(In)Fertility Journey- 3. Before IVF- Hope

This entry is part [part not set] of 9 in the series IVF- In(Fertility) Journey

I have a scientific background, but fertility was not an area I was ever very familiar with. As with many areas of science, the more I learn the more I learn how much is yet unknown.

There are so many labs involved in getting fertility treatments. I’ll just say that for all the labs ordered, besides my wonky thyroid (which my endocrinologist assures me was within reasonable pregnancy range) and a slightly low vitamin D, I was in good health. Here are the most recent (June 2019) numbers along with the (reference range for normal or as indicated): (blood test indicated in red)

BMI (18.5-24.9): 21.6
Prolactin (3-30 ng/ml): 13
Baseline Estradiol (<50pg/ml): <50
FSH (4.7-21.5 mIU/mL): 7.5
Antimullerian (0.18-5.58 for women 36-40yrs old): 3.88
Antral follicle count: 10-20 via trans vaginal ultrasound
Hysterosalpingogram: All clear via x-ray with contrast dye. The only lab that is performed outside of the fertility clinic.

For reference:

Prolactin: inhibits follicle stimulating hormone (FSH) and gonadotropin-releasing hormone (GnRH), which trigger ovulation and allow eggs to develop and mature, so if it’s too high, ovulation may be suppressed, and inhibit pregnancy.

Estradiol: levels change throughout a woman’s cycle. It is low at the start of the cycle, peaks before ovulation and eventually declines again toward the end of the cycle. More info here: https://www.everlywell.com/blog/womens-health/normal-estradiol-women/

FSH (Follicle-stimulating Hormone): one indicator of ovarian reserve. The lower the number, the better. A higher number suggests a lower ovarian reserve. More info here: https://advancedfertility.com/infertility-testing/follicle-stimulating-hormone-testing/

Antimullerian: another indicator of ovarian reserve. Values over 4.0 ng/ml can indicate Polycystic Ovarian Syndrome, and values less than 1.5 ng/ml is likely to have reduced ovarian reserves. In between those two is currently deemed normal.

Antral follicle count: one of the best estimate of ovarian reserve. The number of antral follicles approximates the number of egg reserves in a woman’s ovaries and are predictors of the maximum number of mature follicles that might yield an egg under fertility stimulation during any given cycle. Typically the higher the number the greater the chances of success via fertility treatments, although very high numbers also seem to be associated with higher risks of overstimulation. More info here: https://advancedfertility.com/infertility-testing/antral-follicle-counts/

Semen analyses: Typically the man is given instructions to abstain from ejaculating for two days prior and then to produce a sample within a 30min-1hour window, and get the sample to the clinic within this window. See below. Also, there is so much more than just these parameters that are required for sperm that can fertilize an egg and develop into a healthy embryo, more on that later.

	9.15.2017	6.26.2019	8.14.2020		11.10.2020
				reference		reference
Volume	1.5	1.5	0.5	>1.5ml	1.4	>1.0ml
Liquefaction	normal	normal	normal	normal	normal	normal
pH	7.5	8	8	>7.2
% motile	47	43	51	>40%	40	>40%
% progressive, Sem Fld, Qn	39	35	42	>32%
% immotile	53	57	49
% nonprogressive	8	8	9
Viscosity	normal	normal	normal	normal
Appearance	normal	normal	normal	normal
Count	271.4	270.9	232	>15.0 M/ml	85	>20.0 M/ml
Morphology	12	10	14	>4%	5	>4%

We had the analysis performed at two separate clinics. The reference numbers for each clinic is to the right of the corresponding results.

We have not been using any forms of birth control since 2015. It was time for a little medical assistance. We figured we would try ovarian stimulation and/or IntraUterine Insemination (IUI). Just basically stack the cards a bit more in our favor. The following is the schedule of all my fertility treatment cycles before IVF.

These cycles typically involve two or more closely timed appointments at the fertility clinic. Most appointments involve a trans vaginal ultrasound (US). All these cycles involve stimulation via oral hormone pills that must be taken on schedule. This was my introduction to giving myself subcutaneous shots in the abdomen (see this video), as that was the method of administration for Ovidrel (recombinant human Chorionic Gonadotropin beta), the ‘trigger shot’ necessary to kick start ovulation. Of all the procedures that takes place, the IUI was the easiest. This involved my husband providing a semen sample 2 hours before my appointment, during which a speculum is inserted into the vagina, a thin tube is inserted through the cervix, and the cleaned sperm is injected directly into the uterus- thereby giving them a bit of a ride closer to their destination. In case you are wondering what ‘cleaned sperm’ is, there are a number of methods employed, but essentially the goal is to concentrate mobile sperm and remove anything else in the semen that might inhibit the fertilization process.

Back to these cycles. They typically start out with a trans vaginal ultrasound appointment early in your cycle to check that there are no cysts in the ovaries. Then I start the oral stimulation drugs for typically 5 days. This is usually followed by several additional trans vaginal US appointments for monitoring, and if planned, treatment. The thickness of the uterine lining is monitored because a thickness of over 7 is ‘good’, and necessary for embryo implantation. The number and size of developing follicles in my ovaries are monitored to ensure that there are some (but not too many- don’t want high probability of multiples over twins/triplets), and that they develop to the right size. Follicles that reach a minimum of 16mm are likely to yield a mature egg upon ovulation stimulation, or trigger. Follicles are expected to grow at a rate of 1-3mm/day. Because the follicle is a 3D structure and the ultrasound image is in 2D, and because the follicle is often not perfectly round, the follicles are usually measured across their shortest and longest distance on US and the average of the two is the number that is used to gauge follicle size. The trigger shot is necessary for timing of IUI, if ovulation has not happened on the expected day. For some cycles, we monitored ovulation using at home ovulation kits and timed intercourse around ovulation.

The following is a summary of our fertility treatment cycles. CD refers to cycle day.

8.14.2019	1st Attempt: CD1		Right Ovary	Left Ovary
	CD3-7: 100mg/day Clomid
		CD11- Lining 7.7mm	16mm, 8.8mm	15.3mm, 15,7mm
	CD13: 250mcg Ovidrel @10pm
	CD14: IUI 10am	Sample: Pre- 1.0ml, >15M/ml, 40% motility.
		Post- >15M/ml, 40% motility, >5 million TMC
		CD31: Period started

For this first cycle, I took clomid to increase the number of developed eggs. I took a home ovulation predictor test on CD 12 and CD13, both were negative, so required triggering ovulation with Ovidrel on CD13. On CD14 the sperm was given a boost by injecting them directly into the uterus via IUI. During this cycle, everything looked good. The Ovidrel shot was my first self-administered subcutaneous shot. Later that evening I felt woozy and nauseated, but was fine in the morning. Sample Pre/Post refers to sperm sample before and after cleanup. TMC is total mobile count.

9.13.2019	2nd Attempt: CD1		Right O	Left O
		CD5- Lining 3.9mm	4BAF 0C	4BAF 0C
	CD5-9: 100mg/day Clomid
		CD11- Lining 7.6mm	14mm, 10.5mm	12.4mm
		CD14- Lining 12.3mm	19.2mm, 16mm, 14.2mm, 12.1mm, 12.7mm	25mm
		Over-response, further treatments cancelled.
		CD17: LH peak
		CD34: Period started

For this second cycle, I took clomid, at the same dose as before. However, we could not proceed with further treatments, monitoring showed an over-response this cycle- too many eggs for the fertility clinic to proceed. We did timed intercourse anyway, but nothing happened. Following this cycle, I was traveling, so could not jump into another cycle right away. I had the worst case of cold sores I’ve ever had in my life. My provider suggested either trying a 50mg dose of Clomid (half the previous doses) or Femara/Letrozole at 2.5mg to address the over response.

11.13.2019	3rd Attempt: CD1		Right O	Left O
		CD3- Lining 6.5mm	5-6BAF 0C	5-6BAF 0C
	CD3-7: 2.5mg/day Femara
		CD11- Lining 9.8mm	10BAF	18.9mm 6BAF
		*my records show 6 small resting on right, 1 on left.

	Plan intercourse every other day
	for week.
		CD29: Period started.

For this 3rd cycle, I took Femara. The response was okay. This particular provider did not really give me details on all the follicles that were developing, so I just have these notes. I was really hoping that Femara would work for me; this worked for a friend. Unfortunately, this didn’t work either, and I’m starting to feel discouraged. Following this cycle, we had an appointment for an IVF consult; I really didn’t want to do IVF, but we figured we could get some information. So because of the consult, we were also scheduling a water sonogram, which is similar to an IUI, except with water and the ultrasound probe to ‘map out’ the path to the uterus in the event of an IVF cycle.

3.5.2020	4th Attempt: CD1		Right O	Left O
.	*Difficult scheduling, very stressed.	CD5: ET 4.8mm	4BAF 0C, 11.8mm	5BAF 0C
		*Concern regarding possible cyst. Scheduled
		follow up on CD10 to verify if cyst.
	CD5-9: 5mg/day Femara
	CD9: Provider cancelled appointment


		CD12: LH peak.
		CD28: Period started.

After our IVF consult, there was heavy pressure to begin IVF but I really didn’t feel ready. I wanted to give less invasive methods another try. Unfortunately, Jan and Feb were a bit chaotic and I couldn’t get back into the schedule until early March. It could have been me feeling bad, but it was very difficult to schedule this particular cycle; the only open appointment to start the cycle was cutting really close to my work time. The clinic seemed overwhelmed and I felt that the clinic didn’t have much hope for me. The provider was yet another medical provider I had not met previously. There was concern regarding a possible cyst on my first appointment, so a CD10 appointment was scheduled right away to verify if I was developing cysts. After several calls to verify that I didn’t have COVID symptoms, all subsequent appointments were abruptly cancelled with no further directions. I just hoped that I didn’t have a cyst, did home monitoring and tried on our own around ovulation as indicated by at home LH predictor kits. Unfortunately this did not work. We were ready to try IVF.

On our first attempt, we tried IUI, and for the subsequent ones, we tried ourselves (tracked ovulation using at home kits and timed intercourse-every two days- around ovulation).

Our rationale at the time was this:

For IUI: My husband has had multiple semen analyses, all of which came back normal. If our infertility was due to his sperm somehow having difficulty getting to my egg, or my reproductive environment being inhospitable to sperm, giving the sperm a lift to the finish line might help.

For trying on our own: IUI required a trigger shot for us (we did not observe an LH peak)- apparently my body was not ready somehow. Trying on our own meant that we’d be introducing sperm multiple times to catch when my egg was ready. Also, I have a friend for whom this worked after the second attempt. Finally, the HCG trigger shot made me feel extremely woozy and nauseous, and it just felt very wrong. It could just be that my body was new to this and gave it a shock. The advantage to trying on our own is that we wouldn’t need to trigger ovulation.

At the end, none of this worked. I kept hoping that what my body needed was a little help with producing more/better eggs (something Clomid and Femara would address). Or that the sperm could just use a lift with IUI. I kept hoping that a little help was all that we needed. But nothing worked and I was feeling time creeping on. I knew I was getting older, everything was just making me feel more stress. And so, in the crazy year of 2020, we finally decided to give IVF a try.

As an aside; and I’m sure most people are aware- the providers that planned the cycle may not be the providers you see during the monitoring of your cycle. The providers you see during your procedures, such as IUI, are not the same people who perform the semen cleanup, just as the provider who performs the egg retrieval are not the same people who handle all further processing of the egg. Maybe because of this, I have found that sometimes the providers I see are not very on top of the specific methods used in the analysis or lab procedures. I sometimes feel uncomfortable asking because some areas of fertility treatments (IVF specifically) is an area that is not standardized in the US, each clinic has their own methods and perhaps, secrets to success. They may not feel comfortable sharing their secrets. Which is why people try to go to clinics with good success rates. However, the only measure of that is the voluntary reporting of individual clinics to the Society for Assisted Reproductive Technology (www.sart.org). The most current numbers reported are necessarily a year or two behind due to the cycle length, etc. Another thing to keep in mind is that while we would all like to think that such clinics report all their data accurately, these data are provided from the clinics themselves, and I suspect there is pressure to report encouraging numbers. That’s where Yelp reviews can help. And also, your own experience and observations.

Support Tip: Scheduling and appointments

This particular tip is most useful for the spouse/partner of the woman undergoing fertility treatment, or the person who lives with her. It was super helpful that my husband knew my appointment times and would drive me to my appointments. Having someone go along with me made me feel less alone in this time of hope and getting used to frequent clinic appointments. It was one less thing for me to worry about, and so I could focus on trying for a calm and peaceful state of mind. Understanding that good organization and timing of these treatments (including when to take the oral medications) is good practice should more intense fertility treatments, such as IVF be necessary in the future.

For friends farther away, it’s nice to get a call or text checking in to see how things are going. This can be a long process, and it’s nice to have people to talk to about this as we felt our way along this path. We kept hoping that we’d find what we were looking for along the way, but when we don’t, we had to figure out whether to continue to feel our way forward blind (it often feels this way because we’re in the ‘unexplained’ category), or to stop. It can be a process to arrive at this decision, and often a sympathetic ear can help clarify things.

Rant: Having people looking at and rummaging around down there.

I am a shy person. I speak softly. I usually don’t speak at all unless directly spoken to, or if it’s someone I’m familiar with, or a topic that is very important to me. I’ve always requested female doctors. I got away with it for a long time. All of a sudden, with fertility treatments, you don’t have the choices you had before. In case you’re wondering, it’s easier for me to talk about science and biology, so if I seem a bit wooden at times in my description, it’s because it helps me get over this. I’ll try to keep my euphemisms to a minimum.

You might be able to find a woman fertility doctor, and that would be nice. For me, I don’t want anyone looking down there, but if someone must absolutely, then for goodness sake, let it be a woman, preferably an older one who reminds me of my mother. However, some clinics have a rotating staff of doctors and whoever is on call the day of your appointment is who you get. The first time this happened to me occurred at my hystersalpingogram, I had no idea who was going to perform it.

In case you’re wondering, a hystersalpingogram is a process in which they dilate your vagina, and then insert a tube through your cervix to allow injection of a contrast dye that allows an x-ray to be taken of the uterine cavity. There is an inflatable section at the tip of the tube that is suppose to help lodge the tube at your cervix so that the dye is injected into the uterus and pushed out through the fallopian tubes. This allows visualization of the uterine cavity and fallopian tubes to ensure everything looks anatomically correct, and that there are no blockages.

For my hysterosalpingogram, it turned out to be a male radiologist. I would have totally freaked out except that he asked if it was okay for a female technician to assist. I’m not sure how much she was really meant to assist vs. chaperone vs. keep the patient (me) calm, but her presence and her support during the process was very soothing to me.

You might be wondering, ‘her support’? Yes, she was supportive as the radiologist took a long time to find my cervix. As in there were minutes of total silence. And then he would raise his arm to wipe his sweating forehead- it was clear as time went on that he was approaching my level of stress. Which of course, made me worried whether I was clenching down there and therefore making it even harder on the poor radiologist. The female technician was very kind in talking to me and she actually held my hand. Normally I would never hold a stranger’s hand, but in this case, it was so helpful.

After some difficulty, the radiologist found my cervix (apparently it is somewhat retroverted or tipped toward the back). And then, for some reason, because of the awkward angle, he could not inflate the balloon on the tube, so he had to hold the base of the tube, through the speculum in position during the entire procedure.

Once he got the tube in place, the female technician had to push the button so that the table I was on was moved into position under the x-ray, as the radiologist could not reach it, holding the tube as he was. At one point during the table move, he suddenly yelped “Wait! My arm isn’t long enough!”, and he scootched closer on his little stool. I didn’t know whether to laugh or cry at that point. In the end the results were good, so everything was okay. The poor radiologist apologized profusely and I was so happy the procedure was over.

I’ve accepted that I’m always going to be a little more stressed with a male doctor, no matter how kindly or gentle he is. This hasn’t prevented me from getting treatment and I try to remind myself that this person looks at nether regions all day long, but just saying. If you’re like me and this kind of stuff is upsetting, I totally feel you.

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