Navigating through the IFs of IVF!

So, here I am just popping BCPs (and of course Metformin and prenatals)… but no fix of syringes every night! How I miss them! My life seems to have been taken over by my RE’s protocols. It has (almost) been 5 months since the actual treatment started (i.e. first IUI) and I don’t seem to remember how life is without injecting medications or creating an IF POA for the next several weeks to come. Now that I have officially started the IVF cycle and will be enjoying the BCPs for the next 3 weeks, I had to at least get my fix of information overload to comfort myself. Topics related to IVF addressed below: BMI, E2 levels, SCSA, HBA, PICSI. I will keep updating this post as I find more information…

High BMI & IVF

Having a high BMI, in simple words, being overweight/obese can cause fat deposition in abdomen area… supposedly this can distance your ovaries from the vagi.na. So, during the ER, when they try to reach the ovaries, sometimes they have trouble retrieving the eggs. Hence, there is a cut of limit for BMI for a person to qualify for IVF (varies from clinic to clinic).

Now, I have never been skinny, but I am not obese either (as per the BMI). My right ovary, which is the one which seems to do most of the work… seems to go high up in my abdominal cavity (especially when hyperstimulated) towards the end of a cycle… the RE somehow has to make it come down (by pushing on my abdomen area) for it to be visible in the u/s. My left ovary is never ever a problem. I hope this is not going to be a major issue during ER! I need to work out a little in the next 3 weeks before I turn in to a zombie (with the medications)… may be that will help? I don’t know… but at least I will be satisfied that I tried to help my ovaries… and of course not being lazy and working out is always good!

E2 Levels

I knew Estrogen (E2) levels are pretty important in any cycle, but I never seemed to have registered them in my brain during the CD3 b/w. My FSH has consistently been around 3’ish at CD3. Which supposedly indicates good egg quality and quantity (ovarian reserve)! Similarly, having a very high E2 level on CD3 could indicate poor ovarian reserve or an active cyst (active ovarian cyst secrete Estrogen). Higher E2 at the start of the cycle might also indicate a shorter stimulated cycle and hence poorer follicle/egg quality (not enough time for the eggs to mature). Dr. Google also informed me that a very high E2 during an IVF (ER/ET) could lead to a cycle cancellation, because it could indicate a severe OHSS in the making or some studies even seem to show that E2 levels above 4000-6000 units seem to reduce the chances of implantation. I have read blogs where in spite of good embryos (and good ET), it was a BFN and RE (possibly) attributed it to high E2 at the wtf meet! For more information see the following links: estrogen affects fertility window, poor egg quality and E2 levels, E2 levels, estrogen and progesterone levels for ivf.

This piece of info sent a chill through my spine! What are my E2 levels!? I have been “assuming” that my ovarian reserve is (supposedly) “good”… but maybe E2? I emailed my nurse and it seems that my E2 levels ranged from 50 to 75 at CD3 (during the last 6 cycles). Higher levels (relatively) were noted whenever cysts were identified in the ovaries (or so I would like to believe… I am sure if there are super active cysts, they probably give out tons of Estrogen and not just 10 and 15 units more). The lab cut off for my clinic is 100 units (FertilityPlus says 75 is upper limit in the normal range)… so I guess I am okay (had it not been okay, I would have probably already heard about it from my RE). E2 levels rise as follicles grow… the more the follicles, higher the E2 levels. My nurse mentioned that they do not cancel a cycle for high E2 levels (she didn’t reconfirm the piece of information that I gathered – that very high E2 reduces chances of implantation), however if they are very high, it could lead to severe OHSS (thus cancelling a cycle).

So, I still have "hope"… my FSH is good and E2 is not high-high. I have stopped believing in luck… everything seems to be random and coincidental… or else if luck really existed, I would have already been pregnant (and carried it through) after so many tries! We are doing all we can to shape our future, our destiny… so hopefully we will never have to say that we never tried!

DHA

For the last 1.5 years I have been taking the prenatals that my OBGYN had prescribed (sigh, it’s been that long)! However, the prescription ran out and I had requested my RE to refill it. When I went to pick up the prenatals, I noticed that my nurse had asked for the same prenatals that I had been taking all this while, but with an additional tablet of DHA. Now, I had vaguely heard about DHA, but never really researched about it (every time I come across something new, I realize that there is still so much that I don’t know and there is still so much I could do). So now that I am going to be adding DHA (supplement) to my diet, I decided to look it up. General information about DHA can be found here: Docosahexaenoic Acid (DHA). The DHA prescribed to me is algae/plant based. Now, this is not really an IVF related entry, but I am just trying to summarize all the information I am gathering (so here it is)!

Some of the facts about DHA:

• Advanced Attention Span in Babies Whose Mothers Eat More Essential Fats
• Current research suggests adequate levels of DHA may help increase a developing baby's cognitive functioning, reduce the risk of pre-term labor and decrease the risk of postpartum depression. (DHA Intake During Pregnancy and Breastfeeding)
• DHA can be found in seafood, nuts, meat (organ) products, but is generally not adequately consumed by pregnant women. Average American diet is known to be low in DHA.
• DHA can lower triglycerides (PCOS women tend to have high tryglycerides).
• Fish based DHA could have ocean borne contaminants – mercury etc.
• Low levels of DHA have been correlated with memory loss, mood swings and other mental and visual conditions.

SCSA, HBA and PICSI

I recently came across Murgdan’s post about abnormal sperms and some of the diagnostic and procedures associated with it! (You might already know her and might have read this already.) She has done an absolutely fantastic job in describing SCSA, HBA and PICSI. I am not going to try to steal the show from her... here are the links for her posts (if you haven’t checked it out already): SCSA and PICSI


Just a brief background:

Sperm Chromatin Structure Assay (SCSA): Research indicates that sperm with high-levels of DNA fragmentation have a lower probability of producing a successful pregnancy. SCSA is able to identify DNA fragmentation in sperms.

Hyaluronan Binding Assay (HBA): HBA is a qualitative assay proposed to determine the maturity of sperm in a fresh semen sample. The assay is based on the ability of mature sperm to bind to the substance hyaluronan (a major component of the external coating of female ova (eggs)) necessary for proper sperm function.

PICSI: In ICSI, an individual sperm is selected and injected into an oocyte to achieve fertilization. The PICSI device makes it possible to select a functionally competent sperm (mature, with less DNA damage and fewer chromosomal aneuploidies), indicated by its ability to bind to hyaluronan. Preliminary clinical trials suggest that sperm selected by PICSI may improve clinical pregnancy rates and reduce miscarriage rates.

IUI – Cycle # 1

I started my IUI cycle towards the end of January 2009. The cycle medication normally starts with b/w and u/s on day 3. I was towards the end of my menstrual cycle and was hoping that my AF would start soon (so that I could start my IUI cycle)… though nothing seemed to happen till day 35! So I went in for u/s and b/w to see if I could be induced. Surprisingly, I had not developed any lining on my uterus (to shed during a period), so even if I had been induced, it would not work. The b/w it seems turned out such that… my hormones were at a level that one would have during day 3 of a new cycle. So my RE decided to start my medication.

I administered Follistim (http://www.follistim.com) every night (75 IU for 4 days, 100 IU for 4 days and 150 IU for 2 days) at home starting on day 3 of the cycle. I was scared big time to poke myself in the belly the first night, but honestly it wasn’t bad at all. Though I did realize that I had different sensation every night (from no pain to sharp pain to tingling sensation)! I guess things changed as my body hormone level went up/down. Follistim made me bloated, tired, my boobs were sore, nipples were extremely sore, I was a lot more thirsty, had an increased appetite. My follicles went from too small (less than 10 mm) to 15 mm + as soon as I up’ed my dose to 150. With PCOS (excessive follicles in the ovaries), the doctors do not want to stimulate you to quick, because it could cause a severe hyperstimulation (OHSS: http://en.wikipedia.org/wiki/OHSS). I was monitored (b/w and vaginal u/s) on day 3, 7, 9, 11 and 13. On the 13th day of the cycle (3 follicles > 18mm @ right ovary and 1 follicle > 15 mm @ left ovary), I administered myself the prefilled syringe of Ovidrel (http://www.drugs.com/mtm/ovidrel-injectable.html)! We were supposed to go to the RE on day 14 for the 1st insemination and day 15 for the 2nd insemination (My RE does 2 insemination to increase the chances of catching the ovulation post induction).

Insemination went well! Husbands sperms were collected (both days – good count) and were washed (Sperm Washing: http://en.wikipedia.org/wiki/Sperm_washing). The insemination procedure did not take very long (approx 10 mins) and there was no pain or cramping or bleeding involved. I rested both the days after IUI. The Ovidrel did make me bloated and soar. My ovaries cramped, my feet hurt bad, caused headaches and I was very thirsty… it was manageable and it all subsided within 3-4 days. I went in for progesterone check 4 days past first insemination. Progesterone level was 6.4 units, the doctor recommended taking an Ovidrel shot to up the levels (10 or above is required for implantation to occur). I had similar symptoms to my first Ovidrel shot, though the intensity of all the pain was higher! My ovaries were cramping badly and I couldn’t move much, had some chest pain and had difficulty urinating! I was afraid it was OHSS! I ended up calling the emergency line at the RE’s office and spoke to a nurse. According to her, as long as I had not stopped passing fluids (urinating), I should be okay. She scheduled an u/s and b/w appointment for the following morning. The u/s revealed a few cysts in the right ovary (not very big). Cysts normally subside by the end of the cycle. Sometimes they can persist through pregnancy. If they don’t subside a cycle might have to be skipped (if not pregnant)! My RE mentioned that bloating and pain normally increases towards the end of the day (because of physical activity throughout the day). He also mentioned that since the Progesterone levels were above 3 units (during the progesterone check 4 days past insemination), ovulation had occurred and these cysts were not just left over eggs.

My OHSS symptoms subsided in the next week or so. I was perfectly fine initially during the 2 weeks waiting (2ww). With all the medication I had had thus far, it was hard to tell if all the changes/symptoms were pregnancy symptoms or medication. My August 2008 experience had taught me not to read too much into these symptoms. Though it did not stop me from looking up information online… it just made me a little cautious and less anxious! However as the 2ww almost came to an end, I couldn’t stop myself from trying an EPT! I used the Walgreens brand (I had spent enough $$ last yr to realize that the brand name didn’t make much of a difference) 2 days prior to going to the RE’s office for b/w! It was slightly positive, though it could have been the Ovidrel (HCG)! I tested again the day before (b/w) and the line was much lighter than the previous day! I was kind of mentally prepared for a BFN at the RE’s!

Never ever has this treatment not surprised me (till date)! My b/w results were indeterminate. My HCG level (pregnancy hormone) was 3’ish. If one is not pregnant, the levels are below 2 units. Progesterone levels were 6’ish (not suggesting pregnancy). I was asked to come again 2 days later for another round of b/w. Even though I had anticipated this (after my EPT), I was frustrated and angry! Why me!?! I cried a lot that day, didn’t want to speak with anyone. Though I calmed down after speaking with my husband at night and I was pretty normal from the next day. The second round of b/w was definitely a very BFN for sure! My AF started the following day. I cramped like never before… I could hardly move during the first half of the first day!

Fertility Diagnostic

The extra money that was going towards the insurance finally came to good (?) use. In October 2008, we started going to the RE. We have been fortunate enough to be living in a big city, where finding good doctors and other resources are not as difficult as it would have been had we been living in a remote hamlet!

During the initial blood work (b/w), my husband’s b/w result was great! My cholesterol and sugar was on the higher end of normal limit, which is commonly found in case of PCOS; my insulin was higher than the average that women my age have (but with in limit); there was an imbalance between my testosterone-estrogen-progesterone, fortunately my thyroid was normal; rest all looked okay. Initial ultrasound (u/s) showed several follicles (20+) in each ovary (no cysts). I had hoped that the 20 lbs that I had lost in past 1 yr would help me with all these PCOS related issues; however things didn’t quite change much (from my previous annual b/w)! FertilityPlus.org is a good reference for hormone and fertility bloodwork levels: http://www.fertilityplus.org/faq/hormonelevels.html.

My RE wanted me to start with Metformin which would help with the insulin and sugar levels, and testosterone, as well (PCOS & Metformin http://www.ovarian-cysts-pcos.com/glucophage-metformin-pcos.html).

In the mean while (during my diagnostic phase), my husband underwent semen analysis (SA), which revealed that he had a good sperm count, motility, volume; but a lower than average morphology. This, from what I have read, is very common since there are very strict requirements for the morphology if someone is undergoing fertility treatment. Had my condition been normal, the morphology would not have been as significant an issue as it is turning out to be with my PCOS. To me, since his sperm count was good, lower morphology was not as bad an issue as it would have been, had he had a bad sperm count with a bad morphology (example: 1 good in 100 versus 10,000 good in 1,000,000).