Thalia's fertility journey

The end of the fertility journey

I will never be pregnant again.

Really. We have decided that we don't want any more children. The newborn stage with Junior has persuaded me that no matter how much I love my children, I don't need to be that sleep deprived again. Nor do I really want that emotional struggle with breast feeding again. If we'd started earlier, if I had that much more energy, if we even had the option of conceiving easily, when we wanted to, then it would be on the cards. But two children is perfect for us, and I can't help thinking that having three would start to get very complicated in the parenting stakes - speaking as one of three children.

Just because we don't want them, doesn't mean we wouldn't have a surprise. It's very unlikely, but it has happened to others in our community. Well, we are taking steps to remove that option. H has had the preliminary consult for a vasectomy, and has said he will make the appointment before the end of the week. He said, very forcefully, when I pushed him on whether he was happy with permanently ending his fertility, that even if he ended up in another relationship because I had died, he would have enough on his hands with his two children and would not want more. He is committed to the family we have.

We also have several frozen embryos. I can't actually remember how many, somewhere between 6-8. But they were never the best embryos from any cycle, and if we wanted to use them it would be a long and probably painful process of suppression, estrogen, trigger, progesterone, transfer, and possibly a chemical pregnancy or two before we were done. And besides, we don't want any more children. We don't want any more children.

As others have written, though, it's hard to let frozen potential children go even when you know a pregnancy might kill you, let alone because having more children just isn't right for you and your family. Nevertheless, I am psyching myself up to remove our frozen embryos as an option. We will donate them to research. There is no option that I know of to donate them to another family, and even if there was, I'm too old to be an egg donor in the UK so fairly sure that would rule us out. I'll make that call tomorrow. Or the next day. Or after the weekend, perhaps. Well, we have mentally let them go, at least.

With the vasectomy/donation double hit, we will have no other chances to be pregnant again. And I am sad about that, no matter how I think through the misery of sleep deprivation and the pain of failing again to breastfeed my children successfully. I am sad that Pob will not have a sister. I am sad that I will never again use the little white Egyptian cotton babygro with the two little embroidered silver feet on the breast, the babygro which was the first thing I ever bought for Pob. I am sad that I'll never again have that newborn on my chest, conked out between one suck and the next. I have fallen in love so hard with my babies, both times. I fell in love at different points, and it didn't preclude moments of despair and frustration at the screaming infant at a later point. But I won't get to fall in love like that again.

It's sad, but it's wonderful, too. Wonderful that I got to experience that at all. Five and a half years ago we started trying to conceive, and four and a half years ago I started writing about it. There were moments on the journey when I was convinced it would never happen for us. And then moments where I thought Pob would be an only, and mourned for her and for us that sibling relationship. But now here we are, a family of four, and those who meet us now assume it was all smooth sailing - after all, our children are only 21 months apart, and who would 'choose' that? And we have the boy and the girl that people assume must be what we wanted. We have been so incredibly lucky.

And yes, some of that luck is because I pressured and argued, researched and fought for the best treatment, the best treatment as soon as it was possible, fast, no waiting. But that's just a small part of how we got here. An important part, but a small part. Others argue and fight and research and it doesn't happen for them. I have no rationale for why it happened to us other than the weird quirks of my biology, the randomness of that sperm and that egg, and that sperm and that egg and that test tube and that embryologist and that catheter and that drug and the resulting embryo happening to hit the uterine lining just so, and find just the right blood vessel to colonise, and...

So the fertility journey is done. So what, pray, am I doing with this blog, with this blog title? Not writing much, that's for sure. But this isn't goodbye. It's my space, it's our community even if the community I am truly part of now is more naturally those parenting after infertility, with a strong emotional connection on my part, if not on theirs, to those who were in the trenches with me but who didn't make it out, whose embryos never quite found the right bit of the uterine lining. I will try to change the title to more accurately reflect my life now, but I will remain here until they consign Typepad to the dust. The blog got me through, you got me through, through infertility and pregnancy and breastfeeding and the start of parenting.

Junior is stirring. This post didn't end up being what I thought it was going to be. But it is what it is. And I am here, now. A parent.

Predicting pregnancy outcomes

My medscape subscription just offered up an article on predicting pregnancy outcomes, and I want to copy it and stick it up on the front page of every community board where someone is posting "no heartbeat at 7w does this pregnancy have a chance?" and getting lots of responses like - "Don't give up hope honey, I know someone who never saw a heartbeat and her son is now 4!!!"

The article says that three factors correlate to successful pregnancy outcomes. All factors can be measured by dildocam at between 33 and 36 days post-conception, or 6w5d - 7w1d. The three factors are fetal cardiac activity, yolk sac between 2 and 6mm and gestational sac diameter of 12mm or above. Importantly, "These markers were associated with favorable pregnancy outcome even in the poor prognostic subgroups of women of advanced maternal age and those with recurrent pregnancy loss." For women with recurrent miscarriage, 94% of pregnancies with these three markers resulted in take-home babies. For the over 40s, it was 82%. I know that's still a big grey area, but it's not a bad step in the right direction.

We all sort of knew this, but good to have it confirmed by 1092 pregnancies.

Yet another study showing IUI doesn't help

After the last time I posted about this, a lot of you commented about how IUI had been the right treatment for you, and how at least it was affordable in the US, unlike IVF for many people. Also, a couple of you had diagnoses where IUI was the appropriate treatment - medium-level sperm issues, a lack of cervical mucous, etc. I am fairly sure that this study excludes those factors so read on.

A study published today shows that for those with UNEXPLAINED infertility, treatment with either IUI or clomid had no discernable effect. The doctor on the BBC news this morning pointed out that if you aren't ovulating, then clomid is an appropriate treatment. If you are, it has no effect on your chances of becoming pregnant. Here are the details:

In the six-month study, participants had all suffered unexplained fertility problems for more than two years.

Overall, 101 women ended up having a successful pregnancy.

Of those who tried to conceive naturally, 17% became pregnant and gave birth to a live baby.

For clomid, the birth rate was 14%, and insemination 23% - not significantly different from the chances of success with no intervention.

However, the women undergoing active treatment were more reassured.

The last sentence tells you why doctors keep on prescribing clomid and IUI when they are not specifically indicated. It's very hard to tell a patient to go away and do nothing, or that they are better off with IVF when, in most places in the UK, the local health authority will have a 2-3 year waiting list for IVF and lots of restrictions about who can be enrolled on the list. Or in the US because the patient may not be able or willing to take on the huge cost of IVF before they've "tried everything," or at all.

I'd like to look at the statistics for countries like Israel, where IVF is readily available and paid for by the state. Do more couples go straight to IVF, bypassing these intermediate and less effective treatments?

The thing to be careful about is asserting - IUI is the right treatment because it worked for me. This study shows that you are just as likely to have become pregnant by being sent away to keep going for six months as you are to have conceived with IUI, even if you've already been trying with no success for two years before that. It's just a probability game, and you happened to have hit the one month with IUI when you most likely would have achieved pregnancy without it. However, this is only true if you have unexplained infertility, not if you have a specific condition where IUI can help.

It makes sense if you say - I couldn't bear doing nothing any more, and IUI was the affordable option. That's a personal choice, not about the statistics. It's of course fine to say, we couldn't afford IVF so we went for IUI, but it actually is probably not a good use of your money - you could have saved the money you spent on IUI and spent it on something unrelated to fertility treatment.

Clomid is a bit of a different story - most people hate taking it and it can actively inhibit fertility by drying up cervical mucous. If you are ovulating, it really really should not be given to you. It's just a nonsense treatment.

So the point here is that the numbers by no means tell the whole story. They don't tell the story of how bloody miserable it is to try every month to no avail. At least by taking clomid or doing an IUI you feel like you are taking action to deal with this horrible problem. They also don't tell the story of the money flows in infertility - the intense rationing of IVF in the UK, the extraordinary cost for those in the US whose insurance doesn't cover IVF. Numbers are powerful but not omnipotent. Everyone has to make the decision that's right for them. I just wish the doctors and the insurance companies and the NHS would review their standard procedures and at least start having these conversations with people.

Tonight we sleep the sleep of the just

A veritable bevy of follicles. 21, 19, 19, 17, 15, 13 plus some little ones on the right, 17, 16, 16, 16, 13, 12 on the left. We are to trigger at 2330 tomorrow night and go in for collection on Tuesday.

Yet another new-to-me doctor (nice, blonde, good sense of humour) told me we should be there at 7 on Tuesday morning, but given I've previously triggered at 2230 and still waited hours for retrieval, I negotiated an 8am arrival so that we can be at home with Pob until the nanny arrives.

We put Pob down for her afternoon nap at Granny's house, and are now heading out of the big smoke towards druid country. I am quite nervous about leaving Pob but I know she'll be fine. She'll miss us, but she'll be fine. We'll miss her, but we'll be fine.

What's that story about tortoises and hares again?

I had over an hour at the clinic this morning. First the scan, which showed

• Left: 14, 14, 13, 13, 4<10
• Right: 19, 18, 16, 13, 13, 4<10
• Lining: 10.

So not bad. Heading in the right direction, roughly a mm a day. Which is a bit slow but at least they are doing something.

***

Contrast in doctors' personal styles was observed. The nice doc from last weekend saw me in passing, and said 'Hello Mrs [realname], how are you?' Five minutes later, the doc I saw on Wednesday was the one who called my name for the scan. He called me then went and fiddled with paperwork for a while. Then called me again, while looking straight at me. Then when I pointed out I was standing and waiting he ushered me into the scan room and introduced himself. Which is ok, I guess, better than not doing so if he's not sure he's met me before. But let's just call him Dr Memory for the sake of it, yes?

The whole memory thing was borne out when he ushered me out of the clinic straight after the scan, without remembering to ask I needed more meds. Which I do. Luckily I remembered before I got to the bus stop, so I came back, had to wait around to get someone to give me a prescription, then wait around to get it filled. Luckily in that process I thought to ask if I could do a blood test that Dr Candour has ordered to try and get underneath my blood panel results at the clinic rather than going into town to a specialist lab. They agreed to do it and that saved me a trip, although it did cost me yet another nasty bruise on my arm. Which doesn't look good in short sleeves.

***

Dr Memory left it til 1635 to call me with my instructions for the weekend, which was leaving it a bit late given they close at 1700. The call came 5 minutes after I left a polite but slightly stroppy message, so I do wonder if my paperwork had fallen on the floor somewhere. Anyway, they want me to come in for a scan on Sunday morning. This is not good, as H and I are going away this weekend, without Pob for the first time. A friend is having a rather swanky 40th birthday party at a hotel in the deepest darkest countryside, and we thought we'd have a little jaunt and leave Pob with my mum. Which will be somewhat less fun if we have to get up at 6am on Sunday morning to drive back into town for a scan. I asked if I could come tomorrow, Saturday, instead, just in case that way we can avoid the Sunday scan, and Dr Memory acquiesced. So let's hope they're all clearly growing tomorrow morning - let's say 21, 20, 18 and a bunch of 17s, and then we'll be able to trigger Sunday night and get on with this.

Although to be honest, retrieval on Tuesday and transfer on Thursday will totally bugger up my work week. But that was always going to happen, yes?

Clinics

Why, my dear friend Kay asked, have we gone back to clinic 1, the clinic of Drs Candour and Gorgeous, Shoes and Casual. Only Dr Shoes is on maternity leave, and Dr Casual seems to have flown the nest. Haven't seen Dr Gorgeous either, come to think of it.

Anyway, why clinic 1 instead of top notch best results clinic? Well, because I just didn't like top notch best results clinic (TNBR). They make you wait for hours. They charge you lots and lots of money and then don't give you test results. For example, I still haven't had my immune panel results from them. They kept saying they'd get a doctor to call me and they never did, and every time I called the right person wasn't there. Yet they knew I was pregnant at the time and presumably they should have been practicing decent enough medicine to want me to have the best information to sustain the pregnancy? They called me to tell me 'the doctor really needs to discuss your immune panel results' before they knew I was pregnant, so the sceptic in me thinks the tests show I should have been dosed up with IVIg, which I don't believe in, but when they found out I was pregnant and doing fine, they didn't want to share the results as it makes the test look bad. But I don't know since they won't give me the bloody data.

I have a certain amused connection to them in that it was the doctor who did the day 13 scan on our practice cycle there saying, "there's the follicle ready to go, but don't try and get pregnant this month, you're going to go through lots of tests instead," that encouraged me to go home and jump H's bones, and the rest, as they say, is history, well, Pob actually. So perhaps I owe them that little filip to our conception efforts. But given that we went there because we'd failed at the clinic we liked, and then we showed we could do conception and pregnancy just fine, I don't see any reason to put myself through the stress of a cycle there when we can do it much more easily with a clinic we like and which seems, well, fine. Just fine.

I know, writing this out I sound like an idiot. Why wouldn't we go to the best possible clinic? Perhaps it's related to the fact I don't really believe in IVF for us, but am doing this because it's officially the best way for us to get pregnant. Why do a more painful IVF cycle if I don't think it's going to work? Let's do it with the least pain and get it over with? Perhaps. I would have had a hard time working the last week with the demands that TNBR clinic makes on patients - scans and bloods every morning, lots of waiting around etc etc. I don't need the stress.

Let's see what happens. Hopefully we won't have to go through that painful changing clinics process again. If we fail to get pregnant this time I imagine we should at least consider another move.

Not bad for an old lady

A lovely day for a day five scan. It's sunny and breezy after days of on-again off-again rain and grey skies which yesterday put rather a dampener on Pob's playdate with some other 10 month old babies in the park. I left Pob having breakfast with H and zipped off to the clinic, which is less than 10 minutes away in the early Sunday morning non-traffic.

I only had to wait five minutes or so before a doctor I'd never met before came up to introduce herself and usher me into one of the scan rooms. She was about the most efficient scanner I've come across, and so nice that I had to forgive her for being one of those docs who can't let you look at the screen at the same time. And the good news was that I've got six likely looking follicles on the right, and four slightly smaller on the left. They're all still quite small - around 10mm or so - but worth counting nonetheless. Since the largest one is still only 12mm, I have to go back tomorrow for more scans and bloods to see if I'm ready to start the antagonist.

What a difference lack of suppression makes. Every other time I've had a day 5 scan, they've got all worried and upped my meds. This time things seem to be progressing nicely. Of course half those follicles (or more) could stop growing, or some of them could be egg-less, and of course at least half the eggs are going to be crappy, but this is a decent batch to start off with.

It's Pob's 10 month birthday, and when she wakes up from her nap we are off to the zoo to celebrate and to make the most of the weather. She seems to really love animals so we're hoping she'll enjoy it. And we'll of course get to enjoy her.

Thank you Mr Steptoe and Dr Edwards

In 11 days time, Louise Brown will be 30. She has her own son, Cameron, who was conceived spontaneously just over two years ago. She comes across as a nice, thoughtful, sensible and articulate woman, very aware of the role she's played but in no way starry because of it.

We owe a lot to her parents, to Mr Steptoe and Dr Edwards, and I'm sure a lot of unsung nurses, embryologists, researchers and other doctors without whom the good gentlemen would not have been able to treat Mrs Brown, who had blocked fallopian tubes. It's hard with scientific progress to disentangle the multiple threads that come together into the tapestry which is an individual breakthrough, but these articles give you a sense of the long line of clinical and scientific progress without which IVF would not have been possible. I did not previously know that the first IVF pregnancy ended in an ectopic, for example, although I was aware that Mrs Brown's pregnancy resulted from harvesting a single egg, caught just after ovulation, since the drugs to produce controlled ovarian hyperstimulation and to control ovulation were not yet well developed (hyperstim was already in use, just not put together into the edwards/steptoe protocol).

If we think back to all those many pieces of work, the century (at least) of work on human fertility which led to Louise's birth, we can marvel all the more at what's been developed since. The drugs to help us to produce multiple eggs in one go. Agonists, antagonists and recombinant chorionic gonadotropin (hcg) to control when ovulation happens. ICSI. The understanding that many women need progesterone support after artificial induction of ovulation to support a pregnancy. The use of trans-vaginal needle aspiration rather than laparoscopy to retrieve eggs. Laser surgery for endometriosis. Hysteroscopies to remove fibroids. The ability to freeze embryos. The use of estrogen therapy to support frozen cycles. Progesterone suppositories to replace nasty intra-muscular injections. Automatic dispensing pens for FSH rather than having to mix powders. The understanding of the role of blood clotting in recurrent miscarriage. And so on.

It is extraordinarily difficult to deal with the fact that - and oh so much more so to experience - after all that progress there are still some of us for whom the technology doesn't work, and some of us whose infertility has no apparent cause. In the next 30 years I believe many of those situations will be treatable. Probably not all, but more than today. Roll on progress.

Until more of the causes of our infertility are treatable - and until women's fertility is no longer over at 42 or so - thank you for all that progress has already given us. Thank you to Mr Steptoe and Dr Edwards. Thank you to Mr and Mrs Brown. To Louise and to her sister Natalie - the first IVF-conceived woman to bear a child. Thank you to all those couples who participated in early work on IVF, who agreed to be guinea pigs. Thank you to those who agree to be experimented on today - trying new drug protocols, participating in randomised trials. Many of our children would not be here without you. Thank you.

Bits and pieces of hope

Some interesting articles relating to infertility recently. Here's a digest:

1. Potential for a new kind of pain relief - aromatase inhibitors (those currently used in treating breast cancer) have been shown to be very effective for relief from endometriosis-related pain.

2. PGS does not improve pregnancy rates, or reduce miscarriage rates. The British Fertility Society strongly recommends it is not offered to women unless as part of a defined clinical trial. I think we kinda knew this one - I've certainly seen comments to this effect, but important if your doctor is currently suggesting it.

3. Australian scientists are engaged in a long range study to look at what genes are expressed in blastocysts, and how these vary between blastocysts which turn into live take-home babies, and blastocysts which fail to implant or to turn into embryos which survive through the pregnancy. Very interesting story, which has already identified (no shit Sherlock) that genes involved in cell adhesion, cell communication, and response to stimuli, are all involved. They've also found that up to 20 cells can be removed from the cell lining layer of a blastocyst with no adverse effects. They are aiming to promote single embryo transfer - but arguing that for this to be widely accepted, couples need to have greater faith that SET is likely to work. What I don't quite get is how to transfer this to the clinic setting, as you would presumably have to do the gene amplification within a day so that you could put the blasts back before they start trying to implant. Or perhaps they plan to work backwards so that you could take a cell from a day 3 embryo and test it against their findings.

4. In the realm of "Thalia feels very smug," a finding that many doctors are moving away from ever recommending IUI, and going straight to IVF, which in the long run is often cheaper and less traumatic for couples as it's more likely to work. I've always thought IUI is a waste of time, given how little it improves your chances over trying alone, even with the addition of clomid and/or injectibles. It's also more likely to lead to higher order multiples in the hands of over-eager docs in the US, so a good thing if it's on the decline. Old-fashioned technology.

5. Data that says that IVM may not be the way to go in many instances. Eggs matured in the petri dish have a different pattern of development than those matured in vivo. Which also means that labs should be working to develop culture media that better replicate the ovarian environment.

6. Feed your male partner folic acid. It reduces the level of DNA abnormalities in sperm.

We're back on

This used to be an infertility blog, right? Anyone ready for a return to the regularly scheduled freak-outs that that topic encourages? Yes? No? Well, it's coming anyway.

I seem to have neglected to blog about our visit to Dr Candour when Pob was about five and a half months old. He told us not to stop breastfeeding in order to get pregnant - that a few months would not make a big difference, and no one ever wished they'd breastfed for less time. He considered that we had a good chance at number two, given that I've responded fine on three IVF cycles, we have a few embryos frozen (I think about 6 although some are crappy looking), and Pob is the evidence that there are good eggs in there somewhere. He ordered an hsg and a scan for when my periods had returned, and we went away happy.

I've now had three periods since I stopped breastfeeding. Each time I've had clear signs of ovulation, we've made the most of that opportunity, and my period has sadly showed up 12-13 days later. I'm back on my usual schedule. I had the hsg and the scan during my last cycle, and both were fine. The scan even showed a very healthy set of antral follicles - at least 5 on each ovary - which delighted me.

We reviewed those results with Dr Candour yesterday, and agreed that the next step was a fresh IVF cycle, starting with my next period. It all seems a bit sudden to me. And oddly enough, while I have hope each month we try that I'll get pregnant again spontaneously, I'm not that hopeful about an IVF cycle. Dr Candour says their stats for women my age are 22% for an IVF cycle, whereas the chance for trying naturally is certainly no higher than 10%, if that, so, in his words, "IVF is a lot more efficient in a specific month than trying on your own." He recommends trying a fresh cycle, partly to see what my ovaries are capable of, and partly to keep those frozen embryos in reserve, given that they aren't getting any older, while my ovaries clearly are. He also recommends trying as soon as possible, because at this point, months probably do count.

This was the same conclusion H and I had come to before we showed up in his office, but I left the meeting yesterday feeling just matter-of-fact - this is something we have to try, not something that I put a lot of hope in. Which is correct, because 22% isn't that good a statistic, no? And let's face it, IVF hasn't exactly been the golden ticket for us previously.

So I've got the prescription, and we've got the consent forms, and H is off to do a sperm test early next week. I really really want another baby. I have hope that there is a possibility we might have one, not a lot of hope, but some. I'm just not sure that IVF will get us there. But it's worth a try.

Pob's head

Cranial osteopathy. It's not science, it's not medicine, but it changed my cousin's son utterly. At two months he wasn't meeting his developmental milestones. He was floppy and didn't interact much with the world at all. At three months, after a few sessions of cranial ostepathy, he was a different child. Now he's 6 and is just a great, normally rambunctious, little boy. So when Pob started to scream at the breast at about 6 days old, my cousin suggested I take her to a cranial osteopath to see if it might help. Despite my scepticism, I figured, 'can't hurt, might help' and took her at 13 days old for her first appointment. She visibly relaxed and lengthened during that session but the few feeds immediately afterwards were the worst we'd had, so I didn't take her back until she was around 11 weeks old when yet another lactation consultant suggested it might be worth a try.

At that visit the osteopath apologised for not warning me that things might get worse before they got better. Again, Pob seemed to really chill out during the session and so I decided to take her back again this week. At this session, the osteopath pointed out that the right side of her head was getting a bit flatter than the left. I'd already noticed that she favours turning her head to the right, and have been trying to encourage her to turn the other way as well, but not very systematically. I've tried putting her cot book to the left, putting a mobile on that side of the crib, etc. The osteopath said that her neck is pretty stiff so he did some work on that, and suggested we keep trying to offer her toys, etc. from that side to encourage her to even things out. I'll also take her back to see him in a few weeks time.

I know many of you have had helmets for your children when a problem like this has showed up, usually when they are a bit older, though. Both the osteopath and the paediatrician who saw her when she was born told me that British children tend not to get helmets unless the imbalances are REALLY severe, as it's thought better to correct the root cause of the imbalance rather than the outcome. In Pob's case, it seems to be some neck stiffness, so we'll work on that with the osteopath and see what happens. I'm not worried, but glad to be aware that we should do some work on this. H is worried, and has immediately put Pob on left side boot camp, changing the way he gives bottles, only talking to her from that side, etc. It's quite amusing, he can't bear his perfect daughter to have anything not perfect about her. I'm happy to wait and see what effect bootcamp has before we worry any further.

Two months

Yesterday, Pob was 2 months old. She is suddenly much bigger, much more of a little person. She smiles a lot, particularly at me, but has also started to smile without us smiling at her first, which is apparently one of those milestones. I even got a little giggle out of her a few days ago by making repeated "ooo, ooo" noises at her, although she hasn't repeated this trick. If I come into the room and start talking while she's with someone else, she'll turn her head to try and find me. She can't quite get her head to a 45 degree angle when she lies on her tummy, although she can raise it enough to turn it from side to side. Which we encourage since when she's on her back she has a strong preference to look to the right so H is worried she'll develop a flat head.

She is gradually losing all that dark hair she was born with, but still has enough that she doesn't have that total baby bald head. Her eyes seem to be darkening, but still have a bit of blue in them so I haven't yet lost hope that she will have dark blue or green eyes rather than the dominant brown from my side of the family. her skin is quite pink and white, but with yellow undertones such that she looks best in pale pink, much to the chagrin of her father who'd rather she didn't look quite so girly. I am so enjoying dressing her in the multiple adorable outfits that we've been given, although she HATES being changed so I'm limited to one cute outfit and one sleep suit per 24-hour period, unless she does one of her exploding poos, in which case she gets one more chance at the chic.

She is quite the little angel other than the feeding issue. She plays happily on her mat, or sits in her chair and watches what's happening for up to an hour after a feed. She tells us she's tired by yawning and rubbing her eyes. We swaddle her and put her in her moses basket, and she goes to sleep after a few minutes of chatting or grumbling to herself. She wakes up starving hungry, unless I wake her first, which I often do, just to get her to eat that bit more.

We have fallen into a vague kind of schedule, which I need to make the most of by getting up and doing the breakfast time feed slightly earlier. It's just that she wakes for a feed around 0430, which we finish (after breastfeeding, bottle and pumping) at around 6. By the time I've fallen asleep again it's 630 and when she starts to stir at 8 I'm really struggling to open my eyes, so I often let her fall back to sleep for up to an hour. Which then means by the time we've done a feed every 3-3.5 hours during the day, I'm doing the last feed at 2230, which finishes at 0000, which means I only really get 4 hours of sleep, and 2 hours of a nap each night. I know I should count my lucky stars that I have a baby who sleeps, and I promise you I pour libations to the fates every day for this part of her personality, what I'm bemoaning is my inability to sit up and feed her at 8am which would probably get us into a better rhythm all round. The schedule is allowing me to get the 2 of us out for a walk every day, but not to do much else, thank-you notes be damned.

  The feeding has got a lot easier. Not in that she's better on the breast, she's the same, but I've stopped minding quite as much. I was quite hysterical there for a while. Now I've figured out how to give her a bottle while I pump, we have quite a reasonable rhythm of breast (both sides), followed by bottle and pump. The whole thing takes just over 90 minutes (including nappy changes, burping etc.), depending on how long I put her on the breast for. She'll happily stay there for hours, falling asleep then waking up and sucking again, but after a while I worry about her getting hungry so we stop and go for the bottle. I'm pumping enough to give her breast milk in her bottle for 4 out of six feeds, and she gets formula in the other 2. I'm not horribly upset by this any more, the stuff isn't toxic, it's the loss of the breastfeeding relationship I wanted that I had to mourn, this fantasy of me nourishing my child in a very earth-mothery type way. Well, I am nurturing her, just not in the way I'd intended and heaven knows I couldn't do more than I have done. I guess some people could do more, but pumping six times a day now is as much as I can do without feeling really angry and tired, so that's what I'm doing.

We had her 6 week check up and jabs today. Yes, I know she's 9 weeks but that's the NHS for you. She's now 10lb2oz and back on the 25th centile for weight, while her head and her height are on the 50th centiles. So that's a relief. The jab experience was moderately traumatic for both of us - she screamed blue murder while I had tears in my eyes. After the initial scream, she abruptly went quiet and looked me in the eye, and I swear had such a look on her face - very much "Mummy how could you do this to me when I trusted you." Absolutely terrifying!

So we're doing well. I don't know how much longer I will pump as it's such a time sink, but for now I'm ok with it and I feel good about the amount of breast milk she's getting. I'm really enjoying her, relishing the little personality which is emerging. And feeling very very lucky, every day.

 

Oh well then

Today was a series of small pieces of data, woven into an answer by a very impressive woman OB/GYN. Once we'd heard the story,there was no other answer but that this baby will be born by c-section. But it took a while to get there.

Part 1: the scan
The consultant sonography doctor confirmed that the baby was breach, with her spine down my right side. Her head was a little higher than I've been feeling her recently, which I wasn't surprised about since she tends to move up at night, and sink gradually down the right side as the day goes on. He, again, did not see the fibroid that the two women sonographers I've seen during the pregnancy have noticed, measured and commented on, the one down by my cervix (note - signalling!). I wonder if this is perhaps he doesn't want to go digging down into my pubic bone, which is what it takes to visualise that fibroid. The good news was that everything looked good with the baby. Her growth is on track, the level of amniotic fluid looked good, and he even pointed out she has quite a bit of hair - on the ultrasound it looked like feathery extensions of her head into the fluid!

Part 2: Dr OB
We saw Dr OB briefly for a urine and blood pressure check (110/70, still good). He then directed us to go and see Dr big picture, who would review our notes, scan etc., and help us make a decision about whether or not she would attepmt an external version. I confessed I didn't hold out much hope it would work, since this baby has been in a very consistent position for over 6 weeks now, and he confessed he felt the same, but thought we'd all regret at least not giving it a try. So back we went to the other bit of the hospital to see Dr big picture.

Part 3: Waiting
Before Dr Big Picture could see us, we needed to have the baby's well being assessed. So I got strapped into a fetal monitor device in the day care unit, to measure her heartbeat. She was not Miss cooperative, and kept moving position after the monitor was placed on my stomach. After a while we found a position where mostly the monitor could pick up her heartbeat, but even so about every 2-3 mintues an alarm would go off as the machine stopped hearing her, and I'd have to reset it. She also got hiccups, which was quite entertaining. The heartbeat varied between 165ish and 120ish, mostly around 140 which is what I've measured with the home doppler pretty much throughout the pregnancy.

After about 20 minutes they took pity on me, agreed she was clearly very healthy and extremely wriggly, and took the monitor off. However, it then turned out that Dr Big Picture had been called into an emergency, so we'd have to wait. So we waited. For quite a long time. About an hour and a half maybe? Pob kept making quite major movements, waves of baby moving under the skin of my stomach, as if to indicate her displeasure at all this messing around. She succeeded in getting into a position which actually just hurt me, so I was getting quite grumpy. Not about the wait - an emergency is an emergency - but just about being uncomfortable.

Part 4: The answer
Dr Big Picture eventually showed up and was terribly apologetic about the wait. She took us back to an exam room, and started going through the file. She read this morning's report first, then flicked through my maternity notes. And said "ah, fibroids. When Dr OB told me about you last week, he didn't mention fibroids." (Note: more foreshadowing!!). She then started reading through the other ultrasound reports - the ones from 27 weeks and 32 weeks where the fibroid was carefully measured and commented on. She got me to tell her about the laps and hysteroscopies, and reviewed the pictures from those operations. She felt where Pob was and commented that really Pob was oblique and not breach - her head having moved down at least 10 cm since the scan in the early morning.

After some discussion, Dr Big Picture decided to scan to see for herself what the story was, and went straight to the fibroid. It's about 6x5cm and it's adjacent to the cervix, right in the pelvis. She showed us that none of the baby is down by the cervix, she's all up in the abdominal cavity. She told us how babies just don't choose to be oblique, there is almost always a reason for them staying in that position, and fibroids are the usual culprit. She sketched out very clearly what the situation is. The fibroid has taken up some of the space in the pelvis where Pob's head should have gone. Pob has probably tried to get round (that certainly makes sense given the seismic level of movement I've felt over the last few weeks) but hasn't had enough purchase to do so. In addition, the fact that none of her has been down near the cervix means that that part of the uterus hasn't stretched to accommodate her, so if we try to turn her now, she'd most likely pop back as there isn't enough space for her.

Yup, you got it. Not even worth a try.

Part 5: The conclusion
We went back to Dr OB to update him and book our c-section date. 20th September, at about lunchtime. So Kath and I will have daughters just a day apart. Not quite sure what I'll do about Yom Kippur, which starts on the Friday night, but I think I'll be forgiven in the grand scheme of things. Pob needs the extra time so her lungs can be ready to breathe.

It was good to have a clear opinion, and to really understand why we're where we are. But I really really feel disappointed. Odd, I know, given the ambivalence I started off with about a vaginal birth.  But hearing from you and others about the amazingness of being able to have your body push out that baby, well, it made me want to be part of it. I am not devastated, I recognise 100% that once we have Pob in our arms, it won't matter (that much) how she got here. I also recognise it's the only sensible option at this stage. It's a very small loss in the grand scheme of losses we've been through. But I am sad that I won't get to do it in the old-fashioned way. Also, I find it a bit odd to know in advance what Pob's birthday will be. I feel like she should have some say in this. Odd, I know, but there you go, just one of my many irrational feelings.

This time, two weeks from now, we'll probably, hopefully, be holding our daughter.

Coffee, nectar of the gods

A long time ago, when we first started trying to have a baby, I gave up coffee. It nearly killed me. I love coffee with a firey passion. I drink it black, and I savour every mouthful. I never drank more than 2, perhaps 2 and a half cups of black coffee a day, and I enjoyed every bit of it. I was quite fussy about what quality of coffee I drank. No instant coffee, no bad meeting-room coffee, no Americanos unless I was absolutely desparate. The only coffee chain in the UK which actually brews coffee rather than giving you an Americano is Starbucks, so that's where I went. At home we drank single-source coffee, from beans roasted the day you order them.

Initially I cut back a little by ordering a half-decaf, half-normal brewed coffee at Starbucks on weekdays. Then Starbucks stopped brewing decaf coffee in the UK so that was out. Around this time a study was published which showed that consuming levels of caffeine above 300mg a day was associated with an increased level of miscarriage. We'd been trying for about 6 months. I wasn't consuming that much coffee, but I figured that if 300mg caused a problem, why was I tempting fate by consuming any coffee at all? So I went cold turkey. I also gave up diet coke, mostly because of the aspartame, but I could not countenance giving up chocolate, so that stayed on the cards. So I was getting some caffeine but not much. I substituted funky teas for coffee, and I missed it, particularly at the weekend when H would brew up a pot of lovely smelling coffee and I'd be there with my cup of green tea.

And then I found out that green tea can reduce absorption of folic acid. Which I'm already prone to be deficient in, given my MTHFR homozygosity, so green tea was out. I switched to the Tazo tea, Calm, but clearly it wasn't the same. No jolt of energy, no lovely complex smell to inhale.

This went on for some time. Gradually I started to feel resentful. I'd had enough of deprivation. Two years of failed cycles and miscarriages made me feel I deserved to eat the things I liked. And given everyone around me seemed to get pregnant happily on a diet of coffee, wine, and rich food, I didn't see why I had to suffer. So the coffee started to sneak in. At first it was just off-IVF cycle, while I was on zoladex anyway, so no chance of conception. And it was half a (small) cup of coffee, at the weekends, at home. And then sometimes on weekdays too, if I wasn't rushing off to work. I still hadn't picked my Starbucks habit back up.

And then we went on holiday to Morocco for my birthday. And we know now that I was already pregnant. And I had wine every evening for dinner, and coffee, plenty of it, for breakfast. And somehow, not that miraculously, this embryo hung on despite me creating what Zita West would term a 'toxic uterus' for it. Given this, even once I knew I was pregnant, it was hard to justify being that abstemious again. Of course I stopped drinking alcohol again. To be honest, I can take or leave alcohol anyway, so that hasn't been too much of a hardship. I've allowed myself a few sips of H's wine at dinner, and that's been mostly ok. But the coffee? No, that's a different story. I stuck to the 'coffee at weekends' rule for a while. And then I had a less busy period at work so I was able to have a bit of coffee at home on weekdays. And that turned into most weekdays. The passenger was thriving anyway. I kept going, limiting myself to only drinking coffee from our home brewing, not buying it elsewhere.

Until last week. Last week was very very busy at work. I had to work til 10 a couple of nights (normal in my job, but not normal for me recently). By Thursday morning I felt really really rough. So I went to Starbucks. And I ordered a tall black coffee. Which I drank about 3/4 of. Oh baby, forgive me. But it was good. I haven't been back. But I worry I've now crossed the Rubicon and I'll find another day when I need that weekday cup of Starbucks. And there won't be an obvious reason to resist.

Anyone got any suggestions for how to wean babies off their caffeine addiction?

You know all that debate we had about vaginal birth versus C-section?

I have two baby updates to do. This is going to be a pretty happy clappy post, so if you are not in the mood I totally understand. Also, there are pictures at the end. I've made them small enough I think you'll have to click on them to see them, but just so you know before you get there.

Last Thursday we had a regular check-in with Dr OB. Blood pressure is 110/65 so that's all going well, no protein etc. in the urine. He couldn't be sure of the baby's position but thought she might be breach again. He did, for the first time, measure my fundal height with a tape measure - usually he just uses his hands. He commented that I seemed to be a bit ahead for dates, and that we should check to see if the baby was measuring big and if so, perhaps repeat the gestational diabetes test. I had booked a scan for Monday at our favourite clinic, where we did the 12 week and 20 week scans, so that was just something to put on the list for them. I do wonder about this fundal height thing. I have a bit of belly fat at the bottom of my bump, doesn't that distort the measurement? If he's never measured it before how does he know what's me and what's baby growth?

He also repeated the induction conversation, and it became clearer that they really won't let me go much beyond 39 weeks. He said they'll take it on a week by week basis - if I come in at 38 weeks and the head is engaged and the cervix feels soft, it's time to induce. If the head is still high and the cervix closed, well then they may wait a bit longer. We'll see. We left feeling quite calm and optimistic for a change!

Yesterday's scan was quite miraculous. The first thing that happened was that the sonographer exclaimed how the baby was in a great position for a 3D picture. Before we knew what was happening, there was the passenger's face in front of us. Just the most extraordinarily wonderful thing. She looks like a person! We got two great shots of her, which are below. She was busy yawning and swallowing. It's always utterly miraculous to see her swimming around in there at every scan (and, gulp, she's been scanned 11 times so far in this pregnancy. Please no one tell me scans are bad for them), but to see her in 3D is a whole 'nother level of miracle. I don't know who she looks like, it doesn't seem to be much like me, but she looks amazing. And real - so real!

The rest of the scan went well. She is pretty much average size for this stage of pregnancy, slightly longer femur, slightly shorter humerus (short arms? No good at tennis, then, H will be disappointed), big on one head measurement, average on another. Perhaps she has a funny-shaped head. She also has a big nose and long mouth (my observation, not the sonographer's measurements!), but I will love her regardless of mishapen heads and funny noses.

The only bad news from the scan is that yes, she is breach again. I personally have no faith she will turn given she's been in this position at every scan bar one of this pregnancy, although everyone says it's possible. if she doesn't turn, the whole induction thing becomes moot and we'll have to schedule a c-section. Which, despite me writing ambivalently about birth earlier in the pregnancy, I really don't want. Aurelia really helped me want to give birth vaginally, with her discussion of how wonderful it felt to be able to push those babies out. If I don't get to do that, it will be ok, but it will be a little loss. Not a big one, just a little one. We'll see.

Pictures below, look away if that's the best answer for you.

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This one will stir it all up

This morning a cross-party committee which has been reviewing the government's draft Human Tissue and Embryos bill has reported their findings. Some of these findings support the scientific community - for example, relaxing the ban on hybrid embryos for research. Some are structural or political and I'm not sure are a big deal for patients, such as suggesting that the proposed merger between the HFEA, which regulates fertility treatment, and the Human Tissue Authority, which governs research and the storage and use of human bodies, organs and tissues, does not go ahead.

And then there's the one that I can see a LOT of debate about. And it's the recommendation that donor conceived children have this on their birth certificate.

As you probably know if you read any UK-based in/fertility blogs, last year the government introduced legislation that said that donation of sperm or eggs was only allowed if the donor was prepared to be contacted by any resulting children when they reached 18. That is, the end of anonymous donation. This led to an immediate shortage of sperm donors in UK clinics, which almost matched the extreme shortage of egg donors which has been there for years. The responses to this have included campaigns for donors to come forward, and, I presume although I've not seen any figures, an increase in people going abroad for treatment. My clinic, for example, has no egg donor list, but cooperates with a Spanish clinic which can organise anonymous donors.

If I understand this suggestion, and I haven't read the report itself so I could be wrong, even those who conceived via an anonymous donor in Spain would have to record this information on their child's birth certificate. That's a big change.

The debate about what to tell a child of donated gametes, and what to tell, is a really tough one. Personally, particularly having read the blogs of children and young adults in that situation, plus all the long-received wisdom about adoption and how much better children cope when they know they are adopted as part of their life story (and yes, I am well aware that donor conception is NOT like adoption in many ways), I would want to tell my child. I don't know how I'd tell them or when, given that they'd likely start asking around 2 or 3 and heaven knows how you turn donor conception into an understandable story for a 3-year-old, but I'd want to tell them. For me it would be dishonest otherwise (one of the arguments being made by one of the MPs involved is that NOT putting this information on a birth certificate is tantamount to the state lying to the child), and just setting up the family for later trauma. I don't think it's possible in this day and age that the child would not find out at some point. What happens when they do the genetics part of biology in secondary school and come home to ask mum and dad if they can smell fresias or if they can roll their tongues, or if their ear lobes are attached? What happens when they need a blood transfusion and find out their blood type? There are just too many opportunities for your child to feel you've lied to them. I don't think I'd be able to do it.

Let's be clear, I say think here. I haven't had to be there, so I don't know for sure. But I do think that's what I'd do.

But putting it on a birth certificate I imagine is a huge deal for the parents involved. Birth certificates don't come up at family occasions, as a rule, but it does remove any element of choice from this big, big decision. Is this right? Who should get to make this decision - the tell/not tell decision?

My doctor specialises in being reassuring...

I'm in good shape for 30 weeks (30 weeks!!!). Blood pressure was 110/75, growth is fine (he found the heartbeat of the baby right away this time!), I feel ok apart from the heartburn, ankles have returned to close-to-normal. However, discussing labour today with the doctor he broke the news that they might want to induce me around 38.5-39 weeks. The reason is that in a 'normal' pregnancy the risks to the baby of being born NOW go down until you get to 37 weeks. They then stay flat until about 40w+10, then they start to rise again. However, in women my age and with my history, the flatness doesn't last as long. They aren't sure how long it lasts for, so it's not very scientific, but it is something they worry about. The 2 increased risks are that of pre-eclampsia, which they can monitor for easily, and placental abruption, which they can't and which apparently doesn't always show up as vaginal bleeding. Given his statement last time, that they just won't take any chances with me, it makes sense. BUT I really don't want to be induced, and 38 weeks is really really soon! Certainly puts paid to the idea of working right up to 38 weeks, I know I'll want a bit of time at home to nest etc. before the baby arrives.

If I'm lucky enough to get that time. I went to my ante-natal class today, and one woman had gone into labour this morning, at 32 weeks. She was on terbutaline, so they might be able to stop it, but it was a real wake-up call that (i) we might actually have a baby, and (ii) I might not get the time I want. The doctor's statements just confirmed this.

What they'll do is monitor me carefully. Every 2 weeks from now, then every week from about 35 weeks. They'll decide whether or not to induce based on how I'm feeling, how the baby is growing, any signs of pre-eclampsia or placental abruption, how the cervix is looking, the position of the baby etc. Apparently sometimes they start induction and the cervix just doesn't respond. Sounds like fun, no? Luckily I'm not in any way averse to epidurals as they are more common in induced labour because it comes on so strong when it does start.

I might only have 8 weeks left. It's really quite terrifying. It's not long, and we aren't ready, and I'm realising all the scary things about having a baby. Yes I know it will be wonderful and exciting and the best thing ever, but I do have moments of thinking, as I did this morning when I woke up early and spent a relaxed hour on the sofa, wow, I'll never get to sit here and just simply enjoy this cup of coffee again. There will be someone who needs me. A lot. Almost all the time. That's frightening. And wonderful. And a bit overwhelming. I don't know how it's going to feel, really. But I do know it's going to be more than I can possibly imagine.

All's well

Haemoglobin at 12.6, Blood sugar at 6.3 (sorry I didn't get the units). So I'm not anaemic and I don't have gestational diabetes. According to Dr OB, they don't need to test for GD again within this pregnancy, unless the passenger starts to grow too fast in which case they will look again. So I seem to be in good shape.

H was reflecting last night, as he admired my bump (he is very drawn to it but tends to restrict himself to just stroking it a little when we have a hug, I think he's scared it might bite him or something if he left his hands on it for longer), that it's really been quite a trouble-free pregnancy. And although my initial reaction was "are you kidding??? So the bleed at 13 weeks was just another day in our life???", I think he's right really. Yes, that day was terrifying, and yes, I have been tense on many other days, probably most days, but if you look back on it, other than the embryo being small at 6 weeks, and the bleed, everything else has been ok. The embryo/fetus always looked good from the 7 week scan onwards. All our scans have given us good news. The passenger has no obvious defects. I didn't have substantial nausea. I don't have gestational diabetes. I am not huge and uncomfortable (yet). I'm still sleeping well at night. The passenger kicks me on a regular basis.

I hate to type this as it's one of those gremlin-attracting posts, but I think we've been very lucky. Very lucky to conceive spontaneously given my age and my endo. Very lucky to have a healthy passenger (so far) given my age and what we've been through. Lucky I haven't been made ill by the pregnancy. Very lucky indeed. And today I feel lucky. And happy. And excited.

Fun and games at the doctor's

Today was scheduled to be just a routine OB visit, except it took place at the doc's new digs in London's fancy medical district. He's doing one clinic a week there, and it was convenient given where I'm working today. The only unpleasantness in advance was needing to drink a can of lucozade in preparation for the gestational diabetes test.

My amusement level was raised by seeing the names on the door, which included Dr Candour. I mentioned this to Dr OB, who said that this was a new venture by Dr Candour and one of his colleagues. Dr OB has been given space one day a week for his clinics. The clinic isn't really open yet, so all the equpment is shiny and new, and everything is very, well, polished. It's all very designer - one of those places where the chic upholstery fabric matches the artwork, if you know the kind of place.

The real fun and games started when the doc asked me to lie down on the (leather although covered with paper, and behind a leather screen) consulting-room bed, so he could listen to the heartbeat. He moved the probe gently around, and found my heartbeat several times, but couldn't, even after 7 minutes (I was counting to save my sanity) find the passenger's heartbeat. And although I'd felt her move not more than an hour before, I of course started to panic. The situation felt particularly ironic (or sucky, if you like), as (i) H had had problems getting there, so I'd told him to go home instead, and (ii) I'd just this morning got an email offering baby clothes on sale, and had been brave enough to purchase my first babygro. Very minimalist, I assure you, white egyptian cotton with two little footprints on the front in grey. Yes, of course this is the day my baby dies, I thought. Then I talked myself down off the metaphorical ledge using the conversation I've had in my head several times over the last few weeks. "No, my baby is not going to die, she's just not. We've got this far, damnit, we're going to have a baby." I know it's not logical, but repeating this in my head has been helpful to get through those moments where I panic because I haven't felt her for a while.

After 7 minutes, Dr OB went to get his "old-fashioned trumpet" to see if that would work better, but it didn't. So he escorted me downstairs to meet the very lovely sonographer in her very well-equipped sonography room. It even has an LCD screen set up, high on the wall opposite the bed, so that she doesn't have to turn the screen round to show you what's happening (although I don't quite understand why more clinics don't just turn the ultrasound machine around so that the sonographer has their back to you but the screen is facing towards you). The machine needed to boot up so there was a bit of downtime where Dr OB, the sonographer and I made polite, rather strained conversation. Then she apologised that her gel warmer wasn't on, squirted the cold gel on my stomach, and started the scan. She immediately showed us the heartbeat, at which point I nearly fainted with relief, and Dr OB disappeared to let her do a full growth check etc. Everything looked just fine, all measuring on track, and the passsenger is now head down. The sonographer carefully measured all the fibroids and said it looked ok for natural delivery to her, although the OB would have to decide in the end. The placenta still looks healthy, the passenger was bopping around with one arm up around her head, one leg tucked under her bum, and another stretched out along my side - "using all the available space," said the sonographer. So that was all ok.

The rest of the visit was rather uneventful. We discussed labour again, and Dr OB recommended I go check out this guidance on caesarians, to make sure I'm fully informed about what I want to do. So I'm off to read that shortly. He pointed out again that the stats are dramatically in our favour at this point, and that they will not take any chances with me at all, none at all. Which I do find reassuring (the second part rather than the first as we all know stats lie).

So I'm fine and the passenger is fine and it was just one of those afternoons. GD results will be in on Friday, fingers crossed those will be fine, too.

The Labour and Delivery story

Sorry for wigging anyone out on the last post. I really wanted it to be about our lost son, which is why I didn't get distracted with the L&D visit. But I appreciate the throwaway mention wasn't very helpful. So here is the story.

I've learnt through pregnancy that any number of pullings and often sharp pains in various places in my abdomen, groin and hips are perfectly normal (for me). Some of them can be really painful, but they are over in seconds. Last week I started to get some shooting pains which appeared to be inside my vagina. This was a bit more worrying, but several of you have mentioned that you had something similar, and that they have the same cause as the abdominal pains - ligaments stretching. On Thursday I did a day trip to Rome, and was without water for a few hours in the afternoon, in a meeting in pretty hot room. On the way back to the airport I realised I was feeling much crampier than usual, and started to drink. I got through a litre before I got on the plane, but the cramps didn't really seem to go away. They also felt more like cramps and less like shooting pains. Not hard, full-on contractions, but lots of cramps, like mild period pain.

They continued on Friday, and by the evening I was worried. I felt around in the abdomen and realised I could feel lots of what felt like fast muscle contractions going on low down, where I imagine the uterus is relatively accessible. I remembered Mainland Girl's advice to always ask the doctor rather than trying to be a big strong girl, so I called the 'emergency' number we've been given, which is the labour and delivery ward. I spoke to an extremely harassed-sounding young woman, who after about 1 minute of me talking, told me to come in since she couldn't check anything over the phone.

So we went in. It was around 2245 by the time we got there, and a few people were milling around in the reception area, but no one was there to talk to. After a while a nurse in scrubs came in, dealt with the people ahead of us, then talked to me briefly. After a few minutes she came back to let us into the ward (they are very hot on security in L&D wards here). She couldn't have been nicer, despite the fact they were clearly snowed. She showed us into a private room, and told me she'd be back shortly. Within 5 minutes she'd checked the baby's heartbeat (fine), my blood pressure (fine) and temperature (fine). She told us that a doctor would be in as soon as possible, and then left us to wait. We waited not more than 30 minutes before a doctor in scrubs, who looked about 15, showed up. She was also very sweet, and very apologetically told me she wanted to do an internal scan to look at my cervix. I told her they held no fears for me, and she laughed. She checked my abdomen, which was soft (good) and then did the internal exam, which was no more uncomfortable than usual. She was busy telling me to relax as she put gel on that metal instrument of torture, the speculum, and H and I both had to laugh, it was such an incongrous remark given the images conjured up by the equipment! If they want us to relax they need to make them in nice warm plastic and in nice, friendly colours, or at least amusing ones (polka dots perhaps), IMO.

She reported that my cervix was long and closed, and that she'd done a swab for any infections, and left us, promising to return with a bottle for a urine sample. I was in the bathroom doing that when our OB showed up. He confessed to being disappointed that they'd been so efficient that they'd done everything before he arrived! He had another go at my abdomen, reported again that it was nice and soft, and then spent a good 10 minutes going into the details of exactly what I was feeling, and getting me to rate frequency, pain levels etc. He finished with a detailed description of what kinds of pains I needed to be worried about, and what were fine. This included the highlight "if you feel something like a knife, stabbing through your vagina, that's perfectly normal and nothing to worry about, it is your pubic symphysis opening up." The ones to worry about are when your uterus closes up like a fist, and stays that way for more than 30 seconds or so. Sharp stabbing pains have to be lived with. I can do that.

At no point did anyone make us feel bad for coming in. I did feel a bit silly, but the OB told me they weren't going to take any risks when a 20 week patient called saying she felt crampy, and that it was totally correct that we came in. Then he told us to go home and chill out. I can't tell you how much better I felt throughout the rest of the weekend, knowing that what I was feeling was normal and that everything still looks fine.

And then on Saturday (during a waxing session with my usual lady which didn't hurt any more than normal, so yah boo and sucks to that awful woman who did it last time), I started to feel the baby move. It feels like bubbles, or tiny pushes on my insides. I'm not feeling them regularly, but the baby had a good sesssion last night while I lay on the sofa watching West Wing. It is totally amazing, and bewildering, and joyous, that we've got here.

Fertility controversies, again.

It's been an interesting time in the UK discussion of infertility and treatments recently. The HFEA, the body which regulates the fertility industry, is currently carrying out a consultation to see what it should do to try and encourage single embryo transfer. I'm sure you all know this debate. Here is how it goes:

• Multiple births are inherently bad for the mother and bad for the babies. Even with twins the risks of prematurity go way up, and with that, the risks of cerebral palsy, learning difficulties etc. Once you get above twins the picture worsens again
• Current, legislated practice in the UK is that a maximum of two embryos are allowed to be transferred to women under 40. Over 40, three are allowed
• The aim of fertility treatment is to get women pregnant. Studies have shown that pregnancy rates from two sequential single-embryo transfers are as good as from replacing two embryos in the same cycle. Thus the push to limit women, particularly those who are younger and who produce a reasonable number of embryos, to agree to having a single embryo replaced, and thus to limit the risks inherent in getting pregnant with multiples.
• Various studies have shown that infertile couples, and women in particular, are not fully aware of the risks of multiple births. In fact, twin pregnancies after IVF are coveted by many - "the infertile jackpot" is commonly referred to as boy/girl twins. That way women feel relieved that they don't "have to" think about going through treatment again. Their family is pre-made. In a recent study, however, once the risks were fully explained, the percentage of couples who felt positive about having twins dropped dramatically. So it seems that at least part of the problem is awareness of what you're getting into.

However, there are several other factors involved, which don't get quite as much publicity, although I have seen them discussed.

The first is funding. If you have to pay for a subsequent FET after your fresh cycle, you are presumably less likely to take the risk of replacing just one embryo the first time. In a world where a majority of doctors in the UK want to stop funding for all fertility treatment (although other evidence says that fertility treatment is a cost-effective way to deal with the falling pregnancy rate in developed countries, so another example of short-term cost cutting over long term health of the population), it seems unethical to mandate a lower chance of success for any single cycle.

Second, is the stress involved in cycling. I have seen no evidence that the legislators, regulators and doctors in this discussion fully appreciate just how awful a negative cycle makes one feel. At that moment, the thought of a frozen embryo waiting for you is unlikely to be much succour. So in asking us to agree to single embryo transfers, the HFEA is asking us to agree to increase the frequency with which we are likely to go through that kind of trauma.

Third, is that freezing is not yet a perfect science. If you freeze embryos, you run the risk they won't survive the thaw. So this approach would only be reasonable for women with sufficient embryos that they feel able to take a risk on one or more dying before they even get to transfer. How many of us feel we had surplus embryos at that stage of treatment?

So my position? I would be happy for the HFEA to develop a communications programme that adequately explains the risks of multiple births. This should happen much much sooner than it currently does - what happens now, at least at my clinic, is that on transfer day if you transfer more embryos you get a stern talk from the doctor along the lines of "are you aware of the risks of twin pregnancies," and if you say yes, you get dismissed. People need to know way in advance of that stressful moment that there are major risks involved, they need to know the stats for sequential single-embryo transfers, and they need time to decide how they want to play the risks.

I am however strongly opposed to the HFEA legislating a mandatory transfer of single embryos, no matter how many conditions they put on it (e.g., only for women under 35 with more than 6 embryos at day 3, with no more than one previous failure, etc.). I think it's unethical in a situation where most couples are paying a lot of money for this treatment, to mandate a situation which will immediately become more expensive - perhaps unmanageably so. It also takes away the ability of our doctors to consider our individual situations and help us make a reasonable decision based on our individual characateristics. The letter of the law cannot ever get specific enough to cover every situation. Let's put some trust back in doctors and patients to make the right decision, albeit with dramatically improved information over what is available today.

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

In other news today, poor Natalie Evans has lost her final appeal to use the embryos that were created in 2000 from her eggs and her then-husband's sperm. For those of you who don't know the story, the reason for creating the embryos in the first place was that Natalie was dealing with ovarian cancer, so this move was to preserve her fertility. She and her husband subsequently divorced, and in 2003 he requested that the embryos be destroyed, in line with UK law which says that both parents need to consent to using frozen embryos. She has been fighting ever since. I feel absolutely terrible for her, even though I think that legally this decision is right.

What I find unimaginable is the sheer bloody-mindedness of her ex-husband. How bad could it possibly be for Natalie to raise their genetically joint-children without him? Why cannot he agree that her only chance to raise a family that is biologically related to her is more important than his need to see a complete termination of any biological tie between them? And of course, there is no guarantee that she would actually get pregnant, the whole thing is so damn theoretical. I can only imagine how devastated she must be today. The courts were right, but the case should never have got there. This isn't about legality, it's about basic humanity, empathy and the ability to remember that you once loved someone, and that love is worth something. Easy for me to say, I guess.

I have better equipment than my OB

All I can say is, thank heavens for home dopplers, and thank heavens that I am no miser and bought the top-of-the-range home doppler which shows you the speed of the heartbeat. I decided last night to listen to the heartbeat. I thought it was a little silly, as we had the doctor's appointment this morning, but I wanted to, and so I did. I found it quicker than I ever have before, and it made me very happy.

This was a good thing because the doctor really struggled to find the fetal heartbeat today. He used both of his (rather poxy-looking) dopplers, and only once or twice got a quick burst (1-2 seconds) of what was clearly a fetal heartbeat. He wasn't worried, but I would have been had I not heard it last night. So that's my MO for every appointment going forward, listen the night before so I don't have to worry.

The vast spectrum of blood tests that he carried out last time showed that everything is mostly fine. Annoyingly they didn't run the Protein S assay, which he wanted to give some indication as to whether I would stay on clexane or not. Protein S is part of the blood clotting cascade, and is usually lower (sometimes deficient) in carriers of the MTHFR mutation that I have (C677T). Since pregnancy can lower protein S anyway, he just wanted to see if it would come back within normal ranges, which would indicate I might be able to do without the clexane. They just didn't do the test, despite having kicked up a big fuss when I turned up for all my blood tests about how inconvenient it was, etc. etc.. It was funny to see him talking to the lab trying to chase this. He has a very low-key exterior, but you could see the cartoon steam coming off the top of his head as he struggled to stay cool. The tone of his voice didn't change at all, however. H mentioned afterwards that he'd hate to meet doc in a dark alley when someone has REALLY upset him...

The one interesting thing the blood tests showed was that my haemaglobin is on the high side of normal. Normally this would be a good thing, but given the MTHFR issues, it might indicate that things are not entirely wonderful, risking the kinds of clotting problems that can cause problems later in pregnancy. So given this, he has decided to leave me on clexane at least until 24 weeks, and then reevaluate by doing a blood flow test to see if there are any likely problems. The risks of staying on clexane til then are pretty low. The two risks he mentioned are (i) a situation where you become allergic to the heparin, which sounds pretty nasty, and (ii) severe bone weakening leading to fractures. He says that at the dose I'm on for the length of time I'm on it, these are very very rare complications indeed. He did test my vitamin D, to make sure bone loss isn't imminent, and it came back fine. So my stomach, which is a veritable patchwork of blue, purple and yellow, is just going to continue to look unsightly.

Doc also did a urine test while I was there today, and it showed no protein (good) but a bit of blood which might be ok but might also indicate a UTI, so he's sent it off to be tested. My blood pressure was also a reasonable 130/68, so nothing to worry about there, although as someone who has always had surprisingly low blood pressure til now, it's a bit shocking to hear anything other than: "105/58, are you sure you don't faint often?"

We left with an appointment to come back on 10th May for our 20 week 'anomaly/morphology' scan, and a request that we don't hesitate to come in sooner if I feel nervous. At the moment I'm feeling fine, so I don't know that I'll need to come in any sooner, but we'll see. Thank heavens for home dopplers, again.

15weeks

Sensible OBs

I am only seeing brown blood again this morning, so am somewhat calmer. Just spoke to my OB. I pointed out to him that he (and everyone else) had said not to worry about brown blood, so that when it turned red I understandably was suddenly more worried. He laughed and said as soon as I'd mentioned red blood he'd kicked himself inwardly for going on about how brown blood was nothing to worry about. He said that there was really no point coming in, which is what I thought, since we'd seen that everything was fine on the scan, and that Monday's scan didn't show any blood clots or haematomas or anything like that, so they really just won't be able to tell where the blood was coming from. He insisted that:

• At this stage of the pregnancy, bleeding does not materially affect the chances of the pregnancy turning out ok, particularly after all the good scans we've had. Lots of people have more bleeding than this and things turn out fine
• Intermittent bleeding seems likely to continue, and I have to try not to let it freak me out
• Getting on a plane is now a stupid idea, so I am grounded
• Everything looked fine this week, twice. No sign of any fetal distress

He said to stop the progesterone now, I've got a bloody great placenta pumping out more progesterone than the suppositories can touch, so no reason to continue. So "another karen" we can see if your experience is the same as mine! I do so hope so, it would be wonderful to be able to relax a little, which I think might happen if the bleeding would only stop. Doc is going on holiday for two weeks after Easter, so has booked me in to see him on the 5th. He suggested that we don't need a scan, he will just look for the baby's heartbeat with the doppler. We'll see how I feel when we get to the 5th!

His office called to set up the appointment and were really kind. They gave me a 24 hour number to call in case anything goes wrong, and told me to just come in to one of the wards if so (and not to go to A&E, which is a relief).

So I still think we are in good hands, and I do intellectually know that probably everything will be fine. I do know that, but not sure I'm feeling it just yet. But hopefully it will be back soon.

Why oh why?

Now I'm bleeding and it's red, not brown. Apparently only a few hours of happiness are allowed at point in this pregnancy. We're not going to casualty because I know that as of 1030 this morning everything was fine, and there was no blood in the uterus. I will call OB in the morning to see if we can come in and he can perhaps do an internal exam and see where it's coming from. But it does suck. It would be nice if things could just be straightforward for a while.

1 in 1297, or the same chance as a "promiscuous 15-year-old"

The great professor's clinic was all it was cracked up to be. All white and shiny with a somewhat eclectic art collection. And for anyone who ventures there in the winter, FREEZING cold. Wear your woolly socks.

We waited a while, but not as long as we'd feared, given we'd had estimates of them regularly running 2 hours behind. All the staff were very friendly and kind. The phlebotomist was quick and listened to me about which vein to use. Our sonographer, who seemed to be Spanish, was lovely and sensitive and explained everything to us. They even had a warmer for the gel. We saw kidneys, and arms, and legs, and the spine, and fingers and thumbs. We saw all four chambers of the heart, and were told that the heartbeat was normal, and that the valves of the heart were operating normally. Apparently 65% of Downs babies have valve defects. We heard the heartbeat again. We saw the hemispheres of the brain. I thought I saw something between the legs but she moved the wand so fast (or the fetus moved fast enough) that I can't be sure. It took her ages to be able to do the nuchal fold measurement as the baby just moved around constantly. She kept talking to the baby, asking it to turn just a little bit for her, and even tried poking it at one stage which looked really funny on the screen! Eventually she did the measurement. 1.1mm in one spot, 1.4 in the other. Normal. Everything looked normal. What a lovely word.

The professor came in and took over the wand. Cracked a bunch of jokes. Didn't really look at much, but looked at the print out. The sonographer went to get the blood test results so that they could combine them with all the morphological results. When she'd pressed a few buttons, the professor had cracked a few more jokes and waved the wand about for a little longer in a desultory fashio, the professor told me to sit up, and showed us their calculation screen. Chance of Downs 1 in 1297. Chance of trisomy 13 or 18 1 in 2996. 1 in 1297 is the same risk as that of a 15 year old. "A nasty, promiscuous 15-year-old," said the professor. So there is no need for further testing we said. And he concurred. At 20 weeks we can check everything is still normal, but for now I am happy. We are happy. Relieved and happy.

Hope and learning in the fetal medicine unit

I'm back. I am still shedding brown blood. The fetus, however, is alive and well and moved around well, gave us quite a display. Heartbeat entirely normal. According to scan doc (the same one I saw 10 days ago), there is no sign of blood in the uterus, which is good because (i) as with anything at this stage, there's nothing they can do if there is, and (ii) blood in the uterus is quite terminal apparently. He said the placenta was well formed and large, there was the right amount of amniotic fluid, and that the fetus had grown appropriately. He thought that the blood did likely come from the edge of the placenta, since that's the most likely source, but it wasn't still bleeding and therefore he wasn' t worried.

Small aside. When you say "Brown blood," they say "oh good, it's old blood then, not to worry too much." Can someone explain to me why one shouldn't be worried about old blood? Because presumably old blood must have been new blood at some point, and forgive me if I'm wrong but any blood at all is not really what one is hoping for at any point in a pregnancy.

There is a certain extra-suckiness about this happening at 12w3d where you start to feel that you might get away without a miscarriage, no?

What this experience has taught me is that I'm a total wimp. Not really a surprise. But DinoD and Sami, I don't know how you cope with spotting/bleeding day after day, I really don't. This completely and utterly threw me, in a pregnancy where I really haven't bled at all, other than one spot at about 6 w or so. I've also learnt that our consultant is a sensitive guy, even if he did think I was panicking in an over-the-top kind of way (he didn't say this, but his tone of voice indicated it).

My least rational moment? Worry that I've caused this by pressing too hard with the doppler yesterday, trying to find the heartbeat. I've got a degree in this stuff, people, I know that it's all protected and half of it is behind the pubic bone, but why else would this start the day after I'd been searching for that heartbeat? (I found it, but only after much swishing around looking for it). I won't be doing that again in a hurry.

Or even more irrationally (and no, I don't really think this although I do sort of still believe the doppler one, even through I know it's nonsense), perhaps it's my come-uppance for enjoying a little weep in front of a soppy Greer Garson film yesterday, where her son dies, and she can't have another child, and then her husband dies, so she takes to looking after orphans and realises that that is where her calling is anyway.

Anyway, I've just been to the loo and there is still brown blood there. How I wish it would stop. I don't think I will breathe again until it does. But I've got 10 people coming for dinner so at some point I will just have to put a brave face on it.

It's over

Beta today is 5, so barely pregnant at all. I guess it's better it was over fast than that it dragged on, although of course it hurts like hell. TDFKADC had a helpful conversation with me about it, and was gently encouraging, although I'm not in any fit state to make decisions about it today.

Embryos on board

Thanks for checking in on me. You'll be glad to know that as of 1310 this afternoon, I have three embryos on board - two good looking four cells and one dodgy two cell. The two good ones are from IVF#3, and the one dodgy one from IVF#2. The plan had been to use the three we had from IVF#2, since we got pregnant on that cycle, but one of them croaked on thawing, and the third one wasn't good enough to thaw, in the embryologist's opinion.

The drama has mostly dissipated - I wrote a letter to the doctor formerly known as Dr Condescending (TDFKADC) which she responded to with a lovely, kind email, so I feel a bit less terrified that they will fire us at any moment. For now, though, I just want this cycle to work, these embryos to decide to stick around - for the long term this time.

Update #1

Someone asked/suggested that I at least post updates here of where I am so here goes.

Meeting with Dr Candour today, on day 3 of my cycle. Got the Zoladex injection and a booking form for a frozen cycle, which we will probably start a month from now, all being ok with the ovaries. Scan on 17 November to confirm if we can start the frozen cycle, which will be a medicated one (non-medicated are apparently v hard to get right due to randomness of when ppl ovulate).

Thanks again for lots of lovely comments on the last post.

A one-sided negotiation

I've obsessed about it. I've written endless letters to Dr Candour and Dr Condescending about it. I've written lots of posts about it, but in the end I cannot post or send them. It's all too difficult. I cannot bear the idea of having upset the doctors, at the same time as I am angry at them for having disrupted this seemingly wonderful, supportive, safe space.

I do understand why what I wrote upset people, I am able to empathise with what it's like to read snarky stuff about yourself. I had the experience of being handed a reference about me during an interview, and being asked to explain why it was so negative. It's shocking, and it sucks, and it was very hard to recover that relationship subsequently (although I didn't raise it with the reviewer - I was 21 at the time and would not have known where to begin). But after the initial shock had faded, I wish my doctors had been able to return to the blog, and read all the good stuff, about how much I like them as individuals, and how much I value their expertise. About how lucky I am to have been referred to that clinic in the first place. And to empathise with why I might have been writing in that snarky, selfish way in the first place. I do still feel positive about the clinic in that way, regardless of what's happened in the last week, and regardless of our three failed cycles.

That's all I'm going to say in editorial on the situation (boy it's hard to stop myself). Thank you for all those emails that told me I had nothing to be ashamed about, encouraging me to keep posting. It meant a tremendous amount to me, but I just can't post in the way I used to, and if I can't, this blog seems a bit pointless. I started it so that I could say whatever I liked, whenever I liked, without fear of who was reading, and that's no longer true.

I have decided to stop posting here, at least in the short term. There is going to be way too much going on in my life over the next few months, and I cannot bear the idea of having to constantly second guess myself in what I write here. The most important thing in my life is getting pregnant, and keeping on posting may jeopardise (perhaps has already jeopardised) my relationship with those who are in charge of getting me pregnant. When you look at it like that, how on earth could I justify continuing? I tried to wait until I was less upset to post this, but sadly I'm still upset, as is H, but I felt I had to make a decision, to clear the air, if nothing else.

Please do keep in touch, you all have my email address, that won't change. I will still be in the blogsphere, but this blog will go quiet. Thank you all for everything you've given me. It would be nice to know that the world as a whole recognised the strength, the power, and the humanity of this community. And it would be nice, as many of you said, to know that a few doctors here and there found it helpful to know what it was like to be on the other side of the dildocam. Maybe they do.

Ask again later

I'm in a bit of a funk about the appointment with Dr Candour today. I had a full-on anxiety dream about it yesterday, which included an appointment with Dr Condescending that never quite happened due to her being overworked, but did involve a long period sitting in an office with her with a bunch of other people who apparently couldn't go elsewhere; potential options on what we might do next, prepared by H on scrappy bits of paper and laid out by Dr Condescending for me to pick up and react to (I reacted very badly to the donor egg one); H disappearing to train with some soldiers over lunch, and me getting cross because he wasn't there to talk to Dr Condescending with me; A man conking out while sitting round the edges of Dr Condescending's office, and it turned out to be because she'd given him heparin when she shouldn't have done; us ending up at Dr Condescending's house where her husband walked out in a bad mood and she told me she was 2 days pregnant; me suddenly realising that it was 16:15 and we were late for our appointment with Dr Candour. I should add that in this dream Dr Condescending didn't look like she does in reality - she was fatter, for one thing. My shrink told me that if you dream of someone but they don't look like they do in reality, it's because you're conflating other people with them. I think I might have been adding myself into Dr Condescending in this dream, since the fatter bit would make sense, plus her hair was more like mine.

I wasn't even going to record it, since I know how much you aren't interested in my dreams, but once I started typing it all just spewed up onto the screen, sorry. I am not going to over-interpret it, suffice it to say I know I'm anxious and this didn't help calm me down.

I'm anxious because I'm going to ask some questions about donor eggs, and our chances of success, as well as the more mundane things about when can we cycle and should we do Zoladex again. In fact, here's the list I prepared and emailed to Dr Candour last night - anything missing?

• We want to do another IVF cycle as soon as we can. How soon is that, given that we are trying not to let the endo get out of control?
• Should we do zoladex again? One cycle probably isn't enough for the endometrium re-setting (I know he doesn't believe in that, anyway), so it's really just to keep the endo under control, and since I've now had 4 un-suppressed cycles since my last lap (2 IVF, one post miscarriage, one now), how much effect is the zoladex still having?
• Given the 4 cycles with estrogen floating around, should we do another lap, even in the absence of an indicative endometrioma? (although who knows, I may have one by now)
• Should we do a frozen or fresh cycle? How good are those embryos we've got frozen, really?
• If we get a good number of embryos again on a fresh cycle, shouldn't we be attempting blastocyst transfer? How good is the discrimination at day 2 really?
• Does the HFEA restriction re number of embryos transferred drop on my birthday exactly (13 Jan), or is there some leeway? How much?
• Are we kidding ourselves, and really we should be thinking about donor eggs now rather than later?

I'm also anxious because I'm remembering Julie's mantra from a post ages ago where she talked about what she wished she'd known, and one of the entries was: "If you've had three failed cycles, switch clinics. No matter how much you like your doctor, they aren't working for you." (I'm paraphrasing as I can't find the entry). I don't want to switch clinics. I like the atmosphere at ours, I trust Dr Candour and Dr Condescending, I like that I can email and get answers to science questions, that they know me, that it's convenient to our house, that they are non-profit making, that they designed a protocol just for me. And they did get us pregnant. Once. 

However, I have a sneaking suspicion that I am being an idiot. As I've mentioned before, there is a clinic in the UK which has double the success rates of anywhere else in the country. I know they screen on FSH, but I would pass that screen (assuming it stays where it's been for the last 2 years). Dr Candour says they also do ET at the clinic next door for patients with crappy prognoses, so that those numbers don't show up in their stats. He is a man of integrity, so I don't think he's making it up, but still their published figures haunt me. I also know that they are much harder to work with - they don't tell you what's going on, you have to go in every day for bloods etc., and they don't give appointments so you can sometimes wait for hours (hard to do with work), sometimes you have to come back in the afternoon (similarly hard with work), etc. Plus they push ICSI and IVIG on you, at more expense. But the success rates, how they call to me. A colleague at work got pregnant there, twice - with her son, and then with her twin boys, having had five failed IVFs elsewhere, so she is pushing me to go to them. I don't want to, but I think I'm being stupid. That's not a very good combination.

To clear up a couple of questions from the last post. We can't just suddenly switch to DE, there is a whole procedure to go through and donors are very hard to find in the UK, although I understand that my clinic has a good list and that the waiting time is not too bad (it can be years). So there is no question of doing half my eggs and half donor, for example. Second, Dr Candour doesn't just uniformly suggest five cycles, he suggested five on the basis that three completely negative cycles would lead him to suggest we stop, but we've had one pregnancy so that improves our chances, hence the additional two before he'd figure we were SOL. The reason that doing additional cycles delays adoption procedures is that in the UK, social services demand that you have stopped any kind of treatment before you start the adoption process, and some  even demand a six month wait time, to ensure you have mourned your biological children and let go of that (not sure six months is long enough, but there you go). So while we are still pursuing treatment, there is nothing we can do to initiate adoption. 

I can't help feeling that we're coming to the end of the runway, with no take-off in sight. Yes, I know we had a short-lived pregnancy, but many people have that and never get pregnant again. Yes, I   know my FSH is low, but I still don't stim easily. Yes, I know we produce good looking day 2/day 3 embryos, but who knows what they look like at day 7 or later? And I will be 40 in January. 40.

Let's see what happens this afternoon. I will probably be unable to post until later this weekend since we're heading off to see friends for the weekend, and not sure what their internet connection is like. I'll update when I can.

0dp2dt: Best yet, yet again

One thing I KNOW for sure - our embryos not our infertility problem. In the first two cycles we didn't have many, but we had good ones. This time eight of the nine which fertilised were looking good today. We're very impressed with ourselves. Some might say smug. We even had a five cell, but it wasn't symmetrical - one of the cells was much smaller than the others - so it wasn't top choice for replacement. Instead we put back two four cells. Both were rated 1.5 - i.e., between good and excellent, which is better than the two four cells we put back on day 2 last time. One was even an 'early cleaver' which I, with my haute knowledge of American culture, refrained from asking "Walt or the Beaver?" about. An 'early cleaver' I'll have you know is one which goes to two cells before its compatriots in the petri dish, and is forever after apparently an annointed one. So we put that one back, along with its best friend, the other 1.5 grade four cell. Which as far as I can see is just an ordinary four cell, with a little bit of fragmentation. But you know, I'm not an embryologist so who I am to express an opinion. And they've frozen everything else, five four cells, the five cell and even our little underperforming two cell (which was graded higher than one of the four cells), so we know have SEVEN embicicles to add to the six we already had (although two of those (one from each of the two previous cycles) are totally crap and not worth counting).

Turns out everyone in the clinic now knows who we are, since even the embryologist, who we've never met before, asked how we were doing post Tuesday's drama. I've got a little scar on my forehead, but nothing too impressive, so I feel a bit of a fraud. I do still feel pretty uncomfortable in my abdomen, but its definitely improving day by day so I'm hoping that by the time it starts cramping in a positive way this time next week, I'll be able to detect the difference.

Part of me feels that the clinic has just become our reality. That we go there once a month or so, or more often at 'peak times', and see people, and have stuff done to us, and that that will somehow just go on and on forever. The idea that anyone could get pregnant the 'normal' way seems to exist in some parallel universe that I can't ever remember inhabiting. Yesterday leaving the hospital was like "attack of the pregnant women." Not really surprising since my ward was in the middle of one of the UK's most important maternity hospitals, and we left during the mid-morning scan rush. By the time we got to the car park we'd passed 45 women, 39 of whom were noticeably pregnant. Being the skiving blog reader that I am I know that most of those pregnant women have their own fears and worries, but somehow I doubt they've ever been in a world where going to the clinic is more normal than having sex. Or not most of them anyway. Who knows, perhaps one or two of them were looking at us coming out of the IVF clinic, thinking: "I've been there, I know how you're feeling." I don't know and I can't know.

H asked me today as we walked back to the car today, embryos on board, if I'd give up America's Next Top Model and The X Factor if it would help us have a baby. "In a heartbeat," I replied. In fact, if you could prove to me that anything would improve our chances, I'd do it. Give up chocolate for ever? No problem. Give up reading? If I really have to. Lose 20 pounds? I'd do it. The reason I'm no longer wheat-free is that it doesn't have any effect. The reason I'm not doing acupuncture, similarly. (These might be important things for you, and I'm delighted for you to do them as I don't think they can do any harm. For me, they are not the point). But show me that something, anything, could definitively increase our chances of a full-term pregnancy and I'd be on it like a shot. Rather like us all chugging the folic acid, no? So what do you reckon, what is it that science will eventually discover is THE key to a full-term healthy pregnancy? Or will there never be a magic bullet, we will be forever destined to struggle with reproduction?

Of muffins, boats and follicles

After a late night last night (dinner at a noodle bar and Volver (quite good, not Almodovar's best but Penelope Cruz is outstanding and oh my goodness I just saw that she's only 32, damn her) with my brother), I woke up later than planned this morning. I wanted to make muffins before going to the 9am scan. I woke up at 8 and bizarrely decided to bake anyway, including doubling the recipe, which then made the prep period longer by needing to chop extra ginger. This meant that I'd only just put them in the oven at 0855. Of course I'd intended to take muffins to the clinic, having had a fabulous response to taking them cookies on Tuesday, but they simply weren't close to being ready so I thought that I'd rather be on time sans muffins, than half an hour late with them.

I therefore had to go off to the scan without H, who was given instructions about how to test for muffin done-ness - he doesn't bake, he cooks, so this was quite a bit responsibility. He also felt bad about not coming with me, and, I think, just a tad nervous as the pattern in our relationship is that he drives and I sit in the passenger seat, so I'm not sure he's that keen on letting me loose on his gearbox. But actually, despite not having driven for ages, I felt fine with it, and realised that I'm a total hypocrite as I usually give H a hard time for driving too fast, when actually I'm just as bad once I'm behind the wheel, if somewhat less aggressive about other drivers.

The shoes today were a very smart pair of black stilettos, again around 4 inches high. Although they weren't red, they were so high that I felt I had to comment. (And Kristin, she was wearing some very skinny jeans which surely mean she's lost the pregnancy weight. She's pretty bloody skinny...). I complimented her on her ability to be present on a Sunday morning in high heels, and she said: "Well, it's certainly an art learning to balance on them". Which didn't really give me any insight but at least it was a form of conversation about the shoes. If she's wearing the red ones again on Tuesday for retrieval, I'll ask her about them then. Because yes, we are on for Tuesday.

• On the right: 23, 17, 17, 17, 15, 14, 12 (plus about 3 around 8)
• On the left: 24, 21, 20, 18, 17, 14, 13 (plus about 2 around 8)
• Lining: 11.7

That makes nine possible (over 17mm) and and other three maybes (the 15 and 14s). So the Ovitrelle injection is at 22:30 tonight. If we ever have to do it again, remind me oh please remind me that I stim slowly but do seem to get there in the end.

When I got back around 0930, the muffins were out. Sadly some of them were a trifle singed at the edges, but H doesn't mind burnt bits. They are good, but I'd already cut the sugar somewhat and these were still way too sweet, so if you do make them, I'd suggest using no more than 2/3rds of the sugar suggested in the recipe. The ginger is what makes them delicious, so don't skip that. Or perhaps I had a challenge in translating from cups to grams (although I used Stephanie Alexander who is usually quite reliable). Why do Americans cook in cups? It's so bloody inaccurate for baking - how do I know how hard you tamped down the sugar or flour? And why measure a cup of butter unless it's melted? You are strange people indeed. I'm convinced that baking is my child substitute. I have the whole Jewish food=love thing (oh how I need to cure myself of this before inflicting it on any potential future daughters) plus baking is just so nurturing somehow. Perhaps I could segue the feeling of nurturing into the garden? Somehow it's not quite so satisfying.

I remain quite optimistic about this cycle. I know there is no real rhyme nor reason for this, it's based on the entirely unscientific fact that we got pregnant last time (and perhaps even had some implantation the first time, who knows, with that beta of five two days after I'd started bleeding). I've found myself planning for what happens with scans etc after a positive pregnancy test, telling people I don't want to fly too much in one potentially busy week at the end of September when I'd be one week post pregnancy test, thinking of how we'll feel on our fourth anniversary of meeting, on 27 September, if I'm pregnant at that point. I keep telling myself not to count my chickens, but idle dreaming leads me back to the optimistic space. I think I'm just going to have to live with it, it's not going away, and I'm not sure being pessimistic really offers that much protection against the misery of a negative in the end. Let's see how I feel (assuming we have two to put back, which is still not a definite) in those few days before the pregnancy test where, honestly, last time I KNEW I was pregnant, much as I wasn't admitting it. Those cramps and pullings I was feeling felt so different than anything I'd felt before.

Clearly, several weeks of madness are ahead of us, either way. To edify ourselves we are about to head off to see this exhibition, and have decided to take the river boat to get there since it's such a nice autumn day. I do like weekends.

Inappropriate shoe watch, day 12

There they were again this morning. Bright red, and at least 4 inches high. Do you think she's just wearing them once every 3 or 4 days or so, and that just happens to coincide with our scan days? Or is she so addicted that she's wearing them every day? She was back in a short, colourful wrap dress today, brown with red, yellow and ochre dots. And the shoes, oh the shoes. Let's see if she's wearing them again next week*.

I've been feeling lots of twinges in the ovaries this week, to the extent that they showed up in my dreams the night before last. I dreamt that I peed on a stick and it was positive. I took it into the clinic to show Dr Casual and he agreed I was pregnant, and that the twinges I'd been feeling were in my uterus rather than my ovaries. In some part of this dream I was in a big science lab - the really old fashioned kind they had at my secondary school with old wide wooden benches with the bunsen burner connections at the front. And I realised part way through that pregnant or not, I should have been at a meeting - which was, in fact, the meeting I was supposed to be at yesterday morning. And then I woke up. I'm so sad that my subconscious is apparently not a science geek like me, and thinks that I can get pregnant in some kind of mad immaculate conception kind of way involving no sperm and no eggs.

Well, in fact those twinges seem to be relating to reality - and in my ovaries, not my uterus.

• On the left: 17, 16, 16, 14, 14, 11
• On the right: 15, 14, 13, 13, 13, 11, 11
• Lining 10.9
• E2 3185 (867 US units)

I'm clearly behind where I was on the last cycle at this point, but hopefully things look good enough that we will get at least six or seven eggs. We have to go in for a scan on Sunday, and we'll decide then if it's trigger Sunday night for Tuesday retrieval, or trigger Monday night for Tuesday retrieval. I don't mind in particular, but I'd slightly rather we went earlier rather than later as it gives me longer off work to chill out and let my body do the good stuff. But really I'll trigger whenever they think it gives us the best chance of getting most of those eggs. I'm hoping for seven, although if we can get things going enough I guess that nine might be possible? That would be good.

*Just found out that we're seeing Dr Condescending on Sunday for the scan. If she's wearing the red shoes on a Sunday I'm definitely going to ask about it!

And they're off! (please oh please)

You remember how I was supposed to be getting more continuity of care? You remember how Dr Candour said that Dr Casual would be around and would make a special effort to scan me, do the retrieval etc.? Well, this morning we got in to an unusually quiet clinic at 0710, only for Dr Condescending (yes, she is back from maternity leave) to come up and let me know that Dr Casual would be away for this week and part of next week. Huh? How come he didn't mention that to us when I spoke to him on Friday? I don't want to be too negative about him, I do like my doctors to stay on their respective pedestals, so I'm thinking that perhaps it's a family emergency, although Dr Condescending's manner didn't really indicate that. She was wearing some extraordinary fuck-me red patent leather high heels. Now she always wears high heels - she says she's small and she does it to feel confident - but red patent leather? At 7am in an infertility clinic? And she doesn't half stomp in those shoes.

Anyway, she was very nice - in the way that she is nice although still remaining condescending - and asked if I was happy to get scanned by her instead. Which I was as actually she gives good scan, not to mention being a cracking egg retriever. And the alternative was Dr ICU. Nuff said. Oh the relief when she said - "I'll just show you what's going on - it's good news - before I measure the follicles." So it is good news. Two 10s and two 11s on the right, two 12s, two 10s and a 16 (where on earth did that come from??) on the left. Sounds like we will get fewer eggs than last time (we got 9, but only 5 fertilised) and I'm trying not to freak out too much about that, but just keep on hoping that we have 2 good ones to put back. I do want this cycle to give us at least the same chance of getting pregnant as we had last time.

The slightly less good news is that E2 is only 725 (203 American). Gaah. It's not accurate given the protocol, but it's an indication. It was only 247 on Sunday, so at least it's climbing, but still. Dr Condescending thinks it will be retrieval next Tuesday. Perhaps I'm just getting harder to stim as I get older? The docs aren't worried, and I'm not really worried, I'm just irritated. It would be so nice to be an IVF superstar and get 20 follicles, be able to do blastocyst transfer and have lovely frosties. But I guess that's like saying it would be nice to win the lottery and not have to do this job any more and be able to pay off the mortgage. Just.not.going.to.happen.

Two embryos please. Just two, lovely, symmetrical four cells with fragmentation below 5%. That's not too much to ask, right? That's just like asking for the bus to come along in the next few minutes rather than when you've been waiting for 20 minutes. Or that you look into the fridge and magically find that your husband went to the supermarket and remembered to buy blueberries. Not a miracle, and not a lot to ask. Just a little ask. Please?

Slow? This is funereal...

Not a particularly encouraging morning. The follicles haven't grown AT ALL. Still five less than 8mm on the left, four less than 8mm on the right. That doesn't feel good on day 7 of stims. Dr ICU didn't seem too worried, but he did tell me to put up the dose to 400. The good news is the endometrial growth - to 8.1mm from 6.1mm on Friday. If that has happened, then it means the E2 must be rising. I asked Dr ICU if he'd ever seen the E2 rising and the follicles not growing, and he said no. So we must just be patient, I guess, and assume that when we go in again on Tuesday morning things will have started moving. Tomorrow we'll get the E2 result from today and that will give us some indication. I'm certainly not going to be underestimating the length of my stim - I've booked the week commencing 4 Sept off work, assuming that I'd stim for 15 days as I did last time. If anything I'm going to go longer this time, so it was a good bet.

Problem for me in making sense of this is we've never been scanned on day 7 before. Let's compare anyway, because it's a distraction

• On cycle 1, on day 5 my E2 was 82, and I had 9 follicles under 7mm. On day 9 the E2 was 482 (132 US units) and I had 12, 14, and two under 10 on the left, and four under 10 on the right. We ended up with eight possible, but only six collected due to the endometriomas. Six out of six fertilised
• On cycle 2, on day 5 the E2 was 253 (68 US units), and I had nine follicles under 8mm. On day 9 I had eleven follicles between 10 and 13mm, and the E2 was 1253 (341 US units). (NB this was an antagonist cycle, so the E2 number is not very indicative of what's going on). We ended up with 9 eggs, 5 fertilised.

So I think I should be staying calm. If they all grow between 2 and 4mm by Tuesday, we'll be in a similar place to where we were last time, and that turned out ok. But of course I am stuggling to do that. I'm freaking just a little bit. No, quite a big bit. What I should be doing is being all Zen and calm and remembering Ovagirl's mantra from the first cycle, picturing my follicles: "like coloured balloons, blowing up into beautiful rounded globes of goodness." I'll go and work on that now.

Vignettes

Work is kicking my butt this week, so this will be just a brief snippet of a few things I don't have time to blog about properly.

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I saw the lovely Kath on Sunday. How jealous are all of you? She is just as lovely as you might expect, although, Kath, I have to confess that I wasn't expecting you to be so tall and gorgeous and glamorous. Not sure why, but I just wasn't. She also, dear readers, looks as if she's about 25, damn her. We had a lovely afternoon, wandering around central London, sitting in the park on deckchairs, visiting an art exhibition, and having a proper English tea. The conversation varied from our spouses, to linguistics, to how our hair was behaving in the weather (not), and, of course, to reproductive issues, and then on to parents and siblings and stroppy journalists. It was lovely to meet a new friend in person. Thank you, Kath, for making that long train trip.

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Did anyone see that press conference last week with Mr Bush and all those babies? It was one of the most yet another cynical piece of political positioning. It made me almost apoplectic with rage. Yes, those babies are all very adorable, and I for one don't want to deny them their current existence on the planet. But GW's statement that "how could we have thrown away these children in the name of research?" made me want to scream. How many people are living with Parkinson's because stem cell therapy isn't available to them? How many researchers are trying to understand the causes of cancer and struggling because they can't do the experiments they think are necessary because the materials they need aren't available to them? How many children are dying from childhood genetic disorders that we don't yet understand, whose treatment could be advanced by investigations with donated embryos? It was one of the most breathtaking examples of only presenting one side of a problem that I have EVER SEEN. Phew.

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The nurse from the IVF clinic called me yesterday - this is our new form of IVF orientation appointment now we are old hands. Her first question was: "Is Dr Candour ok with you starting so soon after, umm, what happened in June?" I heroically refrained from saying, "No, I held a gun to his head as he filled out the form and now I come to think of it you'd better head over to his office to make sure he's managed to untie himself." "Yes," I said, instead, "he's given me the zoladex injection so we are already underway." Wasn't that nice of me? I'll get my reward in heaven, I know.

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I know there was something else I wanted to blog about, but it's gone now, so that will have to do.

ESHRE meeting: What our doctors are talking about when they get together

You all probably saw the sexy articles that were presented at the European Society for Human Reproduction and Embrylogy meeting in Prague last week. You know, the ones about the clowns during embryo transfer, and the one about how 20 anovulatory women who got therapy started ovulating, thus proving that we all have to just relax. Well, I was curious enough to go read all the available abstracts. Below is my summary. Because I used to be a scientist I've probably used more scientific language than is helpful, although I've tried to be clear. I hope it's helpful.

There was a lot going on at this meeting. Which puts the lie to H's rather cynical comment when I told him where Dr Candour was last week: "Good to know he's off drinking vodka and visiting titty bars." Then we both cracked up at the thought of Dr Candour in a titty bar. Sadly H's comment probably says more about H's experiences with sales conferences than about how our esteemed doctors spend their time.

I should point out that lots of studies contradict each other. I focused on the talks rather than the posters (at scientific meetings the sexy stuff gets presented in person, and the less sexy or less prestigious stuff is just stuck on a wall for people to look at if they have time). I lost the will to live part way through reading the abstracts for the 1000 or so posters. I also focused on the stuff that's relevant for me, so I'm sorry, I didn't read the stuff on PCOS or anything much on male infertility. I'm fairly sure you will forgive me.

Protocols, response rates and egg quality

1. Antagonist (short) protocol gives lower pregnancy rate (Al-Inany, Egypt)
2. Antagonist protocol doesn't give lower egg quality in a subsequent FET - pregnancy rates with blastocyst transfer in FET cycles are the same whether blastocysts came from antagonist or agonist cycles (Lee et al, Korea)
3. The flare protocol is better than both long protocol and antagonist in poor responders (meta analysis of other studies by Franco et al, Brazil)
4. In most cycles these days, the stimulation drug is recombinant FSH - rFSH (e.g., Follistim/Puregon). Making recombinant FSH involves isolating the gene and inserting it into a production cell culture like chinese hamster cells (lots of cells grown together in a nutrient broth). The hormone is purified out of the broth. Only the pure hormone is produced. This means that unlike un-medicated cycles, there is no involvement of LH in priming the follicles for release. This was not an issue with earlier protocols because earlier stimulation drugs (e.g., Menopur) were produced by purifying the urine of menopausal women, so there was a low level of LH present. This has been an area of investigation - to see if adding low levels of LH will improve the egg quality.
   Adding rLH to stimulation protocols which use pure rFSH in agonist (long) cycles reduces the rate of miscarriage (pregnancy rates are the same). You might therefore expect that protocols using puregon/follistim which are pure recombinant (r)FSH, would give a slightly higher miscarriage rate than Menopur which contains LH as well in small quantities because it's produced by purification from human urine. This was not tested - the study just looked at adding rLH (e.g., Luveris) to the rFSH. Abdelmassih et al, Brazil.
5. BUT adding rLH to rFSH in a long agonist protocol did not result in higher ongoing pregnancy rate. Andersen et al, Copenhagen, Denmark. My thought is that perhaps women's metabolism is so finely tuned that it's hard to see population effects here, it's about the individual woman and her response. But then I'm not an endocrinologist.
6. AND Pre-treating with rLH prior to starting rFSH stimulation in a long agonist cycle (treating with the rLH for a week after down-regging) resulted in a higher percentage of embryos fertilised (number of embryos was the same). No difference in pregnancy rate. Fleming et al, Glasgow, UK and lots of other places,
7. Women with an abnormal response to FSH stimulation given their age and in vivo FSH level may have FSH-receptor mutations. Lalioti et al, Yale, USA.
8. Taking longer to reach the blastocyst stage leads to poorer pregnancy rates in fresh cycles, but not in frozen ones. The hypothesis is that ovarian hyperstimulation may advance the day of receptivity of the uterus, so that putting back blastocysts a day later than the usual day 5 results in lower implantation - the window of implantation has already passed. The same would not be true in a frozen cycle. Mitwally et al, Detroit and Michigan, USA.
9. Prolonged treatment with DHEA does improve ovarian function in women with decreased ovarian reserve. Although a small sample size, there were significant improvements in oocytes retrieved, fertilised oocytes, and normal day 3 embryos. Gleicher and Barad, New York, USA.
10. Antagonist protocol for priming egg donor recipients has a higher pregnancy rate than the traditional agonist treatment. Casan et al, Valencia, Spain.

Implantation and embryo quality

1. Endometrial receptivity is governed by the upregulation and down-regulation of 100s of genes. This gene expression is different between un-treated cycles at day 7 after the LH surge when compared to ovarian hyperstimulation cycles at day 7 after hcg. At days 1, 3, 5, and 9 the gene expression pattern was the same between the two sets. This indicates that at the day of maximum receptivity the endometrium differs in a stimulated cycle, possibly leading to lower receptivity - although we don't know that. Horcajadas et al, Valencia, Spain.
2. Embryo scoring parameters that affect implantation significantly are: Nuclear alignment; nucleolar (the nucleolus is one part of the cell nucleus) number, size and alignment; day 2 cell number, symmetry and nucleation. Everything else did not significantly affect implantation rate (ie many of the characteristics our clinics use including day 3 cell number and alignment etc, and the morphology at day 5). L. Scott, address not given.
3. Many embryos are mosaic - i.e., some cells are chromosomally normal, while others are abnormal. Oocytes are much less frequently abnormal than the resulting embryos (7-10% versus 70% in young women), indicating that errors come during embryonic cell division, rather than arising in the egg itself. The only way currently to screen for mosaically abnormal embryos is PGS, which is controversial and has yet to be proven in a large scale study to result in higher levels of implantation. Lundin, no address given.
4. Cigarette smokers have less receptive uteruses (uteri?). Statement of the bleeding obvious by Soares et al, Valencia, Spain.

Other factors affecting cycle outcome

1. With a yah, boo, and sucks to the article which got all the publicity, which showed that some women with no ovulation who received therapy started ovulating, this study shows that levels of stress had no effect on IVF cycle outcome. Lintsen et al, Nijmegen, Netherlands.

Miscarriage

1. Women with premature ovarian aging have a lower pregnancy rate and higher miscarriage rate, need higher doses of stimms yada yada yada, but interestingly their embryos do NOT show a higher rate of aneuploidy. I.e. something else is causing the higher miscarriage rate , not a simple eggs are crap --> embryos have the wrong chromosomes problem. Weghofer et al, USA
2. Women with recurrent fetal loss (pregnancy loss after seeing cardiac activity) had increased expression of inhibins a1β1and a4β1 compared to women with recurrent loss of empty gestational sacs. They can't figure out the mechanism. Anim-Somuah et al, Liverpool, UK
3. The strongest predictive factor for secondary recurrent miscarriage (after number of previous miscarriages) is the gender of the first child - having a boy is hypothesised to activate the mother's immune system. How that fits with all the controversy around the immunology stuff I don't know. Nielsen et al, Copenhagen, Denmark

Immunology

1. Peripheral blood concentration of natural killer cells (PBNK) bears no relationship to uterine concentrations of natural killer (uNK) cells. PBNK levels don't vary during the menstrual cycle. Levels of PBNK were similar between recurrent miscarriers who carried their pregnancy to term versus those who had another miscarriage. Rai et al, London UK (From Lesley Regan's lab)
2. Uterine NK cells have a strong role to play in implantation, providing the mechanism guiding maternal epithelial cells towards the embryonic trophoblas cells via oxygen sensing and synthesis of a compound called VEGF. Higher concentration of uNKs leads to higher pregnancy survival rate in pigs - concentration goes up three-fold at critical points in healthy embryonic development. Croy et al, Ontario, Canada.

Genetics

1. The egg's polar body can be used to do genetic testing even before selecting which eggs to use for insemination (very creative technique developed by an Italian group in response to the law in Italy which says that only 3 embryos can be created and all must be transferred). More than 50% of eggs in women over 35 had aneuploidy. Ferraretti et al, Bologna, Italy.
2. BUT this misses post-fertilisation genetic problems. Evidence from Delhanty (not sure of address) says that more than 50% of genetic abnormalities in the embryo are post-meiosis and would therefore not be picked up in polar body testing. They found a similar ratio of abnormal embryos in those with recurrent miscarriage and those with recurrent IVF failure.
3. Women with recurrent miscarriage or multiple IVF failures produce very few viable embryos. Only 7.5% of embryos surveyed were normal with PGS, only 1.5% implanted and only 1% produced ongoing pregnancies. Bianchi et al, Yale, USA.
4. Severe male factor infertility contributes to a high rate of chromosomally abnormal embryos (95% in non-obstructive azoospermia). Magli et al, Bologna, Italy.

Endo

1. Endometriosis may be present in everyone, and only become a pathology when a certain stage is crossed. Not clear what that stage is
2. Women with mild or moderate endometrisis have a decreased ovarian reserve as measured by anti-mullerian hormone (AMH) which is produced by small antral follicles. Antral follicles are also more diverse in size in women with endometriosis compared to those without endo. Cunha-Filho et al, Porto Allegre, Brasil.
3. Surgery of even mild endo has a positive effect on pregnancy and live birth rates. Mohammed Saleh et al, Saudi Arabia

Long term effects of IVF/ICSI

1. ICSI children at 8 years old had no substantial differences in development to children who were not the result of ICSI. There was a higher incidence of congenital malformations (10% vs 3.3%) but these were all correctable by minor surgery.

Pregnancy

1. Vanishing twins lead to a higher incidence of intrauterine growth restriction later in pregnancy for the surviving singleton. The later the twin vanishes, the more likely there is to be an issue. Pinborg et al, Denmark

Endings and beginnings

Yesterday happened as expected. Dear Leggy, thank you for clinging onto hope, but really there was none. I did have flashes over the last week of thinking we'd go in and there would be our embryo, heart beating away, but they were just flashes and I was fundamentally unsurprised when the sonographer's wanding showed a gestational sac that had started to collapse. It was long and thin like one of the balloons that you use to make balloon animals with. Only not orange or purple or anything. There was no sign of anything in it, the yolk sac from last week had already reabsorbed. The pregnancy had definitely failed. I got her to tell us our hcg result from last week. It was 9,100. Not really what you're looking for at 7w1d. So really, I think we could all have declared this over last week. No matter, this is the life (or not) we got and I'm not going to get angry at anyone after the fact.

We went up to the private ward to get checked in etc for our ERPC. It stands for the Evacuation of the Retained Products of Conception (that link is patient info from another hospital in the UK  - best explanation I found through googling). It's supposed to be more gentle than a D&C. Then of course we waited and waited. Turned out Dr Candour was in a consultant's meeting that morning so he didn't show up until 9ish to do our pre-op discussion. That was after the nurse had checked us in. During which she asked me if I was pregnant. Which I thought was a bit of a dumb question. And which, for a change, I actually said to her. Well, what I said was: "That's kind of the point, isn't it?" She had the grace to blush, and said, "Sorry, we have to ask everyone."

We also had a little drama in that it had not occurred to me to contact my health insurance company. After the nurse had found this out, the insurance lady bustled up to my room and told me: "You know you must call them to get pre-authorisation before you come in, this really isn't the right way to do things." Luckily I remembered that in February when the insurance co had authorised the wrong date for my lap we had called them that day and they'd been good at sorting it out, so I pointed this out to her, told her she'd have a letter in the files from them from February with all the contact info on, and that my company has a dedicated line to them so presumably I could call them and we'd get it all sorted. She went off to get the letter and I burst into tears. She didn't come back at any point during the day so I assume she got it sorted. Insurance ladies aren't famous for letting you leave the hospital - or even have the procedure - until you've paid.

When Dr Candour turned up he was his usual calm, kind and reasonable self. Which of course made me cry. He hadn't seen the notes from the clinic so I told him that everything looked bad. He was, of course, not surprised, went through the procedure, the risks etc. The anaesthetist was also very kind. It was the same woman who'd done both of my laps, and she remembered (from the notes presumably) that I had problems with dehydration so she told me to keep drinking water until we had to go for the procedure. Which wasn't until around 11:30. So we waited. At around 11:10 a junior doctor came to tell me she was going to insert a drug which would start to soften the cervix. She was, to put it mildly, cack-handed. That made me cry a bit. After that I started to get mild cramping and at 11:30 they wheeled me down to theatre. In the prep room I started to cry again. Not sobbing, just tears running from my eyes. It just all felt so sad. Although I'd started to give up on this pregnancy two weeks ago, I guess it's not really over til it's over. Dr Candour came out to see me again, and after all the prep I was put under at about 11:40. At 12:15 I was waking up in recovery, and by 12:40 I was back upstairs in the room, and H was there waiting for me.

As always after a general my mouth felt horrible, and no matter how much water I drank it wasn't helping much. The nurses were very sweet to me, and H kept asking if he could get me anything. He was trying to work but gave up and watched the tennis instead after a while. I felt ok, just crampy. They kept giving me painkillers, but told me I had to eat before I could have the good stuff. That was encouragement enough so I ate a sandwich at about 13:30 and got some di-hydro-codeine shortly afterwards. That made me feel a bit better. At this point I wasn't really teary any more. I'm not sure why. Perhaps it was a relief that things were over.

Around 14:45 Dr Candour came to see us. He said that everything had gone well. The uterus wall looked good and smooth afterwards so he was confident I would not need a second ERPC (happens in about 8% of cases). He also said that everything looked very sterile and intact, so he did not think I had suffered from an infection that caused the embryo demise. He had sent samples off for histology and genetic testing. I asked if they really had enough for genetic testing given we couldn't see any embryonic tissue on the scan, and he said he didn't know but it was worth trying (This is where I get a little cross about the delay. Presumably we'd have had more chance of finding something if everything hadn't already deteriorated. Oh well). The histology scan will see if there was a problem with blood clotting etc. He asked us to make an appointment to see him in about 3 weeks, when he'll have all the results back and we can make a forward plan.

I had been freaking out over the last few days about whether I am kidding myself even trying this again. At 39, having been pregnant only once in my life, and then with an embryo that had no chance of developing, I wonder about whether my eggs are just never going to make it. I saw that the chance of genetic abnormalities of the embryo at my age is 1 in 70. That's pretty high. So I asked Dr Candour whether he thought that was our chance, that we've had our pregnancy, it's not worth us trying again. He answered that the fact we got pregnant was definitely a good thing. That what they worry about most is lots of cycles of negatives with no sign of implantation. That it's implantation that is the biggest barrier to successful pregnancy, and one that they can do the least about - and the one they understand the least. So the fact we got implantation this time gets us over a hurdle, and, as far as he is concerned, makes it worth trying again. I can't tell you how much of a relief that was. I know that it is entirely possible that we won't get pregnant again next time, or that if we do, that we may have another miscarriage. I know that. But I want to try again so it matters that the doctor I trust to help us make that decision thinks it's worth it.

We were released at around 1600 with a packet of augmentin - prophylactic antibiotics. Unlike last time, the nurse in charge sent a junior down to the pharmacy to wait for our prescription, and wrote URGENT all over it so we didn't have to wait two hours. That was a relief. H and I got home fast and decided on gazpacho for dinner as it was another horribly hot day, and I thought it might work ok with how horrible my mouth felt. H went off to get the ingredients, and we then chopped and blended together. He did a bit of work and I watched a soppy movie. We had dinner (delicious. First time I've made gazpacho but totally worth it) and watched an episode of ER (not sure that was our best choice, but our next Lost episode is the one where you get the back story of the Mr Eko group and it looked pretty terrifying so I thought probably not my best option).

All evening I was mostly doing ok. Each family member texted me which was nice. I wasn't teary. I felt sad but not bereft. I was bleeding a bit but not too much. Dr Candour told me that a little light bleeding might continue all the way to my next period. Around 10 I went to bed and read some more of my fantastic chick-saga type novel that I'd carefully selected last week. No pregnancies, just lots of family feuding and delicious jewels. Then I slept. With a fan blowing because it was so bloody hot, but I slept and I don't really remember the dreams. I slept a lot better than the previous night when I kept waking up with Imelda Staunton singing into my subconscious "maybe they're really magic, who knows" in my ear (yes, I've been overdosing on Into the Woods).

This morning I woke up sad again, but I do feel ok. I'm not going to work til Thursday, but yet I don't feel ill - not like recovering from a lap when I really needed the time off because I was in pain. I have a few cramps, but Dr Candour told me that was the uterus shrinking itself back and was a good thing. And they're really not bad - not even bad enough to take painkillers any more. I'm bleeding a bit, but nothing major. I'm sad, but it's a dull kind of ache, not the sharp, immediate panicky pain of seeing that ultrasound last week. The kind of ache I'll carry around for some time, I imagine. Dr Candour told me I'd really feel the hcg and progesterone coming down, but other than the sadness and feeling of fragility I'm not noticing anything. Luckily the heat has broken a little, so it won't be too miserable being at home today with no air conditioning. I've got gazpacho for lunch and plenty of work admin to keep me busy if I so desire. Or else that chick-saga to finish.

I'll be ok. I want to get on with further treatment so we can see if we can finally get that baby we're dreaming of. I know I'm going to be sad, and I feel a bit lonely, but I know that that's normal. I don't know how I'm going to manage to cope with work again, but I guess I'll manage that, as well. My first appointment on Thursday morning is to get my annual review feedback. Not sure that was my best option, but it's the only time my evaluator can see me. How much do you bet that at least some of the meeting involves me crying? My evaluator is a sweet, but conservative, Polish man so I'm not sure how well he's going to cope. Poor guy doesn't know what he's got coming.

Bringing the end a bit closer

It pays to say (or type) what you think to your doctor. In writing to Dr Candour yesterday to let him know that I didn't want to take him up on his offer of a consultation, I explained that I wanted to go for the ERPC as soon as they could confirm that things were over. He has just written back to say that he can fit me in next Monday, so he suggests I book my scan for first thing that morning, then come straight over for surgery later that day. Sounds like a deal to me. I need to check with him if being on heparin changes anything, but other than that, consider me booked in.

Just FYI, he said that the reason for their conservatism is that about six years ago in Bristol, a woman was told she had had a miscarriage. A week later things were found to be ok. The same thing then happened again with the same woman two years later. Since then "all units scanning this early have diagnosed a miscarriage over two separate scans." Seems to me I've already had the two scans, but I think because the first one did show (perhaps) a fetal pole, that it doesn't count. At least I understand the protocol now. That poor woman.

Thanks for all your comments. I actually found it harder to wake up this morning than I did to get through yesterday. It's the waking up and realising that things are just going to go on being really bad that hurt the most. I don't have the words to type about it right now, no doubt I will in due course. This is why we blog, right? Anyway, thanks again.