Sick & Pregnant

Nothing is worse than being newly pregnant and then becoming sick, especially on New Year's Eve.  Well, I guess being 16 & Pregnant* would be much worse - must look on the positive side!  

I had lovely plans to go to dinner with friends and then to an art exhibit opening, but now I am just stuck in bed with a cup of tea and a box of tissues.

I know there are common medications green lighted for women in pregnancy, but none, however, are category A drugs.  Even Tylenol/Paracetamol is a pregnancy category B drug.  With my patients, I always advise them not to take any medications during the first 12 weeks, and so, I am heeding my own advice being only 9.3 weeks, but boy does it suck.

I have taken elderberry syrup, the homeopathic Cold Calm remedy, drank heaps of antioxidant tea (but not echinacea), made some tofu "chicken" noodle soup (which was delish!), taken loads of vitamin C and have sucked on countless Ricola natural throat lozenges over the last few days all to soothe my throat, reduce my temp (high was 100.5 F/38 C), get rid of my body aches and fatigue and to finally feel better.

I think I am on my way to a new and improved (more immune) and healthier me.  I hope by tomorrow (the new year!) I will feel more like myself and be able to resume the home improvement projects I am trying to finish before my last term starts on 9 January.  Most importantly, I hope my illness has not harmed my little foetus in anyway.  We shall see very soon with my new OB appointment on 4 Jan.

Wishing everyone a lovely, happy and bright New Year.  Hoping your 2012 is filled with hope, blessings, joy, new beginnings and many dreams that come true.  xx

*I don't watch the show, but have heard about it and witness it in real life every day. 

How We Told Our Family

Although I have kept this blog detailing our steps through IVF, I have not made this blog public to many people I personally know.  Our close family, of course, knows we were going through IVF, but we told them each about the pregnancy in a different way.

I told my husband first, naturally, upon seeing a positive hpt and after my blood test came back favorable that afternoon.  I then emailed my positive hpt picture to my sister and my best friend who were both very excited for me.  My sister was the one who came with me to my egg retrieval and embryo transfer and has been such a great support while my husband has been deployed.

We decided to wait until our 1st scan before we told my grandparents and my husband's parents.  I told my grandparents in person at their house on a visit.  They were so excited for me and my grandmother, who talks directly with God, said all things were going to work out perfectly for me.  Good news!

For my in-laws, since they live on the East Coast, I wanted to do something extra special for them.  I wrapped all of their Christmas gifts and put them in a large box.  I then included another white box with a pink ribbon (that's just me hoping it's a girl!).

Inside the box, I placed a copy of the 1st 6.5 wk US picture.  The paper was folded in fours and on the outside read, "Congratulations!"  When they opened the paper they would see the US along with, "You are going to be grandparents!"

I spoke to my in laws on Christmas day and they were SO excited, especially my mother-in-law.  My father-in-law said my MIL jumped up and down when she opened the package.  They have been waiting a long time for a little baby grandchild and it was so sweet to hear their reaction and feel their support.  I then sent them the 8.5 wk US picture and video this week via email.  They are already planning on coming out when the baby is born and have called or visited all of their family on the East Coast to share the good news with them.  It is just too cute.

We are waiting to announce it to all our friends, extended family and Facebook until we are past the 1st trimester and the screenings come back a-okay.  I am so excited though, I can barely contain myself.  I cannot wait to share it with everyone!

Second Ultrasound at 8 weeks 5 days

My second and last US with my RE at 8.5 weeks was Monday.  A heartbeat of 165 bpm was heard and a fetus was actually visualised that looked somewhat like a baby!  I got to see the flickering heart, spine, legs, arms, umbilical cord and even fingers!

I have flipped the US picture upside so you can see the baby right side up.  At top is the head and bottom are the legs, an arm is to the left and the umbilical cord is going off to the right towards the yolk sac.

Here is a video of the heartbeat!  My RE said that there is now less than a 3% chance of SAB/miscarriage after hearing the heartbeat for a second time.  Yay!

Honestly, I am still in shock.  Overjoyed and excited, but still in a bit of disbelief.  I just cannot believe it worked on the first round.  I really thought we were going to be like many couples who have to go through heaps of rounds before we met with success.  What faith, hey?  My RE was thrilled though for us, and I am happy for them as well as my data will help their success rate go up in the women over 35 category.

Sadly, I am graduating from my RE office.  I am 9 weeks today and will stop daily progesterone at 10 weeks.  I will then see my midwife (also my preceptor) on 4 January for a new OB appointment where I will be scheduling first trimester screenings at that point due to my age.

I am excited about going forward and am trying to have loads of faith that all will work out fine.  I am thankful for all my friends' and family's support and prayers.  It really means the world to me (and us!).

Support During Infertility

Just a quick post to give a shout out to my wonderful infertility support group!

I never knew there was a support group in my area until a friend in NYC sent me a link to Resolve: http://www.resolve.org/.  Here you can search for a support group in your local area, and lo' and behold I found one just down the street!

Since my husband has been deployed throughout this entire process, these ladies have been such a wonderful system of support and laughs.  I have many friends who are supportive, but they will never fully understand what it is like to go through IVF.  These women know exactly what is involved and each share encouraging stories from their trials and tribulations of infertility.  The leader of our group even checks on me weekly to see how I am doing.  It has been a lifesaver, literally.

So if you are in need of human, in-the-flesh support, please find a local group in your area via the link above.  If there is no local group in your area, start one!  I am sure there are many others that are in need of an active support group in your city.  

We Have a Heartbeat!

I am still a bit shocked, to say the least.  I was well prepared to hear the news that there had been an early loss.  I have seen 4 patients in the last 2 weeks with SABs (spontaneous abortions) at the 6 week mark.  I did not even look at the monitor initially and was hoping I would not cry.

Then... there was a heartbeat!

Loud and clear at 135 bpm.  I then looked at the monitor in shock and disbelief!  I still cannot believe that I am actually carrying a baby.  That I am really, truly pregnant.  That our IVF worked on the very first round!  I really thought we would be going through round after round before success would find us.  It is still all very surreal, but I am excited, overwhelmed and elated.  I know there is still a chance for a SAB, but I am holding out hope that each week goes by successfully and healthfully.

I have another 9 week appointment on 26 December.  It will be my last appointment with my RE if all is well.  I will then follow up with a midwifery new OB appointment on 4 January.  I want to do 1st trimester screening as close to 10 weeks as possible as there is a decreased likelihood of false positives at this point.  My biggest fear right now is Down's Syndrome or a fetal anomaly.  I am praying daily for a healthy baby that makes it to term with no complications!

Currently, I am looking into hiring a doula.  They book up fast around here, so I am hoping I can find a good fit and one that is free for my EDD.  My due date is 1 August 2012!

Finally, I will leave you with a picture of our little bean.  Hard to see a fetus here, but the yolk sac is to the left and the fetus is to the right.  This is a great website that shows week to week how a fetus grows as seen via US:  http://www.baby2see.com/development/ultrasound_sonogram/first_trimester_scans.html#week6.

As you can see by the website above, our little bean is right on track for turning into an adorable little baby. 

Financial Costs of Infertility Treatment

Outlined below are our costs that we have paid so far for infertility treatment.

• 3 rounds of IUI at $500/ea = $1500
• Infectious disease testing $75 per person = $150
• IVF via the Attain Program (4 rounds - 2 fresh/2 frozen) = $16,500
• IVF sperm workup = $300
• Cryopreservation of sperm (done prior to my husband deploying) = $100
• Daily injectables for 1st round = $3500
• Anesthesia for egg retrieval = $500

Grand total for thus far: $22,550, and for 1st round of IVF:  $21,050.

NB:  Our insurance, Tricare, did not pay for any of the treatment.  The only meds they paid for were Clomid, Lupron and progesterone - all the inexpensive ones.  So much for supporting the troops, especially since it is male infertility factor for us!

We drained our savings of all we had - $9,000 - and the other $7,500 came from a Springstone Fertility Loan.  We had no idea the injectables would be $3500 and so when we received that call from the pharmacy, I almost fainted.  We had to take out another loan for the $3500 as it had to be paid immediately to start the round.  So in total, we took out $11,000 in loans.  The rest of the charges we paid in cash.  In cash total, it was $9,000 from savings and $2550 over time from our checking for a total of $11,550.  It looks like it works out to 1/2 in cash and 1/2 in loans.

I wish we did not have to take out any loans, but I also wish we did not have to drain our savings.  This kind of expense puts a lot of pressure on the process of having a baby.  No longer is a just a nice dinner and a bottle of wine.  Now, it is tens of thousands of dollars.  

Needless to say, even though my RE has said it is fine to go back to regular daily activities, I am still taking it easy.  I have not returned to my daily exercise régime or Ashtanga yoga practise.  I do still walk my dogs daily and go to work, but I am still careful in both of those.  I am holding out for the 6.5 week US on 12 December to see a heartbeat, so I can know for sure I am actually pregnant.  I know many people do many things during the first four weeks, including jumping on trampolines, and still remain pregnant, but with this much money at stake, I'm playing it safe and hoping not to be sorry.

Beta Site

A great site that collects Beta results - now from over 61,000 women - and shows median levels for singleton and multiple pregnancies.

http://betabase.info/index.php

BFP!!!

For those not in the fertility acronym know, BFP = Big Fat Positive!

Monday morning before work I decided to do an early home pregnancy test (HPT) since I had 2 sticks.  I figured I would test Monday and Tuesday and then have my blood drawn on Wednesday.  I had no expectation of being positive at this point.  I had already had so many negative HPTs, that I did not hold much hope for a positive one.  I urinated on the stick (First Response) and then hopped in the shower.  As I was showering I even told myself, "Don't be disappointed when it is negative.  It is still very early."  After my shower, I decided to have a quick peek.  And then a double look.  Then a close up squinty inspection.  I could not believe it.  There were actually 2 lines - one dark, one light.  How could that possibly be???

I quickly readied for the day, and then called my RE office.  I really thought they would tell me to still keep my Wednesday appointment, but instead they squealed with glee and told me to come in right away.  On my way to work I swung by and had my blood drawn for my quantitative B-hCG and progesterone levels.  As I was coming out of the room after blood draw, all the nurses were lined up to say congratulations and give me big hugs.  It was so incredibly sweet!

I received a call from one of the RNs later that day saying my quant level was at 165 and my progesterone was good at over 40.  

At this point, I was still trying to fetter my joy.  I was extremely happy, but I still knew that my quant could go down, I could have a spontaneous abortion (SAB),  and any number of things could go wrong.  I have seen 2 patients in the last week who had a loss between 4-6 weeks, and so I did not want to let myself become too excited or committed to thinking I was indeed pregnant.

It is hard for my husband and I to talk since he is 9.5 hours ahead of me and working a variety of shifts, but I shared the news with my husband in Afghanistan that night via Skype.  I just held up the HPT stick to the camera.  He was shocked and happy and then a bit sad that he was missing it all thousands of miles away.

This was 10 dpt (days post-transfer).  

Now today, on 12 dpt, my quant is 362 (more than doubled!) and my progesterone is still really good (thanks to all those self-inflicted IM injections!).  

Next up is an ultrasound at 6 weeks and 5 days on 12 December.  I am hoping for twins (although my husband is definitely not!), but I will be happy for a singleton.  I just want a very healthy, happy baby that makes it to term.  That is all that really matters.

ET

No, not extraterrestrial (although it all feels very sci-fi), but rather embryo transfer.

I had my only 2 embryos (1-8 cell B with clean margins and 1-4 cell B with fragmented edges) transferred on Friday - day 2 and a very auspicious day - 11/11/11.

Here are my little embies on day 2 - I call them Violet & Poppy.  I am hoping with all hope that at least one of them (although I would love to have twins!) stick and stay, and develop into a lovely little baby.

The embryos are too small to see with the naked eye, but in this short clip of my ET, you can see little white dots (air bubbles and fluid surrounding the embyros) on US.

I am feeling a bit crampy (hoping that is implantation!) but overall doing well.  Still a tiny sore from my egg retrieval (where my RE punctured the vaginal wall bilatterally in order to retrieve eggs from both ovaries), but I am feeling better each day.  I have Friday-Monday off, so that has been a blessing.  I have been doing lots of lounging, resting and relaxing along with trying to work out my landmarks for the IM (intramuscular) self-injection of 1 mL of progesterone in oil (PIO) every night.  This sounds easier than it is.  I am still trying to master it!  So easy to do on another person, a painful quagmire to do on myself.

Ay!  Now, there is nothing to do but wait.  The dreaded 2 week wait (2ww).  I am hoping this 2ww goes by quickly and yields a positive hCG.  My beta hCG will be on the 23rd of November (the day before Thanksgiving, how apropos!), and I can do a home test 1-2 days before although it can give a false-negative.  Not sure yet what I will do.  I do not want to get disappointed early, but I also want to know as soon as possible.  Hoping I can stay sane and positive throughout the duration of this 2ww!

Eggs and Embryos

Received news today regarding my eggs and it is not good.

7 eggs were retrieved.  Only 3 (!) were mature.  All were injected with a sperm but only 2 fertilised.

Ah bless.  So disappointing.  I just do not know what went wrong.  My RE thinks she should have waited until day 11, but sadly, it is too late for hindsight.

I know that I only need one beautiful embryo to implant to make a baby, but I really had hoped that we would have more than 2 in order to make a choice regarding quality and to freeze one or more of them so that if this transfer did not take, I would not have to start injectables again.  I really, really, really wanted to do a FET (frozen embryo transfer) cycle next!  I just am devastated that I may have to start a full fresh round all over again.  I also only have 2 fresh rounds covered by Attain, so if this next round does not work either nor produce embryos for freezing, my IVF rounds will be finished.  It's so scary to think about that!

My RE recommends I transfer on day 2 now since there will not be any opportunity to "wait and see" and make a selection on which embryos are the best.  Both will be transferred regardless.

So, I am returning again to my RE's office tomorrow to have 2 embryos transferred at 1400.  I will know at that time how they have graded our embryos.  Gosh, I hope they are at least decent embryos.  My RE seems to think these two have a good chance as they look really good at this point.  Only time will tell.

All prayers and positive thoughts are well coveted.  I need all the help I can get!

The End is Near!

Monday, I finished my last day of injectables.  Yay!  I was quite happy to finish my injectables as I was starting to have heaps of side effects - excessive vaginal discharge (so much that I had to wear a panty liner because I soaked through 2 pairs of scrubs!), really tender skin where it was beginning to hurt to give subq injections, bruising on my stomach after injections, extremely tender and sore breasts, constipation and an irritable mood.  At first the injectables just made me happy with no symptoms.  In the end, they were really starting to wear on me.

Monday at 2230, I took my hCG trigger shot (35 hours prior to retrieval).

Tuesday, I began my antibiotics.

Wednesday was egg retrieval day.  My sister took me to my appointment at 0830 for a retrieval by 0930.  My blood pressure was sky high for me (140/85) at admission because I was so nervous about being put under anesthesia and waking up in pain.  Luckily, I had my sister there to make me laugh and comfort me.  My anesthesiologist was phenomenal as well.  He put me at ease right away with his good nature and humor, and he really listened to me regarding my anesthesia fears.  I was under anesthesia previously for a tonsillectomy and had the worst time coming out of anesthesia - difficulty waking up and staying awake for over 24 hours.  I have the same issue when I take any prescription narcotics or other meds that say "may cause drowsiness".  In me, they ALWAYS cause drowsiness and it is typically a drowsiness I cannot easily shake.  I will often sleep for 12-18 hours straight after taking those types of medications.  So, it was wonderful to actually have him take me seriously and listen to my concerns instead of blowing me off.  He then gave me only 1/2 of the versed and fentanyl right before the procedure instead of the whole dose.

Before the procedure started, I asked my RE to look and make sure my eggs were still there prior to going under anesthesia.  I did not want to go under if I had already ovulated!  Thankfully, the IVF round was not a loss and I had not ovulated.

I was given versed in the pre-op room in order to calm my fears, and then I was given fentanyl when we were back in the procedure room.  After that, I do not remember a thing.  I was given propofol (yes, the Michael Jackson drug) and I went off to sedation land.

I woke up in my pre-op room, now a recovery room dimly lit with my RN sitting at my bedside charting my vitals.  She asked the usual questions - how did I feel?  was I in any pain?  did I feel nauseous?  I felt fine, actually.  Just a bit foggy in the brain, but otherwise, no pain and I woke directly after the procedure with no hangover.  That was the best thing!  I drank some apple juice and ate some pretzels and then they brought back in my sister.  The RN monitored my vitals for some time until all was good (BP now 114/72), gave me my post-op instructions and gave me my first progesterone injection - 0.25 ml with instructions to give myself another 0.25 ml that evening.

My RE popped in with the news that there were 7 eggs.  I was disappointed in hearing that as we had hoped that there would be at least 10-12.  It was disheartening, but I tried to think positively and hope for the best.

Going home, I was to continue with my antibiotics for 5 days and give myself 1 mL of progesterone every evening. They said they would then call me the following day with news of my eggs.

My sister then took me to Whole Foods for lunch, which was lovely.  I had a nice pretzel sandwich with field roast and a white bean and kale soup.  Yum!  It was nice to spend time with my sister and have someone with me who really cares about me with my husband being gone. She took really good care of me too!  My sister then drove me home, and I spent the rest of the day sleeping and resting - hoping that I would receive good news the following day.

Progress

Friday I had another US and more blood work (having every other day appointments now) and it looks like my follicles are maturing faster than expected.  My RE said we are on track for retrieving 8-12 eggs, but she is not sure if they will all be mature enough.  I am going to have a follow up US and blood work done on Sunday. If the follicles are plentiful and the sizes are good (indicating proper maturity), then I will have my egg retrieval on Tuesday.  My RE says it is a fine balance between retrieving prior to ovulation and ensuring maximum number of follicles possible and that the eggs are mature.

My estrogen is also doubling and increasing nicely.  So far, so good!

I've stayed at 375 IU for Gonal-F each p.m., 1 vial of Menopur each p.m., and 10 units of Lupron BID (twice daily).  Sadly, no decreases in the Gonal-F for me.  This means that I have gone through 3 pens of Gonal-F, and had no more pens after last night.  We never knew the meds would be so incredibly expensive, and when we drained our savings for our 4 rounds of IVF (2 fresh and 2 frozen with Attain), we had no money left.  When the pharmacy called and said our meds would be $3500 and that our insurance would not cover it, I almost had a heart attack.  Literally, I ended up in the ER with PVCs (pre-ventricular contractions).  We ended up having to take a personal loan to pay for our medications.  Our insurance only covered the progesterone and Lupron, so the $3500 was for the Gonal-F ($900 a pen x 3) and Menopur ($80 a vial x 10) alone.  With the RE office not ordering enough pens for me in the beginning (since they are so expensive, they are cautious not to order too many), I was in a panic when I realised I would run out of the Gonal-F on Friday with no way to buy another pen at $900 a pop.  Thankfully my doctor's office donated a pen to me.  Wow - what a blessing and such a relief!  One less thing to worry about.

On the midwifery front, I have made progress in my clincals as well.  I caught another sweet baby boy yesterday increasing my count to 12.  (This count is only my US births and does not count the babies I caught in Ghana.)  My program only requires 20(!) births, which I think is far too low to call myself experienced/ready to practise on my own, so I am setting a goal for myself of at least 60.  I would ultimately like to make it to 100 (they say you feel comfortable with births after your 100th catch), but anywhere between 60 and 100 would be sublime for me.  I also sutured my first patient yesterday with bilateral labial lacs, and a wonderful MD taught me how to tie one handed with my left hand (non-dominant hand).  Now, I can hold my instrument in my right hand and tie with my left without ever having to switch hands or put down the needle.  Woo hoo!  So exciting!

I needed a day like yesterday.  It was such a moral booster.  I made wonderful progress in both my IVF course and my studies this past week.  Excited to see what this next week brings!

November - Good Karma Mandatory!

Since my husband left in early October for his 6 months of working abroad, something has gone wrong every single day.

• My car battery died on 2 separate days and I had to sort out how to jump my car from a instructional pamphlet.
• I got a stress fracture in my right foot from running.
• I re-injured my right SI joint while running.
• I had a chiro appointment to help my back and it some how made it worse!  I ended up not being able to walk for 2 days.
• After thinking we had all our IVF costs covered, the pharmacy called and told me my meds would be $3500!  I about had a heart attack.  I had no idea they would be so much, nor did we have that kind of money lying around after draining our savings of $9000 to pay for the IVF.
• I became so stressed and overwhelmed over the IVF costs, that I ended up in the ER with PVCs!
• Our pool pump broke.
• 2 windows in our house broke and would no longer shut.
• My washer machine flooded the laundry room.
• I came home to diarrhea all over 2 of bathroom floors from one of my dogs who became sick while I was at work.
• I came home one day to find a policeman in my house saying my alarm was going off and ADT could not reach me - they thought I was injured or incapacitated in the house.  Oh great!
• I tried twice to insert an IUD and failed - very humiliating.
• I was told by a patient that my Leopold's were too strong and that I was hurting her.  She told me normally my midwife preceptor touched her gently like a feather.  I just wanted to tell her that there was no way she could possibly feel her baby if she just barely touched her.  Instead I apologised and tried to touch her like a freaking butterfly.
• There was one full day of clinic where it seemed like I did everything wrong and my midwife made sure I knew it.
• I scored a 70% on 2 separate quizzes - the lowest grades I have made in nurse midwifery school thus far.
• My mac book flipped out and my keyboard would not work for a day.  Unfortunately I have no time to take it in for a repair.
• A new gas line was ran in order to install a gas cooktop replacing our electric glass cooktop.  The line was ran wrong and so a drawer was pulling against the line - I ended up with a lovely gas leak and another 4 hour repair.

All this in the month of October.  

This mandates that from here on out, from November on, nothing but good shall happen.  All good karma, all good luck.  Nothing but fairy dust and fairy tales coming true.  I am believing on it. 

Tonight's the Night

And it's going to happen again and again.  It has to happen.  ~Dexter

No turning back now.  It is injectable time!  And it is going to happen again and again, every single night until the 2nd week of November.

First up is Lupron - 10 units both a.m. and p.m. subcutaneous (subq).

Next is Menopur - 1 ml of NaCl reconstituted with Menopur powder each p.m. and injected subq as well.

Last, but not least, Gonal-F (similar to follistim), 375 IU each p.m.

Ta da!  All the injections lined up and ready to go.

Surprisingly, they did not hurt.  The middle one, the Menopur, was a bit sore due to the volume of medicine, but otherwise all went well.  I did experience a bit of a metallic taste after I injected the Lupron on the first day, but that went away after the second day.

My drug counter - sharps container, needles, alcohol pads, meds, prenatal vitamins, B-12 and folic acid chewables, my IVF calendar - everything I need to have a baby. 

The following is a diagram drawn by my doctor to show what happens with the IVF cycle.  Birth control pills are used to suppress my own hormones so that the RE can hijack my system and tell my body to mature more than one egg for this ovulatory phase.

Lupron is synonymous to GnRH, Follistim/Gonal-F is analogous to FSH, and Menopur is similar to LH.  These meds are given over a 8-12 day cycle with every other day US and estradiol levels drawn to see how many follicles are developing and to monitor hormone levels in my blood.  When the time is right and the eggs are at the right maturity level, an HCG trigger shot will be self-administered, and approximately 35 hours later an egg retrieval will take place.

My RE believes I'll produce around 10-12 eggs per my age.  Those eggs will be fertilised with ICSI - intracytoplasmic sperm injection - where 1 sperm is directly inserted into the egg, and the fertilised eggs will be watched as they grow from 2-4 cells on Day 2 to 4-8 cells on Day 3 to a blastocyst on Day 5.

Transfer will take place either on Day 3 or Day 5 depending on how the embryos are developing and the quality of the embryos.  Each embryo is given a grade - A, B, C - and those with a higher grade, such as A or B, are the ones that have a greater chance of implanting and becoming a baby.  Anything below C will be discarded.  My RE hopes we have grade A and B embryos and that she will be able to transfer at least 2, maybe 3 embryos if we do a day 3 transfer.

If she transfers 2 embryos, there is a 35% chance we will have twins and a 1-5% chance we will have triplets.  Any other extra embryos we have (hopefully we will have some!) will be frozen to be used in the next cycle should this one not be successful.  Only 50% of embryos make it through freezing and rethawing, so we do not have a high chance of having extra embryos due to my age and low amount of eggs that will probably be retrieved (younger people can have up to 20 or more eggs retrieved).  I am hopeful though that I will have enough eggs at retrieval and that we will have enough good embryos to have a successful transfer.  Having a few good embryos for cryopreservation would definitely be the icing on the cake!

After the embryo transfer, I will have to wait 2 long weeks before I will be able to know if I am officially pregnant.  I will have to give myself daily IM injections of progesterone for at least 6 weeks and then I can switch to progesterone suppositories.  I am definitely not looking forward to that part as I heard it is quite painful and also difficult to give yourself IM injections in the buttocks.  Usually the woman's partner gives the progesterone injection, but sadly I will have to do it myself.  Worse case scenario, I can ask my midwife preceptor to give it to me.  

Let's hope I am ambidextrous with a needle and highly skilled in self-administration of IM injections!  

PS - Did you know that IVF was this involved??  Even as a labor & delivery RN and now soon-to-be Nurse Midwife, I had no clue what all was involved with IVF.  I also had no earthly idea about the costs (to be discussed in a future post).  After spending $3500 on these meds, they better work!!!

Re-entry Syndrome - like a car crash

I have been back almost a month now from Ghana, but it has taken this long for things to settle down and for life to get back to a semi-normal state.

Re-acclimating to home after being abroad has been quite tough.  Especially after being abroad in a developing nation and being exposed to things I could not help with or change.  Ghana was a life changing experience that was amazing and wonderful, but at the same time heart wrenchingly sad and depressing.  Returning and re-entering into my own country in just 14 short hours door-to-door was a complete culture shock - bright lights, consumerism galore, excessive waste, loud noises, an array of different smells... even the cleanliness was overwhelming.  Trying to acclimate back into my "normal" life was hard.  I felt sad for all those in Ghana whom I left behind that had so little.  I felt guilty for how much we have in our country and how over-indulgent we are without apology.  I felt isolated because no one I know here can actually understand what I have been through and then there are others who are purely not interested.  I met up with one friend who said she wanted to hear all about my trip, but then talked about her life the entire time.  It felt surreal - like all this was not really happening to me; as if Ghana never happened.  It was a sudden jolt, like a car crash, back into my life that I have known for a year, but yet, it was all different.  I am now different.   

This is what is called re-entry syndrome.  It is a real, psychological response that many people - aid workers, soldiers, prisoners - experience when returning to their former life.  It is quite an adjustment.

To top it all off, I came home to find out that my husband was not leaving in the middle of October like we thought, but rather 3 short days later.  That was a hard pill to swallow.  I ended up crying for 3 days straight.

The day my husband left was my first official day of IVF.  I dropped my husband off at the airport in the morning and then went for my IVF counselling alone.  My RE and her nurse were beyond supportive, giving me big hugs and trying to make me laugh.  It was so sweet that they were there for me when I was at my lowest, feeling so alone and bereft.  

My RE took a look at my ovaries via ultrasound (US) and found that my right one had a dominant follicle.  Even though I was taking OCPs, my body was still trying to ovulate.  This was going to postpone the beginning of my injectables and my egg retrieval.  My RE gave me another prescription to take - Aygestin, a progesin - daily with my OCPs to further suppress my follicular development for another week and 3 days.  I have had 2 more US since then and my follicle has slowly decreased in size with my estrogen levels lowering as well.

Today, I had another US and my follicle, which was 20 mm, is now 16 mm and collapsing in on itself.  My estrogen levels are down as well, and that means we are good to go to start the injectables!!!

I start my Lupron, 10 units subq, tonight and then 10 units in a.m. and p.m. until Saturday.  Then Saturday is D-day where I begin my Gonal-F and Menopur.  All fingers and toes crossed for a successful egg retrieval around 8-10 of November and embryo transfer 3-5 days later!

Wow.  This month has been a whirlwind.  I have struggled with transitioning back to my life from Ghana, then 3 short days later I had to re-transition to living life without my husband, my best friend, and finally now - almost a month later - I am getting back on my feet, I am feeling like things are flowing again, and I am having hope for the first time that I may just get lucky and have a baby in 2012.

Goodbye for September!

I'm off to Ghana for a month to do some midwifery work in Takoradi, near Accra and then swinging through Europe to visit friends before I return back home.  I will return to the blog in October to share all my wonderful stories from Ghana and the experiences I had there.

Au revoir!

OCPs today!

Today I start my oral contraceptive pills (OCPs) - ortho cyclen.  I have never been more excited to start OCPs in my life!  I have been off of them for 10+ years now, but with my current 5 day long periods, heavy bleeding and 3 days of intense cramping, I am ready for continuous OCPs for 2 months!

It will be especially nice not to have to have a period while I am in Ghana.  T-5 days until I leave!

OCPs may seem counterintuitive to IVF, but the RE uses them to suppress your own hormones in order to manipulate them externally to induce the greatest chance of high egg count retrieval and implantation with transfer.

Spoke with IVF coordinator at my RE office.  She said she would get a calendar to me out this week via email of what I need to do for the next 2 months in preparation for our first round of IVF.  More to follow!

Case Study

I thought I'd post an interesting case here and see what you midwives, midwives-to-be and medical detective/mystery junkies think.

S:  A 28 year old G3P2002 presents to the community care clinic stating that she is 22 weeks pregnant with a certain last menstrual period (LMP) of 3/17/2011.  Patient states her abdomen has grown larger as it did with previous pregnancies and that she can feel her baby move.  The problem lies in that she has taken numerous HPTs (home pregnancy tests), and they have all been negative.  She has presented to the ER at 8 weeks with spotting where a urine pregnancy and a B-hCG were completed and both were negative.  The ER physician told her she was not pregnant and did not exam her further (no ultrasound or other assays).  The patient is uninsured and so she does not have a primary care provider.  The patient has no other complaints.  Denies problems with bowel or bladder, no nausea or vomiting, no pain and spotting has ceased since ER visit.  Patient is stressed because she says she is sure she is pregnant, but no one believes her.

O:  T 36.4, BP 128/76, P 100, R 40, weight 138 - up 8# since LMP
Head & Neck - mild exophthalmia, no thyromegaly
Heart - tachycardic, regular rhythm
Lungs - clear to auscultation bilaterally, tachypneic
Abd - appears gravid, soft, nontender, no masses noted
Uterus - consistent with 8 weeks, no fetal parts palpated, no movement noted
FHT - none found by doppler in all 4 quadrants
Urine pregnancy test - negative
No US machine at community clinic

What is your plan of care?

Our plan was to order laboratory assays - CBC, CMP, thyroid panel, LH, FSH and prolactin, quant B-hCG, CA 125, and an ultrasound.  However patient is self-pay and would not be able to afford all of the tests.  The quant B-hCG alone was $127.

We referred her to the high risk resident Women's Clinic and she has an appointment on next Wednesday a.m.

So let's take a poll and see what your differential diagnosis would be.  I will report back next week with lab assays and definitive diagnosis.

Latest Update

We have decided not to do a 4th round of IUI.  I would have had the scan this past Monday with intrauterine insemination on Wednesday, but we have weighed the pros and cons and decided against it.  Our RE said that she has seen many successful pregnancies happen with the 4th round, but there were just too many cons to consider.  My thought process was that I did not want to be pregnant in Ghana in case I -

• have severe nausea
• have an ectopic
• have a SAB (spontaneous abortion/miscarriage)
• need a D&C

I also was concerned because I will have to take anti-malarial tablets and of the 3 kinds that are recommended for Ghana - Malarone, Mefloquine or Doxycycline - none are safe during the 1st trimester.  I definitely do not want to contract malaria whilst I am there, but I also do not want to cause undue harm to my unborn child.  Which, I guess in theory, could happen with not taking anti-malarials and contracting malaria AND with taking anti-malarials.  According to the WHO, pregnant women are more vulnerable to malaria as pregnancy reduces the immunity to malaria (an immunity of which I have none of) and increases ones attractiveness to mosquitos due to hormones and pheromones.  Contracting malaria in pregnancy increases risk of illness, severe anaemia and death.  Maternal malaria also increases the risk of a SAB, stillbirth, premature delivery and low birth weight, which is the leading cause of infant mortality in Ghana.

All these thoughts culminated in us skipping our last round of IUI.  

We met with our RE this past week, and told her our decision.  We discussed doing a 4th round when I return from Ghana, but we are already booked for an IVF start date of 27 October, so there was not a way to squeeze in both the IUI and IVF start in October, especially with having to take anti-malarials for 2 weeks post-return.

So, we now are set for the following schedule, some of which has been completed:

1. Husband do pre-IVF infectious disease blood work 
2. Re-apply for Springstone IVF financing at end of August
3. Leave for Ghana beginning of September
4. Husband donate sperm for freezing on 2-3 separate occasions during September
5. Return from Ghana early October
6. IVF counseling 3 October
7. Husband leave for 6 months
8. Begin IVF cycle 27 October

I know there are many more steps between 3 October and 27 October, but I do not know what they are yet.  We will find out on the 3rd!  I know I do need to let Attain know that we are beginning our treatment on the 27th.  They are providing us four rounds - 2 fresh and 2 frozen - for $16,000 USD.  I also need to work out our financing.  Our clinic wants the money up front, so we are going to go through an IVF financing company called Springstone.  We applied earlier with them and were approved for the IVF amount with monthly payments of $300 for 60 months, $335.97 for 48 months, $412.44 for 36 months or $573.50 for 24 months.  It IS quite expensive, like a monthly car payment (which thank goodness, we do not have), but we are going to have to use the financing route as we do not have $16,000 in cash to pay up front by October.  Unfortunately, our application was only good for only 60 days, so we will now have to re-apply.  I hope we are able to secure as good of a rate and financing for the whole amount when we reapply at the end of this month.  

It's nerve-wracking thinking about all that needs to be done and the possibility of not having a successful outcome whilst being out $16,000.  I am trying to be positive, of course, but the fear is still there.  I had a dear friend who just went through her 4th failed IVF attempt.  It is heart breaking.  I am truly hoping and praying for success on the first go-round.  I'd like to get our money's worth, but really, I'd much prefer early success.

A Disappointing Day

I had a hard day at my hospital clinicals yesterday.

We had a patient that wanted a natural, unmedicated birth.  With her previous birth, she was induced with pitocin, had a very difficult labor, and subsequently has a very negative image ingrained in her memory about her birth experience.  This time she wanted to have a simple, serene birth - the one we all dream of.  She presented to the hospital already dilated to a 7 as a G2P1.  My midwife and I thought that this would be perfect for her, and that she'd easily give birth in the next few hours.

After 5 hours of hands and knees, walking, birth ball, rocking, squatting, in and out of the bath tub, lighting candles, and listening to soothing music there was relatively little change in her cervical dilation, and yet she was experiencing increasingly worse contraction pain.  She was beginning to give up; thinking she would not be able to carry on with her plan.  We were not checking her, so I was encouraging her to continue - telling her soothingly that she was almost there, that she could surely make it.  At the 6 hour point, we finally checked her to see if she was close.

Nope.

She was the same.

Upon further inspection, her baby's posterior fontanel was extremely posterior, which is not typical, and we could not 100% decipher what the presenting part was.  It felt like a face.  We had the attending come and confirm for us, and she said it was definitely a face presentation with mentum transverse (MT).

MA or mentum anterior is the only one able to delivered vaginally.  It is done by placing a finger in the woman's rectum and flexing (or tucking) the head forward so the baby can still go through the cardinal movements of delivery.  Unfortunately, this is not possible for MT or MP (mentum posterior) presentation.

Oh sigh.  It was a such a heart wrenching moment to tell her she was not going to be able to physically birth from below.

When I came to get her husband to bring him back for the cesarean section, I asked him if he wanted to bring his camera and he said quietly, "No, I think we'd rather not remember this part."  My eyes welled up with tears and I had to look away.  How absolutely crushing.

Thankfully the baby was born easily and did not need any resuscitation efforts.  Both of the baby's eyes were swollen shut, but there was only minimal bruising over the right brow.  The mom, dad and baby spent the rest of the surgery time trying to bond with their new baby in the OR.  The mother was shaking uncontrollably (due to the spinal anesthesia) and despondent.  The father was quite sad.  It was a bittersweet moment for them.

The attending ensured a triple layer closure so that should they decide to have another baby they could attempt again to have the birth they so desperately desired.  She made sure they knew this, but I am not sure how much comfort it provided in the moment.

I am sure the healing both physically and emotionally will take some time, but my hope for today is that they are enjoying their baby much more and are able to let go of their negative perception of this birth bit by bit over time.

Rounds

This week has been all about rounds and rounding.

On the trying to conceive front, Friday was my day 1.  I'm beginning my 4th and last round of IUI treatments.  I pick up my Clomid today to begin taking days 3-7.  I have my US and blood work on Monday, August 8, and then my IUI will probably be 2 days later if all goes well.

This week was my 2nd week in hospital and I did heaps of rounding on postpartum patients.  I saw 4 patients and their teeny, tiny, adorable babies.  Four patients may not seem like a lot, but postpartum rounding takes a long time.  It is the first and only time the patient sees a midwife during the day and they have loads of questions stored up to ask on top of all the questions I need to ask them and the exam I need to complete.  Then there is also time I have to allot for discussion of their birth and fielding any complaints they may have.  The pressure arises as the clock tick-tocks away knowing that I have patients one floor down in labor that I must get back to and round on as well.  It is a great juggling act of time management, to say the least.

This week I caught 3 babies (bringing my total to 4) and they all went so much easier than last week.  I was able to both protect the perineum, provide space for the baby if needed in the vagina, and coach the patient on breathing and pushing.  I really feel like it is coming together so nicely.  All of my babies had nuchal cords - one I lifted over the baby's head and the other two I helped the babies slide through them.  The transition from catching to tummy is going smoothly now too.  No more fuddling and fussing.  We had a few lacerations (or lacs as we call them), and I began to learn how to repair.  I have not yet attempted it on my own, but I experienced a lot of relaxed teaching time.  I look forward to my first hands-on experience.

All in all my clinicals are going quite well.  I am learning heaps every day and growing by leaps and bounds in my practise and knowledge.  I am also working at the same time with the new OB/GYN interns that have just started and that is a neat experience.  It is fun to be "babies" at the same time and grow up together.  My midwife preceptor teaches the interns as well on the low risk side of labor & delivery, so we are learning side by side.  Hopefully one day what these new interns learn from the midwives about normal, low risk births will make an impact in their own practise with women.  I already hear some interns calling what they do catching instead of delivering.  Wow!  So exciting!  The word of midwifery is spreading.

First Catch!

Most of this blog has been consumed with our attempts with trying to conceive.  It might make one wonder if I do anything else!  Trying to conceive does seem to overtake almost every waking thought I have, but I am still pursuing my dream of becoming a nurse-midwife.  I am doing about 36-40 clinical hours each week now - 2 clinic days and 1 hospital day.  This past week was my first week in the hospital AND my first official catch!  Wahoo!

As a labor & delivery nurse there have been a handful of times where I have caught a baby due to a precipitous birth where the physician did not make it in time, but those times were usually more of a surprise and panic type situation where I was wondering when the physician was going to arrive while catching the baby and simultaneously calling other nurses and techs into help me.  In contrast, my first official catch happened in a very serene, calm, controlled and beautiful way.  We had a patient who was a G2P1 having a natural birth at 40.4 weeks gestation.  She had a doula and did amazing throughout the whole labor.  She walked and rocked, sat on the birthing ball and tried a variety of positions until she found what worked for her.  But at 0300 and 8 cm she wanted to give up.  She started crying and saying she just could not go on, and that she wanted an epidural or something to make the pain go away.  I encouraged her to get in the bath tub and she did.  She sat in the warm water, pelvis open, rocking side to side and moaning with eyes closed breathing through every contraction.  In 15 minutes time she said she felt like she needed to push.  She walked back to the bed and began her delivery.  Half a dozen pushes later she welcomed her healthy, beautiful baby boy into the world.

For my part, I protected the perineum during the crowning and then supported the head as it birthed.  I then gently pulled traction down to release the anterior shoulder and then the posterior shoulder slid right out along with the rest of the baby.  It was quite easy as the mother did all the work, but I still need more practice with my hand placement and coordination of catching the entire baby with both hands and then placing on mom's tummy.  I am sure though that will all come together in due time with practise.

The birth though was just so magical and beautiful.  I know I have said beautiful several times now, but it really was a picture perfect birth experience. The baby needed a bit of transitional support and the nurse even gave the baby oxygen on the mom's belly.  In the end, the mother got all that she wished for - a natural birth with no interventions, no lacerations and she was not separated from her baby after the delivery.  A perfect birth for the mother and baby, and a wonderful first birthing experience for me!

MRI Results

The preliminary results of my MRI came back today.  Report read a "couple" of endometrial invasion islets in the myometrium were noted with only one measurement of 1 cm.  What was seen is consistent with adenomyosis.  I am not sure how many a couple is (2 as seen by US?), and why the others were not measured, but my RE is going to review the films herself and give me a full report in person on August 5.

In the meantime, I am on my 3rd week of acupuncture and have noticed a big difference in my energy, back pain (caused by a previously sprained lower SI joint) and mood.  I am hoping it will have an effect on my cycle this month as well.

I've added 600 IU of vitamin E at bedtime, magnesium 300 mg/d, and vitamin B6 50 mg/d.  I am also drinking a loose chinese herbal tea twice daily that my acupuncturist created for my particular symptoms.

I plan to buy DIM this week as I have read up on it and it says that it speeds excretion of estradiol thereby increasing the metabolism of estradiol and decreasing serum (or circulation of) estradiol levels.  Recommended dose is 600-1200 mg/d.

A variety of websites recommend progesterone cream as well, but I am going to wait to discuss this with my RE as I do not want it to interfere in our pregnancy attempts.

The good news is:  It is NOT cancer (thank god!) and in the end, that we can still go through with our last IUI attempt this August and if that does not work, attempt IVF in October.

The bad news is:  My RE thought we could do the transfer before my husband leaves in October.  However, the lab is closed for most of the month.  So it looks like my husband will have to make several donations, have his sperm frozen and then I go through with the embryo transfer solo.  Not my ideal situation, but it is either that or wait 6 months and watch my age increase by one year and my fertility to decrease even more.

Nope, better to get the good eggs out now before they expire!

Friday's News - MRI

This day did not go as planned.

It all started off with me driving 50 minutes in moderately heavy traffic (read: people who leisurely drive in the left lane and prevent you from passing) two cities away to have my MRI done. Upon arriving at the facility they tell me that I must be mistaken as they do not do MRIs. They point me towards the hospital up the road and advise me to check there. I call my referring RE's office and I am on hold for 10 minutes, so I hang up and go up the road. The hospital radiology department has no record of my name. My RE's office calls back and says, "Oh sorry. Someone must have given you the wrong information. You are meant to be at the hospital here." What??? I am in the wrong city? I was so hot at this point - literally and figuratively! It was 40 C/104 F already at noon and even with the air con in my car cranked to the max, I was still sweating. I begrudgingly drove another 30 minutes to get to the correct hospital and finally had my MRI.

It took about 45 minutes in total for the pelvic MRI, which I was surprised by. I thought with only having to image a small area that it would take less time than a full body MRI. I was too hot and tired to ask any questions though, and after 45 minutes of lying flat and still on a hard table my lower back was killing me as well (due to a previous SI sprain that flares up from time to time). Luckily I was able to pass the time listening to NPR, which helped with not thinking about the teeny tiny cavity I was in.

After my MRI, I do some yoga stretches (downward dog, padangusthasana) in the changing room to ease my back pain and then side step over to the cafeteria to stock up on some nuts, water and fruit before I hit the road again. It is now 3 hours since I left home, and I have to drive another 30 minutes to my acupuncture appointment which will last another 2 hours. Days like this make me really miss the days of public transit in the EU!

I make it to my acupuncture appointment just in the nick of time. I'm all bothered and irritated, but my practitioner is calming and serene. I quickly shed some of my stress. I hop up on the table and have many needles placed in carefully selected areas all over the front of my body including my head (acupuncturist says it is to lift my mood - ha!). I lie there for 30 minutes having a hard time relaxing. My mind is racing and the halogen lamp is bothering my vision even when my eyes are closed. My acupuncturist then removes all the needles, has me lie on my stomach and then places many more needles along my back including one directly in my SI joint. I practically leap off the table on insertion, but it magically starts to feel better immediately. I lie there for another 30 minutes and this time I am able to fully relax. I can no longer see the halogen light in my eyelids and I drift off to a floating type sleep with vivid images flashing before my eyes. Before I know it my practitioner has returned to remove my needles and I am now happy and buoyant. My stress is gone. How does acupuncture do that? It really is so incredibly amazing to me. I eagerly look forward to my next week's visit.

I should hear back from RE in about a week's time. Fingers crossed for good news and that we can proceed with our last IUI, and then IVF in October if not successful.

Post script: I'm on day 9 of my juice detox and it is going well. I feel like I have heaps of energy and have even lost 4 kg/8#. These past few days I have not lost anything more, so I have been a bit worried. I hope I can lose more weight while continuing to feel great.

Friday's News - HSG

I had a hysterosalpingogram (HSG) with saline in my doctor's office on Friday. The procedure is initiated with a small catheter that is inserted through the cervix, then a small balloon is inflated to keep the catheter in place within the uterus and to prevent the saline from leaking out. It is similar to a foley balloon used for dilation of the cervix and induction in labor, but much smaller.

Saline (100 cc or more) is then injected via the catheter into the uterine cavity in order to examine the uterus and surrounding structures via ultrasound.

The procedure itself is not painful - felt like a typical pelvic exam. However, upon first insertion, the catheter was not staying in place and they had to use a tenaculum on my cervix in order to insert the catheter further inside the uterus.

While medicine and science say there are no nerve endings in the cervix, the pain experienced when the tenaculum was placed was intense (you can see here it pierces the cervix in order to hold on to it). It was a searing, tugging pain that felt like my whole uterus was going to be pulled out. I became overly hot, sweaty and nauseous. At one point I even thought I was going to pass out. The nurse gave me a magazine to fan myself, and I began to feel better. Thankfully the tenaculum was only in place for a few minutes until the catheter was inserted further and the balloon was re-inflated. Then they proceeded with injecting the saline.

As an aside: Even though the tenaculum was only in place for mere minutes, I am still having cramping, soreness and an achy discomfort in my uterus a day later. Many practitioners use tenaculums to place IUDs, but after yesterday's experience, I am definitely going to ensure I learn how to insert them without a tenaculum. Hands down, that was the worst gynaecological experience of my life.

My US revealed a few nabothian cysts on my cervix, but nothing to be concerned about there. They are small and benign and typically disappear on their own.

The spot in my myometrium was reviewed. Last time it was fluid filled, possibly blood, but this time it was empty. A second area was also noted with this US. Both appear to be adenomyosis. On one hand, this is a relief as it is not cancer, but on the other, it is still somewhat concerning for me due to the possible effects on fertility and the increasing menstrual cycle pain I have been experiencing. I am also quite stressed by the fact that this has shown up only after commencing with fertility treatments.

Adenomyosis is when endometrial tissue that lines the uterine cavity grows into and within the myometrial (muscle) tissue of the uterus. This endometrial tissue is a glandular tissue that secretes essential nutrients for implantation and growth, as well as blood during menses thereby essentially causing bleeding within the walls of the uterine muscle. This is what causes the extreme pain during the menstrual cycle.

My two spots on US, however, appear to be isolated islets (like these spots on far right) instead of endometrial tissue growing into the muscle (as seen by the arrows here). This is why my RE is not 100% sure of the diagnosis, although she says she is quite confident that what she is seeing is not going to affect our chances of conceiving.

Adenomyosis can cause menorrhagia - heavy or prolonged menstrual bleeding (yes to heavy, no to prolonged), dysmenorrhea - severe cramping or sharp, knife-like pelvic pain during menstruation (yes, definitely - began with fertility treatments and became increasingly worse with each month), menstrual cramps that last throughout period and worsen as one ages (no, only first 2 days), pain during intercourse (no, thankfully), bleeding between periods (no, hopefully never), and passing blood clots during menses (yes - has increased with fertility treatments). The uterus can also increase to double or triple its normal size (don't know yet). Adenomyosis can cause a bearing down feeling (yes) along with pressure on the bladder (no).

I have not asked for my measurements of my uterus, but plan to at my MRI. I have been feeling rectal pressure and lower back pain more and more frequently of late and am wondering if this is due to the increasing size of my uterus. Previously my RE told me my uterus was anteflexed, but I have always been told previously that it was retroverted. We shall see and confirm on both counts with the MRI.

Adenomyosis is mostly found in women over the age 35 (that's me!), typically between ages 40-50. Adenomyosis is dependent on estrogen and grows with an increase in unopposed estrogen or in the presence of an estrogen imbalance. Due to this, adenomyosis often goes away with menopause.

I did not know this before, but someone experiencing uterine surgery, i.e., cesarean section, is at higher risk for adenomyosis due to the cutting through the uterine layers of myometrium and endometrium. However, I have had no uterine surgeries, and am not sure why I would be predisposed to this.

Treatment for adenomyosis is via hormone suppression and balance with oral contractive pills, IUD with progesterone (Mirena), or Depo-Provera. I have also read online about the use of natural progesterone cream as a way to balance the estrogen dominance. Heavy menstrual flow and pain can be controlled with around the clock ibuprofen (decreases blood flow by 25-30% and cramping pain due to anti-prostaglandin action). Lupron can also be used, but it causes a menopausal state with complete cessation of ovarian function and menses, eliciting many menopausal type side effects like hot flashes and can only be used for 6 months. Typically all symptoms of adenomyosis resume after medication cessation. Sadly, at this point in medicine, an hysterectomy is the only permanent cure outside of menopause.

Next Friday, I will have a pelvic MRI to determine a definitive diagnosis as well as to see if the adenomyosis is diffuse - throughout the myometrium - or only localised to the two spots seen on US. I will have the results a week from next Friday. I am hoping my RE is right and that this will cause no impediment to our chances of conceiving and having a healthy baby. I definitely do not want to have a hysterectomy.

My theory is that I have an estrogen dominance issue due to:

1. Drastic increase in weight gain since moving back to US (up 9 kg/20# in 10 months).
2. Fertility treatments.
3. Not practicing Ashtanga/working out regularly.
4. Age - over age 35 estrogen levels rise and progesterone levels fall, progesterone levels are lower due to less consistent ovulation and short luteal phases, the latter which I have. Unopposed estrogen (without progesterone) leads to estrogen dominance symptoms and diseases.

So my personal plan now is to:

1. Return to my acupuncturist (I stopped going when I found out that our fertility issues were due to my husband's low sperm count).
2. Make an enquiry to the acupuncturist regarding DIM and Myomin - I read online both can reduce and balance excess estrogen thereby reducing adenomyosis symptoms.
3. Add supplementation - vitamin E 600 IU at bedtime, magnesium 300 mg/day and B6 50 mg/day - along with my prenatal vitamins.
4. Take a month break from fertility medications to clean out my system.
5. Do a juice fast for 20 days to detox, rebalance and lose the excess weight - I will be following the Reboot plan.
6. Return to practicing Ashtanga 5-6x a week for de-stressing, fitness, health, detoxing and re-balancing. Many asanas in Ashtanga also work to increase blood flow (prana) to the reproductive organs and mula bandha helps strengthen the pelvic floor.
7. Feel better in 30 days!

To Do List

1. Read 333 pages in Varney's Midwifery and Williams Obstetrics about prenatal care and normal pregnancy.
2. Finish laundry - only 4-5 loads left!
3. Reschedule hair appointment that I missed today - knew my appointment was Tuesday, but thought today was Monday. I blame the holiday.
4. Enter 21 patients into Typhon* system. This term I am bound and determined to keep on top of my logging instead of leaving it to the last minute and then scrambling to enter 200+ patients at once.
5. As per #4, leave the last-minute-Laura days behind.
6. Return to practising Ashtanga tomorrow if my ladies holiday^ is over.
7. Life insurance physical and grocery shop Wednesday.
8. HSG with saline Friday.
9. Study, study, study this week due to no clinic/hospital days (preceptor is on holiday).
10. Sleep, sleep, sleep this week due to #9.
11. Complete antepartum case study and worksheet, and write a SOAP note on an unique patient by next Friday.
12. Find a unique patient by next Friday.
13. Prepare for garage sale - price, organise, set-up - must sell many things!
14. Hopefully some time in the next 2 weeks: have some fun!

*Typhon is a patient tracking log for nurse midwives and nurse practitioners in order to account for all the types of patients one sees as a student along with how many births one attends.

^In Ashtanga yoga, female practitioners are meant to abstain from practice during their monthly menstrual cycle.

A Dangerous Lie

A few weeks back now, I had a new OB patient (G5P3013) that was a transfer of care from a physician who she said, "did not listen" and would not allow her to VBAC. Since our hospital is one of the few hospitals in the state that VBACs and has midwives, she decided to switch to our care. Upon taking her history, though, things just did not seem right. She could not recall much about her first 2 vaginal births and focused solely on her last birth which was a cesarean section. She was dismissive of medical history questions and kept interjecting her horror stories about her previous obstetrician. Her children were also the most unruly children I have ever experienced in an exam room. The patient had no control over them and they screamed, physically fought and clamoured up and down the walls and on anything else they could climb in the tiny 8x10 exam room. Ten minutes into our visit, I had a raging headache. I left the room to retrieve the US machine and conveyed my misgivings of the patient and her history to my preceptor. I also warned her about the screaming, but there was no need. She heard them from down the hallway. We both re-entered the room, US machine trailing us.

The appointment ends with the patient thanking my preceptor saying, "You are a wonderful doctor. I am so glad I switched." To which my preceptor corrected her yet again explaining that she was a Nurse Midwife. Ignoring my midwife, she then said, "And your assistant is wonderful too." Ha!

We were not sure what would become of her. We left the consultation taxed, harried, overwhelmed and not even sure if we even wanted her to remain our patient.

Today, a month later, her medical records came in from her previous physician. Lo' and behold, she has had not one, but three c-sections! We were shocked. What if we had never received her records? What if we had helped her to VBAC? The possibilities of what could have gone wrong are both unsettling and frightening!

BFN #3

Another disappointing negative. Number 3 that is.

Luckily this time, due to not getting my hopes up, I have not been sobbing in my bed for 2 days. Instead, last night my husband and I took a midnight swim with a bottle of Pinot Noir and The Gotan Project playing in the background. It was a nice, romantic time to reconnect and discuss our dreams, hopes and fears.

Hopefully one day we will have a child, but it was not meant to begin today.

I again have had raging dysmenorrhea (cramping, nausea and vomiting) and had to take 2 percocets and 4 ibuprofen liquid caps. I rarely take medicine and tried to just get by on 1 percocet, but I was up at 0500 retching and doubled over in pain sobbing. I have never, ever in my life felt so horribly during my periods and am a bit concerned, but my RE seems to think it is solely due to the Clomid.

Today, due to the medicine and pain, I have slept most of the day away, recovering. Luckily now the pain is manageable with ibuprofen. My mind remains unfocused and cloudy though, which does not bode well for my studies that I have to do today.

On my scan this cycle, the fluid filled sac was seen again in my myometrium, so since I am not pregnant, this month will be focused on diagnosing the mass. I go for a MRI on the 15th of July, and will schedule another HSG this week, but this time it will be with saline. I heard from a nurse-midwife colleague of mine who got pregnant both times after a saline flush, so fingers crossed that will work for me as well.

And so the journey continues.

Ready, Set, Ghana

I booked my airline tickets about a month ago and today I finalised my balance payment.

It is official!

I am going to Accra, Ghana, Takoradi more specifically, in September. I am so excited I can barely contain myself!

I am going to be working with Work the World - a UK based company that provides medical, dental, nursing, midwifery and physiotherapy electives and placements in Africa, Asia and South America.

In the UK, unlike the US, nursing students and midwifery students do electives abroad during their training and some even do gap year placements. My university had nothing on offer for a study abroad program, so I have decided to create my own experience via Work the World, a company I had heard about from other midwives and nurses when I worked at Guy's and St Thomas' NHS Foundation Trust.

As I have never been to anywhere in Africa, I was not sure where to go, but chose Ghana as it is a placement that allows for direct and highly involved care. There are 3 other locations in Africa - Dar es Salaam, Mwanza and Arusha, Tanzania, but for some reason Takoradi, Ghana spoke to me. The testimonials from other midwives in Ghana are quite inspiring as well and are what helped confirm my choice.

I am quite excited to go... a bit nervous, as always when I travel to a new country and do not know what to expect, but more agog and breathless than anything. I feel assured that Work the World will take good care of me and provide an easy and engaging experience. The process thus far as been worry-free. Work the World provides a 'My Trip' webpage for each candidate and it has easy hyperlinks to click through to learn everything possible about your upcoming trip along with what to do and when. My last 'to-do' is to secure my visa and pick up my malaria tabs.

Easy peasy.

AMH Results

I was previously quite concerned with my anti-Müllerian hormone results thinking they were on the low end and being overly worried regarding the research journals I had read. I spoke with my RE and she said not to worry. She said if my results were in the 0.1-0.5 range, she would be greatly concerned, but my results are good. Further, she said an AMH result of 1.1 basically tells her that if we attempt IVF, she will be able to collect 10-12 good eggs. That is all that is needed and is quite good for my age. I am buoyed by this news.

My RE also said that while she does not recommend taking DHEA, she also does not recommend against it. She said only one clinic in the US has all their patients taking DHEA and while she does not see the harm in it, it does NOT produce more eggs. It is only thought to improve the quality of the eggs produced. I am still on the fence about taking it as it can cause virilization and I am not keen on that! So I will continue with my prenatal vitamins, liquid B12 + Folic Acid (since I am a vegetarian), flax oil capsules as well as ground flax seeds on my oatmeal in the a.m., vitamin D drops and evening primrose oil capsules. I also do Ashtanga yoga daily which helps on so many different levels - physically, emotionally and mentally.

I am currently reading The Infertility Cure and will report back on the book's further recommendations for fertility boosting.

An Auspicious Round 3

Thursday, 9 June -

Day 1 of cycle. Called clinic and my Clomid and hCG were called in for me. I pick up Clomid at my local neighbourhood pharmacy (only $3 with insurance) and the hCG is sent via FedEx by Walgreens to my front door (also only $3 with my insurance).

Saturday-Wednesday, 11-15 June -

Taking Clomid 50 mg 1 x a day for days 3-7.

Saturday, 18 June -

US to check my follicles. Sadly, I only have 2, maybe 3 that have developed (previously I have had 4-6), but my RE still has hope. There is a spot of concern though - a fluid filled sac in the wall of my uterine muscle. It does not appear to be ominous, but it is peculiar as it was not there in the beginning, showed up in my diagnostic US, was gone for my HSG and round 2, and now has resurfaced. If this IUI does not take, then I will undergo a hysteroscopy and biopsy to find out what it is, but in the meantime, per my RE, I am not to worry about it. Since it is not of immediate concern, the IUI will continue as planned.

Monday, 20 June -

0700 My husband drops off his sample. I do not have much hope as I just had a dream that night that the clinic called us and told us not to bother coming in as his sample was too small.

1030 rolls around and there is no call, so I head into the city to the clinic.

1120 we are shown to our room and I am asked to undress from the waist down. I always like to wear tunics or dresses so I do not have to feel so naked. I take my capri leggings off and sit in the chair chatting with my husband. I do not want to hop up yet on exam table as I never know how long I will have to wait and I hate feeling like a patient.

1125 My doctor pops in just 5 minutes later and asks if I am ready. The nurse and doctor verify with us that the sperm sample is my husband's (what a nightmare it would be to be injected with someone else's sperm!). We confirm that it is. They then give us the good news that the sperm count today was over 10 million - our best count yet! Woo hoo!

1130 I get into position - lithotomy, stir ups, the whole lot (although my midwifery preceptor likes to call them footies - she says that is less threatening). So I am up in the footies preparing myself for a very long and uncomfortable ordeal as it has been before, but it was amazingly super quick this round. Speculum was inserted, sperm was drawn up into a syringe, catheter with syringe attached was inserted through the cervical os via US guidance and voilà!

1132 In under 2 minutes 10 million + sperm were injected into the top of my uterus. We were all surprised. There was no bending, turning and readjusting the catheter or filling up my bladder more. My RE said, "I am taking this as a good sign!" She said she did not know what was different except that my bladder was not as full, but it was quite a different experience and visit. An very auspicious round 3.

1145 After a 10 minute 'psychological' rest and paying our $300 IUI bill, we are out the door, arms around each other, both exceedingly happy.

I told myself before I went into round 3 that I was not going to get my hopes up. The previous 2 times I had such high hopes and was über stressed during the procedure and throughout the 2 week wait (maybe that is why the previous IUIs did not go very well!). Both times ended in a day or two of prone position depression and heaps of crying. This time I did not want it to be like that. I have read The Secret and do believe in positive thinking, but this time I did not want to have such high hopes that could be so disastrously dashed. So I have taken up a nonchalant attitude. I want it to happen, I hope it happens, I am thinking positively that it WILL happen for us eventually, but if it is does not happen this time, I am okay with that. Due to this attitude, I was happier and more relaxed at my visit and am now going to go on with my life for the next two weeks without the obsession and worry that consumed me for the previous 2 rounds. I am hoping things will be different this round, but it will not be the end of the world if they are not.

Now, I am off to spend the week with my husband doing renovations to our home in hope of having it all done very soon. All of these home projects will surely keep my mind active and occupied. My uterus and right ovary (where all my eggs were again - I do not think at this point that my left ovary is working at all) are a bit sore and crampy, but I am hoping that will dissipate later today. No time for bed rest though when there are so many projects still left to complete!

Missing

I have not blogged since March, so for about 3 months now. Where have I been? Well, no where really, but I have not had anything new to blog about and I have been a bit unmotivated as well. If I'm honest, I have been feeling a bit down and depressed in these past 3 months trying to sort out what I want to do now.

We met with our reproductive endocrinologist (RE) in May and have sorted out a plan. We are going to do two more rounds of IUI in June and July and then take a break until after September if neither of them take. I will be gone for the month of September to Ghana to do midwifery work, and upon returning, we will try IVF. Since my husband will be leaving for work for half a year in the fall, he will probably have to make several deposits before he goes and I will undergo IVF alone.

These are the things I have been dealing with. Going through IVF alone, spending the holidays along, possibly being pregnant for a large chunk of time alone and my husband missing out on all of this.

On a good note, we have been approved for the Attain IVF program where we will receive 4 rounds of IVF (2 fresh and 2 frozen) for $16,000 USD. If I were under 35, I could have qualified for having a percentage of my fees refunded if our IVF attempts were unsuccessful. But due to being 38, this is not an option because of the reduced chances of having a successful pregnancy via IVF after 35. Luckily my chances do not go down drastically until I reach 40, so I do have a good chance left still and that is why it is important to go ahead with the IVF even if my husband is not here. Every 6 months I wait, my chances decrease as my eggs get older and fewer.

The last bit of news is that I received my anti-Müllerian hormone (AMH) results. This hormone is suppose to be able to tell how much of an ovarian reserve one has and is a serum blood assay that can be drawn on any day of the cycle, unlike FSH, estrogen or progesterone. The results are as follows:

Interpretation	AMH Blood Level
High (often PCOS)	Over 3.0 ng/ml
Normal	Over 1.0 ng/ml
Low Normal Range	0.7 - 0.9 ng/ml
Low	0.3 - 0.6 ng/ml
Very Low	Less than 0.3 ng/ml

My result was 1.1. JUST above the normal cut off range. I have been researching this in journals and have found that IVF is most successful with a value of 1.24 or greater. The articles recommend taking DHEA. A good blog post about this is by Kylie Hughes: DHEA for low ovarian reserve. Her blog research and linked articles show that IVF success was significantly increased with DHEA supplementation for those with low AMH results. Right now my RE is saying my chances with no intervention is only 1.8% per month of conceiving on my own, 8.6% chance with IUI + clomid and around 50% for IVF. I am not sure if my AMH result now will affect that 50% chance for a successful IVF. These are the things I plan to ask her this Saturday when I go for my scan to see how many eggs have developed for this cycle. If there are enough eggs, as there have been in the past, we will do round 3 this week.