Beta Day

 I called my OB to get betas done there, since this was an unassisted pregnancy. The good news about the OB is that the cost is $0, since my OOPMax has been met, versus $400 at the RE. The bad news is that they don't do same day results. I waited until 3 pm the day after my 10 am blood draw, then called. A hour later a nurse called me back and shared that my beta was 655. At 15 dpo. Amazing.

Repeat today. Results, hopefully, tomorrow. 

This feels truly unbelievable. How could we possibly have a sticky baby when my lining during IVF hovered below 3 at trigger and we couldn't get more than 1 euploid embryo from 27 eggs? There has got to be a shoe waiting to drop. I'm hoping that whatever tenacity has kept the little one growing thus far will hold out, and that s/he'll be healthy. 

Not Entirely Meaningless

 The plan was to try one round of Femara, with my next CD1, while waiting for surgery. In the interim, we enjoyed 'cheap, meaningless sex', as noted in my last post.

Approaching CD1, my temp dropped. My normal pre-CD1 headache started. But then it vanished. And CD1 didn't arrive on the day of the big temp drop, like normal. So I used a HPT on the night of 9dpo. And again on 10 dpo, and 11 and 12 dpo.

It turns out, things weren't entirely meaningless.

The lines have gotten dark enough I'm no longer convinced this will be a chemical pregnancy. Now I'm assuming it will be a blighted ovum, or a trisomy we have to TFMR. That's loss mind for you. Still, the 41 year old who got one single euploid from 27 mature eggs is apparently pregnant, the old fashioned way. Go figure.

Misunderstanding

 The other day, the husband and I were enjoying some, ahem, fun. It was fun that was not preceded by injections, monitoring appointments, or instructions on timing from a doctor. Thus, there was no cost associated. It was also fun at a time when there was no chance of pregnancy. Thus, there was no meaningful impact. 

In other words, I was having cheap, meaningless sex. 

Is THAT what's meant by that term? Apparently I've been misunderstanding all these years!

Not sure what #MicroblogMondays is? Read the inaugural post which explains the idea and how you can participate too.

Assumed Malice

Over the years, I've developed a motto that applies to many situations: Never assume malice when incompetence could explain the situation.

My MIL is currently livid because Amazon delivered a box of canned soups to the front of our relatively long driveway, rather than by our garage or at our front door. They were delivered after dark and wound up spending the night in the driveway, which can't be seen from any point inside the house. It was freezing out, and although the cans are not malformed, she assumes the soup is ruined. She's especially livid because the delivery person apparently indicated 'hand delivered to customer,' which was clearly not the case since the customer was not a driveway. She's focusing on the fact that he lied. If we apply "never assume malice when incompetence is a possibility", then we see that the guy was probably using an electronic device with check boxes, in the dark, in the sub-freezing weather here in MN. He probably just checked the wrong button. Incompetence, not malice. 

The motto applies in the fertility world. After we'd lost the twins and their sister, a dear friend, who had herself gone through IVF (successfully), asked "why don't you adopt?" As frustrating as I found that question, it certainly didn't come from a place of malice. Incompetence might not be the optimal description of where it did come from, but the lack of understanding of others' perspectives is a close cousin to that. 

I try hard to avoid coming from a place of incompetence when dealing with others. I look at the work I'm doing in the social justice space, and I'm woefully aware that some of my words are likely to cause frustration or hurt, without me ever intending such. One situation that stands out to me, from years back, was when I commented on the eloquence of a speaker's words. I love words and language, and I love anyone who can use language elegantly. This speaker, a woman of color, could. I commented to a colleague, also a woman of color, how well spoken the speaker was. Since then, I've seen that "well spoken" is often viewed (and meant) as a way of indicating surprise that a person of color is more intelligent or educated than expected. It is a micro-aggression. That was not my intent, I felt no surprise, only tremendous respect that the speaker communicated so much more eloquently than I could on a difficult topic. But in coming from a place of incompetence with my comment, I caused hurt.

I can't speak to what the Amazon delivery driver's intentions were. I can acknowledge my own intentions, and step up to reduce my incompetence in interacting with others. I can learn new language, I can do things that make me uncomfortable to make others more comfortable. I can't be perfect, but I can try to be better. 

Got It!

 I had been told that I'd hear back about the job I interviewed for on Monday or Tuesday.

Monday and Tuesday passed with no word. 

I went to bed Tuesday night with the thought: "Wow, it's pretty bad when you're the only candidate interviewed and you STILL don't get the job!"

Wednesday I got the call: I got it! 

I'm excited. There's no change in level or pay, but it will be something different, something I have expertise with, and with a manager and team I'm thrilled to work with. Of course, our company moves leaders every two years or so, so the manager will probably get moved soon. I will be sad about that, but in the past it's worked well for my career progress. The one down side of this position is the possibility that I'll get pigeon-holed into it. I've been moved roughly every two years, which has been nice and good for my development. The person currently doing the job I'm getting has been doing it the entire seven years I've worked here. I am one of the only people in the company with the right technical expertise to do the work. That will make it hard for me to move, because the work is crucial to the company's mission, and if no one else can do it, then there'll be no chance for me to step out and someone else to step in. 

All that said, taking this job was a calculated risk. Right now I value stability and work-life balance above career progress. The job level I'm at is the start of the point where you need to be "on" 24/7. I check in on weekends some, but the need to spend a lot of weekend time on work is relatively low, so long as I manage my time effectively during the week. If I moved up a level, I'd be at the point where weekends, late nights, and early mornings are the norm. I'm not interested in that right now. The role I'm leaving had near zero weekends or late nights, but it was also not very stable. I'd been slowly engineering myself out of a job for much of this year by automating a lot of the work I was doing and building out clear processes and tools to allow someone of a lower job grade to do the work. I was going to need to pick up something different in 2021 or face the risk of job elimination. The likely things for me to pick up weren't of much interest. As I was writing this, my company announced mass layoffs in 2021. So hopefully this was the right move to make. I guess we'll see. 

Stupid Decisions

 In the most brilliant case of insurance buffoonery I’ve seen yet, when my company started offering fertility benefits this year under a fertility benefit plan, they dropped anyone with an RE designation from their regular medical plan. No big deal, right? Well, the fertility plan only covers IVF, IUI, OI/TI. It doesn’t cover any surgery or procedures outside of those. I want to have my Asherman’s treated by a surgeon who uses microscissors. Every living surgeon in MN who uses microscissors is an RE and therefore is not covered by my insurance. There was one surgeon who was just an OB, and covered, but he died unexpectedly in June.  Two others are both an RE and an OB.  Although my insurance covers every single other doctor at their network (Mayo clinic), it doesn’t cover them, because of the RE designation. I tried an appeal, given that the surgery is not solely for fertility reasons and they are OBs as well as REs. I was denied.

For a while, I started to panic that this was it. I wouldn’t be able to find a covered surgeon, so we’d never be able to transfer our little day 7. That was not the ending to the story I was expecting, honestly. I sent out a desperate plea, which a dear friend forwarded to her RE. And thus I found an OB in St. Louis who uses microscissors, balloon stents, and long estrogen courses (best practice), coupled with a second-look hysteroscopy (also best practice), to treat Asherman’s. He’s in-network. Did a consult this week, and he’s highly knowledgeable, up on the research, and willing to give my uterus a look. So it looks like I’ll be making the nine hour drive, then spending a week in St. Louis while waiting for the stent to be removed, then driving home, and finally flying back six weeks later for the second look. During a pandemic. Because my idiotic insurance won’t cover a skilled OB/RE who is local.

Despite the worry that this entails, the bigger worry that this doctor brought up is actually that the issues with my uterus are not simply Asherman's, but also the result of problems with my c-section scar. Those can only be resolved via lap. As a result, the plan is to book the OR for a hysteroscopy and lap, start with a hysteroscopy, and convert to a lap if the c-section scar is the issue. So I may be recovering from a lap, 9 hours from home, because my insurance won't cover anyone local. Stupid decisions, brought to you by stupid insurance.

Whining

 Back in the land of long-ago and far-away, when kids were not on the horizon and disposable income could go to things other than medical expenses, I grew to appreciate wine. I grew up 45 minutes away from Napa, my family and I would drive out there for special dinners. After I left the house and my parents divorced, my dad got really into wine. He and his business partners began an annual trip to Napa to thank their employees for the hard work done that year. Dad invited DH and I, and so for about five of the years we lived in California and the trip occurred, we went. 

The trip was always amazing, and relaxing. I began to think of total relaxation as "a Napa state of mind." The down-side of the trip was that I was exposed to some really good wine. Thus, I began to appreciate really good wine. DH and I joined a wine club, and either we bought, or my dad bought for us, some very nice wines. We got a wine fridge, it filled to capacity. We got some wine racks, they filled to capacity. I did my duty to help empty them again! Then this whole 'getting pregnant' business started, and I stopped buying wine, but I also stopped drinking. No drinking while cycling, or while pregnant, or while preparing to cycle again. DH drank the less good wine, but I threatened him with grievous bodily harm if he drank the good stuff when I couldn't. 

Having come to the end of our baby making road, this Thanksgiving weekend, I opened one of the bottles of good stuff. A 2008 Rombauer Fiddletown Zin. That's a little old for a zin, but it had aged beautifully. It was smooth. No tannins left. No hardness, no bitterness. Just jammy perfection. 

I thought about myself and my own aging since I bought that wine. I've got a few less tannins, too. That is to say, that I'm less bitter about many things. I've drawn new personal boundaries around what the 'small stuff' is, and I don't sweat it any more. Quite frankly, in comparison to losing my girls, a lot of life falls into the 'small stuff' bucket. I am also more thoughtful about my actions and how they'll impact others. Part of that is because of raising children, and part of that is because of all the times after my losses that I thought, "I'll be a better, kinder person if I can just have kids." I don't think being kind brought me kids, but it's not a bad thing to strive for!

Unlike the wine, though, I've not been reduced to jammy sweetness. I've developed a new hardness. When it's important to me, I will push and push and push to get to an answer I'm happy with, if I don't like what I'm being told. I will stand up, in situations I would have sat down for in the past. I may not have aged quite as beautifully as the wine, but I have become something different, and something that I consider to be better than what I started with. Here's to aging well, and being able to find a Napa state of mind when needed!

Not sure what #MicroblogMondays is? Read the inaugural post which explains the idea and how you can participate too.

You're the Best (Comparatively Speaking)

 In my ongoing effort to find a new job, another opening at my current company has surfaced. I applied and three days later was scheduled for interviews. Completed them on Monday. I applied largely because I'd rather do anything than what I'm doing now, and this is something I know I can do well. It's not the most exciting job ever, but to some extent a job is as exciting as you make it. I'm actually more excited about it after the interviews because I think there are more opportunities and more organizational willingness to pursue them than I'd originally expected.

Who knows if I'll get this job. I think I'm the only candidate right now, so comparatively speaking, I rocked the interviews! They said they'd make a decision by early next week. Our company has a unspoken rule about internal job movement that you start on day 1 of the month after you get the offer. Thus it would be to my benefit if I don't get an offer until December, because it would be helpful to finish out the year in my current role. We'll see what happens. I have pretty much given up on having any expectations about anything, so I don't expect anything positive to come of these interviews. 

Microblog Monday: The System

 I believe that my success in life has been the result of multiple factors. It’s partly due to my own hard work and reasonable level of intelligence. I worked hard during college to get perfect grades, while working a part time job. Those grades got me into a top grad school with a full ride scholarship, and I worked a full time job for my last two years of grad school. All of that put me in a great place for my first job, and working hard at that and subsequent jobs earned me promotions and new opportunities. I’m proud of the hard work.

But hard work was just one part. My success in life was also due to the fact that my parents placed a high value on education. And they owned a nice house in a neighborhood with great schools. That’s the result of their parents also prioritizing education, and having jobs that paid well enough to send both of them to great schools. My success is also due to the fact that my parents were both successful corporate professionals. I learned from them how to act, and how not to act, in interviews, in professional settings. In a broader sense, my success is partly due to the fact that my parents and grandparents and great-grandparents all had the ability to shape this country in the way that best suited their beliefs, through civic participation.

My employer, like many others, has a social media type channel for our employees. Anyone can post anything. Some is done by corporate communications, some by different user groups, some by individuals. Corporate Communications has recently celebrated some of the efforts to further social justice and racial equity. One individual has railed against that, decrying the notion that systemic inequities exist. He posts often, and with great detail, about how people just need to work harder/behave better to do as well as he does. 

To that, I can only look to my life, compared to the lives of people of color. My parents could vote. My grandparents could vote. My great-grandfathers could vote, even if my great-grandmothers could not before 1920. For many POC, equal access to voting didn’t exist until 1965. While the right to vote theoretically existed starting in 1870, the use of poll taxes, literacy tests, grandfather clauses, and white primaries meant that many men of color couldn’t vote until 1965. For POC, their grandparents and great grandparents did not have a chance to shape the country in the way they thought best. That sounds pretty systemic to me.

Looking beyond voting to education, the inequities in the US are even worse. My parents went to good, neighborhood schools.  My grandparents went to good neighborhood schools. For POC, schools were just being desegregated when my parents were entering grade school. Because of the way schools had been segregated, and because of where POC lived, most POC didn’t have good neighborhood schools to go to. They fundamentally did not have the same opportunities that whites did, and therefore their children won’t have the same opportunities and same role models. Once again, sounds pretty systemic.

Let’s talk about home life. My parents and grandparents grew up in decent neighborhoods. To be clear, my grandparents didn’t have it easy. My grandmother was abused by her alcoholic parents and lived in poverty until another relative took her in. My grandfather was one of seven kids (Irish Catholic) in a family that would have been considered poor back then. Despite that, though, they were able to buy a house in a good neighborhood when they got married. They worked hard at jobs that were good for that time. Even my grandmother was able to get a job. Those jobs, however, would have been unavailable to POC, since businesses could, and mostly did, openly decide to hire only whites. Their ability to buy a home was due partly to their hard work and partly to their race. POC did not have that same opportunity. Further, lending laws, redlining, and covenants crafted by local governments expressly prohibited POC from certain neighborhoods. See this article for a good description of the lingering effects of these practices. That is about as systemic as it gets.

I don't understand the perspective that systemic inequities don't exist. It seems to me to be the utmost example of being self-centered to assume that 'if I could pull myself up by my bootstraps, they could too.' That completely glosses over the fact that "my" bootstraps were miles longer and stronger than "their" bootstraps. I don't know how we can fix these issues. I work at a Fortune 500 company where only two or three people have been willing to challenge the 'no systemic racism' poster, and where our head of Diversity and Inclusion has done a few things that were so jaw-droppingly not supportive of diversity or inclusion I don't even feel comfortable describing them on an anonymous blog. Again, I wonder how can we, how can I, make positive change in the face of such resistance. (For anyone asking, "why don't you reply?", as an HR employee in learning & development, with the current executive order, I've been prohibited from replying on the social media channel as my response could be considered an 'official' HR response and therefore could expose the company to a hotline complaint and resulting legal action.) 

Real Life

Since T and A were born so early, and spent so long in the NICU, I never had newborn photos done. We decided that with fall photo sessions in full swing, we'd sign up and see if we could get at least some professional photos before the kids are old enough for their high school senior portraits! 

Usually the first snow in Minnesota is the second week of November. October is the time of fall colors, crisp night temperatures, and beautiful days. Thus, we booked our photos for late October. The week of the photos, we got nearly a foot of snow. The day of our photos it was below freezing and extremely windy. Minnesota broke both cold and snow records. As a result, instead of idyllic, happy family photos, we had freezing, cranky, real-life ones. A, in particular, was miserable and sobbed any time DH tried to put him down, including when DH tried to pass him to me to hold.

This photo sums it up perfectly.

To be fair, we did get some gorgeous photos thanks to the talented Melissa Kay. Here are two favorites.

Overall, these depict real life, and it's a real life I couldn't be more grateful to call mine. Sobbing toddlers, red noses, and misplaced clothing, I'm happy to experience it all. 

Aneuploid

 We have a little boy with Down Syndrome. 

So that's that. At this precise second, I actually feel ok. Life with two kids is great. It's easy in ways that it wouldn't be with a third. Plus, I love sleep, so I'm not sure how well I'd do with newborn sleep deprivation. Thus my sadness at this outcome is tempered by my realization that there are real benefits to things staying the same.

The hard part now is deciding what to do with our single, day 7 euploid. Actually, the hard part is deciding what I'm willing to do. I'm 100% not willing to do a pre-pregnancy cerclage with only a day 7 embryo. I might be willing to do the operative hysteroscopies, transfer, and if he sticks, then do an in-pregnancy TAC. *Might*. That would be signing up for a great deal of additional stress, anxiety, worry, etc. It would also mean an open TAC, versus a lap-TAC, which I would have done as a pre-pregnancy procedure. So I don't know what I'll decide. We regroup with our RE on Friday and I'll probably ask for a referral to a guy at Mayo who in theory works wonders with Asherman's. It's worth investigating for the sake of the little dude in the freezer. 

Microblog Monday: Today

Today I should get the call with the CCS results for our lone blast. I feel as if I've been holding my breath since May. Whatever the outcome of this call, I'll have to start breathing again. Either in relief, because it's euploid, or in sadness and resignation, because it's not.  Either way, it's time to start moving on.

Not sure what #MicroblogMondays is? Read the inaugural post which explains the idea and how you can participate too.

On Your Fourth Birthday

Today you should turn four. Would you believe that I still miss you as much today as I did on your last three birthdays? That I still tell you both that I love you, every night right before I fall asleep? I do. 

It's funny to me that despite having friends with four year olds, and despite getting to know your little brother and sister, I still can't imagine what you'd be like. I think that's because I want to know you as who you are, not who I hoped you might be. Since I never got an opportunity to learn who you are, there's a blank spot there. It's not a bad blank spot, but a brilliant, shining, sparkling one. It's almost like the aura that's left behind after staring at a bright object. You can no longer see the object, but the aura remains. 

You may not be here with me, but I believe that you are both brilliant. I believe you are both amazing. I believe that no one is as lucky as me, because I'm the one who got to be your mom. 

I miss you, Alexis and Zoe. I love you, my beautiful girls. Happy Birthday.

Outcomes

Because data and organization make me calm and happy, I decided to get the data from my four cycles and organize it. This is not optimized for web viewing, but I think it's interesting none the less.

Here is the outcome for every egg retrieved whose outcome I know. One of my 1PNs has no day 7 record. One egg has no record. The rest are shown below. 

The part that I find interesting is that every single fertilized egg, and even one egg that in theory didn't fertilize (0PN), reached either blast or compacting morula. This last had two non-expanded blasts (1 expansion), so they couldn't be biopsied, but three of four fertilized normally did reach blast. 

Red boxes were aneuploid. Green box is euploid. Yellow box is as-yet unknown.

So there you have it. I suspect that if we were in a position to transfer day 3 embryos, we'd have achieved a healthy pregnancy from some of these. I suspect they just don't do as well in vitro as in vivo. No way of knowing for sure, and it makes me question my decision to do IVF first, then surgery. But here we are. Hopefully round 5 adds another green block or two to the diagram. 

On Choice

 On this day of a historic election, with a newly seated Supreme Court justice who is likely to limit reproductive choice, I feel the need to share this. Go. Vote. Your vote matters. It matters to you and it certainly matters to me. As you vote, think of the real impact of your choices. And appreciate the fact that you do have choices. In the days to come, choices may become more limited for many women, if things trend as they seem to be trending today.

___________________________________________________

Some years ago, we decided that we wanted to have a child. It was a decision made after years of preparation and a great deal of care.

We found ourselves pregnant quickly, but there was no heartbeat at 10 weeks. Based on the size of the embryo, development had stopped about a month earlier, before a heartbeat ever formed. The fact that I hadn’t miscarried or bled, or had any issues, made this what’s called a “Missed Miscarriage.” We were both devastated, despite being told that “this happens.”

Because the baby failed to miscarry naturally, we had to seek medical intervention. I had surgery and we were cleared to try again as soon as we were ready.

Our next two attempts both resulted in positive pregnancy tests that faded away by 6 weeks. Testing determined that our 10 week loss had done damage to my uterus, which was preventing new embryos from implanting. The solution was surgery, followed by hormones to rebuild my uterine lining. 

We implemented the solution and were overjoyed that our first attempt resulted in twins. Although I had only ever wanted one child, nothing in my life has felt as right as seeing those two heartbeats on the screen. I loved them with a fierceness I didn’t know I was capable of.

Testing showed that they were both healthy girls. I don’t think I have felt as happy in my life, before or since, than the weeks that I knew I was expecting two healthy girls. 

Our happiness came crashing down when Baby B, Zoe’s, water broke at only 17 weeks. In Europe, the standard of care for pre-viable premature rupture of membranes (PPROM) is to give antibiotics, encourage bedrest, and wait. The main risk is that an infection will develop, as the baby is no longer protected in her amniotic sac. Here in the US, my doctors, at a top research hospital that is currently saving babies born at only 22 weeks, refused to administer antibiotics. They told me that the risk to me was too great. The likelihood that I’d develop an infection was 100%, and if we took antibiotics it could mask that and would jeopardize my life. They urged me to induce labor immediately, if labor didn’t start on it’s own.

Baby A, Alexis, still had all of her water. Neither girl was showing any signs of distress. I understood the risks to my own life and reproductive health. It should have been my decision to take those antibiotics. I should have had the choice. There are hundreds or even thousands of stories out there of women who got the antibiotics and reached viability. But my ability to choose was overridden by people who thought they knew what was best for me and my babies.

We refused the induction and went home to wait. We were told that if we didn’t go into labor within 1 week, we actually had a good chance of making it to viability. The week passed. Then at one week, one day, Alexis’s water broke as well and contractions started. By the time we reached the hospital, her foot had come through my cervix. She was born the next morning, after passing away during labor. She was beautiful and absolutely perfect and the pain of losing her is beyond my ability to describe.

The infection the doctors had feared set in by that point. My uterus was having trouble contracting as a result. Zoe did not come for another 8 hours, by which point an adverse reaction to a medication left me in convulsions. I hemorrhaged so badly they estimate I lost over half of my blood volume. I never got to see or say goodbye to Zoe. My husband tells me she was beautiful like her sister. I was rushed to emergency surgery, and then a day in the ICU.  It was my choice to stay pregnant and take that risk. I am grateful every day that I got to make that choice, despite the consequences. 

After that, we were assured by our doctors that what happened was a fluke. A risk of a twin pregnancy that had experienced recurrent bleeding. So there was more surgery and more hormones, and amazingly, they led to a singleton pregnancy. Another little girl, who we named Quinn.

I asked the doctors for some additional monitoring during her pregnancy. They refused. As a result, we didn’t know until it was too late that my cervix had opened, allowing bacteria into my uterus once again. Emergency surgery was attempted, but despite its apparent success, Quinn’s water broke 48 hours later.

Again we were refused antibiotics. Again we were pushed to induce labor immediately. Again we made the choice to remain pregnant, so long as I wasn’t showing signs of infection and Quinn had enough water for lung development. 

At the hospital that has saved 22 week old babies, my daughter was born at 21 weeks, 3 days. She was born alive and spent her hour of life in my arms, and my husband’s arms. Feeling her move as I held her is the single most important memory I have, and it was the memory that got me through the grief that followed.

It was my choice to stay pregnant. I’m grateful I had that choice. But because I made it, Quinn suffocated to death as her lungs weren’t capable of breathing. I question myself every single day. I question if I made a selfish decision, trying to keep her alive. I wonder if the better thing to do, for her, would have been to induce labor earlier, and let her pass warm, inside, as her older sisters did. That would have spared her the horror and perhaps the pain of the death that she experienced. 

The reality is that I made a choice. I have to live with it. But I believe that every parent should have the right to make that choice. I honestly can’t tell you what I’d do if faced with the same situation a third time. But I can tell you that just as antibiotics should have been my choice, knowing the risks to my body, termination or continuation of the pregnancy should always be my choice. As a parent, I owe it to my children to make those choices on their behalf, with their best interests in mind – even with the knowledge that perhaps the best interest means ending their lives. No parent ever wants to be in that situation. No parent ever should be in that situation. Still, many of us are. The choice should be ours. 

Artificial Oocyte Activation (AOA) Research

 Since I'm on a roll, it's time for another research-based post. Today's topic: artificial oocyte activation (AOA). The fundamental premise, as butchered by my non-scientific self, is that an egg must be activated by the sperm in order for fertilization to occur. Activation is typically caused when the sperm oocyte-activating factor, phospholipase C zeta is delivered to the egg by the sperm. Eggs that are receptive to this factor then generate an oscillation in calcium levels. This in turn leads to a resumption in meiotic activity. Fertilization failure occurs when these oscillations in calcium levels are not triggered, whether due to sperm or egg issues. 

Going back at least 20 years, researchers discovered that exposing a fertilized egg to calcium rich environments can trigger fertilization. This is true in cases where fertilization didn't happen in that specific egg, and in cases where prior retrievals resulted in fertilization failure, but subsequent retrievals, using calcium, show fertilization. 

As a ballpark, fertilization rates after ICSI should be about 75%. After our catastrophic 1 of 5 fertilized cycle, which in turn followed cycles where only 2 of 3 fertilized, I was concerned about our fertilization. There is research out there showing that high sperm dna fragmentation is correlated with lower fertilization. The same is true of low morphology. (Like all research subjects, there are also papers showing that neither of those things is true!). End result, I requested that we use AOA. Here's the research on it.

This 2019 Fertility and Sterility article grouped eggs by cause of fertilization failure: severe sperm related activation failure, less severe sperm-related activation failure, and assumed egg related activation failure. Fertilization rates went from 10% to 70%, 15% to 63%, and 18% to 57% across those three groups, when AOA was used. Live birth rates went from 0% to 41%, 22%, and 22% across the groups. I suspect this is the basis for my RE's statement that AOA only helps with sperm-related issues, although a benefit was seen in egg-related cases, too.

Article text: https://www.fertstert.org/action/showPdf?pii=S0015-0282%2819%2930330-9

Because there are few things better than a good meta-analysis, here's a 2017 Fert Steril article meta-analyzing AOA using 14 studies with over 1,500 ICSI cycles. It found the incidence of clinical pregnancy was 37% in the AOA group and 16% in the non-AOA group. The live birth rate was 27% versus 9%. The part that I find really interesting was that the fertilization rate was 59% versus 47%, which is significant given the sample size, but I question the practical significance. Blastocyst formation was 50% in the AOA group and 10% in the ICSI group. I suppose that explains the difference in live birth! 

Article text: https://www.fertstert.org/article/S0015-0282(17)30488-0/pdf

Looking specifically at DOR patients, this 2015 Fertil Steril found no difference in results. However, only an average of 2 eggs were retrieved in both the AOA and the control group. The study population specifically excluded couples with male factor infertility, abnormal sperm parameters, or a history of prior fertilization failure. In my mind, this wasn't a useful study, since the population didn't have fertilization issues. There were some other oddities, such as retrieval being 32-34 hours post trigger, and the use of unusual protocols for DOR patients (long lupron). 

Article text: https://www.fertstert.org/action/showPdf?pii=S0015-0282%2815%2901675-1

Finally, a 2018 Human Reproduction article. This looked at couples with two or more past cycles with less than 30% fertilization, or 100% abnormal sperm morphology. This study looked at SrCl2 and calcimycin separately. Both treatments produced higher fertilization (49%, 42%) than plain ICSI (27%).  Live birth was also better (42%, 36%, 23%). Differences were found in which activation medium worked based upon cause of fertilization issues.

Article abstract: https://pubmed.ncbi.nlm.nih.gov/30099496/

Anger

 I'm sorry for the vagueness, but I just have to get this out.

Something has happened at work that has perfectly mimicked research showing that when white men behave a certain way it's called "good leadership" and it's rewarded. When women or people of color behave the same way, it's called "aggressive" or "disrespectful." 

Someone that I have the utmost respect for will have permanent impacts to their career because of this bullshit.

I have escalated through the right channels, but there's nothing I can do at this point because the system itself is not equipped to recognize the inherent racism and sexism and respond appropriately. 

I am so, so angry. I can't imagine what this person will feel when they find out. There are additional layers of bullshit that make it even worse and make me even angrier. 

Our country is broken. The way we treat each other is broken. Even when we have the ability to acknowledge the breaks, we lack the fortitude to fix them. 

Here's Your Sign

They say familiarity breeds contempt. I think it's more like 'familiarity breeds disillusionment'. Maybe 'realism' is better.

We decided to go for one final, out of pocket cycle. Across my lifetime, that means that yesterday was my 12th baseline scan. I'm not really a person who believes in signs, but I'll admit that when A and T's cycle aligned, date-wise, to Alexis and Zoe's cycle, that seemed like a good thing. A sign. I had the same feeling of a 'sign' when our early IVF round aligned to Alexis and Zoe's cycle. When the nurse who did my baseline was the same during my first IVF cycle as during A and T's cycle, that also seemed like a good thing. It felt sign-like. It felt good.

Yesterday's baseline was with that same nurse. Instead of thinking "Oh, that's a good sign!", I didn't even notice. It wasn't until I was driving home again that I thought "Oh yeah, it was Gina. She did A and T's scans and some of Alexis and Zoe's. Her measurements are usually large compared to the other techs, so don't panic that she said you have a large follicle at baseline." Only after going through that thought process did I remember the overlap with my past twin cycles.

By now, I know that no amount of good signs is going to lead to a better outcome. No amount of hoping and praying and visualizing the outcome I want. No amount of wearing the same clothes, or the same jewelry or the same facemask will change what happens. Fertility treatments are mostly a numbers game. The best I can do is hope that this round happens to produce a good draw of the numbers. I can acknowledge the small probability that months of HGH use and careful lifestyle choices have had a positive impact. I can take my meds on schedule and go to my appointments, but no matter who does the scans, either these eggs are euploid, or they aren't. Either they'll fertilize, or they won't. Either they'll reach blast, or they'll get stuck at compacting morula like every other embryo we've created. 

Although I don't believe in signs, I'll still put out a plea to the universe. Please, Universe, let this be a good draw. Let the numbers land in such a way that this one gets us a take home baby. Please. Penitence and persistence and effort don't count for anything in this path, but if they did, I've lived them. So, please. 

Research: Aneuploidy by Age, Day, and Grade

 It's been a while since I've done a good research-related post. Shame on me, that's what happens when life gets too busy! I have a few that I'd like to share. They're basically a chronical of my neuroses, so take this for what it's worth.

Today's topic is aneuploidy by day and grade. Where possible, age is also factored in. My one euploid blast is a day 7 4AA, so I looked for data on grade to set expectations.

Looking at day 5 and 6 embryos, by age and by grade, this 2014 study from Human Genetics & Embryology is probably my favorite, because it shows some of the highest euploidy rates for my age group! It's around 45% of day 5 embryos from 40-42 year old eggs. It also shows AA embryos, regardless of day, having an aneuploidy rate of just over 50%. I cling to this one for hope.

Article text:  https://www.omicsonline.org/open-access-pdfs/morphological-and-kinetic-embryological-criteria-and-correlation-withaneuploidy-rates-how-might-they-be-used-to-choose-the-best-iv-2161-0436-1000129.pdf 

This is another awesome resource, from 2019. It splits out euploidy rates by day and grade, and includes day 7 embryos. Mean maternal age was 37, and in keeping with my own results, it finds that AA blasts, regardless of day, have the highest euploidy rate, including 58.5% of day 5, 50% of day 6, and 63% of day 7. The article also mentions pregnancy outcomes for transfers, and notes that the live birth rate for day 5 euploids is 77%, while the live birth rate for day 7 euploids is 43.8%. 

Article text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6364279/

This 2016 article is more somber, showing a 90%+ aneuploidy rate for day 7 embryos in the 40+ age range. It also lists out pregnancy outcomes by transfer of embryos. The caveat with this one is that the sample is extremely small.  

Article text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4832487/

Meanwhile, here's 2019 Human Reproduction article looking at aneuploidy by day and age. The researchers included embryos with C quality, which might explain their much lower euploidy rates in the 41-42 year old range (25% day 5, 23% day 6, 18% day 7). This also had a lower live birth rate for euploid embryos, ranging from 56% for day 5 embryos, to 45.8% for day 6 embryos, to only 21.5% for day 7 embryos. The split out live birth rates for day 7 embryos by embryo quality, however they lump everything 4BB and greater into the same "good quality" bucket, which sees a 26% live birth rate. 

Article text: https://www.rmany.com/content/2-our-team/1-physicians/dr-eric-flisser/what-is-the-reproductive-potential-of-day-7-euploid-embryos.pdf

So there you have it. If you're wondering what the probability of aneuploidy is for your embryos, based on day, grade, and age of the eggs, here are some of the top research articles. There are more articles available, although most older ones relied on day 3 blastomere biopsies, and therefore produce a different picture than day 5/6/7 blastocyst biopsy.

Dear Embryologist

 Dear Embryologist,

When you called me with my day 6 update on Saturday, you refused to share the grade of my blast with me. You told me I had to wait for my regroup, in 3 weeks after my CCS results are back. You refused even when I, truthfully, told you that I'd specifically asked Dr. B if I could get grades at the time of biopsy, since I'm banking, and she expressly agreed. 

I know that this is a job for you. Sharing grades with me would slow you down and you were already calling late on a weekend. (Although, to be fair, you were calling me with my egg sheet in front of you, and that egg sheet contained the lone embryo's grade, so simply reading the words "It's a day 6 3bb" wouldn't have taken very long.) You were certainly right in telling me that grade is not a perfect predictor of aneuploidy, although I was also right in mentioning that higher grades are correlated with higher aneuploidy.

I vaguely understand your hesitation. Please allow me to articulate why this was important to me.

Having a child is the single most life-changing activity out there. Sure, your career impacts your life, but you can always change careers. Your choice of spouse or partner can change your life, but you can also change spouses or partners. Having a kid though, fundamentally alters every moment of every day for decades, if not longer. 

Here I am, working on the single biggest event in my life, and because of infertility, I have almost zero control over it. How crazy is that? You control your career choice. You control your partner choice. But in my case, infertility, the most control I have is writing a very large check, taking my medications as instructed, and keeping my body as healthy as possible to maximize my chances. In other words, I have very little control. 

Information isn't control. But information is about as close to control as I can get. Information lets me plan my next steps. It lets me prepare for the most probable outcomes. Information is pretty much the only panacea for the pain that comes from the lack of control of something so fundamentally important.

In the course of a single breath, you have the opportunity to share information that can help. Information that can reduce the pain and anxiety. That ten second inconvenience for you will dramatically reduce days of anxiety for me.

I know that this is a job for you, but it's life changing for me. Please reconsider your response and your actions in the future, and think about how some empathy and kindness could make a world of difference to someone who is hurting.

Regards,

Me

Hello There, Yet

 Two weeks ago I noted that my cycle was going amazingly well, but I was waiting for the proverbial other shoe to drop. 

It's dropped. To convey my emotional journey via emoticon:

Eight retrieved! :-)

Seven mature!!! 8-)

Four fertilized. :(

One low grade, day 6 blast.  :'(

Four fertilized was only one less than the total I'd had fertilized in my last three cycles. And those cycles had produced three blasts for biopsy. Also, my lab reports a 50% blast rate. Thus I was dreaming of three blasts and realistically expecting two. In a big picture sort of way, one is certainly not that much less than two, or even three. But one isn't enough to hold onto hope, given my age. If we'd had three blasts, we'd have had a realistic hope of one euploid. With one, there's no realistic chance. To be fair, I don't actually know its grade - that's a post for another day when my blood pressure has dropped - but I don't think the refusal to share it with me bodes well. 

Mental Models

 I am trying to keep my mind in a healthy place during the wait for our day 6/7 call and the start of our last cycle. In doing so, I realized that my mind seems to have two settings: living life, and waiting for something. This is waiting in the sense of: I'm putting in serious amounts of effort with the hope and expectation that something good will come of it. My focus is primarily on the effort and the possible outcomes. 

Most of my life has been 'waiting for something.' Waiting to get into grad school. Waiting for my PhD. Waiting for my first leadership role. Waiting for a promotion. Waiting to have kids. Waiting to have enough saved to be financially independent. 

Since having the kids, though, and settling into various jobs at my current employer, I've spent more time focused on living life. That's living life in the sense of: concentrated focus on what I have today versus what I want for tomorrow.

Realizing that I'm back in waiting mode, but if I consciously shift myself to living mode my anxiety reduces, has been unexpected. I'm not sure it's really dawned on me before now the extent to which waiting mode has been detrimental. That's because even when deeply entrenched in periods of waiting, I am someone who routinely stops to appreciate the daily joys in life. I will marvel over the colors of leaves, or a hillside of fireflies. I notice and mentally celebrate every hug I get from the kids and DH. I smile every single time I see the plant my girlfriends gave me, which is miraculously still alive 4 years later! I have always assumed that those are signs that I am living my life, and if you asked me, I'd tell you my life is great. But the waiting still brings anxiety with it, even when the joys aren't overlooked. For today, I'm trying to focus on living. Yes, it's living while waiting, but if the focus is on living rather than waiting, the stress is lower. If the waiting ends with bad news, then it's good that I'm in living mode, because living mode is where I need to be once this round of waiting is over. 

Then There Were Four

To my absolute amazement, of the eight retrieved yesterday, seven were mature. Alas, even with the calcium ionphore, only 4 fertilized. To be fair, 4-5 fertilized was my dream number, since I never expected to get more than 5 mature, so I shouldn't complain. 

Fertilization at 57% is vastly better than our 1 of 5 last time, but slightly worse that the 2 of 3 I've had previously. I don't know if the calcium helped, or not, but I'm glad we did it. Now, we wait. Saturday for the day 6 update. Sunday for the day 7 update. If anyone makes it to biopsy, then another 16-ish days for CCS results. 

In the meantime, a few amazing things have happened. First, I found out that because we didn't get any embryos last time, I have an insurance credit. It will be enough to cover one FET and all meds. That's a savings of at least $7k, which is huge. My mom also offered to cover the bulk of another round of IVF. So the plan is to see if any of our four make blast. If they don't, then I feel good shutting the door on another baby, because clearly our gametes aren't up to the task. If we do make blast, then we'll roll immediately into another retrieval cycle. My numbers have gotten better and better each cycle, so there's a real benefit to charging ahead and not waiting out a cycle or two for CCS results. This is a plan I feel genuinely good about. 

Grow, my magnificent four! Grow, and make blast, and be normal. It's a lot to ask, but I'm asking it anyway. 

Eight!

 I just had to post through my retrieval stupor. My RE retrieved eight follicles! 

Sizes at trigger were 22, 16. 8.5 (left) and 20, 19, 14, 13, 5.5, 4.5 (right). Based on that I know they won't all be mature, and the fertilization call tomorrow will probably be the usual bummer. Still, for this moment I'm wildly happy with my ovaries and what they've done. 

It's Not All the Egg

 Can I rant for a minute? I guess it's my blog, so the answer must be yes.

What the heck is the deal with always placing 100% of the causality for fertility issues on the female end of things?

Look, I'm over 40. I know my eggs are not in the best shape in the world. And my uterus, well, that's not a pretty place. But our recent 20% fertilization rate is reasonably likely to be the result of sperm issues, and not just egg issues.

I asked my RE about artificial oocyte activation. Her response was that it probably wouldn't help us, because it's only for sperm issues rather than egg issues. 

Hello?!? Not to point out the millions of tiny elephants in the room, but we're dealing with sperm that has consistently had 1% morphology. Sperm that has a DFI on the SCSA of 30%. Many, many clinics would call that male factor infertility. But no. Not here. Here it's all about the egg. 

Grrr. This makes me angry. Because if we focused on the sperm in addition to the egg, maybe there's something more we could do. Like Zymot. Or PICSI. Or AOA. 

We are going to do AOA. And maybe we'll have 0% fertilization this time, and it will prove that the issues are all about the egg! I am ready to stand corrected. But I fail to understand why, given the information we have today, we must assume that everything is an egg issue.

Yet

I work in Learning & Development at a big company. This year we've really been pushing training on growth mindset. To oversimplify, this is about the idea that learning and growth should be valued over performance and perfection. The hallmark words of a growth mindset often include "yet", as in: "I can't do astrophysics, yet." The "yet" indicates that you're aware that you can learn it and will in the future.

I had a monitoring appointment today. For me, things looked pretty promising. I still have a decent cohort of follicles growing together. In reflecting on this news during the drive home, I thought: "Well, the news isn't bad, yet." 

While it doesn't reflect a growth mindset, I really do feel like I'm just waiting for the bad news. Maybe it didn't come today. Maybe it won't come before retrieval. It's coming, though. It's odd, but I think only having one of five fertilize last cycle crushed me in a way I wasn't prepared for. I knew I wouldn't have many mature eggs. I knew any embryos would most likely be aneuploid. But a 20% fertilization rate? That I was not prepared for. To know that I actually managed to get five mature eggs. . five!. . . but it was all for nothing because four didn't fertilize, that's crushing. 

So I sit here waiting for the next crushing blow. I'd guess I'll trigger Thursday or Friday. I guess I won't give up, yet.

Last Chance

 I did my first shot for my last chance IVF cycle this morning. AFC of 8. I just need one euploid out of this, although selfishly I'd like two! I find myself pep-talking my ovaries, pleading with the universe to let us get a good embryo from this, and simultaneously not expecting anything good at all. I guess the cynical optimist has finally run out of optimism. 

I have a birthday this week. The birthday where my odds of a euploid embryo go from 38% to 29% based on my clinic's data. I've never been sad about a birthday before, but now I am. 

Monitoring on Saturday. Wish me luck? 

I am/have been pretty conflicted about this cycle. After getting 5 mature last cycle, I wanted to do MDLF again, but with artificial occyte activation (AOA) to combat the 20% fertilization rate we had. My RE insisted on another antagonist cycle, since we've gotten blasts from those. I really don't love this plan, and it's the first time that I've been truly unhappy with a plan to move forward. It doesn't feel good, especially since we've "gotten blasts" when having 2 fertilized, and once we only got one blast. So having one fertilized and not reaching blast doesn't seem unexpected. I also don't want to be on extended Clomid for a fourth time, given my lining, although I know that extended Clomid is CCRM's "thing" for poor responders.

All this messaging came via my nurse. In order to discuss with my RE, I'd have to cancel this cycle and wait for a regroup in 4-6 weeks. While I'm usually pretty patient, the thought of another 8+ weeks to cycle again, while having to maintain my diet, was enough to break me. So I'm trusting my RE and going with the antagonist cycle. 

Because I like putting things in one place, here's the history we're basing decisions on.

IVF #1: Estrogen & cetrotide priming. 300 Gonal/150 Menopur/100 Clomid/HGH/Dexamethasone. Cancelled after 13 days, only one follicle remaining.

IVF #2: Estrogen & short testosterone prime. Luteal phase stim due to triggering a lead on CD2. 300 Gonal/150 Menopur/100 Clomid/HGH/Dexamethasone. Cetrotide added around day 10. 6R/3M/2F/2B - aneuploid.

IVF#3: Estrogen & long testosterone prime. 300 Gonal/150 Menopur/100 Clomid/HGH/Dexamethasone. Cetrotide added around day 10. 4R/3M/2F/1B, day 7 euploid.

IVF#4: No priming. MDLF 20 units/2x/day. 300 Gonal/150 Menopur/HGH/Dexamethasone. 5R/5M/1F/0B.

If I include my 6 OI/TI cycles, I can assume that we always had at least one blast, because we always had a positive beta. Based on CL cysts, I always had 1-3 mature. Thus, taking the most conservative assumption, those were: No priming. 175-225 Gonal/75 Menopur/vaginal estrace during stims. 1-3M/1-2B/0-2 euploid.

This does point out that we get euploid blasts with cycles that don't use MDLF. But I should also point out that we never needed Cetrotide on our OI/TI cycles. My LH always stayed low, probably due to the vast amount of vaginal progesterone I was on. Given my cancelled antagonist primted cycle, I really wonder if the antagonist limits follicular maturation for me, despite sizes increasing. 

Sadness

 I know I said I'd prefer the bad news because it means less waiting. Be careful what you wish for. I got the bad news. Our lone embryo hadn't reached blast by day 7 and was discarded. 

That makes 15 retrieved, 11 mature, 5 fertilized, 3 blasts, and 1 CCS normal.

I'm sad. Not 'you just lost a baby' sad, but 'this feels like the passing of a nice, badly wanted dream' sad. I suppose the upside of living through all-encompassing grief is that it helps you appreciate simple sadness!

I'm also angry. My clinic is having good success with artificial occyte activation. After my first two rounds both produced 66% fertilization rates with ICSI, I should have requested AOA for this last round. With five mature, we should have gotten to at least a few fertilized and a blast or two. Why didn't I advocate for myself? I couldn't have predicted a 20% fertilization rate on round 3, but it also wouldn't have hurt to try it, based on the growing body of evidence that it helps. I asked the embryologist and she said that the four that didn't fertilize showed no signs of fertilization, as opposed to fertilizing abnormally. AOA should have helped with that. 

We have one last shot. Assuming our nanny doesn't have COVID, I should start my next cycle by next week. In my mind, I vacillate a million times a day between "There are a lot of benefits to not getting another embryo. Life will be much easier with only two living kids. We can focus more on then. We'll retire earlier. I am at peace and if we don't get an embryo, I will accept that and move on." and "We are so close. And I may have leftover meds. We could swing paying for one more cycle out of pocket if I didn't have to pay for meds. Just one more."

I am usually very financially driven, so to help comfort myself in the event that we don't get another healthy embryo, I'm going to put it in writing here what "just one more" would really cost. Below are actual and projected expenses, while making the very generous assumption that our first FET would work:

2020 Medical Costs:
Insurance OOPMax: $10,800
HGH Cost (five rounds, including a cancelled cycle): $4,660
Estimated 'one more' cost: $16,500 + meds.

2021 Medical Costs
Insurance OOPMax (for cerclage and Asherman's surgery): $10,800
FET: $5,400
FET meds: $4,000

Total, if FET #1 worked and we do 'one more round': >$52,690
If we do get another CCS normal, and don't do 'one more round', we're looking at: ~$35,660.
If we don't get another CCS normal, and we stop here, we'll be at: $15,460, plus whatever reasonable medical expenses we're likely to have next year, so perhaps our deductible of $3,000 = $18,460.

So the difference between another kid and not is $34,230-$17,200.

Good grief those numbers are awful. It does help me feel better about reaching the end, although it doesn't ease the sadness at all. Really it just adds sadness for the state of health insurance in our country. 

Microblog Monday: Waiting Fatigue

As I sit here, waiting on the day 6 call, which has led to the wait for a day 7 call for the last two cycles, I realize just how much the endless waiting is wearing on me. There was the waiting for CD1. The waiting for the call to say I was cleared to start stims. The waiting for the first monitoring appointment where I'd get a sense of how things would go. The waiting for an entire extra cycle due to cancellation. The waiting for trigger instructions. The waiting for retrieval. The waiting for the fertilization call. The waiting for the day 6 and day 7 calls. The waiting for the PGS calls. So much waiting. 

I feel intensely guilty and selfish to admit this, but I almost want to get a 'nothing to biopsy' call today, because that means I won't have to wait on the CCS call. It would most likely mean the end of the road for us, but I'm honestly so fatigued that I might be ready. I never felt this way in the past. Despite all the losses and surgeries and treatment cycles and the awful HG pregnancies, I was ok with waiting because waiting meant something good might happen.

Now is somehow different. Perhaps because it's not just that it's waiting, it's that it's incredibly high-stakes, life changing, physically demanding waiting. I've been sick enough with bad nausea for the last two retrievals that it's been a harsh reminder of what I'd have to wait through for 9 months of pregnancy. In addition, psychologists talk about being in a state of 'activation.' If I'm honest with myself, all this waiting has meant endless activation. And now our nanny is out sick, and it looks like it might be COVID, so we're waiting on her test with the knowledge that we'll have to cancel our last retrieval cycle if it's positive. And I had promised myself I just had to wait through one last retrieval, which mean 3-4 last weeks, but if this is COVID, it'll be at least two months. Although two months is nothing in the grand scheme of things, it might be the proverbial wait that broke the camel's back.

Mixed News

 Retreival from my microdose lupron cycle was yesterday. Follicle sizes were: 23.5, 18.5, 18, 15.5, 12, 11, 9, 8, 6.5. I fully expected to get the same 2-3 mature we always do.

We got 5 eggs, four mature and one that matured over night! I was so excited.

Alas, only 1 fertilized. One. It blows my mind that I could go from my best cycle ever, to my worst. 

We're going to exhaust my insurance coverage on one last retrieval, and I think we're going to do MDLF again. I'm also going to request that we use calcium ionophore in the culture medium, as that's been show to increase fertilization. With 2/3, 2/3, and 1/5, fertilized, I think it's what we should have been doing all along. Aside from calcium ionophore, does anyone know of any ways to improve fertilization? This was ICSI, which my clinic requires for CCS testing.

I desperately hope I can get one more euploid. I've now done 4 back to back rounds of HGH, which in theory may help with egg quality. If only those eggs can make it to blast. 

Microblog Mondays: Streaks, Revisited

 You prepare yourself for the call. The only call you can fathom, given a day 7 embryo and your 40 year old eggs. The call that says, "I'm sorry, but I have your CCS results back and your embryo is aneuploid."

You prepare, but you never get a call.

Instead, while in pre-op for your next ER, you hear a voice asking, "Is she still awake?" Next thing you know, your nurse is in the room, and you can tell even with the mask that she's smiling. "I have good news for you guys" she says. And then she tell us that we have a perfectly healthy day 7 boy. 

I cried. DH teared up. Both nurses teared up. The surgical nurse asked my IVF nurse if this was what her job is usually like, since the surgical nurse never gets to hear that end of the story. 

When my RE came by a few minutes later, I got to tell her, because she didn't know yet. SHE teared up, too.

We got fewer eggs at retreival than I expected. We'll see if anyone is mature or fertilizes. But, guys, we have a euploid! He'll never get to leave the freezer if we don't get at least one more, because I won't put myself through all the surgeries unless I have at least two euploid. But for this one tiny moment, with one ER remaining, I have hope again. And I love that beautiful little boy in the freezer. 

Sales Gone Awry

 I'm not a sales person. I would be a terrible in Sales. I always paint the full picture. If I was selling you a frog, you'd hear "This fellow has a great green and is a fabulous hopper, but he has quite a few warts and a habit of peeing on people who touch him." Not exactly an outstanding sales pitch, there.

I get a lot of unsolicited sales pitches at work from potential vendors. A lot. Per my junk email folder, 2,610 unwanted pitches since Jan 1. I am pretty aggressive at using 'unsubscribe', yet the junk continues. I filter anything I've seen before into a junk folder, but that doesn't always fix the problem. I don't know if it's the economy, or the fact that many people are under extra pressure, but I am getting more aggressive sales pitches this year.

One particular vendor, whose unsolicited email messages I've 'unsubscribed' from at least three times, has taken to having their sales guy call me repeatedly and send personalized email in addition to the boilerplate messages. This week alone he's left two voice messages, sent four personalized email (3 in one day) and two boilerplate messages. 

Does that actually work with anyone? Does anyone who has ignored a dozen email messages and two voicemail in two weeks, not to mention two or more messages a week for the last two years, suddenly answer the phone and say "Why, yes! I've been looking for a vendor just like you! Please, allow me to open an unlimited PO and start sending me bills! I have millions just waiting to be spent with your company!"? 

In case you can't tell, I find unsolicited pitches highly irritating. I'm busy and I don't feel like it should be my responsibility to repeatedly tell a vendor 'no', whether directly or via 'unsubscribe'. This is especially true given that I never expressed interest in any of these companies! Despite the fact that this behavior really grates on me, I'm usually polite.  Today, after the third voicemail this week, I snapped. I fired back an email. It might have used phrases like "Enough already!," "unwanted deluge of email," and "complete inability to respect my unsubscribe requests." It was not the height of professionalism or respectful behavior. It will probably return to bite me in the ass someday. At this moment, as long as he stops bloody contacting me, I'm willing to take the hit.

How can I be in a world where human contact is so limited, and yet be so annoyed by human contact? Something must be wrong with me.

That Time I Did Microdose Lupron Flare

So here we are, my third/fourth IVF attempt. Because I view the whole thing as one grand, emotionally draining, financially devastating science experiment, I asked to do MDLF this time. What can I say, I haven't done it before, and I like pushing buttons to see what happens. This was an as-yet unpushed button. 

I have no idea yet what the outcome will be. My first monitoring appointment is Wednesday, so we'll see then. My AFC was 7, not great, not as bad as it's been. We have a chance, at least, albeit not a good one. 

In some ways, there's a good chance this week could be a repeat of two weeks ago. Then I got the calls that I hadn't gotten the job I wanted, and we had no blasts make it to freeze.

In an unexpected turn of events, I wound up with a lone day 7 4AA blast that was sent off to biopsy. Knowing that it's a day 7, and I'm 40, it doesn't really have a chance. See here for a great study on aneuploidy by day and grade.  

I'll probably get the 'aneuploid' call about that around Friday. The job? Well, when I got the 'you didn't get it' call, the manager also told me she was trying to get another vacancy. I think if she does, I'll be the selected candidate. Today's the day she'll find out. So there's a good chance I'll also get the 'sorry, didn't get the vacancy' or even the 'got it, but you're still not selected' call this week, too.

On the upside, after the calls three weeks ago, these won't be as bad, because I already thought I hit the worst case scenario. These will just be a confirmation of the worst case scenario! Exposing myself to the possibility of a good scenario brings with it the large risk of the worst case. So I'll grin and bear whatever calls I get this week, and keep chugging a bit further knowing that as long as I'm chugging, there's a chance of a good outcome.

A Decline in Hope

 The one thing that DH and I have had going for us in our entire 'trying to have living kids' journey is the fact that we pretty much ALWAYS reach blast. All but one or two months we tried to get pregnant, we did. Now most of those were chemicals, or losses, but the ratio of pregnancies to attempts was amazingly, improbably, consistently high. That was the main reason why our RE thought our outcomes from IVF might be better than you'd expect from our numbers.

Round one bore that out. Two fertilized led to two blasts for biopsy.

Round two marked the end of that hope. Just like last cycle, we had three mature, but only two fertilized. Unlike last cycle, neither met the criteria for biopsy and freezing.

I've known from the start that we had a very low chance of success, given my age and numbers. I know that adding PGS, while necessary due to the cerclage, realistically lowers our odds even further. Today though, was the first time I felt in my soul that we really have no chance. It was the first time I felt convinced that this is just the proverbial fool's errand.

We have two rounds of IVF covered by insurance, and we'll use them both. I am still maintaining a strict anti-inflammatory, low carb diet. I am taking all of the supplements. I am doing every last thing I can think of to do to maximize our chances. I haven't given up in my behaviors, but I think I've given up in my heart.

This sucks. But you know what? Yesterday, just after the call from embryology, T came upstairs for snack time. I squatted down to meet her at the top of the stairs and the first thing she did was run to me for a hug. So as much as it sucks that there probably won't be another tiny human for us, I have everything I could ever possibly want right here already.

Microblog Monday: Disappointments

 Alas, IVF attempt #2 is turning into a real dud. Despite an AFC of 5-8, it looks as if I'll only have one, maybe two mature follicles. This is after 3.5 weeks of testosterone priming overlapping with 4 weeks of estrogen priming. I'm now on stim day 11 and expect I'll need day 12, too. I know the estrogen priming is important to bring down my FSH, but man, I do not respond as well after estrogen priming. 

I'm sad. I'll go through the motions of this retrieval and the next two, but given how poor this response has been, I no longer feel any sense of hope that we'll get embryos. Last cycle looked so great, right up until retrieval. If this one already looks poor before retrieval, I have no hope for what's next.

The one positive in this messy cycle was the call I got from the on-call nurse on Sunday. She called after monitoring to give me my next steps. When she introduced herself, she told me that I probably wouldn't remember her, but she was my c-section nurse with the twins! I had not recalled her name, and never would have assumed it was the same person at my RE's office as at the hospital, but I definitely remember her and her kindness. I also remember how happy everyone was, because they'd also seen me during my 27 week hospitalization and they were so glad we'd made it to 31. Getting to say 'hello',  to thank her for her kindness back then, and tell her how the twins are doing was a bright spot in an otherwise dark week. 

In other dark news, I applied for a position I'd really like at my current company. I interviewed last week, but am fully expecting a decline later this week or early next week. The hiring manager had initially encouraged me to apply, but hiring practices have changed in a way that I'll be a lower priority candidate. I also didn't have a stellar interview. It wasn't bad at all (I think), but I didn't knock it out of the park, and I would have needed to in order to be selected. I know there are a ton of other well qualified applicants, so it doesn't hurt, but I'm still sad. I'm anticipating getting both the 'nothing was mature/fertilized' call and the 'sorry, you weren't selected' call on Friday. 

White COVID Guilt

I've heard from several sources, off the record, that my workgroup is unlikely to return to in-person work this year. Given Minnesota winters and cold/flu season, I suspect that means we won't return until next spring.

I am feeling a great deal of cognitive dissonance over this, and over COVID in general. At this moment, my life is much better because of COVID. I get to be home to wake my kids up, and snuggle with them while they have their morning cup of milk. If I'm not in meetings, I get to say 'hi' to them at meals and snacks, when they come upstairs to eat. I get to go on walks with them daily. These are all things that I wouldn't be able to do if I was commuting, trying to batch cook meals, and lay out work clothing each day. I haven't had to set an alarm since mid-March - although that's because I always wake up by 4:30 am. I'm not stressed or rushing to get to work, and then to get home from work before our nanny leaves. Fertility treatments are so much easier when I'm home for all shots and no one sees me leave the office for appointments. On a pure quality-of-life basis, my quality of life has gone up drastically.

And yet people are dying of this disease. Many, many people. Kind, good people who would have so much more to contribute and who can't because of COVID. It's terrible and I can't begin to say that I want it to be here. On a personal note, I'm worried about my job. Our income will be down at least 25% this year. So I struggle. I struggle to reconcile gratitude for all the benefits with the horror of the cost. How can you appreciate something that's killing people? How utterly selfish is that? But I sat this morning, Aaron cuddling into my lap and hugging me tight while he had his milk, in a way that never would have been possible if not for COVID. And how can I not feel at least a bit of gratitude for that opportunity?

Somehow this entire cognitive experience mirrors some of my feelings about the ongoing dialogues on race. I know how lucky I am to have grown up a white woman in a well educated, upper-middle class family. I know that there are systemic factors that made my life easier, that have led me to this point of happiness. While I'm certainly not grateful for those systemic factors, I'm cognizant of the fact that they exist and assisted me. I am grateful for the outcomes in my life, but I feel ashamed at the knowledge that those same systems that supported my outcomes facilitate entirely different outcomes for BIPOC. I question myself, as to what practical steps I can take to dismantle those systems. None of the answers that come to mind feel like enough. 

I'll keep searching. Keep looking for ways to leverage my experience to improve the lives of others. I'll probably keep being crap at it, but I'll also commit to ongoing learning, so hopefully I'll get to be less crap! 

The Streak Ends

You prepare yourself. You think through the different possible scenarios. The version where the call says both embryos are healthy. The version where only one embryo is healthy. The version where the call says neither are healthy.

You remind yourself that your life is awesome and no matter what the call says, it will stay awesome.

You prepare yourself, and you guard your heart against the future.

And your heart still breaks when the call comes in that neither are good.

48 XX, +3, +4. 45 XY, -19, +21, -22.

This means an end to our streak of healthy twins from July cycles. I don't take for granted how lucky we were to have that streak. I do grieve that it hasn't continued. On to the next cycle.

Microblog Mondays: Along Came a Spider

For the past few weeks, there's been a daddy long legs spider in our shower. Now, I'm no fan of spiders, but I try very hard to appreciate their benefits, and leave them alone as long as they leave me alone. This spider had been content to hang out (literally) in the far corner, so I left her alone.

Today she must have been feeling inquisitive, because she decided to come over for a visit while I was showering. It was at that point that I realized she was carrying a clutch of eggs. My first thought was: "I bet SHE doesn't have to use Gonal to hyper-ovulate." Followed by: "How small of a needle would be required for a spider on the injection pen?" Followed by: "Wow, it's a good thing I don't have to talk to anyone this early in the morning!"

While I'm ok with one spider in my shower, the thought of many, many baby spiders was a bit much for me. Let's just say that there is no longer a daddy long legs spider in our shower. Here's hoping I can get a fraction of as many eggs as she had!

Microblog Mondays: With Love

I always like to tell myself that our three oldest girls know that we love them, even if they're not still on earth with us. On Friday, I think I got the message back that they know, and they want us to know that they love us, too.

Of our living kids, T is not a cuddler. She's firey and independent, and absolutely amazing, but she's not a cuddler. DH and I took Friday off to 'celebrate' Quinn's 3rd birthday. We did a long bike ride on our favorite trail and visited the Arobretum. Those were things we had deeply hoped to do with our kids. We also got curbside takeout at the restaurant we've gone to to celebrate each pregnancy.

When we got home, for the hours between our arrival and T's bedtime, she would repeatedly run over to me, climb in my lap, bury her head in my should and hug me. Sometimes she'd bring her stuffed Bunny, and all three of us would just snuggle in a long hug. She's never done that before. She's never done that since. I don't think my behavior was any different, since DH and I had had a really nice day that felt like the right tribute to Quinn. Thus I don't think she picked up on something being off. Instead, I believe that Quinn was whispering in her little sister's ear, telling her that it was a tough day for Mom and Mom needed a hug. Sometimes something beautiful comes at a very unexpected moment. This was one of those times.

Rocking My Girl

We have a rocking chair in the kids' room. It's nice and cushy, and big enough that I can sit with both of them on my lap for bedtime stories. For the first 12+ months of their lives, we rocked them to sleep in that chair. It's a good chair.

This morning when I woke up, I closed my eyes and pictured myself rocking Quinn in the chair. I spent a good 30 minutes holding and rocking her, in my mind. I felt sad, but at peace.

Happy Birthday, Quinn. I love you.

Still There

We know, from our long history of failed pregnancies, that DH and I routinely make blasts. You can't have a chemical pregnancy if the embryo didn't survive and grow for at least 10 days. Because we had at least a chemical with almost every cycle we attempted pregnancy, we know we always had 10 day old embryos.

Despite that, with my age having increased and the setting of an IVF lab, rather than a uterus, I wasn't expecting to get any blasts from only two fertilized eggs. Color me shocked, then, that embryo one reached blast on day 6, and embryo two on day 7. The day 6 is only graded a 3BB, and the embryologist refused to give me the day 7's grade (WTF?). Given that plus my age, I know the probability of these being euploid is exceedingly low, but I'm proud of my little fighters, having held on to blast and biopsy.

We should get our PGS results a day or two before I have my baseline for my next cycle. Irrational or otherwise, I'm going to hope that at least one comes back euploid. Actually, let's be honest, I'll be hoping that both come back euploid, even if a day 7 embryo is at much higher risk of miscarriage!

Three more weeks of testosterone and estrogen priming, and we'll see if we can produce a few more blasts.

Happy 3rd Birthday, Beautiful Girl

Friday will be Quinn's third birthday. It's almost impossible to believe that so much time has gone past, yet here we are with her little brother and sister turning 17 months on her birthday. I still miss her, and her big sisters, every day. When I look at T, I wonder if Alexis, Zoe, or Quinn would have been similar in temperament or looks. I wish so badly that we could have gotten to know all three. I send a hearty "fuck you" to the people who say that we wouldn't have T and A if we had our older girls, so it's better that we lost them. There is no way the complexity of feelings around the presence of living children as a result of lost ones should be reduced to 'it's better.'

A year ago, we booked a trip to take the Grandmas, T, and A up to the Boundary Waters, to "visit" our older girls. We booked the trip for Quinn's birthday. We should have left yesterday. It kills me to do so, but given COVID, we've cancelled the trip. If we didn't have the twins, we'd still go, no thought necessary. I missed visiting the girls last summer in a way that's almost instinctual.  Still, I won't risk exposing my living kids, and with closures and cancellations, we'd have had little to occupy their time with. I deeply hope to return next summer, but I know better than to plan for it.

For now, I send all my love to Quinn on her birthday. If a spirit exists and hers is out there, I hope she knows peace and love.

Hitting the Ground

Tomorrow we'll hear if either of our embryos made it to blast and biopsy. I am not optimistic.

I know, intellectually, that the consequences of these cycles are less impactful than any previous cycle. The difference between no living children, and more living children is vast. We've already crossed to the side of that chasm we desperately hoped for, so these cycles can not possibly have the same impact that our first six did.

While my brain knows that we'll be completely fine and happy no matter what happens with these cycles, my emotions are another matter. My mind feels like a tiny animal, trapped in a cage and racing around it trying to find the exit. In this case, instead of an exit, I'm looking for the answer to what will happen.

I've heard it said before, "It's  not the fall that kills you, it's hitting the ground at the end." I think that doesn't hold true for me in this situation. The fall is what's killing me. Once I hit the ground, I can have closure and begin to move on. While I'm still falling, there's the terror of knowing that hitting the ground is likely, and the hope from the possibility of rescue.

We have two, maybe three IVF cycles left before my insurance coverage runs out. I figure that's six months, plus the month-long wait for PGS results. That means I've got 6-7 more months of falling. If we get euploids, it'll be many months more than that, but I'll cross (or jump off) that bridge if I can get there! For now, I'm pulling out all my tools for calm and acknowledging that it's ok to hope for the possibility of rescue, even when the probability is hitting the ground.

Ready, Set Go! No, Stop!

My first egg retrieval was on Wednesday. The nurse told me to expect cycle day 1 in 4-14 days. I went home, felt fine the next day but pretty yuck by Friday. I also started bleeding on Friday. That's 2 days post ER, for those keeping track at home.

Despite the fact that it seemed way too early for CD1, I called it in. They told me that since I did a luteal phase stim cycle, it was entirely possible that this was CD1. If so, at first they said I'd do a long testosterone prime, and then after checking with the Dr, they wanted me to start stimming for my next cycle on Sunday. I got this call at 1:45 pm on Friday, and scrambled for the next four hours to get meds ordered and the cycle authorization submitted. 

By Saturday I was still feeling pretty rough. (Side note: a fringe benefit of DOR really ought to be super easy ER recovery. Why is this not the case?!) The four pounds of water weight I'd put on in a day were gone, but my right side hurt and my digestive system was all kinds of messed up. Still, I went for a suppression check. I figured they wouldn't bring me in if there was no chance of proceeding.

My right ovary is a hot mess. Six cysts. No antral follicles anywhere. So, back to the testosterone priming plan. They're also adding in estrogen priming. I have mixed feelings about that. Our first esrogen priming attempt, which also included cetrotide priming, ended in no response. We cancelled and I mentally wrote off the thousands of dollars I paid in OOP costs. The next cycle was testosterone primed, but I also had multiple estrogen producing cysts. In fact, my E2 level was higher at suppression check in attempt #2 than in my estrogen primed attempt #1! And my ovaries responded. So it seems I can do just fine on estrogen priming. I will push back and refuse any cetrotide priming this cycle, if they suggest it. And I will hope that the E/T priming will work again. As always, it's just one grand science experiment. 

Two Has Worked Before

At least, that's what I'm trying to tell myself now, to manage the disappointment.

Yesterday we retrieved six eggs. My doctor was extremely pleased and said she felt good about our chances.

Today embryology informed me that only three were mature, and only two fertilized.

Two years ago this week, we had 3 mature, and got T and A.

Four years ago this week, we had 3 mature, and got Alexis and Zoe.

So, two has worked for us before. But before I wasn't 40. Before those embryos were growing inside a person, not a petri dish. Before those embryos weren't going to need to pass CCS.

I'm sad. We start the next round with my CD1. I'll ask about the maturity rate and if we need to change anything.

I think my worst case scenario is actually winding up with 1 CCS normal embryo. If we have none, we're done. If we have two, I'll do the TAC. If we only have one, I don't know if I'm willing to do the TAC. That's a limbo I don't love.

Send good thoughts our way? I'll take prayers, or wishes, or just happiness if you've got any to spare. I'm not doing so well on the happiness right now.

IVF Round #1.5, the end

Despite the issue with cysts, IVF round two commenced two days after trigger with an AFC at 11 and one remaining mature follicle, in addition to two corpus luteum cysts. I suspect that means another follicle was missed from the prior day's ultrasound, but there's no changing now.

Day 5 monitoring looked really promising (for me). I had a cohort of six follicles between 9.5 and 12.5, and a couple smaller ones.

Day 7 we'd dropped down to only four in a similar range. The left ovary had given up the game and the max follicle size there had dropped to 9.5 from 11.5.

Today is day 9, and I've got 5 from 12.5 to 21. It's odd, because the tech showed me the screen this morning and the screen reflected a 22 and an 23 as the leads, and an 11.5 on my left side. The u/s report they sent is smaller on all follicles.

So, I got the trigger call. Dual trigger. Tonight. Retrieval on Wednesday.

The trigger and pre-op instructions sent to me via portal were: a) for a woman with a different name (same first initial), b) for July 9, with surgery on July 11. Also, my lab results, sent via portal, were mostly for estradiol, despite being labeled as LH and P4.  I am not overwhelmed with confidence.

So, here we go. Four years ago this week, we triggered and convinced Alexis and Zoe, from 3 mature eggs. Two years (less two weeks) ago this week, we triggered and conceived A and T from 3 mature eggs. Maybe, just maybe, we'll get a eupolid or two out of this crop of ~4.

Assuming no concerns from our RE, we'll jump into our next cycle immediately. I'm going to ask about MDLF, since EPP + antagonist is clearly not my thing, and this wasn't as successful a round as it could have been. Think good thoughts in our direction?

IVF, Round #1.5

Another day, another IVF attempt.

To recap our last episode, after starting with an AFC of 8, by stim day 13 the ultrasound tech excitedly proclaimed I had one follicle. We decided to cancel the cycle. I was instructed to do several more days of Clomid, then trigger, then start testosterone and progesterone for 10 days.

CD1 arrived and I went in for my suppression check. The same excited tech wouldn't tell me my AFC and just kept repeating that someone would call me when my labs came back. I knew that wasn't a good sign.

The call informed me that I have an AFC of 12(!!), but I also have two simple cysts at 15 and 18mm. If I had to guess, I would guess the tech missed a few smaller follicles on my last u/s before cancellation, and the increased FSH caused by the Clomid matured them. Who knows. Anyhow, the plan is to trigger again on CD3, then return for monitoring on Saturday.

I can find no research on triggering to remove leads, or what that does to AFC. Nada. I know luteal phase stim cycles are becoming a thing, and that research suggests you can get as many embryos from luteal phase stim as from regular stim. I'm trying to remain hopeful. If anyone knows of any research on triggering to remove leads, and what happens after, I'd love to hear!

Also, shoutout to Progyny and VFP pharmacy. I got the call at 2 pm that I'd need to trigger the next day. I didn't have any Pregnyl on hand. If I was still with CVS Specialty, I'd be shit out of luck, because 2pm my time is after their shipping cutoff. VFP got my Pregnyl out priority overnight, so it arrived the next day (today) at 7:30 am. The prices, with insurance, are a bit insane for the Menopur, but so far the customer service has been pretty good. They also had some issues with neglecting to send me Menopur injection needles in one shipment, then sending me an extra 60 in the next. Overall, it's a MUCH better experience than CVS Specialty, and I'm grateful.

Finally

For many years, DH and I have been members at the local arboretum. We've loved wandering the grounds and watching the seasons change. From our very first pregnancy, we've looked forward to sharing it with our children.

We went there when pregnant with Alexis and Zoe, and talked about how much fun it would be to bring them back for long walks. After we lost them, on our first visit back, there in the lilac garden we ran into another couple with a double infant stroller - clearly newborn twins. It hurt, but we held out hope some day we'd be back with our own kids. During my TAC recovery, the arboretum was the first place I went, to wander among the Christmas displays. It holds a special place in our hearts.

Last summer I was still in too much pain, and pumping too damn much, to get out to the arb with the babies. Now with COVID, it's on a 'tickets only' basis. We managed to snag tickets for last week. It was awesome. The babies had fun. We had fun. The day at the arb that I'd dreamed of finally came.

I'm overwhelmed with gratefulness for where my life is. There are so many utterly terrible things happening around the world, even right here at home in Minneapolis. I know I'm tucked in a privileged bubble, and although I feel guilt, I'm also grateful for the joy that affords me.

IVF #1: Cancelled

Today was stim day 13, or thereabouts. I lost count. All I can tell you is that I've hit my OOP Max on my med orders. Ouch.

For monitoring, I got the super peppy ultrasound tech, who always seems to have trouble finding my ovaries, and sometimes seems to have trouble finding my uterus. At the end of the scan, she excitedly told me that my largest follicle had grown to 13! (The screen behind her said 16.) I asked if there were any others, since I'm doing IVF and one isn't very helpful. She told me that my 4 had gone to 6. She was chipper about it, then fled the room.

Note to others: When telling an IVF patient that she only has one mature follicle and won't get more, don't be fucking chipper about it.

The nurse who called later told me we were good to start cetrotide, if we were ok with retrieving only one. I asked if the doctor thought we could do better, given my AFC of 8 and past unprimed cycles with 3-4 mature. Several hours later I got a call back saying we could cancel. I was told to continue Clomid for 3 more days, trigger with Pregnyl, then start testosterone priming for my next cycle two days later.

Problem 1: when they put me on clomid, it was for 5 days. Those five days ended 3 days ago, so I"m not on clomid now. It's not possible to continue taking it when you've already stopped taking it. Apparently they're putting me back on clomid and keeping me on clomid once CD1 comes and the cycle starts. I suspect I was supposed to still be on it, and this was a medication error. That doesn't make me feel chipper. That really doesn't make me feel chipper when I know that clomid raises FSH, and my high FSH level is the number one thing we're trying to combat.

Then I get my calendar for this new cycle. Stims start July 2, which I think is roughly 4 years to the week that we started stims for Alexis and Zoe's cycle. We always have good July cycles, so I'll take that.

Based on the calendar, I'll do luteal testosterone priming, then clomid, menopur, gonal f, dexamethasone, and saizen. I stay on the clomid the entire time. All of this looks good, except for a little note that reads "Continue taking Estrace until STIM begin." Ignoring the grammar, there's a big Problem 2: Nowhere on the calendar does it say to START taking estrace. It is, practically speaking, difficult to continue taking something that you've never started taking.

So there you have it. Cycle 1 was a crash and burn and cycle 2 is, thus far, going to be confusing.

I am remaining obstinately hopeful that our July 2020 cycle will produce babies as beautiful as our July 2018 and July 2016 cycles.