The ART Coaster, Again

The roller coaster lives on.

I had a monitoring appointment today, my fourth this cycle (plus baseline). I was thrilled with the outcome: follicles at 22, 19, and 17. Lining at 6.18 and trilaminar! It's not going to get any better than that for me, so I'm happy. I assumed we'd trigger tonight, especially since my LH appears to be climbing.

Then the call came in: stim for one more day, return for monitoring tomorrow.

Really?

By tomorrow, that 22 will be at least 24. Larger follicle sizes on older patients are not typically good quality eggs.

If past experience holds, my lining will only get worse by tomorrow. It might be thicker, but it won't be trilaminar. In other words, given all past cycles, waiting a day will make things worse. I develop cystic patches each time they try.

Then there's the extra monitoring. At $575 an appointment, with 6 appointments, we've spent an insane amount on this cycle. This will mean monitoring on days 7, 8, 9 and 10. WTF?

The last hit: we're going to the boundary waters for our anniversary and to scatter Quinn's ashes. Pushing trigger until tomorrow means that if this cycle results in a positive home test, I'll either have to cancel the trip, or wait nearly a week for betas. That wouldn't matter at all if I thought that waiting a day would improve our shot, but given the first two points above, I definitely don't.

Also, new sonographer today. Hands down most painful t/v ultrasound I've ever had. Partly because she managed to drop the gel off the transducer onto the table, meaning there was no gel on the probe when she put it in. Partly because she couldn't find my ovary, decided my bowel was in the way, and started mashing my abdomen with her hand to 'move your bowel'. Spoiler: ovary was not hiding behind my bowel. Partly because, when mashing my stomach didn't reveal the ovary, she must have decided it was down toward my spine, so she angled the transducer such that she was pressing hard on my urethra. Did I mention I have a UTI? I do. It was the longest ultrasound I've ever had and I came close to telling her that we needed to be done. Lots of yoga breathing. New sonographer? She's on again tomorrow.

Only on the ART roller coaster can you go from so thrilled about the results to so down in an hour or less.

How Big Is It?

Let's face it: size matters.

That is, follicle size matters for maturity. As of yesterday, I had three follicles: one at 19, one at 16, and one at 14.5. I have seen good research on follicle maturity by size in IVF conditions, where the oocytes will be retrieved, but I wondered: what's likely to be mature in IUI cycles with gonadatropins?

The first distinction is just that: size for gonadatropin injection cycles. Clomid cycles are a different ball game, and better outcomes are seen with larger follicle sizes. For injections, though, the best study I found is a fantastic 2005 article in Human Reproduction, looking at pregnancies attributable to different follicle sizes. Their focus was on preventing multiple gestations, but in evaluating that, they examined pregnancies attributable to specific follicle sizes on day of hcg trigger.

Human Reproduction, Volume 20, Issue 3, 1 March 2005,  Pages 756–760,https://doi.org/10.1093/humrep/deh677

Fundamentally they found that pregnancies could be attributed to follicles 14 and up. Very few pregnancies were attributed to follicles of 14 and 15 mm. The majority were from follicles >16. This is a lower size than I'd have expected, so I find it quite interesting. That said, I know that on Quinn's cycle, I had two follicles, with the smaller one at 14, and both matured, based upon the presence of corpus luteum cysts later. On the twins' cycle, I had follicles at 22, 18, and 16, and the 16 did not mature, based on CL cysts.

A 2010 article in Fertility and Sterility found the highest pregnancy rates in cycles when 3 or more follicles were greater than 16 mm on the day of trigger, but this study didn't report on anything related to smaller follicles.

I'm still hoping we can get 3 mature this time, to maximize our chances.

And the Hits Keep Coming

Today's monitoring was good! All three follicles are still growing, lining is up to 5.6 and trilaminar!

There's hope! There's hope for 3 mature and lining over 7! I up my estrace to 2x/day, and I go back again for more monitoring tomorrow, although that seems early to me. My utterly anal chart is below.

Unfortunately, that was the end of the good news. DH's sperm frag test came back.

Research shows that fragmentation above 27% is correlated to recurrent miscarriage. DH is at 30%.

Fuck.

Fuck, fuck, fuck, fucking fuck.

So many thoughts. So many emotions. Resignation. Anger. Sadness. Fresh loss.

Now is not the moment I'm going to process it all. Now is the moment I'm going to go inject more FSH, shove a few more pills in uncomfortable places, and keep going. Now is the moment I'm going to grieve silently. Once this cycle is done, we'll figure out what comes next.

Thank you to everyone who has sent encouraging words and who has been cheering us on. At this moment, it means more than you can know.

Stim Day		7/16	2/17	12/17	2/18	18-May	7/18
	AFC	9 R=6; L=3	4 L = 2; R = 2	7	5 L=3;R=2	6 L=3; R=3	9 L=5; R=4
0	E2	49.1	18
	P4	1.81	0.31
4	L follies	12.5, 8, 8	6.5	12, 10.5	14, 11, 8.5	5, 4.5, 3	9.5, 8.5
	R follies	11, 9, 8.5	9.8	5, 3.5	7,4	5.5, 5, 4.5, 4	11, 5.5
	E2	803	585.5	188	622	725	691
	P4	2.68	0.07	<.05	0.07	<.05	0.1
	LH	8.24 miu	2.73	3.38	2.12	1.32	1.58
	Lining	6.9 triple	5.7, fluid	4 uniform	5.7 triple	4.97 triple	5.2 triple
	FSH	600	600	900	1100	1100	900
	Menopur		0	300	300	300	300
	Day	7	7	7	6	8	7
6 - 7	L follies	19.5, 13.6, 7	5	17.5, 16	16, 13.5, 9.5	3	15, 13.5
	R follies	16.5, 15, 10, 8	14, 9.5	6	9	9.5, 9.5	16
	E2	1294	432	718	1023	252	739
	P4	1.66	<.05	0.07	0.08	<.05	0.1
	LH	1.03	1.15	2.8	1.61	0.51	3.03
		6.9 triple	6.7	6 triple	7.77 mixed	5.2 triple	5.6 triple
	FSH	1050	1275	1575	1350	2300	1575
	Menopur		0	525	450	600	600