Our frozen embryo transfer

Some of you may remember that the fresh embryo transfer after our recent donor egg IVF cycle was a bit of a disaster. Out of 15 fertilized eggs that had been developing well as of day 3, we only had a single 5-day blastocyst, and it was not the best quality (4BC, where the number is the stage of development and the letters are the quality of the components). When I asked the doctor about the potential for the remaining embryos to catch up, he was a massive dick. And to top it off, I hadn’t properly timed my water consumption to fill my bladder, meaning that my uterus wasn’t visible on the ultrasound screen, and the embryo transfer had to be done ‘blind’.

It was not the best ending to our first donor egg IVF attempt, which had been going so well up until that point.

Well lo-and-behold, five more blastocysts ended up making it to freeze on day 6, and I’ve spent the last few weeks growing an exceptionally cushy uterine lining for a frozen embryo transfer (FET) attempt. I say ‘attempt’ because there’s always the possibility that the embryo will fail to defrost. Unfortunately, you don’t know if this is the case until the day of your appointment. Since our appointment was first thing in the morning in Belgium, we made our way there the night before without knowing if there’d even be anything to transfer.

The call

We were still at our Airbnb the next morning when we got the call: the embryo survived defrost! We were thrilled, and we vowed that this transfer would go better than the last. I immediately chugged twice as much water as I had the last time (followed by another 500mL for good measure), and I vowed that under no circumstances would I ask the grumpy doctor any questions. (“I’ll just nod mutely to whatever he says, scout’s honor!”) We also expected the embryo to be better quality (4BB), since we knew we had at least one of those in the freezer.

You can imagine our surprise, then, when we showed up at our appointment to learn the embryo was only a 3CC — i.e., not as developed and poorer quality than our best frozen embryo (Strike 1). I couldn’t fully take in what he was saying and immediately asked a question (Strike 2) about why we were transferring this poor-quality embryo, to which he responded that the defrosted embryo is chosen randomly (Whaaaaaat??)

IMG_3992
The 3CC blastocyst that we transferred on Thursday.

I kept a brave face and we went ahead with the transfer. There was a big screen where we watched a magnified video of them sucking the embryo up into the transfer device thingy (that’s the technical term), and then the technician handed it to the doctor through the window in the wall. My bladder was full enough to see my uterus on the ultrasound screen (though at 17mm, it’s probably hard to miss). After the transfer, we saw a new white mark where the liquid containing the embryo had been successfully deposited.

PUPO, but not hopeful

This all went down last Thursday, which means I am once again Pregnant Until Proven Otherwise (PUPO). But despite what my well-meaning friends/family keep assuming, I am neither excited nor hopeful. The thing is, once you’ve gone through multiple failed transfers, it becomes hard to imagine any other outcome, particularly when the doctor says the embryo ‘isn’t the best quality’. I understand that poor-quality embryos can still result in beautiful babies, but I have also seen the statistics on implantation rates as a function of embryo grade. I’m not being negative — just realistic.*

With that said, I am still extremely grateful to our egg donor, Marie, for giving us the chance to make it this far. I’m also grateful for the four more embryos (‘frosties’) still in the freezer. And I’m happy to report that we had to stop three separate times for me to pee on the 2-hour drive home from our transfer. So, you know, at least I’ve finally got the full-bladder part down for the next try.

xx

*Ok, maybe I’m being a bit negative, but I recently read that IVF is as stressful as divorce or cancer in the family, so it’s bound to happen. (The progesterone shoved up my hoo-ha probably isn’t helping either.)

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 piƱa 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.

Pregnancy symptoms during the two-week-wait

I haven’t posted in nearly a week for good reason: I’m tired. Like really tired. So tired that I had to skip the Gay Pride Parade in Amsterdam this past weekend, which I was TOTALLY looking forward to. Why? Because I was so exhausted from being awake for 2 hours that it apparently necessitated a 3.5-hour nap. (This is really not helping my reputation with my husband as ‘the most ridiculous human being ever’.)

If you aren’t familiar with the IVF process, this may sound really hopeful. After all, I’m nine days past my 5-day transfer (9dp5dt if you want to be hip with the lingo), and well past the point where the embryo should have implanted in my uterine lining (if it has decided to grace us with its continued presence). So…maybe the exhaustion is a promising sign…meaning that I’m pregnant!

That would be *awesome* if it were the case. Unfortunately, there’s no way to distinguish real pregnancy symptoms from those caused by the hormone supplementation that is also required at this stage. In particular, in addition to the estrogen pills I’ve been taking three times a day for over a month, progesterone is also necessary in the second half of the cycle to help prepare the uterine lining for implantation and potential pregnancy. It’s started right after the egg retrieval by both ‘regular’ (non-donor-egg) IVF patients as well as by the recipients of egg-donor IVF embryos, and honestly — I think it’s the worst part of the whole damn process (injections & vaginal surgery included). My progesterone comes in the form of vaginal suppositories that must be inserted three times a day*, and which manage to leak out even after the requisite 30-min period lying down. Because women facing infertility treatment clearly don’t have enough to deal with already, so now we also get to have leaky vaginas!**

‘Pregnancy symptoms’ on progesterone

The bigger problem with taking progesterone during the two-week-wait is that it it’s exactly the hormone you would be making naturally if you were, in fact, pregnant. This means that many of the side effects we associate with pregnancy are actually due to progesterone, and that taking additional progesterone during the two-week-wait can be a total mindf@$k. As a result, here is an incomplete list of just some of the ‘pregnancy symptoms’ I’ve experienced during my previous (failed) two-week-waits while on progesterone:

  • Cramping
  • Bloating
  • Nausea
  • Gas
  • Diarrhea
  • Constipation
  • Headache
  • Backache
  • Dizziness
  • Sore boobs
  • Vivid dreams
  • Fatigue/drowsiness
  • Mood swings
  • Loss of appetite
  • Increase in appetite
  • Shortness of breath

As I mentioned, those cycles failed, so these symptoms were definitely side effects of the progesterone (or just fabricated by my anxious brain). But when there’s finally a real chance you might actually be pregnant, and when you are experiencing any/all of these symptoms, it’s really hard to just dismiss them as false alarms.

Is there any way to tell between progesterone side effects and actual pregnancy symptoms?

So is there really no way to tell the difference? No small, previously overlooked symptom (e.g., a twinge in the pelvis!) which might finally and conclusively spell the difference between progesterone side effects and real pregnancy symptoms? (“Siri, are pelvic twinges a side effect of progesterone?!”)

Spoiler alert: basically every possible symptom can be a side effect of the progesterone. Having ZERO symptoms can also still mean you’re pregnant, or not! Different women respond differently to both the medication and actual pregnancy, and women can also respond differently during cycles, even if they have the same outcome. I’ve had sore boobs one cycle and not the next, and they both resulted in Big Fat Negatives (BFNs). There’s literally NO WAY to tell besides a pregnancy test, which for me, at least, is still several days away.

In future cycles (should it come to that), I hope that I will finally take my own advice and give up the symptom-spotting once and for all. For now, I’m going to google “9dp5dt cramping backache success stories”. Because for the next couple days at least, there’s still hope.

xx

*If you ever see a sticky note on my office door that says ‘telecon’, now you know what I’m really doing.

**Leaky Vaginas is going to be the name of my new FemRock band.

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…

What are the odds of this donor egg IVF cycle working?

Some people we’ve told about our current donor egg IVF attempt automatically assume that this cycle will work — that we will walk away with a baby. While we are certainly way more optimistic about this cycle than our previous three (non-donor-egg) cycles, unfortunately, the odds are still not 100%…not even close. So in the interest of managing everyone’s expectations, what are the odds of this donor egg IVF cycle working?

I won’t leave you in suspense: the answer is 25%.

Yep. 25%. Depressing, right?

Of course, the exact value will depend on the quality and quantity of eggs they get from our egg donor, Marie. But given her age and the number of eggs they aim for, we are going through all of this effort — multiple international flights, daily injections, disrupting four peoples’ work schedules, and spending thousands of euros — for a one-in-four shot. In other words, don’t get out your baby booty knitting pattern just yet.

So how is this value calculated? As I said above, the two main factors are egg quality and egg quantity. Egg quality decreases with age, where the AMH level can give a rough indication. Marie has a fairly normal AMH level for her age (even a bit above average), but she is still 36. So as high-quality as her eggs may be, we can’t expect them to compare with those of an 18-year-old.

By egg quantity, I mean the number of eggs that Marie grows during the stimulation cycle. I had previously read that they aimed for 10-12 eggs in an IVF cycle. However, apparently 15 eggs is already getting into the territory of ovarian hyper-stimulation syndrome (OHSS), which can cause complications for the donor (in addition to decreasing the quality of the resulting eggs). In order to steer clear of those complications (and since it’s not a very exact science), our clinic will aim for 6 eggs in this cycle. Combining this number of eggs with Marie’s age, we arrive at a 25% chance of it working.

All of this is nicely summarized by this chart from my doctor, which I snapped a (poor-quality) picture of at our last appointment. It shows the predicted live birth rate as a function of age and egg number. The important thing to notice is how the live birth rate starts decreasing again above 15 eggs. Even with a younger donor, this would limit our success rate to 30% (for 6 eggs) or 40% in the very best case of exactly 15 eggs.

IVF live birth rate
Chart from our clinic showing predicted live birth rate as a function of number of eggs and donor age. Note that the success rate starts decreasing again for a large number of eggs, where ovarian hyper-stimulation syndrome (OHSS) can cause complications for the donor and affect egg quality.

In summary, not only are the odds not 100%, but it’s actually likely that this cycle won’t result in a baby. We will continue to be cautiously optimistic, but don’t expect me to be googling gender-reveal cake recipes quite yet.

Thanks

The response to this blog has been overwhelming, so I just wanted to take a moment and thank everyone for reading it.

I know that for many of you, reading a blog about infertility is not exactly how you’d normally choose to spend your leisure time. Then again, I never thought I’d be writing a blog about infertility, and yet here we are

For those of you who don’t know our donor, Marie, I want you to know that she’s totally on board with me writing about all of this. She even gave me the push to finally start it. I’d been thinking about starting a blog for a while, but until recently, it would have been all too doom-and-gloom. Obviously we’re still grieving that ‘natural’ IVF didn’t work out for us, but we’re also hopeful that this new path — egg donation — will be more successful. After all, Marie had both her kids on the first try, so her eggs are clearly top-quality. (If you could buy them at the grocery store, they would be those expensive cage-free organic ones.)

Just to be clear, Marie and I are also both chronic over-sharers, which Marie calls a ‘personality flaw’ and I call a ‘character asset’.

I also want to be clear that I don’t think I’m the first person in the world who has ever had this idea. When I told a (similarly fertility-challenged) friend about the blog, she said “Great, I’ll add it to my Saturday morning infertility reading list”, and she wasn’t even being sarcastic. There are many other great infertility blogs already out there written by fellow ‘IVF warriors’, like The Infertility Voice, Life Without Baby, Dreaming of Diapers, and (my personal favorite for best title) The Impregnable Woman.

There’s also a ‘National Infertility Awareness Week’, which, by coincidence, was this week. #NIAW

I’m really hoping this blog will be a short-lived pursuit, only necessary to keep our family/friends in the loop during this (last??) crazy leg of the journey. But I’m also a scientist — I understand the statistics — and I fully understand that it very well may not be. So thank you again for reading & following — your support means the world to us.