Follow me on the crazy, hopeful, discouraging, funny, and ultimately successful (one way or another) path to parenthood while facing infertility.

Sunday, December 26, 2010

Ins & Outs of IVF

I have realized that I throw the term "IVF" out there all the time, and haven't really explained exactly what that is. IVF, or in vitro fertilization, is the top of the food chain when it comes to infertility treatments. It is the best shot and the end of the line for those who struggle with infertility but want a biological child. When paired with egg donation, sperm donation, or embryo donation, IVF can even give you a partially biological child that you nurture internally and give birth to. It is an amazing process and the technology really blows my mind. What blows my mind even more is that it is largely not covered by insurance -- some states mandate coverage but NY is not one of them. Yet, with IVF you have the least chance of multiples since the process is so controlled, and it has tremendous diagnostic value. You can actually see the egg and the sperm interacting, and see what happens when they meet and multiply and turn into embryos (hopefully). Your second IVF has a greater statistical chance of working than your first, in part because of everything your medical team can learn about how your reproductive functions are or aren't functioning by monitoring everything happening the first time. This is why I am not totally depressed that IVF #1 didn't work out, because it gives us a much better chance of succeeding with IVF #2. (Hopefully we end there!) So, here are the ins and outs of each stage of IVF, for your educational reading.

Phase 1: Suppression
Suppression looks differently for different protocols--some people need more and some people need less. For me, suppression is the birth control pill and then Lupron injections with the pill for a week, then just Lupron alone for a week, then a low dose of Lupron until egg retrieval. The Lupron basically shuts down your system so that it starts from scratch with the medications that encourage follicle development. It puts you into a menopausalish state so that the medical team can really finagle everything going on without your own hormonal surges (which in my case are faulty) interfering. The low dose of Lupron throughout the cycle is to keep you from ovulating on your own, which is a very bad thing with IVF. About a week and a few days into Lupron injections you have your baseline ultrasound, to make sure that your ovaries are nice and quiet (no cysts). If it's your first cycle, they do a trial transfer to get measurements on your uterus and practice threading the catheter through your cervix to deposit embryos without disrupting the uterine lining. Lots of fun. If all is clear, then you move on to Phase 2.

Phase 2: Follicular Development
In a typical woman, each month one follicle develops on an ovary, grows to maturity, and then ruptures, releasing a mature egg on its journey to be fertilized (or not). When you do an injectible IUI (intrauterine insemination), you are doped up on Follicle Stimulating Hormone (FSH) so that you produce multiple follicles and give a better chance for sperm to hit their mark. Typically you don't want more than 4 or 5 mature follicles because you don't want to risk having a litter. With IVF, you are pumped up with as much FSH as is appropriate for your given diagnosis or issue, because you want as many eggs to reach maturity at the same time as possible since they will not be fertilized by chance by roaming sperm inside your body. They will be fertilized in a very controlled environment and then a limited number of embryos are returned to their cozy home. Therefore, the follicular development phase in IVF is INTENSE. In my first cycle, by the end I had 18-22 or so follicles that looked like they could be in the mature range by egg retrieval. Sounds like a lot but not all of them will survive to embryo stage. Because so few of mine did the last time, I am being pumped way up to produce lots more. To put this in perspective in terms of bodily comfort: a normal ovary is about the size of an almond. Mature follicles are around 18-24 mm in diameter, and if you have 18-30 or so of them (say, 10-15 on each side), your ovaries blow up to the size of large navel oranges. If you experience mittelschmerz, or the sensation of pain at ovulation, you have an idea of what ONE follicle can give you in terms of pain. It is not comfy! I find that wearing elastic or stretchy waisted pants a few days into injections is absolutely necessary. I am puffy and visibly bloated. Plus, in order to get your follicles to do their thing, you need to take FSH via injections. I take two medications: Follistim and Menopur. Follistim is probably my favorite because it comes in a pen. You don't even feel the needle stick because it's so thin and the pen is so much easier to handle than a syringe--no awkward grip, no flicking the bubbles out that never totally disappear--it's awesome. Menopur is a different story. I hate injecting this drug because it requires a syringe AND it requires mixing powder and liquid. I am not a medical professional, so why must I turn my kitchen counter into a pharmacology lab? And, because you are drawing up liquid and then injecting it into the vial of powder and swirling it around to draw back up into the syringe so that you can inject it into your unsuspecting belly, there are particles in the liquid that don't totally dissolve. These particles equate to a very, very unpleasant injecting experience. The shot burns like a motherflipping wasp sting. You can't get the medication on your skin because it's an irritant (awesome) and if you manage to get it into your belly fat without getting a drop on you, you just get to go straight to the awful awful burn. I did discover after speaking with a nurse about how heinous the shot was that icing the injection site before swabbing and sticking makes a HUGE difference. I will tell you I am not excited about injecting the new dose of this drug, because it involves drawing up the liquid, injecting it into the powder, swirling, drawing up the mix, injecting it into another vial of powder, swirling, and THEN drawing up so you can inject twice the particles into  your scared little belly. Should be fun. BUT, as unpleasant as that drug is, the combo of it and the Follistim make for some beautiful follicle growth. Which leads to Phase 3.

Phase 3: Trigger/Retrieval/Fertilization
Throughout the follicular development phase, you are monitored with ultrasounds and bloodwork to make sure that your follicles are developing nicely and your estrogen levels are rising appropriately. Once everything looks awesome (and you are supremely bloated, stabby, and uncomfortable) you are cleared for trigger. You take your Ovidrel shot, which maybe you've taken with IUIs before. Before, the trigger shot served to release your eggs from the follicles so that after the insemination the sperm would have something to meet. Now, the trigger shot serves to ripen the eggs in the follicles so that they are mature and ready for harvest. The terms are more than a little surreal--I feel kind of like an egg farm at this point. The follicles really swell up after trigger and the day after is incredibly tender. However, the day after trigger is the first day that you have NO SHOTS! Not one. No Lupron, no Follistim, no Menopur, nada. Which is nice because after retrieval you trade 3 comparatively dinky 1/2 inch needles for the mother of all needles. The day after trigger you go in for your egg retrieval, which is a surgical procedure under anesthesia where an ultrasound-guided needle is used to pierce the vaginal wall and go into each follicle to flush and retrieve those precious eggs. Sound uncomfortable? It is. You come out of the surgical room and your ovaries are incredibly sore. Apparently, after they're flushed, they seal back up and fill with fluid and can actually be bigger than they were before. Percoset is a lovely prize after that procedure. You can ask about your egg haul (but you won't necessarily remember it through the haze of anesthesia), and they will be able to tell you how many were harvested. You have to wait to see how many were capable of attempting fertilization and how many actually fertilized. While you were out, your husband produced his contribution and then his washed and hand-picked swimmers are prepared to be injected into your mature eggs in a dish. Amazingly, injecting sperm into an egg does not guarantee fertilization. Your eggs are fertilized and then you wait for your call from the embryologist the next day to see how things are going. From the moment those eggs leave your body, you are totally and completely obsessed with how they are doing. In the days leading up to my retrieval, I was consumed with the idea that I had ovulated through the Lupron. If this happens, there are no eggs to retrieve and the shots are for nothing. I was terrified of this. Once I was assured that my eggs stayed out, my new obsession was how many? What quality? How are they doing? You trade one stress for another.

Phase 4: Transfer and Wait Wait Wait
The day after retrieval, you get your call from the embryologist with news on the progress your little pre-babies are making. They tell you how many embryos you have and whether you will have a Day-3 or Day-5 transfer. I had a Day-3 transfer, which means that our embryos were better off back in my uterus than continuing to develop (or not) in the petri dish. Embryos should have 8 cells by Day 3. A Day-5 transfer means you have super hearty embryos--they have to be blastocysts (many many cells already divided into the part that will be the baby and the part that will be the placenta). This kind of transfer has a higher success rate, but it is a gamble to see if your embryos will make it that far. If you have extra embryos, they have to survive to Day 6 in order to be frozen for future cycles. Those are SUPER hearty embryos because they must survive the freezing and the thawing process. I didn't have any of those last time but sincerely hope to this time. A frozen cycle is much more economical than starting all over fresh. I got my call last time that I had 5 embryos, and by the time my transfer came I was left with two viable embryos: one was 8-celled and the other was only 6, but they transferred both in case the other was just playing catch-up. You go to the same room where you had retrieval, but this time you are awake and there are no needles jabbing your privates. You get a picture of your embryos and they inject them through a catheter into your uterus. You can see the whole thing on the ultrasound screen--the embryos are too small to be seen with the naked eye but you can see the swish of fluid containing the embryos go out into your uterine cavity. It is really, really cool. Now all that is left to do is wait. Well, wait and get a giant shot of progesterone in your behind every morning. It's really kind of mean--you have to start the progesterone-in-oil (PIO) shots right after egg retrieval, and then you continue them until either you get the news that you aren't pregnant, or if you ARE, you get to take them for up to 10 weeks or so! Yikes. This is a 1.5 inch thick needle in a syringe that has to be injected into your butt muscle on your outer hip area. I CANNOT do these myself, Bryce has to do them. But, they are vital, because they keep your lining nice and plush and keep it possible for an embryo to implant and grow in your uterine environment. But they suck. Icing is mandatory, as is heating your ass where the shot was because otherwise you end up with big lumps of oil and bruising. It really is nasty. But, it is all worth it when you get your "Congratulations!" call after the wait is over! (I'm only entertaining the "Congratulations" call at the moment, not thinking about the "I'm so sorry" call I got in September that was nothing less than devastating.) Just a note, though--the progesterone is mean. It mimics early pregnancy signs, so you have tender boobs and super tiredness but it's likely the progesterone, not actual signs of pregnancy. It fools you and plays cruel mind games with you. Only the call will tell you you're pregnant!

So there it is, IVF in all its intense, magical glory. I am SO grateful to have this technology available. I am SO lucky to have a husband who is a willing partner in undergoing all of this craziness so we can get pregnant and have a baby. I am SO appreciative of all the many people who are very familiar with my reproductive system and will make this dream a reality.

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