A small (17mm) victory

The last couple of weeks didn’t exactly go to plan. I’ve been prepping for a frozen embryo transfer (FET), where they will carefully defrost one of the extra embryos that resulted from our recent donor egg IVF cycle, then place it in my uterus with what is essentially a high-tech turkey baster. To prepare my body, I stopped taking my birth control pills and started taking estrogen (Progynova) in order to grow a nice thick endometrial lining. And to prepare my mind, I timed all this to occur while I was sipping piña coladas on a Greek island.

Unfortunately, I managed to come down with a nasty little case of laryngitis on the last ~5 days of our trip, which instead saw me pitifully sipping chamomile tea in bed. My clinic assured me that the cocktail of pain killers and antibiotics I was taking wouldn’t negatively impact the upcoming transfer, but I was still bummed that I wouldn’t be as healthy and rested as I wanted.

Lining check

Fast forward to my first day back from holiday, where I started my workday nice and early with a date with Wanda*. The point of this 12-day scan is to ensure that the ovaries are quiet and the uterine lining is sufficiently thick to allow for implantation.

The ideal lining is at least 7 or 8mm thick and displays a distinctive ‘triple-line’ structure that indicates good ‘estrogenization’ and healthy growth of the endometrium. I’ve never had any trouble in this area, but growing a sufficiently thick lining is one of the hardest parts for many women facing infertility.

After confirming my ovaries were dormant (I could have told her that!), the doc headed over to my uterus (it’s like Mrs. Frizzle and the Magic School Bus over here). Immediately her eyes bulged, and she pointed at the screen like ‘Get a load of this’. She asked me to repeat what medication I was taking, and when I answered Progynova, 2mg, three times a day, she said “Well it’s working.”

Since I don’t have nearly as much experience as she does staring at fuzzy ultrasound screens, I still didn’t really know what she was talking about…until I saw her measure the endometrium thickness: 16.93mm.

My 17mm triple-lined endometrium in all its glory.

Since I posted this image on Thursday, Instagram has been losing its collective mind. And with good reason — studies show that pregnancy rates correlate with lining thickness. Many women struggle to grow a lining even half this thick, which probably explains the plethora of heart-eye emojis in the photo’s comments. From all the oohing and aahing, you’d think I posted a photo of a puppy in a mailbox rather than an ultrasound of my uterine tissue.

How did I grow a 17mm lining?

In addition to the heaps of admiration, one commenter asked the question everyone really wanted answered: “Holy hell. 16.93???? How?!”

At first I didn’t think anything of it. I’ve always grown a fairly thick lining (~11-12mm), so I thought maybe it was just a natural gift (& the world’s lamest superpower?) Still, it’s almost 50% thicker than usual, which seems like quite a large deviation. Maybe it’s a weird side effect of the antibiotics I’ve been on? Or maybe that wondrous week I spent spread-eagle in the sun somehow did the trick?

Then I had a realization so obvious that I’m embarrassed it took me as long as it did: I was taking an iron supplement this cycle. I didn’t think of it earlier because I was taking it for a totally unrelated reason. Namely, I’ve been feeling particularly tired lately, and a friend mentioned that low iron levels could be the culprit. I happened to have some sitting around in the medicine cabinet, so I popped it in my pill case without a second thought. I only took it for about 10 days due to unpleasant side effects**, so by the time my ultrasound rolled around, it was totally off my radar.

I can’t be sure it was the iron, of course. There are too many other variables, and I don’t have a control group. But it makes a lot of sense, since iron plays a vital role in the creation of healthy red blood cells. So if you’re looking for ways to thicken your uterine lining, you might consider some combination of taking a Greek holiday, developing severe laryngitis, and talking to your doctor about an iron supplement.

xx

* Wanda is the trans-vaginal ultrasound wand used to check one’s uterus and ovaries. We’ve been having a torrid affair for over a year (don’t breath a word to my husband).

** This is my polite way of saying severe abdominal bloating and constipation. At one point, there had to be at least five Greek salads in there.

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.”

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’.

What does donor egg IVF entail?

I’ve been busily blogging these last few weeks about our current donor egg in-vitro fertilization (IVF) attempt, just naively assuming that everyone else already knows what that means. Then last week, two friends (and avid blog readers) asked me who will carry the baby if we get to that stage. Great question! And one I should have addressed earlier. Sometimes I forget that other people don’t also spend their every waking hour reading about, preparing for, or talking about IVF. With three failed ‘normal’ attempts under my belt, as well as our latest foray into donor egg IVF, I’m basically an expert. So please allow me to explain what donor egg IVF is, and how it differs from regular IVF.*

So in a regular IVF cycle, you only need two people: a man and a woman. It begins with the woman taking medication to stimulate follicle growth (‘stims’ if you want to be hip with the IVF lingo). This comes in the form of a liquid that is injected into the thigh or (if you’re super hardcore) the stomach. The woman also takes a medication to suppress ovulation, so that it can be triggered at exactly the right time. This may be a nose spray which makes one feel like one has continuous post-nasal drip, or it may be another injection which needs to be mixed first by breaking a glass vial, because obviously that’s very safe and I’ve definitely never cut myself doing that.**

The woman does these ‘stimming’ injections every day for around two weeks, depending on the specific protocol. After the first ~5 days, she needs to have a blood test and a vaginal ultrasound every couple days. The ultrasound technician will check how the uterine lining is developing, as well as how many follicles are growing in each ovary, if there are any. (Normally only one follicle will develop to maturity in a non-IVF cycle, but the idea of the ‘stims’ is to increase the odds by growing multiple follicles.) The technician will record the number of follicles in each ovary and, if any are larger than 10mm, they will record the size. Or, if you’re like me and don’t grow (m)any follicles, this may turn into a game of ‘find the ovary’.

Once the biggest (‘lead’) follicle reaches a size of around ~20mm, the doctor will have the woman ‘trigger’ ovulation by taking another medication. This is also an injection, again administered in the thigh or stomach (because the woman probably hasn’t had enough needles poked into her recently). This must be taken exactly 36 hours before the egg retrieval surgery, so that the follicles will be nice and mature, but not yet bursting.

The man’s big moment to shine comes the next morning, when he deposits a sperm sample at the hospital. Then, exactly 36 hours after the trigger injection, the woman has the egg retrieval surgery. This is a relatively minor surgery (though it does involve more needles), and I will describe it in more detail in another post.

How does donor egg IVF differ?

In the case of donor egg IVF, you need an additional woman: the egg donor. The main difference is that almost all of the steps I’ve described so far then apply to the woman who is donating eggs, rather than the hopeful mother. The other difference is that the hopeful mother also takes medication (but in this case, to inhibit follicle growth) and has regular ultrasounds to check her uterine lining, since it is she who will (hopefully) carry the baby — not the donor. That means that after the egg retrieval, the donor’s part is done.

All of the subsequent steps (waiting to hear how many eggs are mature, waiting to hear how many eggs fertilize, waiting to hear how many embryos develop, and more waiting to hear if there are any to be placed back in and any extras to be frozen) are the same for both normal and donor egg IVF. If an embryo makes it to transfer, then it is placed in the hopeful mother with what is essentially a high-tech turkey baster. That kicks off the final stage of waiting: waiting to see if the embryo sticks and develops into a baby.

*Note that I’m only referring to actual in-vitro fertilization (IVF) here, not intra-uterine insemination (IUI), a less invasive procedure which is often tried before resorting to IVF.

**I’ve definitely cut myself twice breaking the glass vial. I can’t imagine this is legal in the US…

A big week: egg donor screening

Last week was a big week. Our egg donor, Marie, flew all the way from the US to Europe with her husband. His mother flew to their home from a different state to watch their kids (along with her mother) while they were away (because apparently it takes a village for us to even have a baby). And directly after meeting them at the airport for their evening arrival, my husband, Marie, her husband, and I rented a car and drove the 2+ hours directly to Belgium to get a quick night’s sleep before our marathon schedule of donor egg IVF screening appointments the next morning.

Given the potential for complications, I think it all went relatively smoothly. Maybe it’s because they have two small children, but Marie and her husband were champs even with so little sleep. After flying all night and going to sleep after midnight the following day, they were up by 7:30 and we were checked out of the Airbnb by 8:15. We got everyone checked in at the hospital, where my husband and I had an appointment at 9am with the psychologist and Marie and her husband had an appointment with the geneticist. We then met with the egg donation nurse while they had appointments with the psychologist and fertility doctor. Finally, we all had a joint appointment with the egg donation nurse. Just typing it all out again is making me tired.

All of the appointments went quite well, at least as far as I can tell. The psychologist didn’t bring up anything that we hadn’t already considered in detail. I had already mourned my fertility (for the most part), and I also already knew about ‘early telling’, the recommended method for telling your kid they are a donor egg baby. Marie said their appointment with the psychologist was also quite pleasant, and thanks to the detailed emails she and I have been sending back and forth, there were no surprises in their appointment with the fertility doctor.

The geneticist was the big wild card, as we had been warned she could be quite strict. However, Marie said that appointment also went very smoothly. She seemed happy with the lack of major hereditary diseases in Marie’s family tree, so the in-depth medical history Marie’s mom had done proved unnecessary. And we even got some good news: although we had previously been led to believe that Marie would be unable to donate if she was a carrier for cystic fibrosis (CF) or spinal muscular atrophy (SMA), the geneticist clarified that it would only be a problem if my husband is a carrier too (which makes soooo much more sense).

After Marie got her blood drawn for the CF and SMA tests, we all met with the egg donation nurse, a miracle-worker by the name of Bernadette. She’s the one who had arranged for us to come in May for all this, as the earliest opening they had at the time was not until July. She also ends all of her sentences in ‘voilà!’ For example, “And then the needle punctures the ovary, and voilà!” Obviously we love her.

Figuring out the timeline with Bernadette proved the trickiest part of the day. There are a bunch of things that need to happen before the actual donation cycle, so it’s sort of impossible to predict when that might occur (assuming Marie gets approved, which we won’t know until her latest blood test results come back and the various doctors present their findings at the bi-monthly staff meeting). One of the biggest uncertainties is where I am currently in my cycle (which, thanks to my condition, is less of a “cycle” and more of a random walk). Here, Bernadette once again saved the day by arranging a spur-of-the-moment ultrasound, then whipping out a needle and drawing blood from my arm right there in her office. Voilà!

After the appointments (and 4+ hours at the hospital), we drove directly back to Holland so we could return the rental car on time. Marie and her husband then had <24 hours at our house before their flight back home. All-in-all, they were on the ground for 48 hours and in the air for 20. It was a whirlwind trip, but despite the intense schedule and lack of sleep, I think we can call it a success. In her classic straight-shooter fashion, Marie even texted me from the airport:

“Can’t wait to return! Vaginal procedure and all!”