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.

Ghana bound

I have decided to do an elective in Ghana via Work the World in September when I am on my 3 week break between summer and fall terms. There I will be working in a hospital in Takoradi - a 4 hour drive west of Accra along the coast of the Gulf of Guinea. The experiences other midwives and students have had sound phenomenal. I am quite excited to go, albeit a bit nervous as I have never been to Africa and do not know what to expect of the country or the healthcare. I imagine it will be quite shocking at first and not at all what we are use to in our Western industrialised nations.

To enter Ghana I had to have a pre-travel appointment with the travel clinic and found I needed both Typhoid (only good for 5 years and my last was in 1991) and Yellow Fever, which certification of receipt is required to enter Ghana. Upon receiving the news that I was not pregnant (again) I quickly secured my vaccinations since you cannot take either whilst pregnant due to the live viruses they contain.

This now delays my next IUI since I need to wait a month before trying to conceive after taking these vaccinations. I was a bit skeptical about trying another round of IUI in May though, as both Malaria meds are pregnancy C category and if pregnant, I cannot take Doxycycline at all. I also read that mosquitos are more attracted to pregnant women (hence why many pregnant women in Ghana also have malaria), so I am a bit leery about that. I am following up with my physician to ensure it will be okay to be pregnant and go to Ghana. I definitely do not want to work so hard to get pregnant to then put my baby or myself at risk of being infected with a disease.

I have asked for a consultation with my physician, but it seems that all appointments are booked up for consults until May. That is a bit disappointing. I am hoping to get in before we do our next round as I would like to discuss our short term and long term options. Obviously I know we can do another 2 rounds of IUI, but there are further issues to contemplate. I will be gone to Ghana for 3 weeks in September, and sometime around September my husband will also be leaving on business for 4+ months. We hope to inquire about sperm freezing as well as speak about our options with IVF to include how it would work if my husband is gone, financing, risks, etc. I never thought I would consider IVF, but it looks like we are heading that way. I just do not know how it will work with me being out of country most of September and my husband leaving the same month. Possibly we have to do egg retrieval and insemination before he leaves with implantation after I return? These are the questions I would like to learn answers to.

I will be 39 this November. I feel like my time is running out. I want to be pregnant before I turn 40 as success rates after 40 drastically decrease while risks of Down's Syndrome and other age related issues increase.

Gosh. Hoping for a miracle!

BFN

... aka Big Fat Negative.

Took a pregnancy test on Wednesday and it was negative. Started spotting on Friday. Period started in full force today, Saturday. This has got to be THE worst period I have ever had - heavy bleeding, countless golf ball size clots and the worst cramps I have ever experienced. I do not like taking meds, but I have taken 2 Fioricets and 4 ibuprofen. I was going to head down the Percocet way, but am finally feeling some relief. Thankfully! I am not sure if the medicines I am taking to get pregnant are having a direct impact on my menstrual period or not. My physician said Clomid can increase bleeding and dysmenorrhea with periods. I also added progesterone suppositories to this round, so maybe that also has an impact?

Sorely disappointed again, but at least we are only out $250 instead of $500 (although $250 is not small change either).

Round 2

This past Sunday we went for our 2nd round of IUI. This time I forewent the US and hCG shot to force ovulation thinking that it might go better if I went with the natural rhythm of my body. I used ovulation sticks to detect my LH surge and then went in the day after my surge was detected, which was Sunday.

I did not have any ovarian pain this time around and since I elected not to do the US, I do not know how many eggs were produced. There is at least one, but I am thinking there is not much more than that since I did not have the ovarian pain and tenderness this cycle. I actually felt nothing while on Clomid this time.

On Sunday, my husband's sperm, after washing, was only 4.5 million this time. As aforementioned, below 5 million/ml is not good, but they still went ahead with the IUI since it was close to the 5 million. I was really shocked and disappointed that we went from 9 million the 1st round to half of that on the 2nd round. I know I should be thinking positively, but I am just not very hopeful this go round.

Since my period started earlier than expected this last cycle, the doctor also gave me some progesterone suppositories to give some support during the luteal phase. I am hoping that helps a baby stick!

On Monday, my husband had a follow up urologist appointment that I also attended. The physician was quite knowledgeable and helpful. Of the three repair options for the varicocele, my husband has decided on the laparoscopic procedure as it is minimally invasive and has the highest success rate over the old standard procedure of going through the muscle with a long hernia type scar or placing materials in the veins to occlude them. It is a longer surgery time - up to 4 hours - but it has the highest rate of being successful the first time, it has a faster recovery rate and it has a high success rate for increased fertility. The only drawback is that we cannot pursue any assisted fertility options for 4 months after his operation. That means that we will need to finish up these 4 rounds of IUI before he can have his surgery. This places his surgery in July of this year. The urologist also stated that it can take up 9 months to see a marked improvement in fertility but that up to 60% of patients will then go on to conceive naturally.

I am not sure what is going to happen in our future, but I really truly hope that one of these IUIs are successful and that we do not have to visit the dreaded IVF decision or hope and pray for a spontaneous, natural pregnancy 4-9 months after the varicocele repair.

Adoption

Last week I had a teenage patient who was gang raped and decided to give her baby up for adoption. She was not sure what race the baby would be, but found a lovely couple who was happy to have a baby regardless of circumstance. The mother of the baby and the adoptive couple were both Caucasian, but the baby had a chance of being Caucasian, or a mixed African American or Hispanic race. The adoptive parents were fully aware of not only this but also that the birth mother could see her baby and change her mind about the adoption at any time leaving the adoptive parents bereft and emotionally spent.

Upon the birth of a beautiful Caucasian/African American baby girl, the mother held her baby close, smelled her, kissed her and then asked the adopting parents, "Do you want to hold your baby?" There was not a dry eye in the room.

At discharge the birth mother hugged the adoptive parents and said, "Thank you for adopting my baby. I know you love her and will give her a good home."

This epic event gave me pause and much to contemplate. If 4 rounds of IUIs do not work, would I be able to give up my dream of having my own biological child and adopt? Would I be able to love another person's child as my own? Would I fall instantaneously in love with a baby as this couple did?

After much soul searching into the deep abyss of hidden feelings, I came to the conclusion that I could not.

I really, truly want to experience it all - conception, pregnancy, labor and delivery, breastfeeding, sleepless nights - the whole kit and caboodle. I know I would be giving up my entire dream if I adopted.

I also cannot imagine that I could love a stranger's child as my own. I see babies born on a daily basis and whilst they are sweet, cuddly and precious, I am not in love with them nor do I feel an emotional connection to any of them. It is hard for me to imagine feeling that same unconditional love and joy for an adopted baby as I see parents express for their own children. There is something to be said about that bond that is formed during pregnancy and the emotions experienced at birth - all of those mechanisms, hormones and emotions link the mother to the child intuitively. I know a bond can be created with an adoptive relationship, I just do not know how it is formed.

I do know that I would not love a child instantaneously. Maybe it would grow over time, but I do not see in myself the same characteristics that this couple had. I have several friends and patients who have adopted and I admire them greatly. They love their adopted children unconditionally and as their own, and for those that also have their own biological children, there is no difference between how they love and treat the children. In my family, I have seen several family members treat their adoptive children and step children differently, and in the case of the step children, horrifically. I know I could never treat a child cruelly but I worry that I would not love an adopted child enough, completely.

My heart does hurt for all those children waiting to be adopted, especially in countries like Russia and Romania where they are failing to thrive due to a lack of love and human touch and solely existing on boiled fruit juice and a couple spoonfuls of food a day. I wish I could love and help them all, but realistically this is not possible.

After looking at countless pages of babies and children waiting to be adopted, I started to wonder why there were not more people willing to adopt. But after looking into the costs for adoption, I understand a bit better. I found that the cost for adopting vs IVF is virtually the same (oftentimes adoption fees are even higher than IVF), and with IVF, parents are given the chance to go through pregnancy and have their own biological child for the same price, if not less. It is no wonder more people opt for IVF over adoption.

This was definitely a challenging soul searching journey that brought up many ugly realities that I was saddened to face. In the end it left me feeling morose and worried that we may not be able to have our own biological children.

If only we could see what the future holds!

So it's a varicocele?

My husband went to see a reproductive urologist this week and found out that his infertility/low sperm count is due to a varicocele in his left testicle. A varicocele is an enlargement of the internal spermatic veins that drains blood from the testicle to the abdomen and back to the heart via the renal vein on the left and the inferior vena cava on the right. This enlargement causes increased temperatures around the testicle which in turn causes decreased sperm count, decreased sperm motility and an increase in the number of deformed sperm - all of which my husband has.

Varicoceles are present in about 15% of the male population and 40% of infertile men. A varicocele develops when the one way valves in the spermatic veins are damaged causing an abnormal back flow of blood from the abdomen into the scrotum causing a hostile environment for sperm development.

Varicoceles most commonly are corrected surgically either by tying off the dilated veins around the testicles thereby diverting the blood or placing a coil or other barrier inside the vein, called percutaneous embolization, which also redirects the blood flow. Improvement in semen quality post operatively is seen in 50-90% of patients after 3-6 months. Pregnancy rates after surgery improve by 30-50%.

My husband's surgery consultation will be on 14 March. We are still going to go through with Round 2 of our IUI treatment per our RE's recommendation, but then if not successful again we will take a month off and allow my husband time to recuperate before trying again for Round 3. Hopefully with the repair our chances will increase greatly!