No Response

No response from my ovaries. No response from my uterus. Lining below 4, follicles below 6.

Increase dosage, return on Saturday.

It's not looking good, ya'll. I'm on a much higher dosage than I was for my last 'no response' cycle, and still, nothing. Heck, with Quinn's cycle, I'd had half the FSH of this cycle, and still had a follicle at almost 10.

I suppose I shouldn't be surprised, since I ovulated so late my last two cycles. Apparently my ovaries are off. Glad to see my months of acupuncture and clean eating are working wonders. Amazing that I responded in December and February, but not now. Maybe that means there's hope for a better result in the future. Optimism springs eternal.

Monitoring #1, February

Today's monitoring was ok. Not my best, but my lining is better than last time. I'll try to stay hopeful. My numbers-loving self added to my chart below.

They want me to come back again Friday. I've always done appointments after 4 full stim days, and then 7 full stim days, so I was hoping for/expecting a Saturday appointment. Instead it will be Friday and force me to miss a meeting. I am so grateful my job has some flexibility, and I have so much respect for people that juggle IF treatment without this type of flexibility.

Stim Day		Jul -16	Feb-17	Dec - 17	Feb-18
	AFC	9	4	7	5
4	L follies	12.5, 8, 8	9.8	3.5, 4	14, 11, 8.5
	R follies	11, 9, 8.5	6.5	12, 10.5	7,4
	E2	803	?	188	622
	P4	2.68	<.05	<.05	0.07
	LH	8.24 miu		3.38	2.12
	Lining	6.9 triple	5.9 triple	4 uniform	5.7 triple
	FSH dose	600	600	900	1100
	Menopur dose		0	300	300

Also, totally random, but I live in MN, where the population is a whole lot whiter than it was back in SoCal. There is one place I go that's the exception to this: my RE's office. I see more diversity in the waiting room at the RE than anywhere else I've been in MN. At least 50% of the other waiting patients aren't Caucasian, usually more. I don't know why, and I wish no one needed an RE, but it's nice to see that diversity exists somewhere in the Twin Cities!

Monitoring #2

Yesterday was my second monitoring appointment. To cut to the chase, I had follicles that were ready, but my lining wasn't. So, we keep on chugging and I start to worry about how big a follicle can get before it's "over cooked." I go back tomorrow morning, and assume I'll trigger if my lining has made it. Just for grins, I've included my cycle data below, along with my historical day 8/9 stats.


Day 4
             2016         |   Feb 2017  |     Dec 2017
R:        11, 9, 8.5   |     6.5          |     12, 10.5
L:        12.5, 8, 8   |     9.8          |     5, 3.5
E2:      803            |       ?           |     188
P4:      2.68           |       ?           |      < 0.5
LH:     8.25           |       ?            |     3.38
Lining:  6.9 triple | 5.9 triple   |     4 uniform
FSH    600             |   600           |    900
Menopur   0        |       0            |     4 vials    

Day 7
             2016                |   Feb 2017  |     Dec 2017
R:        19, 13.6, 7        |     9.5            |     20, 17.5
L:        16.5, 15, 10, 8  |     14.5         |     6, 8
E2:      1294                  |       432        |     718
P4:      1.66                   |       <.05       |      .07
LH:     1.03                    |       1.15       |     2.84
Lining:  6.9 triple        | 7.0 triple    |     6 homogenous
FSH    1050                 |   1275           |    1575
Menopur   0              |       0               |     7 vials


Day 8/9
             2016               |   Feb 2017  |     Dec 2017
R:        22,18,7,4        |     11            |     
L:        18,16,10,8      |     16.5         |     
E2:      1690                |     1027        |     
P4:      2.59                 |      0.12        |     
LH:     0.76                  |      1.15       |     
Lining:  6.9 triple      | 6.0 triple    |     
FSH    1200                |   1875          |    

Menopur   0              |       0            |     
Trigger       Yes!          |   Not yet    |

CCRM, Again

My other appointment for the week was back with CCRM. None of the other issues matter if we can’t get pregnant again. With my one follicle response to 2400+ iU of FSH in February, I wasn’t sure what our odds of another pregnancy are. That’s especially true as I turn 38 in October. I wanted to get Dr. B’s take, find out how she’d treat us, get her input regarding chronic endometritis, and make sure she didn’t see a concern about the TAC. Thus, off to another appointment. Here are notes on what we heard.

1. We make good embryos. We have success during cycles that seem improbable. We should be able to get pregnant again. (Hah, famous last words!)
2. Consider a gestational carrier. (Dr. N suggested this as well, but thinks with the TAC we don’t need one.) The challenge would be getting enough euploid embryos, but Dr. B thinks we could accomplish that. No matter what, she’ll up my dosages aggressively for my next cycle.
3. Check out the ute more thoroughly. Instead of the saline sono we have scheduled, do a diagnostic hysteroscopy. Do this before the TAC so there aren’t issues.
4. Be really aware of what a TAC means if you have a second tri loss. She’s treated patients with TACs who have been successful in subsequent pregnancies and those who haven’t. Hysterotomy to end the pregnancy is substantial surgery.
5. Related to #4, be aware that at 38, the risk of genetic abnormalities goes up. Be prepared for that. 
6. Up my meds. Start with 150 menopur, 300 FSH, and use cetrotide if lead follicle(s) grow too fast. Target 3-4 follicles. Consider priming in advance of the cycle. 
7. She supports doing a longer course of doxy, starting prior to the cycle, if we push for that. 

If she thinks we can get pregnant again, and Dr. Haney did too, then I think proceeding with the TAC is the right call. I can’t speak to our embryo quality, having never seen one, but our three daughters were beautiful, and that I can speak to!

As for the gestational carrier, my logical side knows that would be our best chance at a living child. They’re all right about that. However, between the cost of IVF and surrogacy, we’re talking around $100k. That same logical side, the one that created a 20 page Excel workbook to track all our finances each year, that side can’t get on board with that much money, after the tens of thousands we’ve already spent, for a chance at bringing a baby home. Because nothing is guaranteed, even a gestational carrier. So, my ute it is.

My SIS and endometrial biopsy are next Wednesday. Wish me luck? Also, I have to get meds ordered from CVS Caremark. I'm certain that will be more painful than the biopsy. Sigh.

Not There Yet

I wish I had some great update, but I don't. Or perhaps I should say that my great update is that we haven't been cancelled! Here are the latest numbers, with the best comparison to last cycle I can give:

Last cycle:
CD11, after 8 nights of Gonal F 150 iU, 1200 total iU
Right = 22, 18, 7, 4
Left = 18, 16, 10, 8
LH = 0.76 miu
P4 = 2.59
E2 = 1690

This cycle:
CD11, after 4 nights of Follistim 150 iU, 3 nights of 225 iU, and 2 nights of 300 iU, 1875 total. 
Right = 16.5
Left = 11
LH = 1.37 mIU/mL
P4 = 0.12 ng/mL
E2 = 1027 pg/mL
Lining = 7.9 mm

So, two more nights at 300, and I go back. Hopefully I can get at least one mature follicle and keep my lining decent. 

Getting Worse

Saturday morning was my second follicle check. I was hoping that with the increased dosage of Follistim, I'd see some good progress and my estrogen would be up. Instead, my estrogen has dropped and I still only have one follicle in contention. I'm upping my Follistim dosage to 300 iU a night and I go back again on Monday. The nursing staff warned me that unless there's improvement, my cycle will be cancelled.

It makes no sense, but I've got this thought that keeps running through my mind: Maybe Alexis and Zoe were the babies we were meant to have. Maybe they're the only babies we were meant to have, so there will be no more. I love them so much, and I'd give just about anything to have them arriving, safe this month as originally planned, but I hope they are not the only children we'll be parents to.

Here are the numbers this cycle vs. last:

Last cycle:
CD10, after 7 nights of Gonal F 150 iU
Right = 19, 13.6, 7
Left = 16.5, 15, 10, 8
LH = 1.03 miu
P4 = 1.66
E2 = 1294

This cycle:
CD9, after 4 nights of Follistim 150 iU and 3 nights of 225 iU
Right = 14.5
Left = 9.5
LH = 1.15 mIU/mL
P4 = <0.05 ng/mL
E2 = 432.4 pg/mL

On the Coaster

At the start of this cycle, I reminded myself that every ART cycle is a roller coaster. You get good news and are feeling good, and then you get crap news and are sure you're out. Rinse and repeat until the end of the cycle. That definitely happened last time, and I knew it would happen this time.

Last appointment: Uterus looks good, both tubes are open, ovaries look great. Great news! Thrilled and expecting good outcomes from cycle.

Today's appointment: First monitoring appointment of this cycle. Compared to last time, it's looking pretty terrible, and I could tell the nurse was disappointed. I only have one follicle in contention, compared to 6 last time. Out of 6 last time, we got 4 mature eggs and two healthy embryos. This time . . .? Let's just say I'm feeling like we're out, and it's only the 5th day of stims.

Numbers are below.

Last cycle:
AFC = 9
CD7, after 4 nights of Gonal F
Right = 11, 9, 8.5
Left = 12.5, 8, 8
LH = 8.24 miu
P4 = 2.68
E2 = 803

Today:
AFC = 4
CD6, after 4 nights of Follistim
Right 9.8
Left 6.5
LH =
P4 = 
E2 = 
Lining 5.9 mm

I increase my Follistim dose to 225 iu/night, and return on Saturday for another look. 

Back At It

It's official - we are cycling again. My cyst check ultrasound showed no problematic cysts, and my blood work was normal. I started Follistim, 150 IU, and Estrace, 2mg, twice a day, yesterday. My RE said the Doxy wasn't necessary, since I'm finishing up a z-pack thanks to an ear infection.

First ultrasound will be on the 1st.

It's entirely too much to ask for, but I'll ask anyway: I want what we had last time, just with an additional 20 weeks of pregnancy, and healthy babies who come home with us, in our arms.

And So It Begins

I headed back to the RE’s office last week. While I have no intention of trying again until March or April, I’ve missed so much time from work that I wanted to get the appointment in before I returned to the office and would have to leave early to take it.

I’ve said it before and will say it again: I have the utmost respect for my RE, her knowledge, and her skill in this field. I feel confident that my treatment plan reflects the most up-to-date science, and that my input is consistently considered. I would highly recommend her to anyone else.

I have less confidence in some of the information that comes from the (otherwise wonderful) nursing staff. Case in point: DH and I both had communicable disease screening done last June/July. The nurse I’m communicating with told me that we’ll both need to be retested.

Now, I had several blood transfusions due to hemorrhage after delivering the girls, so I don’t mind being retested, although it’s been far less than a year and I’ll have to pay out of pocket. But I couldn’t understand why DH would need more testing. We don’t have  MFI, so we get to try to get pregnant the quasi-old fashioned way: drugs, ultrasounds, and sex. DH will be going nowhere near the RE’s office, and will therefore pose a risk to no one but me. Thus, I asked why he needed to be tested.

The nurse informed me that it’s an FDA requirement, because “he might expose you [me] to something.”

At first, I was righteously indignant at the FDA. In the first place, they have no business in my sex life. In the second place, do they really think that the only way I’ll be “exposed” is if I have treatment? They are protecting me from exactly nothing. Finally, why in the bloody hell should the government force me to pay for testing just because I need injections and ultrasounds to get/stay pregnant?

But after being indignant for a while, I went searching for the actual government regulation. Because I’m a) curious, and b) stuck at home in pain with nothing better to do. You know what I found? 21 CFR 1271.90 (2), which is the regulation that requires testing for “human cells, tissues, and cellular and tissue-based products” (aka sperm/egg/gamete donations) specifically exempts “Reproductive cells or tissue donated by a sexually intimate partner of the recipient for reproductive use”. In other words, DH should not need to be tested. (Should anyone be aware of other relevant regulations, please let me know. In all my searching this was the only thing I could find.)

Thus, the bullshittery of frustration, bad information, incompetence (wait until my next post about good ‘ol CVS Caremark), and frustration has begun again. Happy f-ing New Year.

Out of My Hands and Into My . . . .

Here I sit in the dreaded 'two week wait' - the period between ovulation and when a pregnancy can be detected. I think the TWW is dreaded by most women because it's a time when nearly everything is out of your hands. The only thing you can do is wait and see what happens. (Actually, in my case that's not true. Everything may be out of my hands, but thanks to progesterone and estrogen supplementation, that's just because everything is in my vagina instead!)

My coping method for stress is to do something. Anything. So the TWW is the antithesis of how I productively deal with stress. Thus, I've used the time to do a bit of research on how this cycle has gone. And the result is that what I've found doesn't bode well for the success of my cycle.

Study after study, in the context of IVF, have found that having a progesterone level on hcg day that's over 1.5 ng/ml is correlated with extremely low clinical pregnancy rates. The hypothesis appears to be that the cause is an endometrial lining that is no longer conducive to implantation.

Hmmm. . .let's think back to my cycle. Lining, per ultrasound on injection day? Cystic patch. Progesterone level? 2.59. Well, crap.

I couldn't find any research on this topic specific to IUI/TI, so I'll hope it's less applicable here, but I know better than to expect a miracle. Time to prepare for the next cycle by asking my doctor how we manage this.

Trigger Warning

Yesterday afternoon, at 3:45, I finally got the call from my RE's office. They wanted me to trigger. But the trigger shot that I had gotten via my insurance? The one that had taken multiple phone calls, extreme stress, and required DH to stay home to sign for? Did they want me to use that? Nope. Because of my bloodwork results, they wanted me to take a different product.

The new trigger shot was a brand called Pregnyl. Since this is a specialty mediation, there is only one pharmacy in the Twin Cities that has it in stock. So I drove there. At rush hour. And because this isn't my insurance's specialty pharmacy, I had to pay out of pocket, the full cost, with no hope of reimbursement. What was the cost, you ask? Well, if I'd ordered it online from a different specialty pharmacy, the cost would have been between $70 and $84. The cost listed on my doctor's office paperwork was under $100. If I'd ordered it via my own insurance's specialty pharmacy, the cost after insurance would have been $34 and untold aggravation. Instead of that, I paid $330. For the bloody generic, because they were out of the brand name.

$330 for the generic.

I am Not. Happy. My blood work was largely unchanged from yesterday. If they'd told me they wanted to change the trigger yesterday, I could have jumped through the insurance hoops, or rush ordered from the other online specialty pharmacy. But they didn't. So I paid nearly four times what I should have.

Adding to my annoyance is the fact that the 'Estimate of Charges' for this procedure provided by CCRM is substantially inaccurate. They estimated only one set of blood draws. But that's patently wrong, because they draw blood at both baseline and at monitoring. That's a minimum of two draws. They also draw progesterone, LH, and estrogen, but the estimate only includes the first two. Their estimate includes a blood draw fee of $20, but they've charged me $25 each time instead. At $115 per test, plus the blood draw fee, it adds up fast.

In my case, I wound up with an extra monitoring appointment and an extra blood draw. I'm more than happy to pay for more monitoring to get the cycle right. I'm not happy that their original estimate left off testing that they always perform. That's sloppy and misleading at best.

So what's my overall out of pocket for procedure and medication? Including the trigger shot I didn't use, $2,754.

That's Me!

Tomorrow will be my next monitoring appointment. I'm worried. Yesterday I felt like something was going on in both ovaries. Now everything just feels normal. There are no twinges or pains. I'm worried that somehow a single dominant follicle took over, on the left side that might be blocked, and there'll be nothing on the right side that can be fertilized. I'm worried my lining has tanked for some reason. I'm worried that there's no possible way I can have two good appointments in a row. I'm worried there's no chance of this working. Blah.

Also, after 14 days of crinone, followed by seven days of vaginal estrace, my lady bits are feeling raw. I'm uncomfortable, bordering on hurting. I'm not entirely sure how I'm supposed to make sex happen with this rawness getting worse, but I guess that's just how this goes.

In slightly cooler news, I was able to get the full report on my karyotype from the lab. It actually includes pictures of my chromosomes, shown below. You can see that 9 has one inversion. Pretty cool, if you ask me.

We're still waiting on DH's lab work. Although the turnaround time is 10 business days for karyotyping, LabCorp says that "due to the holiday on 4th, it hasn't been 10 days." Um, DH had blood drawn on June 23. If you start counting business days on June 24, and you exclude July 4, July 8 was 10 days. Today is the 13th. I'm seriously angry about this, and somewhat suspicious they lost his results. Why is no one competent?

What a Difference Drugs Make!

The last few days have been interesting. I've had a quasi-vacation to Colorado to cheer my husband on in a bike race. While there, my RE called to say that my inversion isn't likely to cause any problems, and we should proceed with the injections and pills.

So we did.

Thursday was CD3, and the first day of Gonal F and estrace. The estrace is twice a day, the Gonal F is 150iU. I've read people saying that the shots aren't painful, and I agree. It really isn't. The only time that was unpleasant was when I had to give myself an injection in the back of my Dad's minivan as we drove back to our rental condo after DH finished his event. A bouncing van, plus trying to be discrete since my step mother's sister and her husband were also there, does not lead to a comfortable shot!

Anyhow, today was my first monitoring appointment. Overall, it went well.

Follicle sizes were as follows:
Left: 12, 9, 8
Right: 11, 8.5, 8

Lining was 6.9 mm with triple stripe pattern! That's a win, since my lining is the area we know is problematic. The nurse described it as "beautiful" this time, which is a first for me.

E2 is 803, P4 is 2.7, and LH is 8.2. I'm a bit worried about how high P4 and LH are, since my RE wants me to continue with shots for another three days and return for a new ultrasound on Thursday. Cross your fingers for me that I don't ovulate before then?

Over There

Yesterday I had my baseline ultrasound.

Let's start with the good news: my blood flow is normal!! That means there aren't bloodflow issues to explain my thin lining. One tiny relief.

In other news, my antral follicle count today was 9. That's not great, but given my low AMH, it isn't as bad as I feared. That also reflects an echogenic spot on my left ovary. Right ovary had 6 follicles, left had 3. It took a while to find my left ovary, and the nurse's words were, "Oh! it's way over there!" How is it that my anatomy is so unexpected?

Now I wait to hear if we get to proceed or not. Dr B, here in MN, is going to confer with other doctors in the group out in CO and call me with an opinion on what comes next. That's because of my karyotype results. I really appreciate that my clinic takes the approach of consulting with one and other. From an adult learning perspective, that's how experts build more expertise, so it's good to know it's happening.

Verdict is. . . .

There are times when I feel truly bad for medical professionals. They spend years, decades even, studying and training. They continue learning as they practice and complete CE. Still, the human body is an amazingly complex system, and not every human's complexities follow an expected pattern. That means there are times when the best explanation a medical professional can give is, "I don't know" or "It doesn't make sense."

So, what was the outcome of my follow up appointment? Well, the saline sono, taken in early May, and the HSG from last Friday both suggest a horrendous case of Asherman's syndrome. But both of those are imaging techniques that don't directly visualize the uterus. The hysteroscopy, with photos taken after the saline sono but before the HSG, shows a normal uterus. The surgical notes written by the doctor who performed it didn't indicate any evidence of Asherman's, or anything other than mild scarring. The actual pictures should be the gold standard, but they are completely inconsistent with the sono and HSG. So the verdict? "It doesn't make sense."

Where does that leave us? Well, we could keep doing tests. Maybe we'd start getting consistent results, maybe not. Either way, we've now done all the tests that can be done, so we'd have to start repeating things. Verdict: probably not enough incremental value to be worth the drawbacks. Alternately, we can go back to the original plan: an injectable cycle in July, with monitoring of lining and follicles. Verdict: This approach will should tell us how my lining responds, which is a critical part of the question. The risk is that it won't tell us if both tubes are open. We could spend the money and the time on the cycle, and ovulate on the left side, where we don't know if my tube is open.

Total cost of more testing versus an injectable cycle will probably be similar. If they run multiple tests, that would be more expensive. It all comes down to a question of what really matters? And what really matters is: can I grow a lining that will support an embryo? Going the injectable route should answer that, because if I do have severe Asherman's syndrome, I won't grow sufficient lining no matter what medications they throw at me. If my uterus is healthy enough to grow a lining, it probably means the HSG was flawed, and I'm not as worried about tubal patency.

So, we will try the old fashioned way this cycle. We'll pray for a healthy, fully implanted embryo out of that. If I do get a positive test, we'll monitor the hell out of it! I am not optimistic, since I've had continued spotting since the HSG, but hey, I'm not going to turn down the excuse to spend some quality time with DH. ;) If this cycle doesn't work out, I call C.CRM on Day 1 and go in for Day 2 or 3 labs and an ultrasound, and then we start drugs and see what happens.

How will it all work out? Well, I'll give the most common answer from my own profession, which also deals with human beings and their irregularities: "It depends!"

We Have a Plan!

Today's consult with CCRM's local office went well. The doctor asked me to sum up what's going on in my own words, but also seemed to be well versed in my medical history. It was clear she had read all the files sent over, as she brought up things I didn't mention. She agreed with the goal of getting a pregnancy that lasts for 9 months, and didn't claim the issues to date were bad luck. While she agreed that my AMH means we should move with some speed, she also reminded me that it's really most relevant to IVF. Since we've gotten pregnant 3 times thus far, she told me, nicely, to stop worrying about it.

Unlike my OB, who said that uterine lining thickness only matters for IVF, Dr. B at CCRM expressed concern about my lining based on the sonohystogram in May. DH asked her to explain and she said that the lining helps to nourish the pregnancy during/around implantation, and therefore is important. Her target is 8mm. She noted that thin lining can occur when you have a short follicular phase. Alas, that isn't an explanation for me, since I typically have a 14-17 day follicular phase, which is normal. Increasing estrogen should help build the lining, and we know from my last labs that my estradiol is low.

Given all of this, her recommendation was twofold. First, proceed with additional testing of other potential factors to explain the losses. I'll cover the testing in a later post. Second, unless that testing identifies a cause, we'll treat the lining issue. Doing that will entail FSH injections and vaginal estrace to build lining, along with monitoring and timed intercourse. Post ovulation, I'll use progesterone for luteal phase support, although she doesn't think there was any issue with my progesterone level of 14 during the last chemical pregnancy. Testing is to be completed this cycle, monitoring and medication next cycle.

I also asked about lifestyle changes I could make. I was told no caffeine, no alcohol, keep eating fruits and veggies, keep exercising. Easy peasy - all of that I already do. I asked about DHEA due to my low AMH and she said she'd just read a meta analysis that found DHEA had no impact on DOR other than causing acne. She's taken it off her recommendations list. Note to self: she told me she'd give me her supplements list, but she didn't, so I need to follow up.

Overall I feel really good about this as an approach to see if we can address the miscarriages. I have a few follow up questions I'll need to ask the nurses, that didn't arise until after I looked at the written instructions, but I don't think that will be a huge problem.