: that I love him no matter what, that it's worked in the past (on our wedding night and on honeymoon he had no problem, even without drugs), that I'll do what it takes to help him. Nothing seems to help.

He has an appointment with a new counsellor when we get back from holiday. He's cancelled it twice for work, I just hope he doesn't cancel it again. It's not about the conception, really, we can do that other ways as you guys pointed out, it's about us having a strong marriage which can survive anything. I am convinced he is the man for me, but I think a marriage needs a sexual connection, and he's lost that confidence.

This sadly meant that he was in a bad mood for the rest of the evening because we'd resorted to using the syringe. It is the old cliche - he felt like less of a man, having to do that. In the end I left him to watch motorbikes, and came upstairs to read some more blogs. I'm sad for him but don't know how to help him with this. In the end, I can't make his brain ok about this. Only he can do that.

We've decided to cancel your treatment on the grounds that you might actually become pregnant

Well, the title says it all. Lining 10.5mm. On the right, one at 22mm, on the left, four - 17, 16, 16 and 14. They consider (now they tell me) anything above 14 as possibly fertile, so that gives us five follicles, and the cycle is cancelled.

We saw yet another doctor this morning, and lo, she was pretty much as bad as Dr ICU. Let's call her Dr Condescending, for the sake of argument. Before she even scanned me she sat us down to give us the speech. When I asked her very calmly about all the research I'd done, she told me that of course she'd seen lots and lots of patients, and therefore she knew that there was a high chance of multiples in my case. I asked her why, she told me that it was because of my lining and because the follicles kept growing, "even in the absence of the Puregon". I pointed out several times that since I had been taking Puregon in the evenings, I'd only been without it for 12 hours, so it was hard to tell what my follicles would do in the absence of it.

Given the research I'd done, I also asked about converting the cycle to IVF. She said not possible since I would have had to have taken the GNRh agonist by now. Not according to one article I read, but there you go.

We got the whole, "It's policy" speech, and most maddening of all the: "I know how you feel" comment. I really wanted to deck her at that point.

Eventually I gave up and we left, and I sobbed. As we were leaving she threw in the point about: "and no unprotected intercourse, either."

I know you guys are going to tell me to just have sex. But it's not that easy for us. H, remember, has a problem with impotence. This situation is pretty much guaranteed to make it impossible for him to perform. He also informed me this morning that he hasn't renewed his prescription for the impotence drug so we don't even have that crutch.

I really do feel devastated. I know it's nothing compared to what many of you have been through. But I really felt this was our cycle. We'd have a May baby, just as I always wanted (and fantasised about this time last year). I've taken two weeks off "to relax". HAHAHAHAHA. I won't be able to keep taking days off when treatment comes up. I feel like this was our chance and we got it snatched away from us. This month I put a moratorium on any travel for work, and mostly my clients understood. I don't know how I can manage to organise another month where I don't have to travel for work.

I know there will be another cycle. It just doesn't feel like it right now.

It's the all the fun, all the time show

IUI#1, Day 10.

Dr ICU is slightly less unpleasant in person than he was on the phone. Yes, it was he who did my scan this morning. A bit of the racing driver phenomenon (nyeeeeeeeaah, round the corner, vrrrrroooooooom, vrrrroooooom, nyeaaaah (sorry cannot find the right way to type racing car noises, but basically it's lots of vigorous moving around the corners without much warning)), but not as much as the one I had on day 2. He also did the v disconcerting thing of frowning a lot at the screen, looking worried, and at one point turning to the student who was in the room to say: "Can you see the endometrium? It's not very well defined..." Given the numbers below I think it was a screen thing rather than a problem with my lining, but who knows. He also said nothing for the first 5 minutes or so, which is also very disconcerting. So I was very disconcerted.

H eventually saw I was a little tense, and asked if I was ok, at which point I got up the courage to say: "I just need to know what's going on". Then Dr ICU started letting me know what he was doing, frowning all the while.

• Good news: Lining 9.5mm
• Good/bad news: Right side: One follicle at 20mm, one still at 11
  Left side: Four follicles: 15, 14, 14, and 13mm
• Bad news: My temperature was up this morning

So it looks as if one egg has either already gone, or is about to go, and the others won't be ready. I know that's not a disaster, but it's so much less than I was hoping for. They will wait for the bloods and decide at lunchtime if we should come in tomorrow for insemination or wait til Monday -they don't do inseminations on Sundays.

***********************************************

Update: E2 is 2601 (708 US), LH 3.5.

So I haven't ovulated and don't seem to be about to. Thank goodness. Dr ICU told me that I need to come in for a scan tomorrow, and in the meantime stop the Puregon. If there are four follicles at more than 17mm they will cancel the cycle. If there are three or less, they will go ahead. I asked him if he had any clinical evidence that it made sense to cancel the cycle with four follicles given my age, and he said "It's not clinic practice to give patients clinical evidence". GRRRRRR. I asked him if there was any scope for discussion on the issue, he told me "It's clinic policy, if you'd read the material we gave you, you would know that". GRRRRR.

This conversation went round in circles somewhat until I gave up. Scan at 08:30 tomorrow. Wish me luck. Not sure what to wish for at this point, I guess it's three follicles at 17 or larger, and that the other two stop growing. Wierd to wish for something that the research says is less likely to get me pregnant, but there you go.

Cautiously moving forward

Thanks so much for all your help over the last 24 hours. I'm feeling a little better about it today. The one thing I don't know is exactly how many follicles I have to have before the clinic will refuse to do IUI. But when I see them tomorrow I hope that there will be 4 good ones and that there won't be an issue on that basis. Thinking about all you said and about our lack of success so far, the chances of multiples has to be minuscule, so I'm ready to push for IUI almost regardless of the number of follicles.

I did the injection last night, and tried the stomach after your comments, but actually I think the leg is easier for me, so I'll go back to that tonight. Perhaps since I'm only injecting such a small volume that makes a difference?

I did my fertility yoga this morning and it's a lovely day here so I was feeling all blissed out as I walked to the tube until I mistakenly read an email on my blackberry telling me my feedback from the course I did two weeks ago wasn't good and I should look for opportunities to improve. I couldn't open the attachment there and then so fretted about it all the way to work. Then I opened the attachment and found that actually it's pretty good and with a couple of specific things I can do differently (slow down my speaking, crack a few more jokes so I seem more accessible (help! I can't do jokes!), and make more specific comments in the breakouts). That I can do. So I'm a bit cross with whoever sent the email for freaking me out, as doing these courses well is something I pride myself on. So I'm going to try to let it go with a few deep yoga breaths, then re-throw myself into my day.

Thanks again guys, I really appreciate your help and support. Virtual cookies for everyone - what type would you like?

Speaking too soon: a little known but deadly disease

As you may have guessed from the title, there is now a potential issue. Of course, if you were less optimistic than I, you might have guessed that from the post below. But I was enjoying my happy day too much to want to spoil it with worry, at least for a few hours. For the same reason, I've decided to leave the post below intact rather than spoil it with my new bad mood. So if you haven't already, you need to read the post below first.

Dr I can't understand a word you're saying because my English is crap and I don't want to have a discussion with you anyway (Dr ICUWBMEICAIDWTHACWYA, or Dr ICU for short) just called. I have five follicles. Two on the right, three on the left. Three are at 12mm, one at 11mm, one at 10mm. Hormone levels: LH 4.3, E2 2000. Before you freak out, this is in the UK measurement of pmol/litre as opposed to the US measurement of pg/mol, so the US equivalent number would be 545 (thanks Mare!).

So the good news is I respond well. The bad news is maybe I respond too well. If all five continue to develop, we will get cancelled. If we have three, they will go ahead, but only if we sign all sorts of disclaimers about multiple pregnancy. Now H and I have discussed this, and as an academic option, we have agreed that we would do selective reduction if we have more than twins. I know that's a very difficult point of view for some people, and who knows how I will actually feel if it comes to that, but that's what we think we can handle.

It's a bit ridiculous because given we have not got pregnant for over a year on our own, what's the chance of 5 or even 2 eggs fertilising, developing and implanting successfully this time? But suddenly we have to think about this. If it was up to me I'd go ahead even with 5, but the clinic won't - not sure if that's a legal obligation or not.

I'm pissed off because the doctor was such a plonker. He kept asking me why I wanted to know things, and when I asked him for the units of the E2, just to be on the safe side, he asked me if I was a medic before he would give them to me. When I asked several times if I should continue at the current dose, he said things along the lines of: "I would have told you if we wanted you to drop the dose." Yes, fuckwit, I know that, but I'm asking you a question about what's going to happen if I continue, and what is likely to happen if I reduce or stop the dose? Why can't you tell me why it's a bad idea for me to stop taking the drugs or reduce the dose somewhat. He never answered the question. Do you guys know? Would all the eggs just stop developing?

I'm also pissed off because before we started the cycle I asked if I really needed to do the drugs since I seem to ovulate fine on my own, and they didn't really give me a satisfactory answer but insisted that this was the right way to do an IUI cycle. It's still possible they were right, it just doesn't feel that way right now.

I don't really have any option but to continue as I'm scared all the follicles will croak if I drop the dose. I go in again on Friday for a scan and more bloods. I've gone from being 100% convinced that in 3 weeks we'd be pregnant, (Stupid, I know, but I was enjoying it), to being 60% convinced that we won't even be able to try.

Where's that optimism when you need it??