Thursday it is! ...ER for IVF # 1

Just heard from my nurse – the retrieval is Thursday (and not Friday). My E2 is screaming high and they do not want it to blow the roof off… it is 4680 (ICLW’ers: please read my previous posts for my follicle scan/count story)! I will be triggering tonight (with just 1 syringe of Ovidrel – I guess normally it is 2) and have to go in again (tomorrow morning) for b/w and u/s.

The dates so far for IVF # 1 are as follows...

• Egg Retrieval (ER): Thursday, July 23, 2009
• Egg Transfer (ET): Sunday, July 26, 2009 or Tuesday, July 28, 2009
• Beta: Thursday, August 6, 2009
• Tentative WTF appointment: Thursday, August 13, 2009… this is something I asked for! No, I don’t want to have that meeting, but just in case things don’t work out in our favor, I am not willing to sit on my ass till September mid/end wondering what went wrong. It is very difficult to get an appointment with my RE and on top of it he is supposed to go out on vacation around end of August... hence the tentative appointment!

I have already started loading up on Gatorade and drinking tons of water. As you might have already figured, I am shit scared of OHSS with the big team that I am carrying. I just ran the last batch of errands before my IVF break. I am trying to ease my DH’s woes in case I turn in to a zombie! I hope I look back and laugh at how much I prep’ed being worried that I would be knocked out with OHSS. Any tips about how to deal with it are greatly appreciated.

My Jackfruits - IVF # 1 B/W & U/S Update

I stopped counting after my RE went above 25 follicles on each ovary. There probably are around 60 or more follicles in there. It sounds unbelievable to me and even to type this up, I feel like I am bluffing! My ovary dimensions are ~ 50 x 70 mm. The ovaries don’t look anything like they normally do… they look like a big-ass pomegranate… or may be more like Jackfruit (commonly found in Asia). Surprisingly I feel less discomfort than I have even felt during IUI stimulation (with 1 to 5-6 follicles with Follistim)… maybe it’s the Lupron! However, I am becoming an emotional wreck... I can start crying for any reason… I haven’t shed too many tears as yet, but I am at the verge of bursting out for anything out of the normal. I am so scared that this is abnormal and will result into not so healthy eggs and the cycle will be doomed!

When the RE just glanced at the ovaries, he was sure we would be triggering tonight, but after the measurements he realized that there were quite a few at around 15 mm, and he wanted them to grow more… so most likely we will be stimulating for one more night and will be triggering tomorrow for a Friday retrieval. Oh and it took him around 10 minutes to count and measure my package! Of course I do not have the blood results as yet… so will know for sure this afternoon. I also asked my RE if it would take longer for the ER for me since I have so many follicles, he mentioned that it will be a few minutes more than it normally does. He also confirmed what I have feared… since I have so many follicles, I will have a lot more discomfort after the ER and they will prescribe some pain medication. At my RE’s clinic, it seems that they clear out each and every follicle (even if they are less than 10 mm) during the ER… which reduces the chances of (severe) OHSS… I am not sure if this is the norm or this is something specific to my clinic.

5th b/w and u/s today (July 21, 2009 – after 8 days if stims).

• Follicle count: ~50+ eggs (both ovaries combined) measuring 11 to 18 mm
• E2: 4680
• Ovidrel Triger tonight
• Uterus Lining: 11mm (Type 3)
• Next appointment: Wednesday, July 22, 2009
  

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4th b/w and u/s (July 20, 2009 – after 7 days if stims).

• Follicle count: 30+ eggs (both ovaries combined) measuring 11 to 16 mm
• E2: 2619
• Follistim: Reduced to 75 IU
• Lupron: 10 units
• Uterus Lining: 11mm (Type 3)
• Next appointment: Tuesday, July 21, 2009

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3rd b/w and u/s (July 18, 2009 - after 5 days of stims).

• Follicle count: 8 between 11 to 13 mm (several between 5 to 10 mm)
• E2: 900
• Follistim: Reduced to 150 IU (from 225 IU)
• Lupron: 10 units
• Uterus lining: Type 3, 8 mm
• Next appointment: Monday, July 20, 2009
  

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2nd b/w and u/s (July 16, 2009 - after 3 days of stim).

• Follicle count: 20-30 follicles in each ovary... all less than 10 mm
• E2: 500
• Follistim: Reduced to 225 IU (from 300 IU)
• Lupron: 10 units (stays same)
• Uterus lining: Type 2, 5 mm
• Next appointment: Saturday, July 18, 2009
  

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1st b/w and u/s (July 13, 2009 – no stims).

• E2: 67
• Follistim: 300 IU
• Lupron: 10 units

Answers to IVF Questions

We meet with our RE last week for an IVF consult. The RE explained in detail what the IVF procedure would be like. He also answered several questions that I had come up with (see post Q for IVF for background information). Below is a summary of all the questions he answered:

Do we need to do a Clomid Challenge Test and Basal Antral Follicle Count?
No! My day 3 FSH has been < 5 for the last 5 tests (indicating good quality/quantity). I seem to have tons of eggs during every scan and they have had to watch out to make sure that they did not over stimulate me during IUI. So quality and quantity should not be a problem and we do not need to do any more diagnostic as of now.

What are the chances of me having endometriosis? How can we confirm?
Minimal, nothing (cyst/scars) seen in u/s and I do not have any pains and aches.

What are the standard IVF protocol (lupron/long, flare, antagonist) used at the clinic? Which one suits me best and why?
Lupron, since that seems to suit the best for PCOS patients.

How many minimum mature eggs required to continue with IVF (egg retrieval)?
4 minimum

Will we be doing a Mock Transfer?
Mock transfer was already performed prior to IUI and it’s an all clear.

What is the optimum lining of the uterus for implantation? Have I had triple stripe lining?
Optimum lining is 6 mm. I have had at least 8-9 each time. I have had triple stripe lining (also called as Type A) during the pre ovulation u/s.

Should we be doing a PGS/PGD?
PGS/PGD is not recommended unless there is a genetic disorder identified in the family or if there are multiple miscarriages. RE will not recommend this now. When all chromosomes are screened there is 97% reliability in the screening results.

Do I qualify for the clinic’s Embryo Quality Study?
I do not, since I have PCOS.

What are the success rates for IVF and FET?
IVF success rate in my case is approximately 60% and FET success rates is approximately 50%.

For IVF - ICSI or Assisted Hatching? GIFT/ZIFT an option?
GIFT and ZIFT are rarely used since the success rates are very low. ICSI is the way to go. Assisted Hatching is performed when a day 3 transfer is done, this helps in implantation.

My progesterone level 4DP-IUI has been around 6 units? Is it something to be worried about?
Progesterone level of 5 is required for implantation (which is also supposed to be the level indicating that ovulation has occurred). With IF treatment the RE’s like to see a 9. Since I am taking Prometrium, I should not be concerned about low progesterone and lack of implantation.

Should I be concerned about OHSS during IVF? How is that monitored/controlled? Does OHSS lead to IVF cancellation?
During egg retrieval (ER), all the follicles (mature or not) are emptied, therefore the chances of hyperstimulation post retrieval is very low. There will be some discomfort since the ovaries are large, but severe OHSS is probably not a concern. Regular u/s and b/w will help in monitoring the ovaries.

Day 3 or 5/6 Egg Transfer (ET)?
RE recommends transferring 2 embryos in my case (assuming 2 good embryos are identified). Day 3 transfer will be performed if two really-really good embryos are identified (remaining will keep growing in the lab for a possible FET). It’s quite obvious that uterus is the better incubator (as compared to the lab), so transferring the really-really good embryos in the better incubator early makes sense than leaving them out (in the lab) for the next 2-3 days. If there are several embryos doing well and it’s hard to tell which ones are the really-really good embryos, we will be waiting till day 5/6. This will give a chance for the really-really good embryos to stand out… these two will then be chosen and transferred (remaining will keep growing in the lab for a possible FET).

Is Baby Aspirin recommended?
RE’s clinic prescribed Baby Aspirin to patients for two years (after studies showing increased successful pregnancy rates). However the clinic did not see any increase in pregnancies, where as they noticed increased bleeding and bruising in patients. They no longer recommend Baby Aspirin.

IUI – Almost Cycle # 2

I went in for day 3 b/w and u/s for this new cycle (early February 2009). I was positive and hopeful! There was 1 cyst on my left ovary. The doctor mentioned that if the cyst is not secreting any hormone (which would be detected in the b/w), we should be okay with starting a new cycle. The b/w was good; we could start the 2nd IUI cycle!!!

I started off with 75 IU of Follistim again (for the next 4 days). I had started to feel a little discomfort during these 4 days. I went in for day 7 b/w and u/s. I had more than 5 cysts each greater than 50 mm in my right ovary and a few small ones in my left ovary! My ovaries were almost double the size. The cycle had to be cancelled! I was disheartened!

Currently, I am towards the end of this “waiting” cycle. My ovaries have cramped once in a while and I have been tired at times… no other pains in this month! I am going for acupuncture once a week and have not really done any yoga this month (I am too afraid that my ovaries are the size of a football). Hopefully, I will get my AF naturally and the ovaries will be fine.

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!