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.