First Shot

The first injectable drug in the IVF cycle is called leuprolide. It looks like this:

Opening it up, you find a 14-day kit that includes the drug, the required needles, and even the alcohol pads needed to clean the injection site:

The little vial there holds 2.8mL of the drug. That's 14 of the typical 0.2mL doses. We're using it for a different purpose and so use a smaller 0.1mL dose. We paid $99.00 for it.  The needle is tiny. Here's the shot, loaded and ready:

The fingers there are mine, so they're pretty big, but I think the scale is clear.  The needle is very short.  It's a subcutaneous shot.  That means it goes into the fat under the skin.  In practice, what I do is clean a patch of Sarah's tummy with the alcohol pad, pinch her skin, stick the needle in, and inject the drug.  The drug is aqueous, so it goes in quick.  Whole thing is over in five seconds max.

Trial Transfer

On Thursday we had trial transfer, which is a sort of dress rehearsal for embryo transfer.  In both cases an external ultrasound is used to guide the insertion of a catheter through the cervix and into the uterus.  (In the case of embryo transfer, the embryos are then squirted through the catheter and out into the uterus.)  The idea is that every woman's anatomy is slightly different, so it's best to practice the transfer ahead of time, before there are embryos in the room and the clock is ticking.

In Sarah's case, the transfer is simple and takes just a minute or two.  So that's good.  We also got a chance to speak to the doc about the results of all of the lab tests from a few weeks ago.  The results are all good, too:  all of Sarah's blood tests are in order, and I remain capable of fertilizing every oocyte in the state of Mississippi in one fell swoop.

Perhaps more importantly, Trial Transfer Day is also Payment Day.  So Thursday at 1:00 we forked over two checks (we pay separate global fees for lab work and doctors' services) totaling about $7,000.  Some of it can be refunded, I guess, but we're now totally committed.  Later that night, Sarah posted on Facebook that she'd "officially begun".  I think that's right; from here on out, everything is paid for, scheduled, and programmed.

Surgery

The original schedule for our IVF cycle looked like this: trial transfer on May 6th; egg recovery the week of May 31st -- June 4th; embryo transfer sometime in the range June 3rd -- June 9th. As a part of this schedule, we went in for preliminary testing on April 22nd.  We each had a test done: semenalysis for me, sonohysterogram for Sarah. 

A sonohysterogram is a test in which the technician inserts a catheter through the cervix, then pumps water into the uterus to sort of inflate it.  In the meantime, she uses an internal ultrasound to scope out the shape and texture of the uterus as it inflates.  This allows the tech to detect any defects in the uterus or its lining. 

Well, by now you know where this story is going: they found such defects.  Specifically, they identified rough patches in the uterine lining that they figured were likely to be endometrial polyps.  These are common in PCOS patients, and usually benign; if you're a woman with irregular periods, you may have them and not even know.  For our purposes, they;'re troubling for a  simple reason: the polyp occupies a region of the uterine wall and renders that region useless for embryo implantation.  So, if 10% of the uterine wall is covered by polyps, the chance of successful implantation is reduced by 10%. 

Obviously when you spend $10K or more on an IVF cycle, you want to maximize the chance that it will work.  So, when we heard the news we scheduled surgery to remove the polyps. The surgery is minimally invasive; they insert a endoscope into the unterus by way of the cervix, and the only cuts are the ones that separate the polyps from the uterus.  That surgery was performed on Friday, May 14th.  It was entirely successful; the polyps (which I have pictures of; I may post them later if Sarah agrees) were removed, and as I write this (on Sunday the 16th) Sarah is more or less fully recovered. 

So now we're on again.  The new schedule looks like this: trial transfer on Thursday May 20th; egg retrieval the week of June 14th -- 19th; embryo transfer sometime between June 16th and June 23rd; a yes-or-no pregnancy test soemtime around the first of July; and a one-baby-or-two ultrasound (as needed) in late July. 

I'll add descriptions of each of these procedures as we go.  It's going to come fast now.

The Easy Problem And The Hard Problem

We're really beginning tomorrow.  More on that in a minute.  As I started to write a post about what's happening tomorrow, I became clear that I wasn't nearly ready to do all that.  The post required so much background information that it got totally clogged with commas and dashes and parentheses, oh my.  About halfway through, I decided the whole thing was unreadable, so I ripped all that stuff out and put it in this post.  If you know the Story So Far, feel free to skip ahead to the next post.

Sarah and I have two basic fertility problems.  You can think of them as the Easy Problem and the Hard Problem.  We'll take them one at a time. 

The Easy Problem is a condition called polycystic ovarian syndrome (PCOS).  Not too very long ago, this diagnosis was somewhat controversial; when we were first diagnosed in 2005, I looked into it and found a heated argument about whether it existed at all.  In the intervening years, this controversy appears to have died down.  There's still not a definitive "cause" of PCOS, but the most popular theory seems to be that PCOS is a sort of pre-diabetic condition.  Women with PCOS don't have unregulated blood sugar, but they do have much higher than normal levels of blood insulin.  The body is still producing insulin and the insulin is still doing its job, but only at a much higher concentration (ie, dose) than normal.  And at this higher-than-normal concentration, insulin starts to have deleterious side effects.  Most importantly to the fertility patient, the excess insulin interferes with the woman's normal hormonal cycle. The result is as you'd expect: irregular mentrual cycles, anovulation, and infertility. 

Treatment for the Easy Problem is simple and cheap.  It resembles the treatment for Type II diabetes: control your diet, exercise, lose weight, and take a drug called metformin, aka Glucophage.  In diabetics, of course, the goal of these measures is to lower and control blood sugar concentration; in PCOS patients, the goal is to lower and control blood insulin concentration so that the body's other hormones can do their job.  In our case, this treatment has been largely (if incompletely; more on that in the next post) successful.  It also costs about $36/month (the cost of the metformin at our local drug store; throw in Sarah's half of the gym membership and you're up to a whopping $56/month), which is nice.  And all would be well, if it weren't for the Hard Problem.

The Hard Problem is that Sarah's tubes, um, do not exist. When treatment with metformin, Provera, Clomid,  etc. failed, she underwent a test called a hysterosalpingogram.  In an HSG, a clamp is placed over the cervix and an X-ray reflective dye forced through the clamp into the uterus.  Meanwhile, a radiology type watches what happens with a fluoroscope.  In a woman with normal anatomy, the dye will fill the uterus, then flow up the fallopian tubes and spill out into the abdominal cavity near the ovaries.  In Sarah, the dye flowed up the tubes and stopped; her tubes were closed at the ovary end.  Shortly after learning this, Sarah underwent a laprascopic surgery to open the tubes; er OB/GYN basically went in and cut her tubes open at the ovary end.  This was fairly expensive (I think we laid out about $3000 for it)  and not that promising as a treatment, but it was the Next Step at that point so we did it. After the surgery, the doc (again, this is our local OB, not our ART guy in Memphis)  put Sarah on a mega-dose of Clomid for six months --- the idea being that the tubes he cut open were only likely to stay open for six months, so it was best to maximize the chance that we'd get pregnant in that time.

(As an aside: if you've never lived with a woman on the maximum dose of Clomid...well, it's an adventure.  A chemistry friend of mine coined the term "emotionally labile".  I think that works.) 

Well, six months came and went, and no baby.  So OB guy referred us to ART guy, who explained that (contrary to what you learned in 7th-grade health class) the fallopian tube is not simply an tube for the egg to fall through, but an active participant in the fertilization process.  The ovary end of the tube is supposed to have "petals", like a flower; these petals are supposed to reach out grab the egg after ovulation, and cilia on the inside of the tube are supposed to move the egg down the tube.  Even after they'd been surgically opened, Sarah's tubes were so badly damaged that they could not perform these functions.  With this in mind, Dr. Ke (a/k/a ART guy) told us that:

1.  our best chance to get pregnant was through in vitro fertilization (IVF), a procedure in which the action that usually happens in the fallopian tubes instead happens in a petri dish; and,
2.  once we decided to go ahead with IVF, it would be best to have Sarah's tubes removed, since blocked tubes fill with a toxic fluid that can spill back into the uterus and reduce the chance of having a successful pregnancy through IVF.

After careful consideration, we decided to go ahead with these recommendations.  In the Spring of 2006, Sarah had her tubes removed.  Shortly thereafter we underwent a successful IVF cycle, and our daughter Ainsleigh was born in the Spring of 2007.  (She's gone now, but that is another story.)  But the both the Easy Problem and the Hard Problem remained.  And now, in 2010, we've got to deal with them all over again. 

And here we go...