Never Out Of The Woods....

Damn. Just when you think everything is moving on the right track and you're good as gold, synthetic hormones rear their ugly heads.

It was just hours ago that I was feeling super optimistic and hopeful about this cycle. And then I went in for the post-Clomid follicle check. 

<crash>

As I mentioned, my dose was doubled this cycle to 100mg in hopes of higher egg recruitment. Didn't do much... My largest follicle is measuring 18.9mm and the next two, in the left ovary that loves to ride the short bus, are measuring 14mm and 11.2mm. And my uterine lining, which normally measures in the mid 8cm in thickness (very good) is only measuring 6cm today (unacceptable). 

Translation?

This double dose feels like a complete waste. It didn't do what it was meant to do in terms of egg recruitment and it thinned my lining to a point that requires me to load up on another synthetic hormone. Now I have an rx for 4mg of estradiol each day. My insurance company initially denied coverage on the prescription and then the pharmacist had to override their judgement in order to fill it for me and additionally expressed concern over the higher-than-normal dosage. We only had about $450 left in our FSA account last I checked which I expected to just about cover this last cycle. But going on the estradiol with such a thin lining means that I need an additional ultrasound before IUI trigger and transfer. So, an extra $180 out of pocket gets thrown at this. 

Fuck off, man. Acupuncture Jane, help me out!

Double Down on the Emotional Rollercoaster

Long time no see, huh? See... the thing is... everything was feeling really stable for a while there. I felt like I was on a really good track going the natural route. And then the Clomid hit.

Well I guess that sounds misleading. Rewind the tape. Go back about 5 weeks. We visited friends in Cali (with a side trip to Napa, woo!) and while we visited this super sweet family with two little boys and a brand new house, I started my CD1. Yep, blood in the panties (ugh, what a gross word, panties, makes my arm hair stand up). Given our surroundings at the time, I guess J and I got to feeling antsy so I made the phone call to CCRM on Monday saying that I'd like to go for another Clomid cycle. A day later, I went for my cyst check, was obviously all clear, and started up the same 50mg clomiphene prescription. The IUI was relatively uneventful and the following two weeks were equally uneventful. I   knew before the two week wait was over that the only thing I was waiting for was the dreaded period. But, lord, did that motherhecker hold out on me. I spotted for 4 days before it finally came through. When I called CCRM to report my CD1 (again) and schedule a cyst check (again), I learned that Dr. M wanted me to try this final IUI cycle with 100 mg.

So we're doing a big, bad double down on the Clomid. In the real-life world, I've had massive drama with my brother; a big fight with my mom due to the drama with brother; we adopted a puppy; I interviewed for a job, got the offer and turned it down; we fell in love with a house, put in an offer, won the bid, and then were told 20 minutes later the other buyers outbid us; ate and drank plenty of things I shouldn't have; and my dad was in a car accident (dad is fine, car is totaled).

ohmigosh.breathe

Through all of that, I frequently found myself thinking, "Gosh you're handling this well. Prior to the acupuncture and yoga biz, you'd be flipping out right now!" Welp! It took me a solid 2+ months to get on that straight & steady track and took 2 days of Clomid for all that hard work to unravel. I just totally fell apart last night. Looking back, I don't even know what the catalyst was. I recall going into the bathroom to get ready for bed and just staring a myself in the mirror. I felt overwhelmed by a feeling of worthlessness, hopelessness. Cognitively, I knew there was a lot of blame to be placed on the medication, but that surely didn't stop the tears from coming on hard and fast. It's hard to shake the feeling of failure when you believe you're doing everything you can and still finding no success. Helpless.

And then there was the episode (two episodes, coughcough) of Transparent on Amazon Prime that had me choking back tears this morning. Oy. But there was going to be a peak to match my low, dark valley! Two bright spots in my day were on the way...

The Lost Cycle

I knew something was off but had no thoughts on what it could be. I got the period, but a day late. That on its own is unusual for me. It showed early Saturday morning as we were getting ready in Breck for a huge hike we'd planned. I was fully prepared for an uncomfortable hike - advil, prescription pain killers, extra tissues and plenty of lady supplies in a ziplock bag.

A couple of hours into the hike I was in need of a toilet, stat. But when you're in the middle of a mountain range, there is no powder room in which to freshen yourself up. I eventually found a short pile of rocks to tuck behind and fix things up. It was ugly. I haven't had to change my supplies like that within a couple of hours for.... years..... I mean, so. many. years. Ugh.

Well ever since that episode on Saturday morning, I've had virtually nothing. A touch more than spotting, but less than what I'd consider "light." I went in to have my ultrasound checkup this morning to clear me for the Clomid script.

I left empty handed. But not with empty ovaries. My right side has a big, black cyst. 3cm. So this will henceforth be known as the Lost Cycle. My body won't even produce a mature egg so that we can try naturally. So that's that. I sent a panicked email to Jane the acupuncturist to get some perspective. I completely fell apart in the car once I arrived home. Big, loud, pathetic sobs with massive tears just exploding from my tear ducts.

I'm lost.

Experimenting with TCM

Yay! More acronyms! TCM has floated around in various blogs I've meandered through and some fertility books and websites. The acronym doesn't usually "stick" for me and I need to go look it up, but I think it's here to stay. Traditional Chinese Medicine.

When we first met with Dr. Minjarez at CCRM, she did mention that I may want to consider acupuncture, as several of her patients had seen some success in pairing the western medicine ART techniques in which CCRM specializes and traditional eastern methods with which many of us in the US are unfamiliar. My takeaway by the time of our regroup in June was that our numbers were so strong, an IUI was sure to be a success - I'd consider the additional spend on acupuncture only if the IUI didn't work.

So it was only one unsuccessful round for the IUI. I haven't totally lost hope or anything. But I just figure, if a little needle poking and some of the dietary wisdom from the ancient Chinese can only assist my attempts at 'assisted reproduction,' why not go for it? I anticipate starting the Clomid again tomorrow and having another transfer two Thursdays from now. In the meantime, as part of my TCM experiment, I've had my first acupuncture session, I ordered a recommended book (The Infertility Cure), set up two more acu appointments related to my IUI schedule, and started up 3 additional supplements - Vitamin D 4000 mcg, methylated folate and a spirulina based greens powder. Dr. Jane has also prescribed me yoga at least 1-3x a week and aerobic exercise 3-5x, as well as a particular kind of meditative deep breathing.

When I read things like bananas encouraging "dampness," and are therefore something I should avoid, I admit I feel some skepticism. But it's also the same practice that discourages refined sugars, processed foods and stress. That all makes good sense to me! If I need to avoid bananas in favor of plenty of other veggies, fruits and good grains, I guess I can make it work. Like I said, it is a bit of an experiment, but it is also something I'm trying to approach with an open mind and some enthusiasm. Cause hey, you never know!

Pre-IUI Ultrasound

Today was my first check up since starting the Clomid. The ultrasound showed some impressive results!

8:30am - Monday, July 7
The first part of my appointment was the actual ultrasound with Jessica. It was pretty straightforward and I watched on the screen while she measured various follicles. Not much was going on with my left side... as per usual, at this point... but there was some activity going on in the right ovary that she was checking out. The process didn't take long, maybe 10 minutes total. Afterwards, I dressed and headed back to the waiting room and gorged myself on back issues of US Weekly. Amazing how many freaking celebrity babies are in that mag. Including a special spread on North West's first birthday party! Oy...

9:00am - Monday, July 7
My nurse called me in to review the results and do a backdated IUI consult. (Normally this is done prior to starting your Clomid course. I couldn't do the consult at the proper time since we were traveling, but Dr. M went over a bunch of important dos and don'ts at the June 20 appointment.) Other than the superficial side effects from Clomid, like mood swings and hot flashes, there can also be internal side effects. It frequently dries up whatever cervical mucous there is (impeding the production of eggwhite mucous which is problematic for couples using Clomid with intercourse), and can hinder the growth of a nice, fluffy uterine lining which can complicate implantation.
My ultrasound showed really positive results! My lining measured a healthy 8.9mm, which is right where it should be, even in a 100% natural cycle. As the ultrasound tech had suggested, nothing was really happening on my left side. There were three follicles, all measuring less than 10mm and not nearly large enough to mature and rupture as eggs. On my right side, however, there are three good looking follicles. My measurements are 22, 19 and 15mm. Our nurse gave me two insights that I thought were particularly interesting: First, if there are more than 3 viable follicles, they will cancel the IUI cycle due to the chance of multiple fertilizations. Second, as you can probably deduce from that statement, it is more common for the Clomid to stimulate only two viable follicles rather than three and so we've just upped our chances of a multiple fertilization. I had to sign an informed consent form to go forward with the cycle as scheduled.

***

Let's just pause for a moment. People can get real fired up when they hear any of the following: "multiples," "twins," triplets," and "Clomid" even. For people labelled as "Unexplained Infertile" like ourselves, it's important to remember the law of small numbers you're dealing with, as well as the risks associated with multiple embryos. For starters, our chances of getting pregs this cycle are only 8-12%, which I believe is only about half the likelihood of a normal couple conceiving in a given cycle. If we are lucky enough to end up with fertilization and implantation and a BFP (yep, "big fat positive" test), the stats on having two of those eggs become fertilized and give us twins? Only 10%. I'm no mathematician, but 10% of an 8-12% window seem like awfully miniscule odds! And one step further, the chances of triplets - all THREE of my eggs being fertilized - would be under 1%.
In the years that Clomid has become a popular prescription for fertility issues, doctors have come under fire for the resultant multiple births and associated risks. Due to that, many REs (reproductive endocrinologists) are extremely sensitive to multiples and therefore do what they can to control the math.
Women have twins. It happens, naturally. What's the big deal?? That's what I had thought, too. The most common risks in a multiple gestation probably don't seem all that scary to someone who hasn't had a baby because we hear about happy-ending stories all the time: poor vision, pre-term labor, low birth weight. Modern medicine makes these things seem commonplace, but as an expectant mother, you don't want to see your infant up against any of these things. There are also very serious complications that range from miscarriage, stillbirth, diminished brain development (i.e. cerebral palsy) to problems for mom like elevated blood pressure, diabetes, and greater incidence of nausea/vomiting. So... no thanks.

***

The original plan Dr. M devised for me meant that I would monitor my cycle for ovulation with OPK strips and then call the office when I had a positive. Given my great response to the medication and the size of the three follicles, our nurse determined it was best to trigger my ovulation with Ovidrel (an injection of hCG, human chorionic gonadotropin). Waiting too long could either allow the follicle to grow too large, or allow ovulation to occur naturally at a time that wasn't ideal for the IUI transfer in the office. I was given a pre-filled syringe of Ovidrel with strict instructions to get it home to the fridge and then administer it PRECISELY 36 hours before my transfer. So, 9pm tonight. Yipes!

I'm excited. I'm optimistic. I'm hopeful. I'm also a little nervous. Excuse the pun, but I'm afraid of putting all my eggs in one basket - meaning, the mathematical odds of this working on the first try aren't terribly high. So I'm trying to toe the line between optimism and realism. Not an easy line to draw. The current strategy: put all of my faith behind this procedure - we are very strong candidates for success - and if it doesn't work out, know that we've still got plenty of resources to lean on for more attempts.

HERE WE GO!

Cycle Day 7

Today is the seventh day of my cycle and I've taken the full course of clomid- all 5 pills at 50mg doses. I'm definitely feeling the overstimulation in the ovaries, though primarily in the right side. In my previous two natural cycles I've had ultrasounds that showed my right ovary was dominant and my HSG revealed a very slow spill of dye on the left. Just gives me pause, room to wonder what the deal is with my left side and why it's riding the short bus. 

Aside from feeling my hyperactive ovaries kicking into gear, I'm pleased to say I'm not feeling many other symptoms - probably because I'm on what seems to be the lowest dose. This last week I've been "vacationing" at my parents' in NJ and my mom and I are swapping lots of stories, memories, general catch up stuff. Whenever she lobs one at me that is even remotely emotional I get crazy choked up. Funny enough, that's the extent of my over-emotional, PMS-y mood swings. So far :) J's parents are visiting Denver with us for this upcoming holiday weekend and I'm a little anxious about ending up with sick mood swings while they happen to be staying with us. Eeek! I'll need to remember to stay focused, present and calm. 

Rx: Clomid

So we had our regroup appointment with Dr. M on Friday the 20th. As I mentioned, I was kind of freaking out about it, expecting a bunch of news that I wasn't excited about. Stuff that would just extend our timeline.

Well! Wasn't I surprised!

VARICELLA
My number one freak out was about the varicella (chicken pox) vaccine. I felt devastated when our nurse told me that it was highly recommended that I start the series. It is a live virus vaccine taken in two doses separated by 30 days. After the second dose, you must wait an additional 30 days for the live virus to dissipate and not put a potential pregnancy at risk. Looking at my current cycle on the calendar, that was putting us at a three month delay which just felt like an absolutely crushing blow.

When I discussed my chicken pox history with Dr. M on Friday, however, she gave me a pass! Her opinion was that after having the vaccine only 2 years ago and having such decreased immunity to it, I am most likely in the small minority of people who are never fully immune. No continual vaccinations will change that. I just need to be careful, of course, about who I am around and the level of travel I plan over the next several months. No problem!

ENDOMETRIOSIS
After my fun trip to the ER on Day 1 of my last cycle, I had a hunch that Dr. M may suggest a laparoscopy to look for endometrial tissue outside of my uterus. She certainly was concerned after hearing my account, and the procedure was suggested. However. Dr. M also cited recent studies showing that removal of the tissue is really only effective for pain management, not fertility. Since my pattern seems to be a entire year without much pain at all, it seemed like overkill to have a surgical procedure to A) look for something that may not even be there and B), if found and removed, would likely not affect fertility. There are risks with even the simplest surgeries. If you were desperate to have a baby and someone was telling you that your entire reproductive area would be at risk for infection or worse... how likely would you be to sign up? I'm a total ninny about pain, but this pain only jumps out and grabs me once a year. It's just not worth the risk.

Putting a laparoscopy on the shelf also takes away a month (cycle) of surgery/recovery time. Deciding not to go forward was a major win for our timeline and also fully supported by Dr. M. We're feeling good about the choice. She also prescribed me vicodin as a "just in case" measure so I can stay out of the ER if there is a next time.

DRUGS/ASSISTED INSEMINATION
My next freak out was a bit of a catch 22. I'd started feeling really weird about the concept of someone else impregnating me in a lab. So impersonal, the very definition of clinical, it made me feel sad to think that J wouldn't even be in the room when I got injected with the magic juice. The catch 22 here is that I also realize that we are basically out of options now. There's no point in continuing to try unassisted.

Dr. M's assessment: I will start Clomid starting on Day 3 and we will try for an IUI cycle. Clomid goes for 5 days. Around Day 10 or 11 I am scheduled for an ultrasound to measure my follicles. At that time I'll also be doing OPK testing and then they schedule J to come in to provide his sample. The lab takes 2 hours to "wash" the sperm and then I will come in to have the washed sample inserted into my uterus. No, it's not romantic. But maybe it'll finally be the solution we need.

This should feel similar to having a pap smear. After the procedure, I get about 10 minutes to rest and then just go about my day. Go about my day? Seriously? No sure how I'll be able to do that. An IUI cycle is far less expensive than IVF and so we can go a few tries in terms of affordability. One caveat of a Clomid-assisted cycle is that you should only go for three cycles on this medication. I suppose because of the effect that it has on your hormones and the overstimulation of your ovaries, it starts to get risky to use it for more than 3 cycles without a break.

So we're starting right away. None of the delays that I was so worried about in the last couple of weeks. This pretty much puts us exactly where I hoped we would be on the calendar when we first started talking to CCRM. A week ago I was thinking that we had to wait for three months. Now, in one thirty minute appointment, I'm carrying this hope that in the next three months we may have some good news! What a relief. On the one hand, I almost want to celebrate. But that feels a touch premature right now. For the time being, we're happy to just feel a sense of relief and be able to finally make forward steps.