The Game Plan

     My last Depot Lupron injection was May 1st - the last in a series of 3. You can read more about my premature foray into menopause here. While I have been on Lupron injections, I have been working with Dr. Kwak-Kim, a Reproductive Immunologist based out of Chicago, to formulate an immune protocol for my FET. My RE has been out of the country visiting family, and he is now back in action, and together we also came up with a plan. The marriage of this entire preparation is overwhelming.

Here's what we got so far:

5/1 last Depot Lupron injection

5/3 begin Prednisone as part of immune protocol to decrease cytokine level

5/17 blood work for Dr. KK - CBC, metabolic panel, TSH, NK cells and Cytokines (NK and cytokines have to be drawn and then mailed to Dr. KKs lab - a local hospital is willing to do this "courtesy draw" so long as I supply the orders, test tubes, etc - which Dr KKs office supplies me with)

5/23 Baseline u/s for FET...if all goes well I start estrace and Augmentin ( a broad-spectrum antibiotic to r/o endometrial infection)

5/28 Begin Lovenox as part of my immune protocol

5/31 Repeat the blood work panel from 5/17

6/3 Fly to Chicago to have my uterine blood flow checked. I am also due for a lining check for my RE so I plan to have them do it there...if all goes well, I'll start progesterone

6/8-6/10 ****crossing my fingers SO DAMN HARD**** that this will be a transfer of 2 blastocysts.


So many thing are different about this cycle, and these differences bring hope. Hope is a scary thing.

Our prior cycles were antagonist with equal parts Menopur and Gonal F. The only difference between them was the fact that we used estrogen priming for IVF #2. Both yielded 7 usable eggs, of which 4 and 3, respectively, fertilized. Both cycles were 3dts - our first IVF we did an eSET, and our second we transferred two.

This cycle has been a total 180...we did MDLF with estrogen priming, we used a lower total dose of stims, we used a small amount of Menopur instead of equal amounts, we added HGH, we found out that I was heterozygous for MTHFR and began treating that with Methylfolate, we visited the RI who put me on levothyroxine for my thyroid, I took prednisone during stims for my cytokines, I began self-treating cytokines with fish oil and chia seeds, we primed my uterine lining with Depot Lupron for 3 monthly injections, we are doing a FET for the first time, and we have blasts!! Something we have never had before...and, finally, I'll be on lovenox for poor uterine bloodflow and prednisone for my cytokines. If that doesn't work, we will use IVIG, which was somehow, some way, approved by my insurance (but will still be $520/infusion until we hit our OOP max).

Whew...did you keep up with all of that?

These changes excite me, but they also scare the shit out of me because nothing will guarantee that it works. I'm at a point where I feel it is impossible to be pregnant, and I am trying so.damn.hard to keep my chin up, pretend the glass is half-full, keep my eyes on the prize, see the silver lining, and all sorts of other cliché things that people say when you want to crawl in a hole and die over how shitty your life is going.

Time will tell, and for once in this whole shitty journey, I'm really hoping that it is finally MY time.



IVF #3: The Conclusion

    
     It was the best of time, it was the worst of times. Yes, my latest IVF cycle can be paralleled with the timeless classic, A Tale of Two Cities. Somehow, some way, this cycle managed to be my worst and best.

     To get straight to the good stuff, on Propofol Day egg retrieval day, we retrieved 12 eggs (!!!) but only fucking 5 were mature. I knew this. I had predicted this shit. My estrogen on the day of trigger was 3100+, which was by FAR my highest yet, but, having been around the block too many times, I knew better than to get excited. Highest highs followed by the lowest lows. That is all IVF is to me.

    Aside from the 5 mature, it looked as if a few more may mature in the lab. Thankfully, two more did. That brought our total to 7. Seven. This is the same number of eggs retrieved for IVF #1 and 2! My ovaries are pre-set apparently.

   The Holy Grail of this cycle came in the form of ICSI. This is the first time we did it and 6 of our 7 eggs fertilized! All 6 were still cookin' by day 3, albeit 4 were good and 2 were crapping out. We decided to press on to blast. That was terrifying! Three were blasts on day 5, and one was able to be frozen that day, with the other two frozen on day 6.

   Now that I am a few weeks out from stims, in my non-hormonal state, I'm thrilled with this cycle. Three blasts!! 3!!! We have never, ever had a blast before! Yet, in my drug-induced stupor I was a mess. It was so hard for me to reconcile that we had 12 eggs but not all 12 were mature. And I was frustrated with our low blast rate, even though it is an absolutely normal and expected number. I was ungrateful, and hormonal, and bitter. Truthfully, I was having a hard time with the reality that I won't ever make it rain eggs. I won't ever be the girl who gets 25 eggs and 19 embryos and winds up with 10 frosties. And I hate that. I was also feeling a ton of pressure to get many embryos because this cycle was to be followed with depot lupron for three months for my wonky endometrium, after which, I may not stim as well for a while.

   On day 6 after retrieval, I got an e-mail from Dr. Wang and he told me the second blast had been frozen but we still had to wait on the third, which, without some growth, wouldn't make the blast cut. I lost my shit. I wrote a long and angry e-mail (not anger directed at him) and he immediately called me. This is why I love him and he's the best ever. He spent thirty minutes talking me off the ledge and, telling me that my cycle went just as expected, explaining why he really felt that depot lupron is the right choice for me and giving me some hope. He made me feel so much better, and I was able to begin to realize how wonderful this cycle went.

    We all agreed not to test the embryos at this juncture. I'm praying that we have at least one baby in there. Please, oh please. It's time. It really is. I hope the HGH did it's job and we have some excellent quality pre-babies in there.

    As for now, I'm slowly settling into a menopausal state and trying to enjoy a well-deserved break from infertility treatments. Hopefully I can take some time to decompress, relax, focus on school and try to get back into shape for a short period of time before my body is (hopefully!) ruined by a baby.
   

You too, uterus?!

Source

     For an entire year now, since the dawn of our time at the RE, I have sung my praises far and wide for my uterus. Specifically, my endometrial lining. My lining has been the shining star of my reproductive system. It builds up like a champ and reliably puffs up to its desired thickness like a deliciously tempting pastry, it develops a trilaminar appearance with ease, and has been complemented on by many a reproductive specialist.

     Recently, my uterus, as a whole, has been taken down a notch by the identification of a Narbothean cyst by Dr. KKs people, and by finding out that my uterine blood flow was less than stellar. However, the nail in the uterine coffin came when I received my EFT results.

     My lining has failed me and I need to enter a lupron-induced menopause for three months before my next transfer.

     Gone are the days of endometrial superiority. My lining can now retreat back to the Island Reproductive Organ Misfits with the rest of my lady parts. 

     According to Dr. Wang, we did the EFT due to my endometriosis diagnosis because studies have suggested that women with endo have a higher chance of having a dysfunctional endometrium, which can negatively impact the implantation process. My results showed the receptivity of my endometrium to be decreased. To explain it further, Dr. Wang said that the endometrium is largely composed of two components - the stroma and the glands. The stroma is like the scaffolding of a building that holds up a structure while the glands are the structures embedded within the stroma that are important in the implantation process. Basically, the stroma and glands harmonize in response to the hormonal changes throughout the menstrual cycle, which allows the endometrium to prepare for, and accept, the implanting embryo during the "window of implantation."

     From my EFT, it appears as if the glandular portion of the endometrium showed delays in development, which may affect its ability to allow the embryo to implant. This specific issue is called Glandular Developmental Arrest (GDA). This was determined during the EFT analysis when they went to look for a protein in the glands called cyclin E. Normally, cyclin E is present 5-6 days post ovulation, however, to prepare for implantation, the levels should drop low. High levels of cyclin E would suggests that my endometrium did not develop properly to allow for effective implantation. Normal cyclin E levels should be less than 20%, and ideally less than 10%. Mine came in at 30%. 

     High levels are normally caused by endo, hydrosaplinx and/or an endometrial infection. I've had enough things shoved up, around and into my vagina and uterus to rule out hydrosalpinx, and I have endo, so, yup. Therein lies the reason. 

     I also have high neutrophil levels which is indicative of an endometrial inflammation, which is also common in endo. 

     Naturally, I asked a few questions about this whole situation. I asked if my chemical pregnancy was a "good" sign and he said that it was, but that repeated chemicals are, in his experience, a common presentation of this lining problem. We can also treat for an endometrial infection but the possibility of that is low, and that, the success rates associated with the three months of lupron are exceedingly high. 

     So, that's that. We can now add my uterine lining to the list of fucked up reproductive pieces. For now, I'm hoping beyond hope that my oves yield a few good eggs (& embryos!) to transfer in May. So.Far.Away.

A Dr. KK Update

     Welp, I finally had my follow-up telephone consult with Dr. Kwak-Kim. It's not that I waited long, it's just that I'm impatient. All-in-all, the follow-up went really well!

      It's a bit difficult to understand her at times due to her accent, and the fact that we were communicating over the phone. She also didn't really explain things well. It was a bit difficult to follow along with what she was explaining, and particularly, to understand what lab values of mine were off or normal. My only real complaint was that she didn't seem to know me from a hole in the wall as she was speaking to me...I could hear papers rustling as she was speaking to me, so I kind of got the impression that she was viewing my results for the first time as she mentioned to me I should have a thyroid scan done, but I did have one done at her office, but she didn't see the notes until I pointed it out. Also, whenever their was an elevated value, she didn't quantify it, so I don't know how "off" it was. To be fair, I didn't ask.

    First things first, my TSH came back at 2.66. This has been pretty consistent over the last year, except for a reading I just had in December where it was 1.25. None of my REs have been concerned with it, but she would prefer it to be under 2, so she prescribed 25mcg of Synthroid daily.

    Second, and what I already knew, blood flow to my uterus isn't great, so she prescribed lovenox injections for transfer. We have planned for a freeze-all for this IVF in anticipation of this, so I'll begin taking it at some point before that. However, a curve ball was thrown...I need to fly back to Chicago for another ultrasound to see if my blood flow has improved once I start taking it. It makes sense, but damn, I wasn't anticipating that.

    Finally, she said my T Helper Cells were elevated, I think. She may have been referring to my Th1/Th2 Cytokine Ratio or they may all be the same thing. I can't tell and this is where I got the most confused during our conversation. She's prescribing Prednisone to begin a few weeks before my next stim cycle. I'm actually already in my next stim cycle, but Dr. Wang already prescribed me Prednisone for my high normal Th1/Th2 so I started that when I began my protocol as well instead of having started it a few weeks ago like KK would have preferred.

   She did mention that if the Prednisone didn't work, I would have to do IVIG, but I'm pretty sure that is where we draw the line. It's super expensive, and even if it is covered by insurance, I don't know that I'm comfortable with using a blood product if it isn't absolutely required. In any event, she's running it through my insurance because coverage, if applicable, can take a while.

   Mostly, I'm overwhelmed with the amount of blood work required. I have to go back in two weeks to re-do my TSH and see if my Synthroid needs to be altered, as well as my free insulin level (which was normal, but she said it was higher than it should be for my age...so, maybe that's because of the 20lbs I've gained, or my crazy sweet tooth..) and two weeks after that.

    My plan is to e-mail her NP to explain that I'm stimming already so they know where I am in the process and can  view my lab results with that in mind. When I wind up having my FET, I'll follow her protocol fully. It's overwhelming adding a third provider to the mix, but I'm happy we went this route and can add a few more things to my protocol and hopefully find some success.

    

The Endometrial Function Test

      Yesterday my husband and I took a trek to SIRM-CT to visit with Dr. Wang and allow him to stick another fun tool into my uterus in the name of infertility. On the plus side, it was my husbands birthday and I gifted him with a sperm DNA fragmentation test. He got to jerk off and I got pieces of my uterus scraped out. Fun day.

    Truth be told, I've tolerated all of the invasive infertility tests like a boss. And yes, I'm pretty damn proud of this. There isn't much my reproductive system does well, so if pain tolerance is something I can brag about on behalf of my ute, then so be it.

   To date, I've had the HSG, an in-office hysteroscopy and a 3D saline sono and haven't really had any difficulty or great discomfort with any of them, but this test had me a bit nervous. I couldn't find my gluten free ibuprofen (yup, the life of a Celiac patient...) so I decided to go commando on the pain control front. I was stationed in a typical obstetric room and Dr. Wang showed me the tool he would be using. It looked a bit like this:

Source

     Basically, it's a plastic catheter that has an inner portion. You insert it into the uterus and gently pull back on the interior portion which creates a vacuum-type force that aspirates the endometrial contents into the catheter. The goal is that the RE will continue to aspirate as the catheter is slowly removed so a variety of endometrial tissue is obtained, and not just tissue from one spot. Basically, you need a representative sampling of tissue for the most accurate result. Dr. Wang had to go in twice to get enough tissue. It wasn't uncomfortable getting the catheter in, but I'll admit there was some discomfort as he was aspirating, but nothing that I couldn't deal with. I felt some intense cramping but it wasn't anything beyond what I have felt with my period. However, I will say, if you wanted to die during the HSG or any of these other in-ute tests, then this once won't be a piece of cake. It was pretty quick, and then it was done. My husband was allowed and encouraged to be in the room, which I really appreciated. Its high time he sees some bloody catheter action and realizes that my portion of IVF treatment isn't all illicit back-alley patient rooms with porn assortments at the ready.

   All-in-all, I believe the test is costing us $595 + shipping. We chose the EFT over the E-tegrity test because Dr. Wang felt that it's the "safest" test. He said that there have been incidences where the E-tegrity test has come back normal, but the EFT came back abnormal, yet he hasn't really seen it come back the other way around. So, worst case scenario, the EFT comes back erroneously abnormal and you receive treatment for it....but I think that is much better than getting an incorrect normal result and wasting more embryos on a shoddy uterine environment.

   Now, we wait. The DNA fragmentation results should be back in a week or so. We are doing ICSI regardless, it's just a matter of whether we add PICSI into the mix instead. It will take about two weeks to receive my EFT results, and I have my follow-up with Dr. KK in about two weeks as well. Then, as of February 8th (hopefully!) we have our baseline and start stims for IVF #3.

 I really feel confident that once we sift through all of the results, we will really have our full infertility picture, which, for better or worse, will be such a relief.