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.

Other People's (IVF) Babies

Today, I went to visit my friend EAM at the hospital. She delivered two beautiful baby boys on Friday. EAM and I have known each other for nearly two decades, but I think it was over the last couple of years that we have grown even closer. As I've said before, for better or for worse, infertility changed me forever, so when she told me three years ago over lunch, "We've been trying for a while, but nothing yet..." I immediately shared all of my IF-wisdom and told her to get checked. I basically walked her through a lot of the same things I talk about here. It's become instinctive now. I know that something is going on even if a friend tries to hide behind her silence. In those situations, I will in no uncertain terms announce that we had trouble conceiving, and then I'll keep the door open for them to open up if they want. And without fail, they always do. And the first question always is, "How did you know that we are going through this?" Like I said, it's bigger than me now. Some have gay-dar, I have IF-dar. I just can't help myself.

Well, it took her a few tries, but EAM is now a proud mama: the joy, pride and raging hormones included. Seeing her babies reminded me of how strange it was (and still is) that I never felt jealous or resentful when my fellow IVF friends (real or virtual) crossed the threshold and became pregnant (and eventually mothers). Somehow, knowing that they had a tough time getting there made it ok to finally bask in the glow of motherhood. In fact, walking the streets of NY and seeing the double strollers, I would immediately proclaim "Ah, IVF-babies!"as though it made it ok that these moms were parading their kids around me, reminding me why I was sticking myself my countless needles ever day. Even today, mothers of multiples have a special place for me. Last week, I met a mom at the toddler gym. She walked in with her twins and somehow, I instantly felt connected to her. So strange. I mean, we probably have nothing in common, truly. And yet, the pervasive bond of IF is immediate. This mom, of course, has no clue of our "bond." And who knows, maybe we'll never discuss it, but I silently will nod with approval, "Yeah, you're one of us!"

Now I wonder, during my years of coping with IF, was I unfair to mothers who had singletons? With singletons, it's not as obvious to tell whether the parents struggles to conceive or if they were a result of a fun night of good old fashioned sex. Maybe some had also struggled and were also deserving of compassion. And today, perhaps, perfect strangers around me are shooting darts behind my back when they see me with my son -- completely oblivious that if they simply said "We've been trying for a while, but nothing yet..." I would drop everything, listen to them, share what ever information I have (heck, I'd even take them to the RE myself) and most importantly tell them that I know how they are feeling.

How do you feel when you see IVF babies around you?




P.S. As more IF-friends around me become new parents, I think I'm inspired to start writing a second blog about parenting after infertility. I'll keep you all posted.

Versatile Blogger Award

I started this blog just a short few months ago with the hopes of helping others navigate the rough seas of infertility. So it was an incredible honor when I found out that Jay Bronte at The Two Week Wait bestowed upon me the Versatile Blogger Award.

As I gather it, I first have to thank the person who nominated me (of course! I have manners). Then share seven things readers might not know about me. And lastly, I have to pay it forward my selecting eight other bloggers I’ve recently discovered (but who haven't been nominated yet).

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Thank you Jay for recognizing my blog! Coming from a talented and smart cookie like yourself, it’s an even greater honor. You inspire me to be a better blogger and to continue on my humble path to help women like yourself.

1. I used to be a fashion stylist. I still loooovvveee fashion – I have a stuffed closet and a tower of magazines to prove it.
2. English is my third language, but I guess through the years, it’s become my first.
3. I love good food. I love to prepare it, eat it, watch it on TV. And while I’m on the subject, I have a thing for desserts. Even if I’m full, I claim there’s room in my “second stomach” for some sweet treat.
4. My non-obviously-hot-guy crush is John Krasinksi. A good sense of humor and charm will go a long way with me.
5. I’m strangely incapable of watching any movie that involves an animal getting hurt, but blood and guts with humans, bring-it-on!
6. I never leave the house without some concealer for my perpetual dark circles.
7. I’m hyper critical – mostly of myself. I second-guess every decision I make. In fact, I’m sure I’ll go over this list after posting it, wondering if I should have written it differently.

I would like to bestow the Versatile Blogger Award to the following fab bloggers:

1. Cenk@ Cafe Frenando
2. The Sartorialist
3. Non Chalant Mom
4. Sunshine @ Waiting in Sunshine
5. Keiko @ Hannah Wept, Sarah Laughed
6. Circus Princess @ Circus Children
7. Waiting for a Baby Bump
8. Amber @ Born in a Barn

Letting It Out: Expressing Your Frustrations with Infertility

Loud screams are echoing through my house these days. My 18- month-old son seems to have reached his terrible-twos ahead of schedule (no surprise of course!). He will throw himself on the floor, kick and scream if he doesn't get his way... While I watch him in disbelief (is taking away the now almost empty tube of toothpaste worthy of a rage so great?) I do envy his pure freedom of expression. There’s no second guessing yourself, no second thoughts about societal norms – what you feel is what you show. Frustrated that things didn’t go your way? Let out a loud “Noooo!!!” and throw yourself on the floor. Someone take your toy away? Hit them and snatch it back. Can you imagine if we as adults could be so unfettered with our emotions? 

 

I can’t tell you how many times I have sat across from a friend who complained about pregnancy being so hard while I silently grinned and beard it. What I really wanted to do was to give them a piece of my mind; tell them how good they have it; that a little morning sickness is nothing next to the heartache of infertility.

I have always found it baffling that us infertiles will bottle up our sadness in order to make “happy fertile people” feel more at ease, rather than them trying to comfort us. Babyshower to be organized for the office secretary? Sure, I’ll get the “It’s a boy!” balloons. Ultrasound pictures shared with the world on Facebook? Well, what good is a friend unless she gives the picture a big “thumbs up”? 

Why do we fear expressing our true emotions to the world, when we have every right to be angry, sad and frustrated? The only place we seem to be allowed to truly FEEL is behind closed doors. I can vividly recall the many times I have ran to the bathroom after a public “we’re pregnant!” announcement or burst into tears the moment I got into the safety of my car after a visit to the OBGYN's office. At the very least, maybe there should be areas in public where you can go into a sound proof room, let out a big scream and go back to your table as though nothing had happened.

All I know is that for now, I’m really starting to think I could learn something from my toddler. So if you’ll excuse me, I have to run around naked because who wants to wear clothes in this heat anyway?!

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. 

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.

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.