This Time Will be Different

I published this post on my other blog, but I figured it had some relevance here too…

Sometime this year, my husband and I will start the process of trying to conceive baby #2. This moment is still months away, as there are a number of moving pieces that have to fall into place before we can reasonably attempt any baby making. At minimum, I need to wean, get my chicken pox vaccine, and get my period back. Since we have five frozen embryos from our IVF cycle, we are planning on jumping right into doing a frozen transfer as soon as we are in a position to do so, therefore there will also be the various tests and procedures that our clinic requires before proceeding with a transfer, not to mention coordinating our schedules with both the clinic where our embryos are, and the clinic where we will do our monitoring for the cycle. The many joys of procreating by committee will soon be upon us.

While I have tried hard not to speculate about what trying to conceive will be like this go around until the time comes, in the last few weeks I’ve often found my mind spinning as I try to process the ramifications of what getting back on the baby making train will mean for us. This is due partly to the fact that we are starting to have preliminary discussions about what our timing is going to look like, and that I am getting close to weaning Baby Boy (I had planned to breastfeed him to a year, which is another two months away, but based on his lack of interest over the last few weeks I suspect our wean date will come sooner than that). I have also recently read a lot of blog and twitter posts that touch on some of the issues I have been struggling to get my head around, related to life after infertility, secondary infertility, and infertility amnesia.

I have no idea if or when we will have another baby. If we do have another baby, I don’t know if we will get pregnant via frozen transfer, natural conception (ha – sounds like immaculate conception to me!), or through further fertility treatments. I don’t know if it will happen on our first try, or after multiple attempts. But despite all of the uncertainty, rather than feel panic at the thought of climbing back on the roller coaster, I am at peace with whatever our outcome may be. I am at peace, because I know that the worst is behind us.

The experience of infertility while trying to conceive Baby Boy was akin to falling down a deep chasm, and having no idea how far you had left to fall, or what sort of landing you would have. Along the way, we were willing to grasp at anything that would help us achieve a quick and safe landing – in the six months before we conceived Baby Boy, my husband and I agreed that we would pursue donor eggs, donor sperm, or surrogacy if we got any indication that any of those would resolve our infertility (unexplained infertility is its own deep chasm, but that’s another story).

I am a planner by nature, and while trying to conceive Baby Boy, having a plan gave me some semblance of control over an uncontrollable process. I was always two steps ahead: if the current cycle/treatment option failed, I had a plan A, and then a plan B if plan A failed. At the time we conceived Baby Boy, I had my plan A and plan B all set, and my husband and I had the resources (financial, emotional, physical) to keep going balls to the wall until we achieved our goal. We were not at the point where we had an end date (whether fixed on the calendar, or based on a number of things happening, or not) at which point we would change course to pursue adoption (when we had last discussed it, this was an option my husband was not interested in), or living permanently child free.

While overall, our mindset was that given enough time and treatments, we would eventually be successful, not knowing how our story would end was still terrifying. The future held so much uncertainty, and there was no way of knowing how much more heartbreak in terms of failed cycles, pregnancy loss, or even just the cruel passage of time we would have to endure before we held our baby in our arms.

This brings me back to my original point about starting the process of trying to conceive again. No matter how many times I turn the idea of it around in my head, I come to the same conclusion: this time will be different.

This time will be different because we are not starting at zero: not only do we know way more than we should about all the ways that conception can go wrong and therefore are intimately familiar with how difficult it can be; but the existence of our five frozen embryos (that paradoxically only exist due to the extent of our struggles first time around), mean that we are starting out ahead of the game.

This time will be different because we are no longer in a chasm of unknown depth. I can look ahead and know with certainty that I will not have to endure multiple fresh IVF cycles in order to bring my baby home (I am not ruling out the possibility of doing another fresh cycle if none of our current embryos take, but I don’t see a scenario where I would do more than one more fresh cycle). I know that if we are to have another child, it will take us less time to conceive this time around than the 3+ years it took us the first time, for the simple reason that due to my age it has to (I’ll be between 37 and 38 when we start trying again).

This time,  there are limits to what we will go through in order to conceive. I know that we will transfer each of our existing embryos until one sticks, but if we are not successful, we are not going to go to heroic efforts to have another baby. Lastly, knowing that we had the strength to survive failed cycles and pregnancy loss the first time around gives me comfort that if needed, we have the strength to survive again. All of these factors mean that when we start trying again, we will be able to feel, or at the very least, see the ground below our feet. We will be able to reach our hands out and find something sturdy to hold on to, rather than grasping at air as it slips through our fingers.

This time will be different because no matter what happens, I will never forget that even our “worst case scenario” of being parents to one healthy, amazing baby boy is many people’s dream.

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And the Wait Begins..

I haven’t posted much lately, and I never did write about the follow up appointment after our first transfer failed. As a result, I haven’t written much about this cycle, or the plan if it doesn’t work.

So, I’ll start with a brief synopsis of where we’re at. As I wrote about in most (all?) of my recent blog posts, I moved across the country in the middle of my two week wait from my first cycle. We had an appointment with a clinic here in Toronto lined up just in case the IVF did not take, which took place in early August.

A few days later, we had our WTF appointment with the RE in our old city. I did write a draft of a post describing in some detail how it went, but in a nutshell what came out of it is that we still don’t know why we’re not getting pregnant (via IVF or otherwise). So, the diagnostic aspect of IVF did not give us any answers, other than to say that both egg and sperm quality are great, and we make lots of very good looking embryos.

We decided that for this FET, we would do our monitoring appointment in Toronto, and fly back to our old clinic for the transfer. If this does not work, we are considering shipping some of our embryos to Toronto to do our next cycle here (probably 2 out of the 5 we have left – I’m still nervous about shipping them, as is my old clinic).

Our RE already pulled out most of his tricks on us with the first FET, so not much changed in the protocol this time around.

We did the intralipids and heparin again, but did add a steroid to the mix. These things should help us with any undiagnosed immune or otherwise weird implantation type issues, because that’s really all that’s left. And we decided that after only transferring one embryo last time that this time we would transfer two.

While overall, I would say my RE treats aggressively, he is conservative when it comes to the number of embryos to transfer. Wherever possible, he recommends a single embryo transfer, especially if it’s a day 5 transfer, and the blasts are high quality. As much as possible, he wants to avoid multiples, and I tend to agree with him.

I want my next pregnancy to go smoothly, with as few complications as possible. I’ve already had a pregnancy that did not go well (miscarriage), and one that never really started (chemical), so I want to do whatever I can to ensure that the next pregnancy makes it. While I understand that there is only so much you can do on that front, one guaranteed way to increase your risks across the board is through a twin (or higher) pregnancy.

Pretty much every possible risk, from incompetent cervix, to preeclampsia, to premature birth is magnified when you have are carrying more than one baby. Many women pregnant with multiples end up on bedrest for a significant portion of their pregnancy in order to try to manage these risks, which must just magnify the stress.

And the risks don’t end with pregnancy – babies born prematurely have more health issues, some of which can be lifelong problems. For example, cerebral palsy is ten times more common in twin pregnancies than in singletons. And lastly, there are what my RE described as the “psycho-social risks” once the babies are born, and the parents are overwhelmed dealing with two (or more) babies who both have the same needs at the same time.

Based on all of that, I was happy to transfer one embryo the first time around. But, when that didn’t work we had to decide whether to up the stakes this time. My husband was all for it, but it took me a while to come around.

I had been worried that if our first transfer did not work I would regret only putting one back in, but in the end I was at peace with our decision. I know that we did the right thing by only transferring one embryo, and if I had the chance to do it over, I would do the exact same thing.

However, the decision about how many to transfer second time around was much harder. I asked our RE what he recommended, and while he wouldn’t come out and recommend we do two, he did say he understood why we would want to try two this time around.

In the end, I did some crude math and decided I was willing to take my chances with two. Probably the biggest factor was thinking about the possibility that if we put one in this time around and it didn’t take, we’d be looking at another failed cycle and heading to a third transfer. If the third one took though, it’s a result we could have achieved earlier by transferring two this time around. And emotionally, I think there’s a big difference between being successful on the second transfer vs. having two failed transfers under your belt and having the stress mount that things aren’t going to work out. Yes, I’ll admit it, I’m getting impatient.

A related consideration was miscarriage risk. Again, if we put one back in and miscarried, it’s a very different story than putting two back in, having a vanishing twin, and still ending up with  a healthy baby. And this time around, my desire to get pregnant first and worry about the consequences later outweighed my desire to minimize pregnancy risk.

When we got to the clinic for our transfer today, our RE sat down with us to talk about our embryos. As in our first transfer, our embryos thawed perfectly. Once again, we heard that they looked like they had never been frozen, and once again both the RE and embryologist gushed about how they couldn’t look more perfect.

We went into the procedure room, where I changed and got ready for the transfer. The embryologist then told us that this morning when the embryos were thawed, our RE had started to wonder whether we should really be transferring two, since they looked so good and he felt they had a high chance of both implanting. Sure enough when he came into the room, he asked us whether we were sure we wanted to go ahead with two. He offered that we could transfer one and refreeze the other.

It was not an easy decision, but we talked it over and decided to stick with the plan. Hopefully no matter the outcome of this cycle, I’ll look back on this as the right decision. In the meantime, for the next twelve days I’m pregnant until proven otherwise.

Into the Freezer

Wow, I can’t believe the fertilization rate was the last thing I wrote about! To be fair I did write a post on day 3 that had some updates in it, but I never posted it since I wanted to edit it some before posting, and here I am a few days later and it’s horribly out of date. So here’s the new and improved up to the minute update on how things went for our embryos. I’m going to write another post about how I’m feeling.

After getting the good news that 12 of our eggs fertilized, the next step was a call the following day to tell us how many embryos we had and what the quality was. Again, I was nervous for the call, but again we had fantastic news!

On day 2, we had 9 embryos (apparently the other 3 fertilized eggs were “multi-nucleated”). All 9 were doing very well – one was a 2 cell, and the other 8 were 4 cell, which according to the embryologist is exactly where they should be on day 2. She then went through the rating system with me. Our clinic has a 20 point rating, and all of our embryos were grade 18 to 20 (grade 18/19 being considered high achievers or “very nice embryos”, and grade 20 being the best grade, and apparently quite rare – we had two of those). So, since we had a lot of strong embryos in the running, we were probably heading for a day 5 transfer on Father’s Day.

Our clinic sets up a day 3 transfer appointment with everyone, just in case. If everything looks a go for a day 5 transfer, then you just have a consult to discuss the embryos and how many should go back in. So on Friday morning (day 3), I had to drink 32 oz of water an hour before our appointment, just in case we’d be transferring that day.

We got to the clinic and sat down in the waiting room. One of the nurses said to me “Is your bladder full?”. I nodded. “Go empty it.” she said. I happily went to the bathroom, relieved with the news that our little embryos must be doing well.

Our consult started with the embryologist reviewing where we were at. On day 3 all 9 of our embryos were 8 cell, which again was right where they should be. All were still rated 18-20, and 3-4 of them were already compacting (which apparently is a very good sign).

Then it was time for the Dr. to take over. He repeated what we all knew – that the cycle had gone really well so far and that our embryos were in great shape. He said that in terms of pregnancy rates, they see the same results for embryos graded 18,19, or 20, so from that perspective it would be hard to pick the “best” embryo. He also said that at this rate we can expect to have some left to freeze, probably around 4.

The Dr. also told us that so far based on how good everything looked, the IVF cycle had not given us any further diagnostic information about why we weren’t conceiving. He did say though that upto this point, the egg has been the dominant force in embryo development, but on day 3, the sperm DNA starts to take over. So we’d see what happened over the next few days and if things started to go downhill it could point to a sperm issue.

This stressed my husband out to no end, and he got pretty melodramatic with me and made me promise I would get a sperm donor if there was something wrong with his sperm (he’s not a typical male, in that he can get pretty emotional at times). We both nervously awaited the day 4 update. We still had 9 embryos going strong, 3 of which had developed into morulas, and all of which were now graded 16 to 19 (16 being average, and 17 being high average). The embryologist made a passing comment to the effect that “We discussed yesterday that we don’t know why you’re getting pregnant, but now we might have some more information.”, so of course I had to spend the rest of the day comforting my husband that our embryos were still doing fantastically well, and remind him that the embryologist had said that it was difficult to grade them on day 4.

Day 5 was Father’s Day and we went in for our potential transfer. As I’ll write about in my next post, due to some early OHSS, we went in expecting the transfer to be cancelled. Once again my husband was terrified to hear how our embryos were doing, but while in the waiting room, the Dr. walked by and told us “Your embryos are looking good.” “See?” I said to my husband. “There’s nothing to worry about!”. Of course he still found something to worry about “Good? Not great?” he said.

As expected, upon examining me, the Dr. recommended we freeze all the embryos we could and do a frozen embryo transfer in July, which we didn’t argue with at all. The embryologist then came in to give us the final verdict. “On day 5, we have 9 embryos.” She then went through all the details: we had 4 blastocysts, 4 early blastocysts, and one that was just past the morula stage. Eight of them were rated 17 to 19, all of which would be frozen that afternoon, and the last one was only rated a 14, and therefore wouldn’t make it to freeze. Finally, my husband was able to breathe a sigh of relief.

The rest of the day, despite having to delay the embryo transfer for a month, both my husband and I felt very positive about how things had gone. Every once in a while we would look at each other in wonder “Eight! Can you believe it?”.

And finally, for the first time, I was able to say to my husband “Happy Father’s Day.”

Off Topic……Kind of

My head has been swimming the last few days with something other than infertility and IVF. As I mentioned in an earlier post, we will be moving this summer. My husband’s official paperwork for his job has yet to come through, but they have agreed on all of the terms of the offer, and everyone at the new job seems to know he’s coming and has been sending him congratulatory notes. So at this stage it’s 99% for sure, and it’s just a matter of getting through some red tape before it’s 100% final.

He will be starting on August 1st, and I expect to be available to work sometime in mid August. Given that this timeline is still a ways away, and we’ll be going through IVF in April, I decided not to start any serious sort of job search until May once I knew whether I was pregnant or not. In the meantime, I’ve been focusing on getting my resume together and putting the feelers out to a few people I know who could keep an eye open for some job opportunities when the time comes.

If the IVF is successful, I would be due mid January, and starting to show when we moved in August, so my thought was that in that case I wouldn’t look for a full time job immediately (as I don’t expect anyone would be hiring me for a full time position once I waddled through their door), and instead would hopefully ride things out with some contract work through to December and look for something more permanent after the baby was born.  

I also decided that if the first IVF does not work, I will do another fresh cycle right away, regardless of whether we have any frozen embryos to transfer after the first cycle. There are a number of reasons for this:

a) Money – At the clinic I’m at now we can sign up for a program where if the first cycle is not successful, we get a significant discount on a second and third fresh cycle as long as they are done within 9 months. I figure I will probably need another fresh cycle at some point, either this time around if a frozen cycle was not successful, or later on in the future when we’re trying for #2. So doing another cycle at my current clinic right away will be cheaper than doing a cycle later at a new clinic once we move.

b) Timing #1 – I checked with my IVF nurse, and I’ve done the math and I should be able to get started on a second cycle in late June, which means that timing would work well with our move timing. Worst case scenario, I can stay here a few extra weeks once my husband has already moved. However, if we wait until we move, I have no idea when we’d be able to get started again as we would have to find a new clinic in our new city. On the bright side, unlike here where there is only one game in town, there are a ton of different clinics we could go to. However, I have no idea what the wait times are, and what sort of referral we would need to get in, and I imagine the “better” clinics will have longer wait times, and I am so sick of waiting, waiting, waiting!

c) Timing #2 – The sad reality is that I’m not getting any younger. As it is, our first IVF will be with 35 year old eggs. If that doesn’t work and we do a frozen cycle next (assuming we have any embryos left) and get pregnant from that, our next child would be conceived with 38? 39? year old eggs, which is definitely getting up there and I think makes our chances a lot worse than they are today. I’d rather have any frozen embryos from this year’s cycle(s) on standby for when I’m older, in the hopes that they will give us a better chance of pregnancy than starting from scratch with older egs (this applies to whether we’d be trying naturally, doing IUI, or IVF really). I read recently that reduced fertility as you age and enter menopause is really all about the eggs. Obviously your hormone levels play a part too, but that can be manipulated through drugs, so if you have embryos to transfer, really your chances of pregnancy even later on can be pretty good (witness all of the celebrities getting pregnant with twins in their late 40’s and even early 50’s).

d) Familiarity and expertise – Not only am I used to my clinic, but based on everything I’ve read and heard, it’s a damn good one! Their IVF success rates (especially for women 35 and over) are really good, and my RE is very respected and draws many out of town patients. I’ve even seen this a bit with my care, in that I think he has been more aggressive with certain things than other Dr.’s would have been given my history to date. So I’m nervous about starting over somewhere else where the RE may not be as open to trying new things.

So much for a post about my job prospects! I guess that will have to wait for my next post. To be continued….

Frozen Army or no Embryo Left Behind

Last week the IVF information package from our fertility clinic arrived, in preparation for our IVF cycle starting in late March. In addition to price lists for various IVF related services and medications, it included oh, about fifty forms that we had to sign. A few of them were consent forms that we understood the various risks and possible side effects of an IVF cycle, but the vast majority dealt with our potential future frozen embryos and how (and by whom) we wanted them handled.

A frozen embryo is a miraculous, yet also terrifying concept. It represents a budding future human (your own child!), yet also a potential source of guilt and anxiety if it turns out that you have extra embryos left over once your family is complete. Hence all the forms asking what fate we desired for our embryos under all possible combinations and permutations of outcomes. In one night we decided what would happen to them if one of us died, who would have “custody” in the event of a divorce, and whether they should be destroyed or donated to science if for some reason we stopped paying our storage fees and the clinic was unable to track us down to collect payment. Heavy stuff all around.

While in theory, both of us supported donating them to science, or for use in IVF instruction, in the end we decided that until we actually know what it’s like to  have our own frozen embryos, we would only allow them to be used for our own purposes. We can always change our minds later.

In the meantime, going through this process got me thinking in all sorts of directions. For example, if you conceive a child from a fresh IVF cycle, and then their sibling is born from one of the frozen embryos that came out of that cycle, really it’s quite possible that their birth orders could have been reversed…or they could have ended up as twins.  There’s such a fine line separating one outcome from another.

In a strange way, the possibility of frozen embryos also made me question my ideas about what size family I wanted. I’ve always felt that two kids would be great, but feeling that I wouldn’t want to leave any embryos “on the table” so to speak I wonder if I would want to continue to transfer any further embryos I still had at that point? Hard to know from my current vantage point how that would play out.