Intrauterine Insemination (IUI)

Assuming that all looks pretty good for you and your partner, one of the first steps on the path to conceiving your baby through Artificial Reproductive Technology (ART) will be to try a few IUIs. Either because your RE thinks you need just a little extra help or because you need some time to ease into IVF, an IUI is a low-tech procedure that has brought success to many. Also, of all infertility treatment options, IUIs are more likely to be covered by your insurance, so if your RE thinks you might have a shot, why not give it a try?

There are two types of IUIs: a natural IUI cycle -- where you won't take any medications and your RE will monitor your natural ovulation to perform the insemination -- or a medicated IUI (most common). A medicated IUI entails taking either oral meds (usually, Clomid) or injectables to stimulate your ovaries. If you're using injectables, I would keep an eye out that your are not over-responding to the drugs and making too many follicles -- that's how you can end up on the Today Show with sextuplets. You should be monitored carefully.

Timing is everything, so once your RE determines that your follicles are mature and your LH is about to surge, you will be asked to take an Hcg shot to help release the egg(s) within 36 hours of the shot*. When given the green light, make sure that your partner doesn't ejaculate until the day he's due to provide his semen sample. On the morning of your insemination, your partner will make a deposit. His sperm will will be washed and prepped for your visit. The procedure is quite simple and painless: the washed sperm (don't be scared, it's going to look bright pink!) is placed in your uterus via a small catheter (think pap smear test). You can lie there for 15-20mins (take your iPod) to make sure all the sperm are swimming to the top and not leaking out. Fourteen days after your insemination, you will stop by the clinic to take a pregnancy test.

The most important thing to remember when going down the IUI road is to set a limit to them. Statistically, if you haven't gotten pregnant within 4 IUIs, your odds of getting pregnant from that point on are quite small. It's simply not worth wasting your time with them if you are paying out-of-pocket or are working against the clock; IVFs are far more effective. So if you're RE is encouraging you to try IUIs with no end in sight, I say get out of there fast.

*Some studies have shown that the success rates of IUIs can increase up to 6 percent when you do a double IUI, meaning you are inseminated two days in a row. In that case you will go in 24 and again 48 hours after your Hcg shot. I guess you could try a double IUI if your RE is open to it (although if your insurance company is paying for the IUI cycle, they will probably reject payment for the second insemination.)

It Takes a Village to Make a Baby

It's a rude awakening to realize that you will not be creating your baby the old-fashioned way. When you look at your child, you will not remember the romantic situations that preceded his/her conception -- no candlelit dinner, no exotic vacation setting, not even the mundane sex on a school-night. In your case, you will remember the countless shots you took to your abdomen, the daily visits to the clinic for monitoring, the poking, the prodding by more doctors and nurses you can count on both hands, the cold surgical rooms, the anxiety.

The sterile environment of your clinic will become your second home: you'll sign in, wait in a sad room sitting on neutral furniture from the 90s with many other women -- all more anxious than the next -- and hope they call your name soon so you can get out of there. You'll go into the blood draw room, where you'll be lined up but hidden ever so slightly by hospital curtains. You'll try to be pleasant with everyone, because after all these nurses are often times your lifeline; they will call you, give you directions and sometimes they'll break the bad news. Then you'll be ushered into the ultrasound room, where you'll take off everything from the waist down. You've done this so many times, you've lost all prudishness. Staring at the paint-by-numbers art hanging on the walls, you'll patiently wait for your doctor (or ultrasound technician) to knock on the door. You'll wonder how things look in there and what's next. Finally, she/he will walk in and ask you how you are and get to work before you get a chance to answer. You'll robotically say you're fine, but wish you could answer that question honestly: I'm depressed, lost, isolated. Infertility sucks... You'll get your update on your follicle count and quickly get dressed. But not so fast, because you have to stop by the billing office to make sure to pay your co-pay, because after all, this is the business of making babies.

Oh, and let's not forget the best part: you and your partner won't ever be in the same room when your baby is actually being conceived. You had your eggs retrieved in an operation room while your partner ejaculated to an undesirable porn magazine. Romantic, isn't it? And while you're home, wondering what's going on, an embryologist will make the introductions: "Egg, meet sperm!"

So baby-making didn't quite turn out like you'd imagined, huh? You probably won't be able to share any of this with your future child(ren). But the one thing you will have that others won't is a picture of your baby/babies when they were only embryos and that's priceless. You will get attached to that picture they'll hand you at your embryo transfer. In fact, I remember DH drawing arrows with a name for each embryo. If that cycle works, you'll keep that picture forever. If it doesn't, you'll shove it in a folder, along with the rest of them, where Little Anna, Jack and Laura will be nothing more than another scar on your heart.

I wonder what I will say when my child asks me about where he came from. I don't think I have an answer to that just yet, but I will be able to show him a black and white image of himself, and tell him that he was loved when he was only made-up of 8 cells.

P.S. I heard about this children's book called "I can't wait to meet you" by Claudia Bates. Finally a book to help us tell our story. I'll review it on a separate entry.

Testing, 1, 2, 3: Preliminary Tests Before IVF

One of the first things your RE will do is to run a few preliminary tests to help determine what may be preventing you from getting pregnant or staying pregnant. I'm hoping that by this point you had your OB/GYN run the baseline hormone tests (FSH, E2, P4, LH), but if not, then your RE will definitely do so.

Next, she/he will do an ultrasound and check if there are any visible cysts, polyps or anything out of the ordinary. If your RE discovers cysts on your ovaries, you are most likely suffering from Polycystic Ovarian Syndrome (PCOS), which can result in anovulation and is a common cause of infertility.

You will be asked to make an appointment for a hysterosalpingogram (HSG) where your RE will inject a contrast dye that will flow through your fallopian tubes to provide a clear picture of your tubes and uterus. An HSG is done 2 to 5 days after your period has ended but prior to ovulation. This is an uncomfortable procedure (you will not be put under) and some might say, a bit painful. Come prepared with a sanitary pad, some Tylenol and ideally take the rest of the afternoon off. Don't skip this test; it allows your RE to see if your tubes are open and to rule out uterine abnormalities like polyps, adhesions or fibroids.

As I'd stated in my last entry, it's important that you write down your conception journey and provide your records from your OB/GYN. Certain causes of infertility are not easily detectable from a simple ultrasound or blood tests; that's where your personal history comes in. Endometriosis (Endo) is one of them. It usually presents itself in the form of very painful periods, frequent miscarriages and heavy periods, and sometimes, nothing at all. Endo cannot be completely diagnosed and/or treated without a laparoscopy, which isn't part of the preliminary tests that your RE will order. But if you have experienced some of its symptoms, your RE may want to do a laparoscopy to confirm Endo and clean it out.

Another test that not all REs will do is an endocrine test to look at your thyroid function. Thyroiditis is a common problem and can lead to several other issues such as excessive weight gain or weight loss, and of course can affect your ovarian function (anovulation being one of its results). So if your RE doesn't run this test, then make an appointment with an endocrinologist ASAP. It's a simple blood test that can be done at any time of your cycle and the results will be available within a couple of days.

Last, but not least, your partner must get a semen analysis. The test can be done on the same day as your first consultation with your RE or he can come back on another day. But my advice would be to have him provide a sample on the same day as your consult -- he's already there, he can't run away. Get him tested. For that, make sure that he hasn't ejaculated in at least 48 hours but no more than 72 hours. If you read my first entry, you know why.

I will discuss many of the above possible outcomes and test in greater detail in my upcoming posts. Until then, remember that these tests (could) hold the key to unlock your infertility. Being able to finally determine the cause(s) of what's been preventing you from having your baby will empower you.

Finding Doctor Right: The Art of Picking Your IVF Doctor

Once you've made the decision that you need to call in the big guns, it's time to pick an IVF clinic and a reproductive endocrinologist (RE). Before getting into the specifics, two key things will play a big role in your selection: (1) which doctors, if any, does your insurance cover and  (2) how many IVF clinics are in your area?

Get your researcher cap on and get to work -- you research before you buy a car, right? Well this is a far greater investment, so don't use any shortcuts. If you have the opportunity to chose between a few clinics, it's very important that you look into them and not simply go for the closest one to your house (we eventually flew from NY to Denver). After all, you are going to be spending a lot of time there between appointments, procedures and follow-ups. And you might not know this yet, but you will look up to your RE as though he/she is now your new god. I certainly did -- I looked at my RE for answers, for guidance and to just make this miracle finally happen for us (more on RE/patient relationships soon).

First, look at hard fact, and by facts I mean statistics. Visit the Society of Assisted Reproductive Technology (SART) to find the clinics in your area and compare each clinic's success rates to the national average. Where does the clinic you're considering rank? The results are broken into 3 main categories: Fresh IVF cycles, Frozen cycles (FET) and Donor cycles. Then look under your age group (under 35, 35-37, 38-40, 41-42 years old). At a glance, the three main results you should focus on when making your decision are:

• Number of cycles: This will give you an idea for how many patients cycle at that clinic. The number only represents the cycles that took place during that year, so for instance, one patient could have done 2 or 3 fresh cycles in the same year.
• Percentage of cycles resulting in live births: This percentage is very important. Unlike "percentage of cycles resulting in pregnancy," live births will tell you more about the final results.
• Average number of embryos transfered: This is also very important to take into consideration. With today's technology, doctors are able to reduce the number of embryos transfered and still keep their success rates pretty high. This is partly why the Octomom story was so appalling to those of us in the infertility world; what credible doctor would be willing to transfer 6 embryos?! People like that give infertility patients a bad rep.

A big caveat here is that the numbers don't give you the full picture: some clinics take on more challenging cases and therefore might have slightly lower success rates, some may be more open to doing certain tests that others won't and most importantly, not a single number will tell you where you will be most comfortable and find success.

Once you've compared numbers/statistics and have picked your clinic it's time to research the RE you'd like to have guide you through your cycle(s). While all REs can help any case of infertility, some have areas of specialty -- donor egg, male factor infertility, polycystic ovaries, high FSH, etc. Of course, going into your very first visit appointment you might not yet know what your specific reason is, but sometimes you do (if you had your OB/GYN run the initial tests I mentioned earlier, you may already have some answers).

There is usually a head to the department and while your first instinct might be to go straight to the top, that's not always the best idea -- he/she might be way too busy for you. When cycling, you want your RE to have time to communicate with you, return calls or emails. But sometimes, that RE might be the best suited person for your case and well worth the wait. You need to make that call.

Once you've picked an RE, he/she will be your point person for the whole time you're at that clinic. He/She will determine your protocols. Be warned that it will be very difficult to change doctors. Having said that, you will meet and interact with the rest of the doctors at the clinic for your check-ins, your egg retrieval, embryo transfer and (hopefully) your initial pregnancy monitoring.

Going into your first appointment, write down all the details about your conception journey thus far, obtain copies of all of your records from your OB/GYN and have your questions ready. Most importantly, do not go there without your partner. This is the beginning of what might be a long journey and it's time for you and your partner to become a team. You will not get through it without being each other's rock. It's time to step up and leave the tension from the sex-on-demand days at the door.