Last Call

On the advice of someone whose opinion I trust implicitly, I went to see a therapist this week - the first of many such encounters, I'm sure. Though the whole IVF thing is not the driving force for sending me into therapy, I felt it was relevant to tell her that we're actively undergoing fertility treatment and that, in fact, the very week that therapy had been suggested to me, was the same week I had learned that IVF#2, Take 3 had not been successful.

There was a piece of me that really didn't want to tell her about the IVF thing at all. Because people make a thing out of it. People ascribe emotional significance and stress to IVF or any infertility treatment that may or may not really be there - without really considering that every individual responds to these sorts of things differently. For me - returning to fertility treatment was returning to my "normal" - returning to my comfort zone in a weird and strange way.

But, still, I knew that it was something that needed to be mentioned, both because this particular therapist is a psychiatrist, so if the question of medication came up she'd know that right now may not be the optimal time to try that route, and because although I may not consider IVF to be a primary stressor in my life, and certainly not the driving force sending me into therapy, it definitely is a contributing factor.

And all that background brings me to the point of this post. While I was talking to Doc P. about the whole IVF thing, I told her that we would likely be attempting IVF #3 in August, but that I don't know specifics, because I have my consult with SuperDoc on July 6th to figure all that out. And I told her that our August attempt would likely be our last IVF attempt. "And I'm okay with that," I quickly added.

I hadn't really thought about those words before they came out of my mouth, and I'm not really certain where they came from. Why was I saying them? What was my thought process? Did I even have a thought process?

While it's true that technically once I run out of covered attempts with my insurance, we can switch me back to my husband's insurance and I can do two IVFs at the clinic at his hospital - the fact is, it's unrealistic to consider that. It's very expensive to go that route (the coverage isn't nearly as good), and the logistics are nearly impossible ... the clinic is an hour in the wrong direction, they batch their IVFs, leaving very little flexibility on schedule, they do ALL monitoring appointments between 8 and 9am during the week, which means that I would never make it in to work before 10 or 10:30 on monitoring days during a cycle, which is impossible. So realistically speaking, it is unlikely that we'll ever be able to go that route.

So the first part of my statement to the shrinkiedink was likely true - this next attempt is likely our last, unless one of us changes jobs again and finds ourselves with kickass coverage again.

But - am I really okay with that being it if it fails, as I expect it to?

I'm not so sure I'm really there yet. I know I said it in large part to keep the therapist from going down a long road of exploring "how I feel" about this particular thing. I don't want to go there. I don't want to focus on this issue. I'm not ready to discuss it. I'm not willing to share that part of me.

I was always so sure that IVF#1 would just be a breeze and we'd just be done and voila! our family would expand and that would be the end of it! Worst case scenario was that IVF#1 didn't work, but an FET would - it had never occurred to me that there wouldn't be anything frozen for an FET. But here I am, looking down the barrell of our last IVF and wondering whether anything will come of it.

I'm petrified of what will come of my meeting with SuperDoc July 6. A large piece of me thinkst that SuperDoc is just going to say that he wouldn't change a thing and this is all just bad luck and we're just going to have to hold our breath and hope for the best - but ... while I know that's probably all true, I guess it would ease my mind to hear that a different approach would yield a better result.

Mostly? I just want to move on.

And I'm quite certain that I won't ever be okay with having my options cut off before I was really done.

It Only Takes One

I know I said I wasn't going to post for a while, but this particular thing has been eating at me, so I need to get this one out. This particular phrase, "it only takes one." It hits me in my gut every time I hear it and I took a long time to figure out why exactly it hurt me so much. After all, it's never meant to be hurtful when it's said - it's always said in an optimistic context.

Part of it, I think is simply because it is just a platitude that is meaningless until something comes of it. Worse, if I did get pregnant, the person who said it can say "I told you so," and I'm not sure there ARE three more annoying words in the universe. Also it seems to invalidate whatever frustration I happen to be having at that particular moment in time - it says, "Yes, all your other embryos were crap, but your feelings about that are invalid, because all that matters is that one." Certainly no one intends to send this message, though. So why does it bother me so much?

Finally, my beloved Barren put her finger on it in two ways. First, she said to me - yes, we all know it's true - it's only going to take one in the end, but platitudes don't implant and make babies, so they don't help. But later she said that really I should consider the math and think about it - and I would realize that, actually? It takes a heck of a lot more than one! And she's right. Observe:

5 Clomid cycles, unmonitored, so I don't know how many eggs, I ovulated, but we'll assume at least one, because we do know I ovulated, so...5 cycles = 5 eggs, 0 pregnancies = 0 babies

5 IUI w/ Follistim Cycles = 11 eggs, 1 singleton pregnancy, 1 miscarriage = 0 babies

1 IUI w/ Follistim cycle = 30 follicles (not all mature, probably 5 mature), 1 triplet pregnancy = 3 babies

4 IVF cycle starts, 2 cancelled, 2 retrievals, 24 eggs retrieved, 17 fertilized, 2 transferred (1 at a time), 0 made it to freeze, 0 pregnancies = 0 babies.

So that's ... call it 45 eggs ... 3 babies. So it actually takes about 15 to make a baby by my math.

Obviously it doesn't work out to quite that math, but my point is that it's taken a helluva a lot more than "one" to make a baby (or three, in my case). And in my 4 IVF attempts, I've made it to 2 retrievals and retrieved 24 eggs and gotten... zero babies. Clearly, it's going to take more than one. Now, obviously, we haven't found the "right" one - but there's also no guarantee we ever will. And maybe the right one was already there, but we didn't pick it.

I know that if I never get pregnant again, I've still been more blessed than I deserve to be. I know that many of you think that I have no right to even continue trying, let alone complain about our failures at this point. But this battle between primary and secondary infertility is ridiculous. These arbitrary decisions about the correct family sizes are equally ridiculous. We know our family isn't complete, just as we know that we are blessed with the family we have. We are not blind to the blessings we have, nor to the suffering that people who haven't made it to the other side are going through.

And the pain I feel in this loss is every bit as real as the pain I felt with each and every loss I felt the first time around.

Official

Not that I needed the final word, but the beta's back and I'm definitely not pregnant. George, Jr. is not to be. I take solace in the fact that I don't have to put my tail between my legs and thank Dr. Hate.

So I can stop the estrace and the PIO. Wait, I already stopped both, because, really? What's the point?

Follow up and re-group with SuperDoc on July 6th to plan out IVF#3. We'd touch base sooner than that, but he's halfway across the globe right now. How dare he?

And that, my friends, is the end of IVF#2 (Take 3). I suspect I won't have much else to say here for a while. I'm not in a very good place right now and I'm not really sure I have anything left to say.

I'll let you know what SuperDoc says in July.

No more PIA or PIO

I talked with my nurse today. I'm going in tomorrow for my beta despite being sick. My doctor this morning said if the plague I have is the flu, I should be better by tomorrow, and if it's not, it's probably bacterial, and I'm now on antibiotics just in case, so I should be okay to breathe my germs on them by tomorrow.

That being said, my nurse gave me her blessing not to take my PIO tonight since my HPT is still snowy white. I told her she needn't worry about how to make that uncomfortable phone call tomorrow with the negative beta and she said, "Oh thank heavens!" Apparently those phone calls aren't easy to make, and occasionally get pretty dicey. She hopes to give me a pleasantly surprising phone call tomorrow, but meanwhile she said it was okay to skip the PIO tonight. Whahoo!

Meanwhile, there's nothing much interesting going on here in perky-land.

No Pressure!

My company is changing insurance plans as of January 2010. They are making the change in such a way that it will mean they get around the Maryland Mandate for fertility coverage.

Awesome.

This means that I must get IVF#3 done in 2009, which means I must get started by August, in case I have another debacle with a couple cancelled cycles before I can move forward again.

Stupid insurance.

A Definition

I love my husband. And you know why? Because if you look in the dictionary under sweet, optimistic, or (most importantly) naive, you'll find a picture of him. Allow me to illustrate with a conversation from yesterday:

Him: Did you take your morning estrace?
Me: Yeah, but really? What's the point?
Him: I'm still hoping George will surprise you.
Me: Honey, George isn't going to surprise me. Today's 15 days post retrieval. Even the stupid internet cheap POS pregnancy tests would have shown something if I was pregnant today.
Him: Okay.
Me: You really think there's going to be a surprise.
Him: I'm hoping George will surprise you.

It's cute, no? So for his sake, I will continue to take the little blue pills and the damn PIO, despite my blubbering in a doctor's office yesterday (see Chez Perky for that one), because, after all, I'd hate for him to say "I told you so" on something that critical, right? (but I still haven't made an appointment to go in for my beta...)

(for the record? No surprises this morning, other than I still feel like crap. And not in a pregnant kind of way - in a "oh my god where are my lungs and all my energy?" kind of way)

ick

Still sick. Still not pregnant (so Barren? You can stop holding out that tiny bit of hope, okay?).

I have yet to schedule my beta, which is supposed to be Friday. I wonder if they'll notice if I don't show up for it? I'm guessing they would notice. Back in 2006 when I was away on vacation (the only real vacation I've ever taken in my entire life) on a beta day (and had told them I wouldn't be there on beta day), they freaked out when I didn't show up for my beta. But then, having not been on PIO, I'd had solid proof that that IUI (#2) had failed miserably.

So ... not showing up for my beta is probably not an option right?

I Am Sick

I am sick.

And I am also not pregnant. I did cave and POAS. Today is 9dp5dt. Otherwise known as 14 days post retrieval. Though I suppose some of you will argue that it's too early to tell, a lot of clinics do their betas at 14 dp retrieval. The fact that my clinic waits 18 days doesn't change the fact that today is probably accurate.

I will dutifully keep taking my PIO until Friday, because I'm a "good" patient (though not good enough to follow my doctor's directions not to POAS), but then I'll just be waiting out the 2 weeks until I can see SuperDoc for a follow up consult to decide the following:

1. WTF???
2. What next?
3. Is there anything I should change about my protocol?
4. Is there any reason I should not start a cycle in August (the alternative is to wait until November, which is not my preference).
5. What are we going to do to avoid another Dr. Hate situation in the future?
6. No, seriously, WTF???

I can't say I'm surprised, or shocked.

7dp5dt, aka The Day Barren Brought the Laughter Back

I've had a really hard time with this cycle, and Barren just "gets" it when a lot of other people just... don't. I feel guilty about it, to be honest. I feel like I should have an easier time dealing with infertility by now. I've been there, done that. More importantly, I'm on the other side of it. I've got a beautiful family, as many people feel the need to remind me. Often. As if that means I should simply be satisfied and be done with.

And yet - I have not resolved my infertility. I have not come to terms with it. Every setback, every failure, every loss this time around hits me as hard, maybe harder, as the first go-around. I think this is partly because this time was supposed to be "easy", or as easy as IVF ever is. And what we've found is that things just aren't as straight-forward as we thought.

The point is, Barren gets me. She doesn't try to placate me with "it only takes one"[1] and other such platitudes. She doesn't tell me I'm being ridiculous. She doesn't point to my children and suggest I should be satisfied with what I have. She recognizes that the pain I have the second time around is just as real as the first time around. She tells me to stop apologizing for complaining at her. She brings me wine so we can whine over wine together.

So I suppose it should have come as no surprise to me when a beautiful, flowery package arrived in my mailbox today, and I saw that it was from my wonderful friend. I opened it up and found this:

The note made me a little sniffly and teary eyed, and though I haven't asked her permission to reproduce it here, I'm going to take a gamble and do so anyway:

Dearest Perky,
Thank you again for your friendship and generosity. I hope that someday soon I will have the chance to return the kindness with more than a bottle of wine and the ability to eat your delicious dinners.
I know you aren't feeling hopeful about this cycle, but if a tiny bit of hope (or
curiosity) creeps in, I want you to be prepared.
Love,
Barren

I knew what would be inside the beautiful, dragonfly wrapping [2] paper, but I burst out laughing when I opened it up:

Thanks, my friend. Laughter truly is the best medicine. I don't promise to use those lovely (but very tempting) tests. But I promise to pass them back to you if I don't. Or maybe use them next cycle when I can muster up the hope to think it's worth wasting a precious FRER.

Barren, you truly are the best person in the entire universe. So... dinner Thursday? ;)

---------------------
[1] Coming soon: a Barren-inspired post on the "It Only Takes One" math and how flawed it truly is.

[2]How did she know that dragonflies are one of my favorite things in the universe? I swear she and I are just the same person. Except she's way cuter and always has an adorable pedicure, and I've never had a pedicure in my life.

Gestating

Because it’s fun for me, every time my husband is trying to annoy me (even jokingly), I say, “No! You can’t do that! I’m gestating!” And I melodramatically throw myself down on the couch, clutching my abdomen protectively, to ensure the safety of our precious morula.

All joking aside, this exchange belies my true feelings about this cycle. Usually, I'm skeptical that a cycle could have worked, but there's always a piece of me that can't resist interpreting every twinge, every smptom, every sign. Usually, even though I won't say it out loud, there's a piece of me that is shocked when I inevitably cave, pee on a stick, and see a sea of white where there *should* be a second line. Even in my sixth IUI, when no one, not even my doctor, thought it was going anywhere - the cycle that was doomed to fail (but resulted in an HOM pregnancy instead) - even then, I thought there was a chance, even though I wouldn't admit it out loud.

But this time I simply cannot wrap my brain around the possibility that this cycle has any possibility of ending well. I don't have even the smallest bit of hope. SuperDoc is heading out of the country for 2 1/2 weeks, and he's leaving before my beta happens. I'm devastated by this, which is ridiculous, but there you go. I never claimed to be rational, and I'm sure the copious amounts of estrogen and PIO aren't helping matters. Anyway, I've made an appointment for a follow up consult with SuperDoc for the first week of July - right after SuperDoc gets back. I figure that way we can talk about where to go from here, because clearly something's gotta give.

Sigh.

I hope I eat my words, but I just... I'm not counting on it. I'm really not asking for platititudes. I can't handle them, really. they won't make me feel better. All I need now is to just ... get from point A to point B.

My Letter to SuperDoc

Here is the letter that I am sending to SuperDoc in the morning. Many thanks to Barren for proofreading, editing and review. You can blame her for not making me cut out more. She made me cut out about 4 sentences. Maybe five. The rest, she said, was too perfect to cut. Who can argue with perfection? Anyway, the letter doesn't say anything you don't already know - so you don't have to feel obligated to read it.


Dear SuperDoc;
As you know, I have been a patient of Ye Olde Fertility Clinic's since 2005, first under Dr. Awesome, and later as your patient until I conceived my triplets through my sixth IUI in February of 2007. I returned to your office in January 2009 for the purposes of pursuing IVF with eSET in hopes of adding a single child to our family. You and I both agreed that this would be the most prudent course of action for both family and medical reasons.

To date, I have been seen by YOFC for initial consults and testing, an HSG, six IUI treatments, OB ultrasounds subsequent to a pregnancy after my fourth IUI and subsequent to a triplet pregnancy following my sixth IUI, follow up consults with several doctors, countless monitoring appointments for bloodwork and ultrasounds, two cancelled IVF cycles, two IVF retrieval procedures, and two IVF embryo transfer procedures. I have even participated in multiple media interviews promoting eSET and YOFC's stellar program.

Until recently, my interactions with each and every one of the YOFC staff, from the receptionists, to the nurses, to the doctors, to the marketing staff have exceeded all expectations. I have been impressed at every step with the level of care, personal attention, professional manner, and attention to detail that each member of the YOFC team has provided to me as a patient. Though I was initially concerned that seeking care from such a large team of providers would mean sacrificing personalized care, I have found the opposite to be true: I am anything but a number.

Not only have I felt that my medical needs have been appropriately addressed, but the office has continually gone above and beyond all reasonable expectations to ensure that my non-medical needs have been met. As an Orthodox Jew, I was initially concerned that I would not be able to pursue treatment because of restrictions related to the Sabbath, but in my very first consult with Dr. Awesome she said, “Don’t worry, we work with Orthodox patients all of the time – while I can’t guarantee you will never have a procedure on a Saturday, we have ways of working with you so that you can sign consents ahead of time, etc. This should be the least of your concerns.” I have always found this to be true – indeed, my first IVF retrieval was on a Saturday and the process was seamless.

It is because of this exemplary care that I have continued to refer countless patients to Ye Olde Fertility Clinic. I believe that there is no better care available in the greater [insert metropolitan city] area for infertility treatment.

I think that this is why it was so surprising to me that I had such an unpleasant experience at my recent embryo transfer on Saturday, June 6, 2009. Dr. I-Hate-Him was the physician performing the procedures that day. As you know, because it was a Saturday, I had to make special arrangements to be there on a Saturday, including a driver, etc. I had made clear ahead of time that I would not be able to physically sign any consents on the day of the transfer and I had been told this would not be a problem.

When Dr. Hate came into the room, he explained which of my embryos was to be used for transfer, and why, and then handed me the consent for transfer. I asked him if it was absolutely necessary that I personally sign the consent and explained that I am an Orthodox Jew and am restricted against writing on Saturdays due to my faith. His response was two-fold: First, he stated “Yes, it is absolutely necessary that you sign this consent. If you do not sign it, I cannot perform the transfer.” Second, he told me (with regard to my religion restricting my ability to write), “There are exceptions, and this is one of them.”

With all due respect to Dr. Hate, while I am quite certain that he is an extraordinary and well-qualified reproductive endocrinologist, I have doubts that he is a well-qualified Orthodox halachic authority. Therefore, his assertion that “there are exceptions” was both condescending and inappropriate.

Furthermore, his first statement was even more troubling. He had made an implicit threat: if I didn’t sign that paper, he wouldn’t do the transfer, and I would have wasted an entire cycle by not signing. As a vulnerable, half-naked patient sitting on an exam table, knowing how much money, time, effort, emotional investment, and hope would be wasted, the imbalance of power in that negotiation was palpable.

“There simply must be another way,” I asserted. “I know I am not the only patient that has had this issue.”

Finally, Dr. Hate left the room to “ask someone else” and returned with two witnesses who witnessed my verbal authorization for him to sign in my place. A resolution was reached. Peace was restored in the transfer room.

I wish I could say this was the end of my unpleasant encounter with Dr. Hate, and I did try to simply put this behind me. We resumed cheerful conversation as he got set up for the transfer. I joked that hopefully this single embryo would not split into identical triplets and he said, “That can’t happen; there’s no such thing as identical triplets.” I told him that, in fact, I know several sets of identical triplets. “No,” he corrected, “You don’t know any identical triplets; just because they look alike doesn’t mean they are identical.”

Though I respect Dr. Hate's knowledge of reproductive endocrinology, it concerns me that he doesn’t know that there is such a thing as monozygotic triplets, and it further concerned me that he felt the need to continue to respond in an argumentative, condescending manner. This may seem like a small matter, and had it not been for the adversarial way in which I had been approached regarding the Sabbath issues earlier, I may never have been concerned about this. But I daresay, it did not inspire confidence in my medical care that day.

Thank heavens for the nurse who provided me with my discharge instructions that day, and the technicians who were in the room during the transfer. Had it not been for their professional, pleasant and wonderful attitudes, I would have left the office that day without any positive feelings about the visit at all.

Ultimately, I am relieved to know that the experience that day will not have any effect on the outcome of this cycle. I know that the quality of care that I have always received at YOFC will remain intact and I will remain your loyal patient and friend, regardless of the outcome. I am, simply, saddened that I now have this experience to reflect on at the end of this particular cycle. Hopefully, it will be overshadowed with better news to come.

Thank you for your time, your patience, and, as always, your outstanding medical care.

Respectfully,


Ms. Perky
Patient # 5903487

cryo report and peeing on sticks

I know it will shock you all to hear this, but... none of my little buggers made it to the freezer.

I'm ... well, I suppose on one level I am upset that I can't seem to make decent embryos (though I do know that my clinic has really high standards for freezing embryos). But on the other hand, I'm incredibly relieved that I'm not being faced with a $1300 cryopreservation bill that I really don't have the money for right now.

Well, you know? I suppose there's always the possibility that George, Jr. will just stick around and this will all be a moot point, right?

Um. Yeah.

My buddy Barren asked when I start peeing on sticks. I hope I don't. I'm just not sure I can deal with the neurosis, the hope, the devastation, the rationalizing, the maybes (maybe it's too early, maybe it's a dud stick, maybe I should try another brand, maybe, maybe, maybe).

I'm sure I'll cave. I have, after all, a pile of the internet EPTs in the bathroom cabinet. How could a girl truly resist?

Couple Quick Things:

1. I am still angry about the doc yesterday. I thought I'd be over it by now. I clearly gave myself too much credit.

2. No, I have no idea what's going on with email subscriptions, bloglines, google reader, or my feed in general. I've even tried re-burning the feed all together and that hasn't fixed the problem either. I'm about read to ditch Blogger all together and just use my defunct WordPress Account instead. Blogger seems like more trouble than its worth - especially as related to privacy, since you can't password protect things (esp. individual entries) - you can only privatize the entire blog and then you're limited to 100 readers, which is why I opened my blog back up.

And Then There Was One

Please note: children are mentioned in this post. I am terrible about pointing this out in general, so I'm not promising to always mention it, but there you go.

SuperDoc had indicated yesterday that he was fairly certain that I would have a Day 6 transfer, not a Day 5. He had said to expect a call in the morning rescheduling me for Day 6, but they had me on the schedule for today, just in case. He seemed so sure of it, that I was surprised that my phone didn't ring this morning. By 11:30, I realized if they were going to call, they would have called by then. After all, I only had a couple hours left before I had to be at Ye Olde Fertility Clinic. Clearly, my Day 5 transfer was happening. How odd. Fortunately, I'm not stupid, and I *had* arranged for transportation to the clinic today, just in case. And my ride arrived at my house, right on time.

I got all checked in and got an ID bracelet on my wrist and taken back to a transfer room. I was told to undress from the waist down and wait with the drape over my waist for the doctor. This reminded me that I didn't know which doctor I was going to be seeing - so I looked down at my ID bracelet to see what doctor was listed. Sure enough, it was one of the few doctors in the practice that I don't particularly care for. Just my luck. Whatever, I thought, it's not a big deal - all the doctors in the practice are extremely good doctors whose knowledge in their field is unquestionably stellar. It certainly doesn't matter whether I like a doctor I don't have to see much - it only matters that I love my own doctor, who calls all the shots on my protocol, and with whom I interact on a regular basis.

And it is with this backdrop that Dr. After-Today-I-Hate-You-So-Much-You-Don't-Even-Deserve-A-Snappy-Pseudonym walked in the room. Aw, to heck with it, that's too awkward to write every time. I'm going to call you "Dr. Loathesome" because I'm too prim and proper to write "Dr. Fucker" every time I have to write your name.[1]

Right. Um. Where was I? Ah yes....

... And it is with this backdrop that Dr. Loathesome walked into the room. He introduced himself to me and said, "It's nice to meet you." I didn't correct him and inform him that we've met at least half a dozen times before. After all, they're a busy practice, and it's been probably 3 years since he's seen me, but hey, I haven't forgotten him, so why should he forget me!? I am memorable, darnit! Right. But realistically, my clinic sees thousands of patients a year, and I wasn't even his patient, so I don't expect he'd remember me. So I'll forgive his transgression and simply appreciate the nicety of his statement, shall I? Moving on...

If I could have written anything down, I might be able to give a lot more detail, but, actually? Probably not, because he glossed over a lot of this.

We went through the numbers. I had 14 retrieved, 8 fertilized normally, 1 fertilized abnormally (this was news to me, but I imagine that's not unheard of), 5 didn't fertilize (I imagine that two of those were the two that were not mature, but he didn't mention that). Today when they looked at the embryos, I had two compacting embryos (morulas), of which one was looking "okay" and the other was clearly lagging behind [2]. I also still had a 5 cell hanging around, but clearly that wasn't particularly helpful. He said that since there was a clear winner between the two morulas, they would do the transfer today, rather than waiting until tomorrow. The reason to wait until tomorrow would be if they couldn't tell today which would be the better choice. Honestly? I think my doctor would have waited until tomorrow. But I'm 100% certain he would never tell me that now. I'm quite certain he won't contradict a decision that a colleague made. He didn't seem hopeful that there would be anything to freeze, but said anything's possible.

I had been a *little* concerned that since my regular doctor wasn't there that there might be some discussion about whether eSET was the way to go, but SuperDoc already had me covered on that and had made it clear that we were only transferring one. So Dr. Loathesome (and I'll explain the pseudonym forthwith) wrote on the form that we'd be transferring one, and turned the form to me to sign. *screech*

And this is where the story starts to turn ... ugly (later it will turn fugly, just you wait).

"Is it absolutely necessary that I sign this piece of paper."
"Yes. You must sign this piece of paper."
"Then we have a problem. I've made it clear ahead of time that I can't sign anything today; that I could have signed anything ahead of time, provided any sort of consent necessary, etc., but that if there was going to be anything that I needed to sign today I needed to know about it ahead of time so that I could ask my rabbi whether it could be done."
"Well, you have to sign it, without your signature, I can't do this transfer today."
"I guess we have a problem then; I'm an Orthodox Jew and the fact that I'm even here today required specific arrangements ahead of time to make it happen. I cannot sign that piece of paper."
"There are exceptions," he said with an exasperated sigh, "and this is one of them."
"Well, I'm glad you went to Rabbi School after you went to Doctor School, but there simply must be another way to handle this. I know I am not the first patient this clinic has had present with this issue."
"Well, I'll go check with someone else," he said, and he left the room in a huff.

While he was gone I sat there contemplating what I would do if he came back and said I had to sign it. Would I just go ahead and sign the stupid piece of paper? Or would I say, "Well, I guess we're doing a Day 6 transfer"? I hadn't made a decision, mostly because I was distracted by contemplating my somewhat full bladder, when he walked back in the room followed by two techs.

"We have a team of witnesses," he said, "who will witness your verbal authorization for me to sign the consent."

So peace was established at the negotiating table, and all was right in the world. Life was good. Dr. Maybe-You're-Not-As-Loathesome-As-I-Thought-You-Were and I went back to congenial discussion while he waited for the embryologist to come in and confirm my identity, etc. The techs asked about my kids. We made small talk about my pregnancy. I told him that SuperDoc was never going to live down the triplets, and he asked how many I transferred that time.[3] Time passed, he got the speculum and catheter in place, and we're chatting. All the while his hands and face are spending alltogether too much time in my lady bits, but you gotta do what you gotta do, right? [4] And then it happened.

I made my standard comment about how this one (little George Jr.) isn't allowed to split into identical triplets. Because that would be wrong. And do you know what this doctor said to me? ME? The mother of triplets? The very-well-educated-mother-of-triplets? You won't believe what this man said to me. Are you ready? Are you really sure you're ready? Positive? Because, me? I'm still fuming over this.

He said, "Oh, you can't have identical triplets. That doesn't happen."

Um.

"Yeah, um, I know several sets of identical triplets."
"No you don't. Just because they look alike doesn't mean they're identical."

Oh thank you for that lesson, asshole. Because maybe I should have been more specific.

"Yes, but the spontaneous, monozygotic, monochorionic triplet girls that I know up in [city near me] that were born at [hospital my husband works at] almost exactly a year ago are clearly identical. You can't have three babies share one placenta and not be identical, unless it's a fused placenta, but there are tests for that."

Dr. Seriously-I'm-Not-Kidding-You're-Really-Getting-On-My-Nerves-At-This-Point made a noncommittal grunting noise.

"Or, you know, the 2 1/2 year old identical triplet boys that I know in [other city nearby]. Also spontaneous."

No response.

"Or my friend in NYC who had two embryos transferred and one split into monozygotic triplets and both embryos implanted, so she was pregnant with quads. She reduced to a singleton. In fact, the very same scenario once happened here at YOFC."
"No it didn't."
"It most certainly did; about 3 or 4 years ago."
"Well I've been here since [longer than that]."
"She was SuperDoc's patient; she had 2 embryos transferred, both implanted, one split into identical triplets, and she didn't reduce so she had quads. SuperDoc told me about her himself when I got pregnant with the triplets - you can check with him."

Seriously. My legs are in stirrups, his hands are in my nether-regions, and he's telling me he knows more about triplets than I do. Not okay.

I'm sorry, but you are not allowed to be contrary with your hands in my vagina![5] No sirree!

Fortunately, Dr. I-really-do-loathe-and-detest-you-Now noticed at that moment that it had been an absolutely indecent amount of time since getting all set up for my poor sad little embryo to appear, so he sent a tech looking for it, and my embryo appeared right then. Saved by the embryologist.

"I hope he's cute," I said to the embryologist, who looked a little ill. "Can I call him George?" She looked mortified. GOOD HEAVENS, PEOPLE! DO YOU HAVE NO SENSE OF HUMOR?

"Sure," said Dr. I-Don't-Even-Care-What-I-Call-You-At-This-Point. "George, Georgette. Whatever. Now let's see if we can get you pregnant."
"Well, I guess I've got to go with George, Jr. The last one was George. And though he was cute, he didn't do me a lot of good. But this one's going to work, right?"
Pause. (In fairness, I think he was busy trying to get the embryo, you know, into my uterus.
"Of course!" said Dr. You're-Definitely-Not-SuperDoc-And-You'll-Never-Be-As-Cool-As-Him.
"That didn't sound so confident."
"I thought that was very confident!"
"You should work on that, Doc," I said with a grin. "Thanks for your help. Hopefully I won't be back here for George III."

My discharge nurse was awesome - she was the same nurse I had for my first embryo retrieval and I loved her. I had a good time with her. So that was great. But all in all, I'm still annoyed. Even 10 hours later. Probably I should get over myself. But it's really hard to get past such an annoying experience because.... let me see if I can explain. You see - my experiences at YOFC are so universally positive and my interactions there are so perfect every time. Every single member of the staff is amazing. Every nurse, every receptionist, every phlebotomist, every technician, every sonographer, every doctor, every embryologist, every member of the marketing team, everyone. Every interaction I have with YOFC is better than the previous one. So for this interaction to have been so jarring - it stands out. If it were just a monitoring session - I'd blow it off and not care. But this was something really significant. Today was a make-or-break-it day. If I hadn't transferred today, I don't know whether they would have let me transfer tomorrow and what that would have done for my odds of success. I don't really want to think about it. Frankly, I almost made him get SuperDoc on the phone. Basically? It wasn't okay.

There's another dimension to this that I haven't touched on. I think that our initial disagreement (over the signature) was problemmatic for another reason. There's an inherent imbalance of power when you've got the big, scary, all-knowing, all-powerful doctor on one end of the clipboard and the (perceived) stupid, ignorant patient on the other and the patient is sitting there half naked with a flimsy paper drape covering her lap with her butt exposed to the back of the room (where the door is and anyone could walk in without any notice). You'd think I'd have no sense of modesty left, but... turns out, I do. I have a personal belief that this last discussion of how many (and which) embryos to transfer ought to occur just before the patient is instructed to disrobe, therefore leaving the patient with a shred of dignity and not putting her in a position of feeling like this imbalance of power is so significant.

The amazing thing is that I may never have noticed this, had it not been for one of the amazing partners in the perinatology practice I went to - she did something that made me feel unbelievably human throughout my pregnancy. Each time I saw her, as opposed to the other practice members (who I LOVED, so I'm not criticizing them), after my ultrasound exams, she would say, "why don't you get dressed and then come into my office and we can talk?" The other doctors gave me just as much information, and probably the same information, as she did at each of my appointments, but she spoke to me as an equal. She made me feel dignified for 10 minutes and allowed me to sit there speaking with her and asking my questions without wondering whether my rear end was flying out of my gown behind me. It was something I always appreciated about her. As terrifying as my appointments could be - at least I was treated in a dignified fashion.

Anyway, as for now, I'm on "bedrest" for the moment. Or as close as I can get to it. We'll see how that goes. I'm told not to drink alcohol or caffeine until I get a negative result or deliver a baby, whichever comes first. Whatever. I feel extremely crampy, which I don't remember from last time. My cervix is also very sore, which I don't remember from last time. And I feel some pain from where the speculum scraped against me on the way out. Pleasant. But I'll assume all of this will go away soon enough. I was going to say that I'm hoping not to POAS, but who am I kidding? I'd pee on one right now if I thought it would show anything. Heck, I might anway, just to have something to compare it to. (I'm kidding. Um, maybe.)

I've already told my nurse to expect me back in August. Optimist that I am.

--------------------------------------
[1] This will be especially funny to any of you who have actually spoken to me in real life and know that not only do I sound like a drunken sailor most of the time, but I could probably make a drunken sailor blush with the language that comes out of my mouth. But I try to tame my mouth when it's being applied to the keyboard. Even I have to wash my proverbial mouth out with soap occasionally.

[2] Unlike early embryos and blastocysts, compacting embryos are not graded. It's not fabulous to transfer a morula on Day 5, essentially because it means your embryos are a day behind, but it also doesn't mean all hope is lost either. For more information on morulas, see Dr. Licciardi's blog post on morulas.

[3] Way to read my chart, Doc. The triplets were conceived on IUI #6 - after I'd specifically asked, multiple times, to be switched to IVF for fear of conceiving HOMs. Hah!

[4] Have you ever noticed that if you like your doctor and they make you feel comfortable that somehow they can be digging around in your vagina and you hardly notice, but if you don't like the doctor, somehow it feels... dirty? Yeah. I don't know how to explain it exactly, but somewhere in the middle of all of this, I started to feel... uncomfortable. Very uncomfortable.

[5] Now, the hysterical thing about that line is that when I came home from the transfer and recounted this story to my very patient husband who was faithfully indignant on my behalf, I used that exact phrase, except I said "lady bits" instead of vagina. And then when I was talking to Barren later and recounting the story again (I think I was more indignant when retelling the story to her!), she said, without hearing it from me first, "You are not allowed to be contrary while your hands are inside my vagina!" So she gets partial credit for this one. But only partial. But how weird is it that we're so connected that we think so alike?

It's Like DeJaVu All Over Again

The phone call from SuperDoc on Day 4 explaining the outlook and the options. The apologetic tone in his voice. The determination to push forward. The sense that maybe things aren't quite as perfect as he'd like them to be. I feel like I've lived this life before. I've been down this path, I know where it leads, and it doesn't lead to the perfect single embryo transfer on Day 5.

In fact, that's pretty much what SuperDoc told me this morning. Things looked "great" on Day 2, but apparently not so great on Day 3, and even less so on Day 4 (today).

Embryo #:	Day 2 Report:	Day 3 Report:	Day 4 Report:
1	2 cell, no fragmentation	4 cell, no fragmentation	6 cell
2	2 cell, no fragmentation	4 cell, no fragmentation	4 cell, no change
3	2 cell, no fragmentation	4 cell, no fragmentation	6 cell
4	2 cell, no fragmentation	3 cell, 15% fragmentation	8 cell
5	4 cell, no fragmenation	4 cell, no change	4 cell, no change
6	4 cell, no fragmentation	4 cell, no change	7 cell
7	4 cell, no fragmentation	4 cell, no change	4 cell, no change
8	4 cell, no fragmentation	6 cell, uneven growth	compacting embryo

Note, SuperDoc gave me no information about fragmentation - but said that the embryo quality today wasn't nearly as promising as he'd hoped. He believes that we'll likely have a [singular] good quality blastocyst to transfer - but he thinks it is unlikely that we will have it by tomorrow and that I'll more likely be pushed to a Day 6 transfer.

This seems to be a chronic problem of mine - the slow growing embryos. This is the same thing that happened to me last time, essentially. By Day 4, I should pretty much be looking at morulas. I should have had 6-8 cells on Day 3. The reason that clinics don't do Day 4 transfers (usually) is that it's difficult to differentiate quality between morulas, so they let the morulas mature to blastocysts by Day 5. But it's unlikely that my almost-morula (Embryo #8) is going to be a blast by tomorrow (Day 5). It'll need the extra day. This is the same thing that happened last time. I did end up with two blasts on Day 6 (none on Day 5), but one was clearly the winner. None of my 9 embryos in IVF#1 made it to freeze. None. It is unlikely that any of these 8 will either.

So what do you do about slow-growing embryos? Not much. According to Dr. Licciardi, from NYU Fertility Center, they really don't know what to do about it. They'll try different things in the protocol to see if it fixes anything, but they never know whether it was the change in protocol that fixed the slow growth issue, or whether it was just luck. Probably just luck.

Since we've always known that PCOS isn't my sole issue with getting (and staying) pregnant, it makes me wonder whether my slow-growing embryos contribute to the issue. But then again, maybe they're only slow growing in a lab. This is one of those places where the science is simply too immature to help answer these questions. We just don't know. So we keep trying.

I have long said that I am grateful to live in a time when the science and the medicine have reached a point that I know, with a reasonable degree of certainty that I can get pregnant with assistance. I went through five years of infertility, countless monitored cycles, 11 medicated cycles, 6 IUIS, and a late miscarriage before having my beautiful babies. But a hundred years ago, even fifty years ago, I wouldn't have been able to push through all of that knowing that there was always a next step available to me. There just wouldn't have been options (regarding getting pregnant, that is), period.

I am incredibly grateful that I live in a time where the science and medicine are so advanced. But I think it bears noting that we are still in the (pardon the pun) infant stages of this research. We have so far to go before we really understand how a lot of the embryo development works. How and why certain embryos are more likely to implant than others. Why, in the absence of chromosomal abnormalities, killer cells, a clotting disorder, etc., recurrent miscarriages occur. It is important to recognize and appreciate how far we have come ... but also to recognize how far we have to go to ensure that our sons and daughters, grandsons and grandaughters, friends and families have less heartache and more hope.

I have hope that we'll have a little George, Jr. on Day 6 this cycle. And that George, Jr. will want to cozy on up and stick around until 40 weeks gestation and make his or her appearance into the world. I have hope that this will be the case.

But I am also making plans. A girl needs to make plans, you know. I'm making plans to start my next cycle in August. It will be my last covered at YOFC. I wonder whether I'll need to use the category, "IVF#3" in my blog posts. I hope not, but I'm making my plans, just in case, because that's what I do.

Club Soda, Anyone? (not for the faint hearted)

So you know how when you're giving an IM shot, you're supposed to pull back on the plunger to see if you get any blood in the syringe before you shoot yourself up with the contents of said syringe? And you know how you always think that it's a stupid thing to bother with because after 47 shots, you've never ever had any blood appear in the syringe, so what's the point?

Well, so tonight, my husband was giving me my PIO, and he pulled back on the syringe and I wasn't even paying attention and he said, "Oh, I got blood, I'm sorry." I thought he was done with the shot and he just meant I was bleeding from the shot. Nope. He meant there was blood in the syringe.

"Okay, well, I think you have to take it out and we'll start over."

I don't know - is that what you're supposed to do? I think so. Isn't that the point of finding out if there's blood? I think so. I honestly can't remember. See, I'm in a lot of pain right now (I have a migraine plus I think I need a root canal, but who has time for that?) so I'm drugged and tired, so I can't really think straight.

So he pulls the syringe out of my derriere and says, "And now there's blood on the floor." I handed him a piece of gauze. And then another when that one wasn't enough. He handed me the syringe which... wasn't reusable. Or maybe it was, but gosh there was a lot of blood in it. I don't know, can you use it again? I'm thinking no, but I dunno, who knows. I'll ask my nurse tomorrow.

So while my husband is trying to get me to stop bleeding, I drew up a new dose of PIO. And then he successfully gave me the PIO without incident. Whew.

Um. So does anyone have any ideas about how to get blood out of beige carpet?

Day 3 Embryology Report

Here's what my Embryos look like today compared to yesterday:

Embryo #:	Day Two Report	Day Three Report
1	2 cell, no fragmentation	4 cell, no fragmentation
2	2 cell, no fragmentation	4 cell, no fragmentation
3	2 cell, no fragmentation	4 cell, no fragmentation
4	2 cell, no fragmentation	3 cell, 15% fragmentation
5	4 cell, no fragmentation	4 cell, no change
6	4 cell, no fragmentation	4 cell, no change
7	4 cell, no fragmentation	4 cell, no change
8	4 cell, no fragmentation	6 cell, uneven growth - not looking great.

So ... pretty good. We can probably say goodbye to #4 and #8. But that leaves us with 6 embryos with good potential. There's some concern about #'s 5-7, but they still have time to continue growing. Embryos 1-3 had a slow start, but they clearly got the message that they should get a move on. I'll get a call tomorrow with more news and a time for Saturday's transfer.

And then on Saturday I'll probably get a call moving my transfer to Sunday, just for kicks. ;) I told that to my nurse while saying, "I hate to be such an optimist and all, but..." and she said, "Yeah, but you know, when you've been around the block a few times, you know how this works." It's all good. So far, the news is far better than IVF#1's embryology reports were. Why, these are downright positive embryology reports!

Embryology Report

Things are looking up. My day 2 embryology report in IVF#1 was not promising at all. One of the reasons I was concerned that my fertilization report this cycle wasn't as good as the fert. report with IVF#1 despite 40% more eggs retrieved was that I was concerned that I'd be facing the same fast attrition that I had faced with the subsequent embryology reports. But, so far, my fears appear to have been unfounded.

Today's embryology report revealed that I have four 4-celled embryos and four 2-celled embryos. There is no fragmentation in any of them (unlike IVF#1).

So I've been moved to a Day 5 transfer.

Shabbos. Of course.

So I have to figure out the whole, you know, getting to the clinic on Shabbos thing. AGAIN. But other than that, I couldn't be more thrilled.

Fert. Report

In IVF#1, I had 10 eggs retrieved, 9 mature, and 9 fertilized. I transferred 1 and none made it to freeze.

In IVF#2, Take 3, so far:

14 eggs retrieved
12 mature
8 fertilized

Retrieval

I admit, I was skeptical that I'd ever make it to retrieval - but there I was at Ye Olde Fertility Clinic today. And they didn't throw me out for having taken my trigger shot early er, late- they just moved me a bit later in the schedule (not by much). Somehow, I had actually made it to retrieval for IVF#2. I hope I don't have to find out what it's like to get to retrieval #3.

Anyway, SuperDoc got 14 eggs - which is phenomenal.

I also love that he came down to do my retrieval... he wasn't the doctor scheduled to do retrievals today, but he came down to do mine, which I really appreciated. I'm in a fair bit of pain, but they gave me fentanyl, morphine, and vicodin at the clinic, and armed me with a bottle full of vicodin for my house. Now I'm really spacey and exhausted and completely incapable of being witty or interesting, but that's what you get.

Fert report tomorrow. The waiting begins