Frozen embryo update!

In the words of children’s author Judith Viorst, this past Wednesday (the day of our embryo transfer) was a terrible, horrible, no good, very bad day. After things seemed to be going so ridiculously well in this IVF cycle — our egg donor Marie produced 15 mature eggs, 100% of which then fertilized and were looking strong in the days that followed — we learned on Wednesday that only a single embryo had developed into a viable day-5 blastocyte. Two others had also become blastocytes, but they were too poor-quality to be frozen. When I tried to ask if there were any other embryos still in-the-running, the doctor was — excuse my language — a ginormous dick. He sounded so pessimistic — admitting it was a below-average response, and even hiding his chart so I’d stop asking questions(!) — and I left feeling completely despondent.

I sobbed the entire 2+ hour drive home from Belgium. Once back at our house, I transitioned onto the couch for further sobbing. I had made a deal with my husband earlier in the day that he had to do whatever I said all day so that I’d feel happy and relaxed after the embryo transfer. Before the bad news, this had come in the form of sassy decries (e.g., “I decry that you escort me around on your arm all day”; “I decry that you stop sending me stupid Reddit videos”). After the news, and back at home, I decried that he leave me be so I could mourn the unfairness of the Universe in solitude.

A sudden turn of events

After such a miserable day, you can image my surprise when I received an email the next morning saying that 5 embryos had been successfully frozen. FIVE! Not trusting my Dutch reading skills, I copy-and-pasted the email into google translate just to be sure. It still said the same thing…FIVE EMBRYOS COULD BE FROZEN!!!

IVF is such an insane emotional roller coaster.

So why the sudden turn of events? Well, my husband and I are still complete newbies when it comes to blastocyte development, since we never made it this far with my own eggs (or lack thereof). Apparently, in addition to freezing any good-quality blastocytes on day 5, they let the remaining embryos continue to develop overnight, allowing the stragglers to catch up. These slower-growing day-6 embryos may still turn into blastocytes which can result in a healthy pregnancy, and they will freeze any good-quality ones as well. I had no idea that there could be such a big change from day 5 to day 6, and it would have been nice if the dick — Sorry, I meant doctor — told us that there was still some hope.

What does this news mean?

Obviously we hope that the embryo I currently have on-board will decide to stay put. However, based on its quality, it only has a 17% chance of resulting in a live birth (though a ~30% chance of pregnancy…fun implications there). If it decides not to stick around, then we can try what’s called a ‘frozen embryo transfer’ (FET) without having to go through the whole egg retrieval process again. Most of the embryos should theoretically survive the thaw, so that would hopefully give us another few chances.

In the meantime, I’m oscillating between cautious optimism and (more statistically realistic) extreme pessimism with the current embryo on board. It’s far more likely that it won’t stick….but there’s still a non-zero chance that it will. I seem to be growing (unwisely) more optimistic each day, which is probably the emotional equivalent of that slow upward climb on a roller coaster before the huge stomach-lurching drop. In that sense, the (potentially poorly translated?) advice that our favorite Belgian egg donation nurse gave me might actually make more sense: “Keep your head on.”

Embryo transfer: the good news and the bad news

Today was one of the biggest days in the donor egg IVF cycle (our fourth cycle in total) that we’ve been undergoing this past month. Not only did our egg donor, Marie, fly back to the U.S. (feeling slightly less bloated, finally), but we were also booked for a 9:50am embryo transfer in Belgium. I woke up at our Airbnb full of hope, filled my bladder as instructed, and made my way to the hospital with my husband.

The last we heard, most of our 15 embryos were still doing really well. On day 3, eleven of the embryos were exactly the right size (8 cells), three more were slightly too small (5-6), and one was too large (>8 cells). Even if those last four were out, eleven still seemed like a really good number. It was also exactly 11x better than my three previous IVF cycles combined.

On day 4, we only had a brief call with the egg donation nurse, but she said that most of the embryos were still doing really well. In particular, while they had not yet advanced enough to be rated & ranked, they were starting to ‘compact’ as desired, and were on their way to transforming into day-5 blastocytes. This gave us confidence that we should go ahead and make our way to Belgium the night before, since there should definitely be something to transfer.

The good news

The good news is that there was one blastocyte to transfer: an intermediate 5-day blastocyte rated good/fair. Since we didn’t have any embryos make it to day-5 with our last IVF cycle, and since our first two cycles used 3-day transfers (where it’s harder to tell if the embryos are good quality), this is officially further than we’ve ever made it before.

The doctor triple-checked my name, retrieved the embryo from the lab in what is essentially a high-tech turkey baster, and squirted that sucker in in probably less than 60 seconds flat. This means that I am now (for the third time) what we refer to in the infertility community as ‘PUPO’: pregnant until proven otherwise.

The bad news

In addition to the news that the embryo we transferred today isn’t of the highest quality (with only a 17% chance of sticking it out for the long haul), we were also a bit shocked to learn that it’s currently the only decent blastocyte. This news really came out-of-the-blue, since everything had been going so well (almost too well?) up until this point.

What about all of the other 14 embryos, you’re probably thinking? Well a lot happens on days 4-5, and it’s common for many perfectly good-looking 3-day embryos to not make it to the blastocyte stage. This is partly why clinics do 5-day transfers: so they can wait and see which embryos are really viable. I’ve seen the number 40% bandied about, so it seems like we’re doing below-average. On the other hand, while two of our remaining embryos are definitely already out (having reached the blastocyte stage, but being rated as poor-quality), it is theoretically possible that a couple of the remaining ones could make it to the blastocyte stage tomorrow. If they are good enough quality, they can then be frozen for later attempts.

So is this really that bad? Normally I would be thrilled to even get to this stage. But since we used an egg donor this cycle for the first time, and since her egg quality/quantity was an order of magnitude better than mine, I had let myself get my hopes up (rookie mistake!) that we’d end up with at least a couple high-quality blastocytes. That would make all of this effort (from Marie, in particular) seem more worth it, and it would give us an ‘insurance policy’ in the form of another attempt.

Without the insurance policy of frozen embryos, it means that if this current ’embaby’ doesn’t stick, we have to start all over yet again, most likely with another donor/in another country (not to mention the financial cost). And I’m getting really, really tired of starting over.

What happens now?

We’re still waiting to hear if any of the slower-growing embryos will be high enough quality to freeze. Other than that, it’s a tense two-week wait until my blood test on 13 August.

In the meantime, I’m finding support in the amazing community of fellow #IVFwarriors I’ve discovered on Instagram. And I’m getting wicked pleasure out of reporting all of the maternity-themed targeted ads in my Instagram feed as ‘Inappropriate/offensive’. Because #infertilitysucks.

Our egg donor’s egg retrieval

On Friday morning, my husband and I rolled up at the hospital in Belgium with our awesome egg donor Marie for her egg retrieval surgery. I’ve been trying to write a post about it ever since, but the past week was such a blur of ultrasounds and international road trips that we’re all pretty exhausted. So instead, allow me to present a brief highlights reel.

The ‘puncture’

The finale of Marie’s past two weeks of hormone injections was the egg retrieval surgery. Marie was never particularly thrilled about this part of the process, but she was even less thrilled when she learned that it’s referred to in Dutch as ‘the puncture’. This makes sense, as it’s performed by sticking a very large needle into the vagina, through the vaginal wall, and into each ovary. A fun way to spend a Friday morning!

Here in Belgium (& the Netherlands), this procedure is done while you’re awake. Our clinic uses a local (internal) anesthetic and a morphine IV to help minimize the pain. Ironically, Marie found the IV (which was placed in her hand) to be the most painful part of the whole procedure. I tried my best to distract her while we waited to be taken back with entertaining anecdotes from my husband’s experience one floor below.

The ‘sample’

At roughly the same time as Marie was being called in for her puncture, my husband had a finale of his own….so to speak. For our first two IVF cycles in Holland, the ‘sample’ (as it’s called) could be ‘produced’ at home and biked over in his jacket pocket. (Can you imagine what would happen if he had gotten into a bike accident??)

Here in Ghent, the ‘sample’ is instead produced in a small room with a tasteful silhouette of a naked lady on the wall and a collection of decidedly less-tasteful magazines. For maximum quality, the ‘sample’ should have ‘accumulated’ for 2-3 days. I’ll leave the rest to your imagination.

The number of eggs retrieved was…

Back in the operating room upstairs, Marie and I were 3rd in line (out of four ladies that morning) for her puncture. We were called back around 10am — almost exactly 36 hours after her trigger shot — and the actual procedure got underway. Marie was pretty out-of-it from the morphine at that point, but I got to watch the ultrasound monitor as the fluid was rapidly drained from each follicle and into a tray of waiting test tubes. Marie had WAY more follicles (17!) than I had ever produced, so she filled up test tube after test tube. No wonder she had been feeling bloated!

Marie’s large number of follicles also meant the fluid couldn’t be processed immediately to find the eggs like mine was (think panning for gold), since the procedure was all done in only about 30 minutes. But shortly after the procedure was over and Marie was back resting in her bed, the nurse came in to give us the great news: 16 eggs had been retrieved!!

If you recall my previous post about the odds of this cycle working, you may also recall that ~15 eggs is the optimal number as far as maximizing the odds of pregnancy. So basically, Marie and her overachieving ways freaking #killedit.

A slight hiccup

There is a downside to Marie producing so many eggs: it puts her at a higher risk for developing ovarian hyper-stimulation syndrome (OHSS), where the ovaries become painful and swollen. In order to mitigate the risk, our clinic puts anyone who produces more than 15 eggs on Cetrotide injections. So although we thought Marie had had her last encounter with a needle, she’s now being treated to 7 more days of daily stomach injections.

How many eggs fertilized?

On Saturday morning, back in Holland, I got the call that 15 out of 16 eggs had fertilized. This is a fantastic fertilization rate, and hopefully it increases our odds even further. When I relayed the information to my husband over the phone, I like to imagine his hands were clasped over his head in a victory gesture.

Now we are waiting to see how many of the 15 embryos continue to divide and develop into 5-day-old blastocytes, when we will hopefully transfer one to my waiting uterus and freeze any remaining for later attempts. Today is already day 3, which means my husband and I will make the drive back to Belgium tomorrow night for a Wednesday morning embryo transfer. Unfortunately, the necessary timing of the transfer also means we will miss the departure of Marie and her family! They all fly back to the U.S. early that same morning, wrapping up what must be one of the most eventful family vacations ever.

By the way, if you’ve ever wondered how you’d react if one of your friends traveled internationally to have elective surgery and potentially give you the gift of life, it may be something like this:

Decked out in surgical scrubs and #thankful

Egg donor’s retrieval scheduled

We’re currently in the thick of our fourth IVF cycle, and our first attempt using donor eggs. Yesterday morning our egg donor, Marie, and I made the ~8 min drive from the hotel where we’ve been staying in Ghent (Belgium) to the hospital there for her 3rd check-up. Marie is now a seasoned vet at the transvaginal ultrasounds that are needed to count and measure the follicles growing in her ovaries. So let’s get down to it.

This latest ultrasound showed she’s still growing around 17 follicles in total — same as the last check. The follicles are growing at different rates, which is totally normal, but it means that only some of them are expected to be the right size to contain a mature egg. In particular, in order to maximize the total number of eggs retrieved, sometimes the clinic decides to sacrifice the largest follicle in order to wait for a larger number of smaller ones to catch up. Even then, there are usually also some follicles that are still too small to contain a viable egg.

Marie now has one follicle that is probably too large (25 mm), but 9 that are the right size (18-22mm). In addition, she has around 5 more slightly smaller ones (15-17mm), some of which may (hopefully) be large enough by the retrieval. Then there are two that are definitely too small (12-13mm). These results are shown in the (embarrassingly poor-quality) screenshot below, which Marie and I shamelessly snapped from the ultrasound technician’s computer. If all of those follicles yield an egg (which is not guaranteed), then we will hopefully retrieve 9-15 eggs in total…a great result, and way more than they retrieved from me in all three of my previous IVF cycles combined(!)

Poor-quality screenshot showing size of follicles in millimeters (y-axis) versus date of exam (x-axis). Marie’s ultrasound yesterday morning (far right column) showed 9 follicles in the correct range (18-22mm), one at 25mm (probably too large), and 5 more (15-17mm) that may also be large enough to contain a mature egg by the egg retrieval. (The 12-13mm guys are sadly too small.)

When will the retrieval be?

After her ultrasound, Marie had a blood test to check her hormone levels. We got a call yesterday afternoon that the results came back in-range, which means that we are good to move on to the next step. So last night at exactly 10:30pm, we gave Marie her final hormone injection: a trigger shot in the stomach (#hardcore). This final shot helps the eggs mature so that they’ll be ready exactly 36 hours later for the egg retrieval, scheduled for tomorrow morning.

Does 9-15 follicles mean 9-15 embryos?

We’re super happy that Marie is responding so well to the medication and that we’ve made it this far. But before everyone gets overly excited, I just want to clarify that 9-15 follicles does NOT mean 9-15 embryos. If it did, our chance of a live birth from this cycle would probably be way more than the predicted ~25%.

To start with, we can’t be sure that all of the follicles (even the big ones) will yield eggs…

Then, of the eggs retrieved, only some of them will be mature…

Of the mature eggs, only some (maybe 70% on average) will fertilize…

Of the fertilized eggs, only some will divide normally into embryos…

And finally, only some of those embryos will make it all the way until the fifth day, when we will hopefully have at least one that can be transferred to me (and stick).

In other words, even with 17 follicles, it’s perfectly possible that we could end up with only one or two 5-day embryos. Of course, that would still be way further than we got with our last 5-day transfer (which was cancelled due to having 0 embryos)! So cross your fingers (or hold your thumbs) that we make it that far. And keep Marie in your thoughts tomorrow for the egg retrieval, which she was less-than-thrilled to learn is referred to in Dutch as the ‘puncture’.

Egg donor’s 2nd follicle check

In my post from Friday, I discussed how our egg donor, Marie, had her first transvaginal ultrasound to check on the growth of her follicles. We saw 17 quickly-growing follicles — a great response — prompting our clinic in Belgium to request another ultrasound on Monday. For this one, we had to come to Belgium, as they also needed a blood test that we’d been unable to get locally in Holland. Additionally, the last ultrasound before the retrieval must be done at their clinic, and they thought she might almost be ready.

We thought it would be nicer to arrive the night before rather than get up at the crack of dawn, and we’d already booked a room near the hospital for the whole week just in case. Fortunately, Marie’s husband also arrived from the US on Friday to help care for their two kids while we’re busy with all this. So Sunday night, Marie and I borrowed a friend’s little red car and made the 2+ hour trip to Belgium.

Joint Ultrasounds

Marie and I both needed ultrasounds, which were scheduled back-to-back. Marie’s was needed to check her follicular growth, and mine was needed to check my uterine lining. You know how some friends hang out by going to the movies, or getting their nails done together? Well we hang out by going to a foreign country and having wands shoved up our hoo-has.

Marie went first, and we were thrilled to see that the 17 follicles were all still there and growing. The largest are already 2cm in diameter, so they’re starting to look quite crowded. Here you see two different views of Marie’s left ovary.

Two different views of Marie’s left ovary, which is growing ~11-12 follicles.

My ultrasound was much quicker, as the technician didn’t need to search for and measure any follicles. She just checked that my uterine lining had the right thickness and structure. It’s currently measuring at ~11mm, which means the estrogen pills I’m taking are working.

We then had to go down to the lab to get a blood test for Marie. It showed that the follicles aren’t quite ready yet. This means we need to go back for another ultrasound and blood test tomorrow.

How is Marie feeling?

Several friends/family members were curious about how Marie is feeling while taking the hormone injections, and the answer is: completely normal. It doesn’t seem to be affecting her mood at all, and until recently, she didn’t have any physical side effects either. Only in the last couple of days has she started to feel a ‘fullness’ in her abdomen, or a slight twinge if she leans over to one side to grab her phone. This makes sense, as each follicle is the size of a large grape — and there are 17 of them in total — so she essentially has a bunch of grapes in each ovary. In her words: “I knew generally where my ovaries were before, but now I can tell you they are [pointing] here and here.”

Our egg donor’s first follicle scan

I’m writing this the night before our egg donor, Marie’s, first follicle scan, with plans to fill in the details later. Since I don’t actually know how it’s going to go yet, I guess I’ll have to write it kind of like a choose-your-own-adventure novel, with alternate endings depending on how it goes. I will write one version that’s excited and hopeful for if we see a lot of follicles growing, and I will write another that’s disappointed-yet-putting-on-a-brave-face for if we don’t see much response.

I do already know how the logistics of the appointment will go from my three non-donor-egg IVF attempts, so I can write about that first. Although our fertility clinic is in Belgium, and although you are required to do the first and last ultrasound checks there, I’ve previously used a local clinic here in Holland to do the intermediate scans. This is much more convenient than driving to Belgium every few days, and they only charge 75€ per scan. Right before my recent test cycle, they actually stopped offering this service for people who aren’t their own patients, but since I’d already been coming there, they (thankfully) agreed to keep doing mine. Fortunately, they also agreed to do Marie’s, since she’s only there as my donor.

Unfortunately, they weren’t able (or willing?) to do the blood tests that are required along with the ultrasounds. For my own checks, I was able to convince the local hospital where I had done my first two non-donor-egg IVF cycles to do those for me during my Belgian attempt. This meant biking 20 minutes across town to do the ultrasound, then biking 30 minutes in the other direction to get blood drawn. This usually also meant arriving to work super late and sweaty, but it was all still better than a 2+ hour drive to Belgium.

However, when I asked the hospital if they could also do Marie’s blood tests, they refused on the grounds that she doesn’t have Dutch insurance. After multiple phone calls to my ‘huisarts’ (GP) and various labs, we never actually found a solution. As a result, we will only be getting an ultrasound tomorrow, and we will have to hope that provides enough information on its own. If not, we may be making a last-minute trip to Belgium.

What happens at the ultrasound?

Like Marie’s initial scan before she started the injections, this will be a transvaginal ultrasound. At this point, I should note that the Dutch doctors don’t give you those flimsy ‘privacy sheets’ (or gowns) that Americans are used to. I’ve gotten quite used to stripping down and walking pantsless across the room to the waiting stirrups, but Marie is fresh-off-the-boat, so her American aversion to nudity is still firmly intact. I’ve advised her to wear a long shirt or dress, effectively creating her own privacy gown.

They will then use the ultrasound wand to have a peek around inside. For non-donor-egg IVF, they would start by checking the thickness and structure of the uterine lining. Since Marie is only donating the eggs — not acting as my surrogate — they will instead head straight to her ovaries. Once they’ve located them, they will look for the dark round spots that indicate growing follicles. They will use the computer cursor to measure the diameter of the follicles, and they will officially count all those greater than 10mm in size.

And the results are…

Marie’s first scan is now over, and the results look promising, with 17 follicles in total. Marie’s left ovary shows 5 follicles greater than 10 millimeters and 7 that are <10 mm, and her right ovary shows 2 that are >10 mm (with 3 more <10 mm). It’s only the first scan, so we will see how many of those little guys can catch up between now and the next ultrasound. Follicles grow 1-2 mm a day, and at the point of the egg retrieval, we can expect to find a mature egg in those that are ~15 mm or larger. We have our fingers crossed for ultimately retrieving at least six (mature) eggs in total — and ideally 12-15 for the best odds. Now we will email Marie’s results to the Belgian clinic, and wait for them to tell us whether we need to make a spontaneous trip to Belgium for bloodwork!

The results from Marie’s first follicle check. Way better than my typical result of a single follicle. Keep growing guys!!