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.”

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.