Primary Clinicals

This blog was started to document both my last year in my Nurse Midwifery program as well as the ups and downs of infertility and trying to conceive and I have yet to post anything regarding the midwifery portion of my life.

Currently I am in my primary care rotation, but my preceptor (also a Certified Nurse Midwife - CNM) sees only OB and the occasional GYN patients, but no primary care and not very many GYNs. So, I have been farmed out to a inner city clinic where I am working with 3 Nurse Practitioners and 1 CNM and am seeing about 20 family planning, pre-conception counseling and GYN patients a day. This clinic also predominantly sees Spanish only speaking clients, so it has been good to not only be able to meet all my GYN patient goals but also to be able to speak Spanish all day and help an underserved, mostly uninsured, population.

Most of my day this past week was spent doing annual well woman exams, i.e., pap smears, and doing heaps of family planning and education. I learnt some new pelvic exam techniques that have been really helpful and useful to both me and my patients, and I also learnt how to identify yeast and bacterial vaginosis infections under the microscope. I also am becoming highly proficient in my speculum exams - I am aiming to do them gently and with as little discomfort for the patient as possible. I will be returning to this same clinic for 2 more weeks, 2 days a week, and then winter quarter will end and the spring term will begin bringing on a full 10 weeks of GYN focus. Luckily, since I am knocking out my primary, family planning and GYN now, I will not have to worry about my numbers for next term.

I have an exam and a research article to finish by Sunday whilst I also have to work Sunday and Monday nights. I will be dreaming of spring break tonight, that is for sure!

No luck

I am not sure what happened, but we had no luck with round 1. I took a pregnancy test on Friday and it was negative. I then started cramping and spotting later that day. That night I worked, and my period came on full force - really heavy bleeding and clotting, which is not typical for me. It was also only day 25 for this cycle, which, for me is a short cycle. It did give me 12 days in my luteal phase, but still my cycle was shortened by 3 days for some reason.

I spoke with my Reproductive Endocrinologist (RE) today and she said that Clomid can have an affect on one's menstrual cycle and bleeding flow. She wants to start me on Clomid again on days 3-7 and follow up with an ultrasound on day 10 to check my follicle production. She said she would also recommend using some progesterone in this cycle for support should an egg become fertilized.

To be honest, I am quite disappointed. Not only that we are not pregnant, but that we spent close to $600 and received nothing for it. It is also hard to understand how 9 million sperm could not meet up with at least 1 of 4 eggs. It really is a mystery. It also makes me quite nervous as I know now that I only have 3 rounds left. Only 3 more chances to conceive before my RE recommends IVF. That makes me depressed. Thinking that we are just that much closer to the end of our chances and facing the fact that we will not be able to have our own children. I know I should not get ahead of myself. 3 more IUIs also means that we do have 3 more 36% chances of conceiving. I am hoping it happens in round 2 or 3 and not in 4 or never.

Sigh. Had a bit of a cry about it but am now trying to be more optimistic. Just not sure how much disappointment I can take. I am really hoping for success with the round 2 and am going to look into other things I can do to increase my chances of conceiving and implanting.

TWW

TWW, aka Two Week Wait, is the dreaded time between ovulation and possible conception where you wonder every day if you could possibly be pregnant this month. You inspect and analyse every single sign and symptom wondering if this could be a valid indication that you will finally be carrying a child.

Even though I am a medical professional and know the signs of pregnancy, I still wonder with each sign and symptom (S&S) experienced. On the other hand, I try to not read too much into each S&S as I do not want my hopes dashed when Aunt Flow comes for a visit at the end of this month.

I am exactly 7 days away from the commencement of my next menstrual cycle and I have had these S&S:

• Spotting
• Cramping
• More spotting
• Pain in my left pelvis
• Breast tenderness - so tender that it is quite painful when my shirt and/or bra rubs against them.
• Constant nipple sensitivity - have never experienced this before

These S&S have left me with much to contemplate. I am looking forward to knowing either way. Either I will be overjoyed with the news that we are finally pregnant, or I will be able to once again enjoy a nice glass of red wine. Only 1 week left until the verdict is in!

Round 1

And should it take, what a sweet Valentine's Day gift that would be for us!

I woke up this morning feeling fine. Tired at 0530, but no aches or pains. My husband collected his specimen and then kept it warm between his legs on our drive up to the city. We had to drop it off at 0700 to be spun, cleaned and consolidated into the most healthy, best swimmers. They were thankfully able to obtain a 9 million/ml concentration. Greater than 5 million is needed for Intrauterine Insemination (IUI). 10 million is ideal and 20-30 million provides the highest rate of success. However, if we were at the 20-30 million count, we would not need IUI. The sample was just short of 10, but the doctor was positive about our chances.

At 0825 we entered a waiting room filled with other couples. I was surprised to see so many people receiving fertility treatments on the same day. I guess I did not realize there are many people out there struggling with infertility issues as well. For some reason I had it in my mind we would be the sole couple waiting for our procedure. On one hand it comforted me to know that I was not alone in this endeavor, but on the other hand it made me contemplate the reason as to why so many of us have fertility issues.

At 0845 we were finally called back. The procedure began easily enough. It is a standard speculum exam and then the doctor takes a syringe filled with semen and attaches a long catheter tube to the end.

This is then inserted into the external os of the cervix, through the internal os and then into the uterus itself. All guided by ultrasound (US).

Upon initiation of the IUI, there seemed to be two problems. My uterus was anteflexed and my bladder was not full enough. After about 10 minutes of not being able to get the catheter to bend to a 120 degree angle, I was given a reprieve to drink more water. 15 minutes later, the physician returned, viewed my bladder via US and determined it was fuller and had thus helped to straighten out the curve in my uterus. This time they used a similar tubbing as the one above, but longer and more bendy - one that is typically used with IVF - and with a full bladder and a bendy catheter, the doctor was able to enter my uterus and inject 9 million happy and healthy sperm.

Overall, the procedure went well. It was painful (think menstrual cramps) on the first attempt, but upon the second attempt, with the right equipment, it all went swimmingly. There was less pressure, no cramping and it was very quick on the second attempt. We even got to watch the semen inject into the uterus via ultrasound. It was exciting to witness the possibility. Now it is all up to chance. Here's hoping one of those swimmers makes it to one of the eggs released and that he has the fortitude then to burrow into the egg and make it inside.

Now on to celebrate a day of love. Happy Valentine's Day!

Side Effects

So far I have not experienced any side effects from my 5 day stint on Clomid. According to my physician the most common side effect of Clomid is hot flashes. According to Drugs.com website, the most common effects are:

Blurred vision or vision problems (spots or flashes); breast tenderness; dizziness; enlarged breasts; enlargement of the ovaries; flushing; headache; hot flashes; lightheadedness; mood change; nausea; pelvic pain or bloating; stomach pain; vomiting.

Thankfully I have have had none of these nasty symptoms. I did experience some pain and tenderness in my right ovary, but that seems to be related to the amount of follicles Clomid induced on my right side.

I gave myself my subcutaneous injection of hCG last night and to be honest, it was not as bad as I feared. The injection site was a bit sore and tender to touch but that quickly dissipated. I did, however, experience some side effects with the injection. Shortly thereafter I began to have a pretty severe headache and then a few hours later felt nauseous. According to Drugs.com these are common side effects along with feeling restless or irritable, mild swelling or water weight gain, depression, breast tenderness or swelling and pain, swelling or irritation where the injection was given.

I do have to admit that I have been quite irritable lately, but I cannot tell if that is due to the stress of everything or due to the medication.

This morning I awoke with a continuing headache and still feeling slightly nauseous. I also have tenderness over my right ovary and pain in my right lower back as well. I know I am in the thick of it now, but this all makes me wonder if it is really worth it. Do I really want to be pregnant? And at what cost? I am feeling quite blue today and second guessing my decision to go through with IUI. These feelings also makes it crystal clear to me that I cannot go through IVF if IUI does not work.

I guess the part that weighs the most heavily on me is that I am completely normal reproductively speaking, and yet, I am forcing my body to mature more eggs than normal and now forcing my body to ovulate off its normal rhythm. Being someone who is as natural as they come and one who enjoys keeping the body healthy and fueled through natural means - organic food and yoga - it seems a stark contrast to be doing something so artificial to my body. Especially when I do not have any fertility issues. Men are lucky, aren't they? Even when the problem lies with them, we still have to be the ones to endure the treatment. If only they could have a share in all this fun. Joy!

With that said, I am looking forward to tomorrow morning. I am hoping with all hope that the first time takes (and that it is not a twin gestation!). Fingers crossed on both counts!

Day 10

Today is day 10 for me. I have taken the 5 days of Clomid and had an ultrasound this morning. It seems the Clomid only worked on my right ovary but I have 4 follicles greater than 10mm plus a few more. Nothing on my left greater than 10.

Will be giving myself the hCG "trigger" injection this evening to force ovulation and then going in for the spin and wash sperm cycle and IUI on Sunday. Even though I am a nurse and am completely okay with giving injections - I am not looking forward to giving myself an injection.

I definitely was shocked by the cost of this round of IUI. $310 for today and another $300 for Sunday. Insurance paid for Clomid but nothing else. After living in Europe where fertility treatments are paid for or covered by insurance, it is disappointing that we find out NOW whilst living in the US that we need fertility treatments and that they are not covered by insurance. We are really hoping that one of these four treatments take (preferably the first one!) as we cannot imagine going through and paying for IVF. I know many people have had success with it but I have watched a friend go through 2 cycles of IVF with such struggle. Thankfully she now is pregnant after her 2nd attempt, but everything she went through was heartbreaking.

Ahhhh the stress! I must think positively, keep stress at bay and go hop on my mat. Ashtanga always makes everything better!

First signs

Our conception project, if you will, began in March 2010. At first it was a casual endeavor, not taken too seriously. After several months of no magic, I decided to buy a Clear Blue Easy monitor to see if and when I was actually ovulating. I was elated to see that, at 38, I was still ovulating every month. I had renewed hope.

August creeped upon us with no change in the story, so I decided to get checked out by a fertility specialist. Typically infertility is a diagnosis attached to those who have been trying for one year without success, but being 38, I knew we needed to be checked out at the 6 month mark. What a relief it was to find out everything was completely normal with me and I had heaps of antral follicles on my ovaries (meaning I had good ovarian reserve as we women are born with a finite amount of eggs and as we age this number drastically decreases).

With this encouraging news, we went back to the drawing board and doubled our efforts. We tried everything we read or heard about from friends and family. I tried Vitex agnus-castus, we tried using pre-seed lubricant (which a same age couple swore by), I drank fertili-tea, we both went to acupuncture and took Chinese herbs and I even did Sirasana (headstands) and meditation after intercourse to use gravity and mind power to will those little sperms to meet the egg.

Nothing worked.

In the meantime, we moved and life carried us away with busyness. We finally found a reproductive endocrinologist in our new city that we really liked and we both went in for a full exam. Our results came in and lo' and behold, my husband has a very low sperm count as well as low morphology, low motility and 47% dead sperm. It was bad news. When the doctor said I would only have a 1.8% chance of ever conceiving naturally, I cried.

My dear husband then doubled his efforts with the herbs and acupuncture. He already eats very healthfully and is in ultimate physical health, so he was not sure what else to improve upon. He saw a fertility urologist during this time, but left without any explanation as to the cause of his low counts. A repeat test in a month's time showed the same results.

That brought us to our only option - to undergo assisted fertility treatments. Our chances for pregnancy with Clomid + IUI (intrauterine insemination) increases from a 1.8% per month chance to a whopping 26% (average 15-20%). So we are giving it a go. We had hoped we could have done everything naturally, but no such luck.

We are now starting our first cycle. Fingers crossed for a sticky outcome!

Where to begin?

In the beginning, I presume.

Just a bit of background: I am 38 years old. Happily married for 6 years, together for 10. We have 2 dogs and enjoy them immensely. We love to travel and see the world and have been spending most of our marriage doing so. We decided this last year in March that we would start trying for a family. So far we have not had any success. We are both vegans and we both practice Ashtanga yoga. I am also in my last year of my Master's in Nurse Midwifery - working towards a DNP (Doctor of Nurse Practitioner) in Midwifery degree.

This blog will be my (hopefully) daily diary of the ups and downs of trying to conceive and the trials and tribulations of being molded into a midwife.

Looking forward to the journey.