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!!

The skinny on IVF medication

Time is really flying these days. Our egg donor, Marie, arrived from the US eleven days ago now, and after an initial ultrasound to check her ovaries, she has already had injections for six days. She’s on the same medication I was on for my last (non-donor-egg) IVF cycle, but the hope is that she will have a much better response than I did. And seeing as I basically had no response at all due to my premature ovarian failure, this is pretty much guaranteed!

Many people are curious about the daily injections she’s taking on our behalf, so let me break it down for you here. As I mentioned in my last post, there are two basic components to IVF treatment:

  1. Inhibiting spontaneous ovulation. Women’s ovaries contain hundreds of thousands of ovarian follicles, each of which contain an (immature) egg. During a normal menstrual cycle, one of these follicles becomes dominant, matures, and naturally releases its egg about halfway through the cycle. In IVF, the eggs (note the plural, see #2) are retrieved from the ovaries surgically, so medication must be used to inhibit this spontaneous ovulation.
  2. Stimulating follicular growth. Normally, the non-dominant follicles die off before ovulation as hormone levels drop, resulting in just one dominant follicle with one mature egg. However, given all of the steps involved to go from egg to baby, I personally think it’s a freaking miracle our species has survived. The IVF process keeps the level of follicular stimulating hormone high, fooling the woman’s body into producing multiple follicles (and thus eggs) in one go, and thus helping the odds.

How does the medication accomplish this?

Of course, the exact medication (and dosages) depend on the country, clinic, and patient, but the medication that Marie is taking for the first part (inhibiting ovulation) is Decapeptyl 0.1mg. This medication turns off the body’s natural hormone regulation, thereby temporarily stopping ovulation. Even though the medication has to be mixed every day — including breaking a small glass vial with your hands — and even though it has to be administered as an injection, I actually prefer this medication to the nasal spray I took during my first two IVF cycles, which gave me a continuous sore throat.

Decapeptyl, a daily injection to inhibit ovulation.

For the second part (stimulating follicular growth), Marie is using 300 units of Menopur, which is actually the maximum dosage allowed in Belgium. This dosage was determined based on her age and AMH level (which, you may recall, is still over an order of magnitude better than mine). Menopur stimulates the growth of follicles in the ovaries using human menopausal gonadotropins that (fun fact) are extracted from the urine of postmenopausal women, who have naturally high levelsSo I’ll just let that sink in for a minute.

How are the injections done?

Both of these injections are subcutaneous, which means they only need to go under the skin and not specifically in a muscle (like the recent injection I had to get). For my last three cycles, I always did my injections myself one-at-a-time in the side of the thigh. Marie isn’t a huge fan of needles, so she asked that my husband and I give her both shots simultaneously to get it over with quicker. This means there’s usually a contest to see whose shot hurt more, which I (administering the Menopur) won tonight.

My husband and I administering Marie’s daily injections. This is how we make a baby… #romantic (Marie wants me to add #NoThighGap)

How much does it hurt?

The needles used to administer both these medications are tiny, so unless you are very unlucky with the placement (like my husband was last night), they usually slip in without much pain at all. What can hurt is the injection of the liquid itself, particularly if it’s cold, or if there are air bubbles in the medication. For this reason, we make sure to get the menopur out of the fridge ahead of time, or hold it in our hands for a few minutes to warm it up to body temperature. We’re also pros at flicking syringes* to get the air bubbles to float to the top — something that I like to imagine makes us look like hardcore drug addicts to the police station directly across the canal.

In my past cycles, I usually found that the menopur burns a little even with these precautions, and I think Marie agrees. You can also bleed a little at the injection sites and develop some gnarly bruises after the fact. But as someone who has dealt with pretty bad chronic back pain, these issues are really only temporary — and thus minor — inconveniences. And as Marie has discovered, it’s nothing a little chocolate can’t help.

*Sidenote: “Flicking Syringes” is going to be the name of my punk band.

And so begins egg donation IVF cycle #1

The last couple weeks have been a whirlwind of activity. First I was traveling abroad for work, then I was sick at home with a souvenir cold, then we had some last-minute German visitors who have been driving around Europe with their 6-month old in a VW bus (I feel cool just knowing them), and then my husband had the stomach flu. With everything going on, we had hardly any time to prepare for the arrival of our egg donor, Marie, and her two kids (ages 3 and 5), who flew in last Saturday from the US.

Two days after they arrived, we all piled into a borrowed car and drove 2+ hours to Belgium for our first appointment. There, Marie had what we in the infertility community refer to as “a date with Wanda” — i.e., a vaginal ultrasound with an ultrasound wand. The point of this first ultrasound is to check that her ovaries are quiet (no activity) before she starts the heavy-duty hormones. Her two girls were particularly curious about the procedure, with the 5-year old asking loudly at one point “IS THAT THING GOING IN YOUR BUTT?!”

Once Marie’s ovaries had been given the all-clear, we had an appointment with the egg donation nurse to go over the tentative egg donation IVF timeline. Then the kids had a quick break in a conveniently located hospital playground while I picked up our €1000+ of medication, delivered in a freezer bag for the long ride home. This was fortunate, as the normally ~2-2.5 hour drive ended up taking 3.5 hours with traffic. The kids were champs and were rewarded with a ride in the bakfiets (wheelbarrow bike) to get happy meals at McDonalds. They happily declared “This has been a GREAT day!”, which, after 6 hours in the car and 2 hours of doctor’s appointments, shows just how terrible kids’ memories are.

Our egg donor’s kids love riding in our bakfiets, which is essentially the Dutch version of a minivan.

Bring on the meds

Marie and I have both been on birth control for the last month to sync up our periods, but we took our last pills this past weekend. I started my period on Tuesday, which means I’ve now started taking the estrogen pills to build back up my uterine lining for the actual donation cycle. This is the same medication I did the test cycle for last month, so luckily we already know I respond to it well.

On Thursday, Marie started her first medication: daily decapeptyl injections to delay her ovulation until the right moment. Marie had me give her the injection, which she found painful and I — even after giving myself 3 IVF rounds worth of injections — found terrifying. It’s one thing to inflict pain on yourself, but it’s another thing entirely to inflict pain on someone else who is just trying to help.

What happens next?

Tonight, Marie will begin the second type of daily injections: “stims” (Menopur) to stimulate the growth of follicles in her ovaries. This means things are really starting to happen! It also means I have to give her two injections a night instead of one…oh joy. This will continue until her follicles have grown large enough in size to have the egg retrieval surgery, which should be around 12-14 days from now.

So what happens in the meantime? Well Marie will have another ultrasound and a blood test this coming Friday to check how her follicles are developing. Depending on how this looks, we will probably have to go back again a few days later. Once the follicles reach a certain size, we will drive back to Belgium for what should be the final ultrasound. Then she will take an injection to trigger ovulation, and exactly 36 hours later, we will cross our fingers that all this Dutch cheese we’ve been feeding her will result in the retrieval of multiple high-quality eggs.

The emotional impact of premature ovarian failure

It’s almost time to break out the celebratory raw herring! Why? Because we are officially less than one week away from the arrival of our egg donor, Marie, in Holland. After so much intense preparation, I still can’t believe it’s finally actually happening. And while the odds are that it won’t work, I’m going to try to do my best to stay cautiously optimistic during this next IVF cycle.

With that said, the cycle hasn’t quite started yet, and I’m currently in a plane somewhere over Greenland, which always makes me emotional (the being-in-a-plane part, not Greenland…that would be weird). I understand this is actually a common phenomenon — perhaps because our tiny monkey brains still can’t process the modern miracle that is air travel. I already (somewhat embarrassingly) found myself nearly in tears while watching Blockers, a movie which is decidedly NOT a tear-jerker. So perhaps it’s a good time to talk about something that’s been on my mind a lot lately: What is the emotional impact of a premature ovarian failure diagnosis?

Maybe it’s hard to understand if it hasn’t happened to you, or if you don’t want kids, but finding out suddenly that you will likely never have biological children is pretty rough. However, I hadn’t considered that it might be even more serious than that until I was researching premature ovarian failure (POF) for a recent post exploring what causes it. One of the first places I looked, Wikipedia, had this to say about emotional health in those who had been diagnosed:

The most common words women use to describe how they felt in the 2 hours after being given the diagnosis of primary ovarian insufficiency are “devastated, “shocked,” and “confused.”[8] These are words that describe emotional trauma. The diagnosis is more than infertility and affects a woman’s physical and emotional well-being.[1] Patients face the acute shock of the diagnosis, associated stigma of infertility, grief from the death of dreams, anxiety and depression from the disruption of life plans, confusion around the cause, symptoms of estrogen deficiency, worry over the associated potential medical sequelae such as reduced bone density and cardiovascular risk, and the uncertain future that all of these factors create.

I knew most of this already from personal experience, of course, but I was struck by the phrase `emotional trauma’. As in, damage to the psyche that occurs as a result of a severely distressing event, and which can even lead to post traumatic stress disorder. I was further struck by the mention of the words “shocked” and “devastated”. Those words sounded familiar… I went back to the first post I had written, where I described receiving my diagnosis, and I used both of those words to describe it. It made sense actually — it was a trauma. Come to think of it, it was definitely in my top-five, and probably even top-three. For some reason, just knowing this has helped me to feel less like a victim, and more like a survivor.

How to get through it

I could talk more about the other physical and emotional consequences of the diagnosis listed in the Wikipedia article — and I’m sure I will at some point — but in the meantime, what else has helped me, personally, to get through it?

One thing that has helped me tremendously, of course, has been Marie’s offer to donate. Going through something like this can be an extremely isolating experience, especially with the constant bombardment of pregnancy announcements and baby picts that compose 90% of my social media. Knowing that someone is willing to go through all this for us is huge, and I’ll be forever grateful even if it doesn’t work.

I realize, of course, that not everyone has a big-hearted (& big-footed) Marie in their lives, so I also wanted to emphasize a few things that my fellow POF-sufferers can do for themselves:

  1. “Come out”. Sharing what you’re going through with friends — and maybe even more generally — can provide you with a crucial support system. If nothing else, it will stop relatives from asking you when you’re having children.
  2. Take care of yourself. The term `self-care’ is usually a bit touchy-feely for me, but it’s actually important in this case. Personally, I recently turned down a request to give 10 hours of lectures at a summer school (which I would also need to prepare from scratch). Another colleague made me feel guilty about this at first, which was particularly confusing because they know what I’m going through. But you know what? They can ask someone who ISN’T coping with an emotional trauma while also undergoing their 4th IVF cycle.
  3. Give yourself credit. Acknowledge that what you’re going through is hard, and make sure to give yourself proper credit. Couples split up and people quit their jobs over this stuff. If you’re at least making it through the day, you’re freaking killing it.

All systems go…with one hiccup

In my last post, I talked about how our friend Marie had been approved as our egg donor, but contingent on three pending genetic tests. Those test results weren’t expected until today (25 June), which was basically the last possible moment in order to keep our timeline for donor egg in-vitro fertilization (IVF) on track. Well, our Belgian egg donation nurse, Bernadette, worked her magic again, and we got the test results back already on Friday 22 June (voila!). The same day, I had a blood test, followed by an ultrasound on Saturday to make sure I’m ready for the first injection. All of the tests came back clear, which means we are officially all-systems-go for a July 2018 egg donation.

I know that probably sounds like something in this process actually went smoothly. But you should also know by now that I enjoy (according to my husband) “doing everything the hard way”. This is why I got my PhD in a competitive field, and why I voluntarily moved to a foreign country…twice. This is also why I decided to accept a work invitation to speak at a conference in the US this week, right in the middle of this whole process.

It shouldn’t have mattered, or at least that’s what I thought. I knew I needed to have an injection during the week I was away, but I’ve already given myself at least 50 injections over the course of our three ‘normal’ (non-donor-egg) IVF cycles. I knew I could get a doctor’s note to fly with the medication and needles, and I figured I could just inject myself with a large dose of hormones in the morning and then go chair the plenary session like the modern working woman I am. Easy-peasy, right?

Wrong.

Literally the day after booking my flights (which I’d already waited til the last minute to do), I called Bernadette about picking up my injection, and she informed me that it was not necessary to pick it up, because this particular injection had to be done by my doctor…in Belgium. Apparently this injection was intra-muscular — not subcutaneous* — and it was very easy to do it wrong. She said it was ok if I wanted to do it myself, but that I had to agree to accept the consequences if I did it incorrectly. And the consequence was a canceled IVF cycle.

To go or not to go?

A mild panic ensued, where I briefly considered canceling my whole trip. That probably sounds like the obvious solution, but I’ve already canceled so many work trips for IVF, and I really didn’t want to cancel yet another. Then I considered trying to call a doctor’s office in the US city I was visiting, but I had had previous bad experiences with medical care crossing international borders. I highly doubted that if I called up a random US doctor, they would agree to inject me with some foreign (literally, including the box and directions) medicine.

Next I called up a Dutch doctor friend, who offered to help me practice stabbing the MASSIVE needle into my thigh before I left, but I was still worried I’d mess it up by not stabbing it in far enough, or too far (…is that a thing?) Then another friend had a suggestion: did I know anyone attending the conference who was a doctor? (Technically we’re all doctors, but not the useful kind…)

Luckily, I remembered that one of my fellow conference attendees is originally from the city I’ll be visiting. I emailed to explain my predicament and ask if she knew any doctors. Lo-and-behold, her childhood best friend is a doctor, and she still lives in the area. After some more emailing back and forth, this friend-of-a-friend agreed to help me!

So this is how it has come about that tomorrow, after I’m done chairing my session, I will take a taxi to the home of a woman I’ve never met before and have her stab me with a very large needle.

*FYI, ‘Intra-muscular’ means the medication needs to be injected into a muscle rather than just under the skin. There was actually a whole separate confusion over whether this was still the case if I got the prescription filled in the Netherlands (where I live) rather than Belgium, as the medication is apparently slightly different (because again…hardest way possible!). The box actually said it could be done both ways, but confusingly, there was no subcutaneous needle included in the package. After multiple phone calls to various medical professionals by my (invaluable) Dutch doctor friend — including to the actual manufacturer — we eventually decided it was a safer bet just to do it intramuscularly. (On a related note, I recommend everyone befriend a medical doctor.)