Tuesday, June 22, 2010

Getting a Second Opinion: It's Not Cheating

So, you've been on your infertility journey for a while under the care of an RE; you've tried a little of this and a little of that, and even received some "baby dust" virtually sprinkled by your friends... and still nothing to show for all this time you've spent agonizing over whether this month is finally your month. Well, it might be time to get a second opinion. A fresh pair of eyes on your case may just be what you've needed all along.

My fellow blogger The 2 Week Wait decided to "grab June by the balls" (her words!) and seek out a second opinion (she was supposed to be "on a break" from trying to conceive, but of course, there's never such a thing when you're dealing with IF). She expressed to me how she was a little hesitant about getting this second opinion as she had a nice rapport with her current doctor and felt that consulting with another RE would feel like cheating on her first. I could certainly relate to that feeling. After almost 2 years and more cycles than I could count on both hands, I had finally decided that it was time to get a second opinion at another highly respected clinic. (For ease of understanding, I'll call the first clinic/RE "A," and the second clinic/RE "B.") It took me a while to muster the courage to call, make an appointment and ask for a copy of my records. After timidly phoning my RE's assistant (praying that I won't have to confession the reason behind my request) and signing a waver for the release of my records, I was finally ready to make the jump.

It's always difficult to get an appointment, but if you can manage to coordinate the dates, try to get in before your next period starts, so that should RE "B" decide to run some Day3 blood work or do a minor surgery (Hystero or HSG) to cover all the bases, you won't have missed the window and waisted yet another month.

Armed with pages and pages of my long history of fruitless cycles, DH and I waited amongst the sea of other childless couples at Clinic B. After so many cycles at Clinic A, I knew the drill, but here, I was back to being a newbie -- suddenly unable to anticipate my next move or take comfort in the faces of the nurses whom I had gotten to know on a first name basis. Finally, we were ushered into the office of RE "B," which made the cheating-on-RE-A feeling that much more tangible. After some initial small talk, we got down to business: RE "B" reviewed my records, made some notes, followed by a few indiscernible sounds (Was he approving or disapproving of my prior protocols), he finally shared his thoughts...

REs, like all doctors, have very big egos. They take pride in their expertise and knowledge (as they should), so more than likely, RE "B" will have a few criticisms of your past protocols (you were triggered too late," "too much stims," etc.) But in the end, you will either leave this new place with a new and improved conception action plan or simply find yourselves back in the arms of your first RE (A one time use of the magic wand shouldn't count as cheating. After all, there were no feelings involved) . In the interest of keeping hope alive, I think it's somehow more desirable to hear RE "B" tell you how RE "A" messed up (either missed something or didn't follow the right protocol) than to hear that you're on the right track and "it's only a matter of time."

To the detriment of your emotional and physical state, having gone through a few cycles in another clinic could actually be a good thing when you're trying to move forward with a new RE -- your response to earlier protocols allows RE "B" to have a better picture of your medical history and possibly devise a more successful protocol. And perhaps, even if RE "B" doesn't have a revolutionary approach, sometimes you just need a change of scenery. Month after month of disappointments at Clinic A has probably left you with some PTSD. You may need a clean slate, a new start, heck, maybe you're just tired of getting calls from the same apologetic nurses ("I'm sorry, your Beta Hcg was negative.").

On your quest to finding your new RE, the same rules apply as your initial search. Find someone who is highly reputable and don't be shy to ask all of your questions. But having cycled a few times somewhere else, you now have the advantage of being more knowledgable about your situation, so with a little research you might find a clinic that has a strong success rate for your specific issue (i.e., high FSH, MFI, PCOS, etc.).

Most importantly, when it's time to finally break up with RE "A" don't feel guilty. Sure, you've gotten to know each other and you've probably looked up to him/her as your personal fertility-god. When we finally had our "What-The-Fuck?!" meeting with RE "A" before we decided to move on, I was heartbroken to discover that our special relationship wasn't that special at all. That I really was just "another patient." I walked in there expecting to softly break up with RE "A" only to leave his office feeling like I had been the one to get dumped. Should you not feel the need to face RE "A" then don't feel guilty to quietly walk away -- just slip out of the surgical chair, close the door behind you and no need to leave a Post-it note saying "Goodbye." This is the business of making babies. No one is doing this out of the kindness of their heart. You and your dreams come first so give yourself the freedom to play the field until you find doctor-right and not doctor-right-now. 

Friday, June 11, 2010

It's Not You, It's...

Last time I talked about how your weight can affect your fertility. Today I'd like to talk about how infertility (IF) affects your weight. In truth, your weight is partly a physical manifestation of the psychological toll IF takes on you. Three studies have shown that a person who is going through IF experiences the same psychological distress as someone going through cancer. Yes, cancer! I just don't understand how our law makers can know this and still not make IF coverage a mandate in all states. But I digress...

As much as the psychological effects of IF is the elephant in the room, it is often overlooked by REs/IF clinics. Unless you are going through a donor or gestational program, no one in the medical field hands you a list of therapists to visit along with your the stack of brochures. Many women feel deep anxiety, depression and a great sense of loss. After all, we played with our dolls when we were little girls and eventually got married with dreams of filling our home with kids, but now we're stuck with this ordeal. These feelings of sadness are further exacerbated by the hormones that are associated with the medications that we take during the course of IF treatments. Several studies have confirmed that the use of medications like gonadotroprins (GnRH) increases the patients' feelings of depression. So the equation goes something like this:

Stress of IF + Meds + Pregnant Women Around You = Depression

We each have our own way of coping with depression and some of us translate this pain into an unhealthy relationship with food. This relationship can turn unhealthy and lead to eating disorders, which perpetuate the IF issues: anorexia in one's desire to control the only thing you can (i.e., your weight) or compulsive eating in one's finding comfort in food. Our loss of self and self-esteem cannot be taken lightly. I always encourage you to seek some counseling.

Unfortunately, in additional to the extreme mood swings that comes along with IF medications, there are also physical ramifications that are involved with GnRH drugs (ovulation stimulating drugs) -- primarily bloating and weight gain. So you're not imagining things, you really are a few pounds heavier. You might find it petty to bring up your weight concerns to your RE in light of the complexities of your IVF cycle, but I do think it's reassuring when you get validation from your RE of the physical transformations you are reluctantly experiencing. Most of the weight is likely to go away after you've ended your IVF treatments. Although, I know for many of us who have done back to back cycles through the years, the weight gain just keeps adding up, making it more difficult to get out of the vicious cycle. Staying away from strenuous exercise, you should take part in light activities like walking or swimming. It will help release some of the tension and make you feel more connected with yourself. 

Which ever aspect of weight/IF scale you fall in, be good to yourself. While your weight is not just a number, don't let it define you either. You are strong and determined to have this baby. Be kind, be accepting and do not be too proud to seek help. 

There is a song by Alanis Morrisette that I love and that I would like to end this entry with: "That I would be good." I hope the lyrics give you the same comfort it gave me.

Tuesday, June 8, 2010

What the Scale Isn't Telling You About Your Fertility

Someone recently asked about the correlation between weight and infertility. I thought that was a really good question and one that is not discussed nearly enough. When going through infertility (IF) we are so focused on what's going on in that mysterious region south of our belly button that we neglect to see what's going on right before our eyes. In thinking about my friend's question, I saw two possible ways to tackle this topic: on the one hand, the effect of weight on one's fertility; on the other is how infertility affects our weight. Today I'm going to focus on the former and provide you with some topline information for your to discuss with your doctor.

Being too thin or too fat can affect your fertility. In fact, an estimated 1 in 5 is coping with IF has an underlying issue with an eating disorder. You do not have to be dealing with a clinical eating disorder to be struggling with weight and IF. People with an eating disorder just happen to be at each extreme of the spectrum, but there are many gray areas before you can achieve a healthy middle.

In a culture where you can't bee too thin, it's very difficult to feel sorry for women who are barely filling a size 0. But in truth, an unhealthy thinness can have a huge effect on your fertility. When you are just 10-15% below your healthy weight (for your height), that corresponds to a third of body fat loss, which consequently leads of menstrual dysfunction (this is called the "Critical Weight Hypothesis"), a common cause of IF. So imagine what someone dealing with anorexia is doing to her body. Living with a very distorted sense of body imagine, people with this eating disorder starve themselves to a point where their organs and reproductive systems are affected. Sadly, in some cases, even after recovery, women who have dealt with anorexia for years may have caused permanent damage to their body. Another group that I would include under "too thin to ovulate" are over exercisers -- those women who spend hours at the gym, running miles and miles on the treadmill and then jumping into a aerobics class, to eventually treat themselves to a mini-smoothie. While the scale might indicate a "healthy weight," the lack of body fat affects them in similar ways as a someone who is overly thin. Behind those perfectly defined abs are women who have very little body fat and therefore have trouble ovulating and hence, conceiving. Whether you are dealing with anorexia, over exercising or are simply too thin, you are very likely to suffer from amenorrhea (no ovulation or menstrual cycles), irregular menstrual cycles, PCOS and reduced egg quality. While it is important to feel good about yourself, especially during a time when everything has come into question as a result of your IF, I urge you to focus on increasing your food intake. Include more good fats (avocados, nuts), lots of protein (chicken, milk) and Omega-3 rich foods (wild salmon). Avoid artificial sugars, especially if you're struggling with PCOS. And don't over exercise. Trust me, your baby isn't going to care if you have a six-pack.

On the other end of the spectrum are women who are overweight. Some women are genetically predisposed to being overweight, others have grown from being an overweight child to an overweight or obese woman, and lastly you have your compulsive eaters -- this overlooked eating disorder involves bingeing on food without purging. To be considered overweight you need to be in the 25-30 BMI, and anything over 30 is considered obese. Above I talked about the importance of some body fat, excessive body fat can have similar effects to your reproductive system as someone who is too thin. Some overweight and obese women suffer from amenorrhea, PCOS with insulin resistance (an inability to process sugars), which ironically can be both the cause for the extra pounds and the result of them. Studies have shown that overweight women aren't as much affected by IF as overly thin women, but the pregnancy risks associated with the excessive weight increases your chances of gestational diabetes and pre-eclampsia. Following a lean diet high in protein, whole grains, fruits and veggies, combined with regular exercise still remains the best way to manage your weight. Recently, women who are overweight and PCOS have found some success when taking Metformin, which has helped with more regular and higher quality ovulation, and yes, weight loss.

If you have been experiencing unexplained weight gain or weight loss, your first step should be to check your thyroid function. Hyper and hypothyroidism can affect your weight and as a result your reproductive system.

Discuss any concerns you have about your weight with your doctor and don't be afraid to meet with a nutritionist who can guide you in the right direction.

Stay tuned for my next entry where I will discuss how IF affects your relationship with food, your body and your mind.

Friday, June 4, 2010

What to Expect When You're ... IVFing

In my last entry, I talked about the emotional transition of letting go of IUIs and gearing up to IVF. So today I'd like to give you a little "What to Expect" -- the IVF version.

There are countless sites that will give you specifics about the technicalities of IVFs and the various protocols that your RE will consider before you start a cycle. What I'd like to do is to give you the broad strokes of things that will take place and the things you need to prepare yourself for as you embark on the IVF marathon -- so pardon the cut-and-dry tone of this entry. 

When you decide to go through with an IVF, first call the IVF coordinator at your clinic and reserve your spot for the upcoming cycle. It would suck to get yourself emotionally ready for a cycle, only to find out that they can't squeeze you in for another 2 months. Clinics like to cycle people in groups and every few months (usually 3), they close down their embryology lab for clean ups. So you need to make sure that your period falls during the weeks/months when the lab is open. 

Next, if this is your first IVF, you'll to sign up for injections class. The classes are usually held by one of the nurses and will walk you through the various protocols and the respective injections. Some will be pre-filled syringes (e.g. Lupron), while other will have to mixed (e.g. Menopur). You should attend this class with your partner. Some women prefer to have their partner do the shots for them. I did the large portion of the sub-Q shots myself, but DH would do the progesterone shots (it's hard to aim for your own butt, but I have done it myself on more occasions than I care to remember). Should you need a refresher on how to mix and/or inject yourself with a specific stim, check out this site. It contains a video for every stim medication you will be using; from how to prep the injection site, to mixing, to injecting. 

On Day 3 of your period, you will go in for blood work to check your hormone levels and make sure that your RE doesn't need to do any last minute tweaks -- most importantly, your E2 should be less than 20. An ultrasound will be performed to make sure that your ovaries are quiet and that there are no cysts. Suppressing your reproductive system allows for your RE to control the stimulation of your ovaries in order to obtain as many eggs as possible. From this day forward, you will be going in for monitoring at least every other day (as you get closer to trigger, it will be every day). 

If all looks good, you will begin taking your gonadotropins, which are your ovary stimulating drugs. The duration that it will take for your follicles to be fully mature will vary on your protocol and how your body responds. My stim period was usually around 10 days. During this time, your RE will monitor your progress via blood work (general rule is for your E2 to reach 150-300 IUs for every mature follicle) and ultrasounds. It's a very fine balance that your RE is trying to achieve before deciding when you're ready for trigger -- a large portion of your follicles have to be mature (18-23mm), but not so much so that you might prematurely ovulate. Also, if the blood work detect a slight LH surge (signal that you're starting to ovulate), your RE will should be able to suppress it. This is why it's so important to attend daily monitoring. There is very little room for error. Sometimes your RE will let go of one or two mature follicles in order to give a larger group of them to catch up. One last component to determining your trigger date is the state of your uterine lining. By the time of trigger and/or transfer, your lining should be triple striped and around 8mm (think fluffy cushion = good place to grow for the next 9 months). I will talk more about uterine linings another time (mine never cooperated).

The stimulation period can be physically uncomfortable. As your follicles mature you will feel bloated and have some tenderness in your lower abdomen. That's because you are growing so many follicles. Everyone responds differently, but rule of thumb is to have around 10-12 mature eggs. But more or less is fine too. At the end of the day, it's about the quality of your eggs and not the quantity of them. For instance, women with PCOS tend to produce more eggs, but they also tend to be lower quality. It is essential that your RE monitor you in order to avoid ovarian hyperstimulation (OHSS), which, if left untreated can cause fluid collection in the abdomen, kidney failure and twisting of an ovary. So keep a close watch on your discomfort level and bring it up to your doctor. During the stim period, avoid working out and doing any strenuous activities. Also, avoid eating soy based products (milk, ice cream, etc.) -- soy mimics estrogen, hence may lead to inaccurate readings of your blood work. Reduce your caffeine intake -- it's hard letting go of that 4th cup of coffee, but you can do. Try to keep the stress levels in your life to a minimum and focus on your health and your growing follicles. You're getting so close!

Approximately 34-36 hours before your egg retrieval (ER), you will be asked to take your Hcg shot in order to release your eggs from the follicles. You MUST take the shot at the exact time you're given by your clinic (not an hour before or after). As I've said before, there's no room for error and timing is everything. If you've been doing most of your stims yourself, well tonight's the night for your DH to show that he was paying attention in class. The Hcg shot is a larger needle that has to be given on our tush. 

The morning of your ER will be like any surgery day -- no eating or drinking prior to surgery. Your partner will have to come with you. He will provide a semen sample (remember no ejaculation for at least 48hrs but no more than 4 days). You will meet with your doctor and the anesthesiologist. You'll be placed on a surgical bed: 10, 9, 8 ... Before you know, you'll wake up in the recovery room with your partner waiting for you. A nurse will check on you regularly and when you're ready you'll have to make a trip to the bathroom. There will be some blood in your urine (don't panic!), but if you can urinate, then you're ready to go home and wait for the emrbyology repot. Plan to take a couple of days off work. This is the time to be pampered by your partner -- eat light foods, drink lots of electrolites (Gatorade), and rest.

As you prepare your body for your embryos to come home and hopefully implant, you will start taking progesterone shots. Most are sesame or peanut oil based. These were the most painful part of the cycle for me as the oil is thicker and the needle quite large. Simultaneously, some REs will also have you take estrogen patches. These are pretty easy to apply. Both of these hormones are meant to prep and sustain the (hopeful) pregnancy.

On the 3rd day after your ER, you'll get a call that will let you know how your embryos are doing -- how many there are, how they look (embryologists grade each embryo and ultimately select the ones to be transferred), and most importantly, whether you'll be doing the embryo transfer that day or on Day5 (blastocyst stage). Again, your partner should come with you. When it's time to go in for ET, drink lots of fluid (no peeing right before the transfer!) and ask for some valium. It's important to remain relaxed during the transfer. Some studies have shown that a difficult transfer can hamper success. Your RE will discuss how many embryos he/she recommends be transferred. A good clinic doesn't need to transfer more than 3. In fact, these days, IF clinics aim to transfer 1 or 2. I know you have a lot riding on this cycle, but resist the urge to transfer more than that -- unless you've been living under a rock, you must have heard of Octomom. After the transfer, you can continue to lay down at the clinic for another 30 minutes. You'll probably receive a picture of the embryos that were transferred. Then, take the rest of the day off to soak in the bliss with having your embryos home.

Twelve to 10 days after ET, you'll go in for your beta results (pregnancy results). A nurse will call you with the outcome (unless you already cheated and took an HPT). I hope that it will be fantastic news for all of you. For the next few weeks, they will keep a close eye on your Hcg levels and your progesterone. You'll have your first ultrasound around 6.5 weeks and you'll officially "graduate" onto the the real world around 8 weeks.

My most important advice is to expect the unexpected. Not a single one of my cycles was text book. There was always something that led me to question if the cycle could possibly work under the circumstances. And my worst cycle on paper (fewer embryos, thin lining, etc.) was the one that gave me my beautiful son. So it's not an urban legend, it really does take 1 embryo (perfect or not) to make it happen. Now tie up those running shoes and remember, slow and steady wins the race. I'll be there along the way cheering for you.