Adapting to Unexpected Changes During Your Cycles

I started this blog because I wanted to help fellow infertiles. I wanted to create a blog that I wished was out there when I was still trying to conceive. You know, some 20/20 hindsight from someone who's been down this road before. I wish I could write every day, but because this blog is more topical, I sometimes struggle to find a subject that would speak to all of you. Perhaps I'm just having a guilt trip for not writing daily. Anyhow... So when my fellow blogger Fox in a Hen House suggested that I talk about dealing with the unexpected, I thought, "Brilliant!" Today, I'm going to make some suggestions about finding ways to deal with the unexpected changes during a cycle. Let me emphasize that I am not talking about situations that finalize a cycle, like a BFN or no embryos can be transferred. I'm solely going to focus on unforeseen changes that can be rectified.

Fox's current situation is a great place to start: she was diagnosed with Premature Ovarian Failure at age 35. After a few Clomid cycles, she started an injectables IUI cycle. Turns out her body is responding amazingly well to the meds and at her first visit, she had 13 follicles! Exploring her options, she has agreed to convert her IUI cycle into an IVF cycle. Now that's pretty unexpected. Usually you hear of IVF cycles being converted into IUIs, but hardly ever the other way around. Fox took things in stride. She adapted. Was she prepared for an IVF cycle? No. But is she going to make the most of it now? For sure.

We probably adapt to a lot of unexpected changes in our daily lives without ever realizing it. But when it comes to IF cycles, it seems we lose all ability to take a step back and accept the new direction our cycle is taking. We have too much vested in the cycle and are too emotionally committed to just go-with-the-flow. I've said this many times before, no cycle is ever text book. Not a single one of mine ever went according to plan. You have to find a way to realize that it's out of your hands. I know that this is incredibly difficult to accept, especially when it seems that most IF patients are Type-A personalities (why is that?!). You must remember that you have put your trust in the hands of a reputable clinic (tell me you did your research!) and that your body is in many ways independent from you. Some days it will surprise you with a wonderful gift and other days, it will disappoint you, like a disobedient child.

So when you have a curve ball thrown at you during your cycle, you need to find a way to adapt. How you ask? Well for one make sure you get a hold of your RE (do not accept playing telephone and having the nurses be your point person). If your RE is any good, he/she will make the time to review your options with you directly. Ask all your questions -- What's happening? What does it mean for the cycle? What are my options? What is your recommendation? You're not the first patient whose cycle hasn't gone according to plan and you're certainly not the last. If, like in the case of Fox, it's actually good news, you need to embrace it. Cycles are lived in short windows of time (even if the 2 week wait feels like an eternity). If you miss out on an opportunity, you will always look back and wonder "what if...." But sometimes, the news isn't good, and in those situations, you must remind yourself that you have come this far and that it's too soon to throw in the towel. A skillful RE/clinic will make lemonade out the lemons you've been handed. They will find a way to optimize the situation; that's their job.

So, let's review a few unexpected issues that may arise and ways to (possibly) resolve them:

• Making too few or too many follicles --> Adjust the dosage of your meds. If no change occurs by the next visit, consider converting your cycle.
• You're experiencing OHSS --> The excess fluid may be removed prior to your ET or you may need to complete your cycle with a FET.
• Lining not thickening fast enough --> Try high doses of vaginal viagra to increase blood flow and go to daily acupuncture.
• Lining is too thick --> If you've confirmed there's no polyp prior to your cycle, a thicker lining shouldn't be an issue.
• Premature LH surge (i.e., pending premature ovulation) --> Administer Ganilerix to curb the LH surge until all follicles are ready.
• DH was unable to provide semen sample --> Either go in there to "help out" or consider freezing the eggs and do a frozen cycle. 
• DH's sample is less than usual --> If it's an IUI, ask to do another insemination the next morning. For an IVF cycle, you only need a few healthy ones.
• Your embryos aren't dividing well --> You can opt to transfer them on Day 2 or 3. Your body will give those embryos a better fighting chance than a petri dish.
• You were expecting a Day 3 ET, now it's a Day5-6 --> This is actually great news and it means that your embryos are doing very well. 

The silver lining here is that most issues that may arise during the cycle have solutions that you can explore. At that moment you may not be able to see those solutions, but your RE is there to guide you in the right direction. You can be proactive and do a little of your own research to ask the right questions; it's the not-kowing that frazzles us. Plus, don't forget that I'm your disposal. I'm happy to answer any questions and even look things up for you to help you make the best decision.

The Infertility Competition

We spend so much time scoring and labeling things and people, it's like we're in a perpetual competition. Most of the time, I wonder who or what we're competing against. But when you're going through IVF you are up against, what often seems like, insurmountable odds. Your FSH has to be acceptable; you have to produce the best quality eggs (and not just 1 or 2 of them!); then your embryos will be graded like the dozen eggs at your grocery store; and at last, should you be so lucky to get a BFP, even that might not be good enough.


As you begin your cycle, it all starts with your FSH levels. Most clinics will have a cut off -- usually they'll want you to have an FSH lower than 12, but every clinic is different. This is one way your clinic weeds out the "bad eggs" (pun definitely intended!). They want competitive success rates, so if your FSH is too high, you're going to be a big challenge to them. So before you can even put your legs up on the stirrups, you're sent to the back of the line  to either do a few months of acupuncture with the hopes of lower your FSH or perhaps to revisit your option of egg donation. Either way, when you've psyched yourself up to start a cycle, there's nothing that will deflate your spirits faster than not even being allowed to enter the race.

Then you're on to follicle counts. What's an ideal number? Who really knows. But most IF literature will tell you that 10-12 mature follicles will yield the best success rates. It's really your RE's objective to try and control the quantity of follicles you produce. If you have PCOS, like I do, you're likely to produce more follicles, but your RE should aim to taper the development of too many follicles, as this will most likely lead to weaker quality eggs (and hence, embryos). However, if you have POF, then you'll be thrilled if you have 5 mature follicles. Either way, remember, it's about quality and not quantity. As cliche as that might sound to you, I speak from personal experience, which I will discuss next time.

Now, you've finally made it to the other side of your egg retrieval and looking at the second chapter of this arduous process: the embryo transfer. As your joint contributions (egg + sperm) develop into embryos, the embryology lab will grade each embryo to eventually select the best two (or three) to transfer back into you. The grading of embryos* will vary based on the age of the embryos to be transferred (Day 3 vs. Blastocysts are the most common stages of transfer) and the quality. Sitting in a backless gown across from your RE, only to be handed something that looks like a report card always left me in a cold sweat. Deep down, you feel like those grades are a reflection of you and your husband (Who are we kidding?! Of course, it's all about you) -- of how well you performed through this obstacle course. Of course it's not about how well you did, but they are your embryos and you want them to have a head start in life (even before the crazy pre-K interviews that lay ahead). At the end of the day, regardless of their grades, you will welcome back any and all embryos your RE has selected for you. All you can hope for is that they stick and don't leave your roof for the next 18 years.

At last, the much anticipated POAS day is here and you are (hopefully) doing a happy dance in your bathroom, holding your positive HPT in one hand to prove to yourself and the world that you did it! You'll go in for your Hcg/beta test to confirm the happy news. And even here, you will have to meet a certain score to validate your pregnancy, because we wouldn't want you to get too happy, right? Ideally your Hcg should be 50 or better at 14 days post ER (for more detailed chart go here). Lower levels of Hcg are usually not good news (there are exceptions) and indicative of either an impending chemical pregnancy or an ectopic. And very high initial Hcg levels will have your nurse proclaim, "Ohh, ohhh... someone's having twins!" Most clinics will have you go in every 48 hours to see your Hcg levels double (or better). The tension will continue to build until your first ultrasound (oh, magic wand, how I've missed you) to check that there is indeed a little bean in there.

In the land of infertility, we strive to be overachievers. We define our worth by the number of eggs produced and the quality of our embryos. But I promise you that when your day comes (and I really hope it does for all of you), you won't care how many embryos you created and what grade they were. There is no telling which embryos will turn into mini versions of yourself (even the REs will admit it), so I say this with caution: this cycle could be your cycle. Here's to hoping. Cheers!


*Day 3 embryos will be checked for number of cells (8-10 cells @ 72 hours); the evenness of the cells (they should be all about the same size); and the degree of fragmentation (you want as little fragmentation as possible).Your embryo will be graded on a scale of 1 to 4, and the ones with the most even cells and least amount of fragmentation will be transferred back into your uterus. However, if you are looking at blastocysts (Day5 or 6), then the key factors are: the expansion of the blast (graded on 1 to 6); the quality of the inner cell mass, i.e. the baby-to-be (graded A, B, or C); and the quality of the torphectoderm, i.e. the placenta-to-be (graded A, B, or C). Every lab has a different scale, so a 5 could mean a good or bad thing depending on your lab. Make sure your RE explains exactly what the letter and numbers mean as it pertains to your precious embryos.

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.

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.