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

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?

I will Love Him and Hug Him and Call Him George

So this morning was a complete whirlwind and nothing was going right for the first couple hours of the morning (all of which related to things best n0t discussed on an infertility blog), but things eventually calmed down and I was working from home before leaving for my transfer (this was part of what didn't go as planned - I had planned to be in the office for at least 2 hours before my appointment...). At some point, I looked at the clock and realized I'd been holding my breath all morning. Nine thirty. They would have called by now if everything had tanked and they were going to cancel. I hadn't even realized that the thought was on my mind.

I set up a document to print at my office and grabbed a bottle of water, a pan of brownies, my keys, and my coat and went on my merry way. I stopped at the office to pick up the document I needed (a little light reading for the waiting room...whee!), and then headed up to Ye Olde Fertility Clinic. I called J, Marketing Supervisor Extraordinaire, as I was pulling into the parking lot. "So I'm early. Do I go upstairs and sit in the waiting room? Or do I bring you a brownie? You wouldn't want to risk SuperDoc eating them all, would you?"

"You didn't really bring brownies, did you?"
"J? Of course I did. I told you I was going to, and I always deliver!"

Needless to say, there was brownie delivery prior to waiting room waiting and document review.

And then my moment arrived... I was whisked back in to the transfer room. Asked to recite my name and social security number a few times, told to undress (waist down) and wait for SuperDoc. No problem. Except at some point I realized that my goal of a so-called "moderately full bladder" had, well, been exceeded. But I was good. Really. For a while. But the clock, it kept a-ticking. 5 minutes. 10 minutes. 20 minutes... Honestly what was worrying me the most was that they'd pulled out my little beauties and decided that they were all pretty useless after all and were trying to figure out how to break the news to a homicidal hormonal fertility patient. And finally SuperDoc walked in.

"So, did you pick a good one?"
"We might have more than one to choose from, but I know which one we're going to use."
"I'm just saying, you know, if you pick a good one, there might be some brownies in it for you, because I know that changes everything for you."
"Well, in that case, we'll be sure to pick the very best one. Since we weren't going to do that anyway."

We talked for a bit about which embryo he was going to transfer, and why.

He then reviewed the "Embryo Disposition Report.
"Okay, 10 retrieved, 9 fertilized, etc. etc. and we're transferring 8, sign here."

I. Lost. It.

I mean, all-out, completely hyperventilating, lost it. I told him I wasn't signing that piece of paper (which CLEARLY said transferring 1) unless he TOOK THAT BACK. No even JOKING about that! Not with that timing.

"Don't you remember my reaction when you told me how many heartbeats there were?"
"I think this reaction might be worse!"
"I think you might NOT get brownies!"

I made the embryologist get me a picture to prove there was just one. JUST ONE. (I have the picture, but haven't been able to scan it yet. Will do so later. I assure you, it's a cute little blastocyst. Early, and not totally perfect, but perfect enough for me. I mean, honestly, it was just a ploy to *get* a picture, but a girl's gotta do what a girl's gotta do, right?

(By the way, SuperDoc did note my "impressively full" bladder several times on the ultrasound. Rub it in, doc. Rub it in. See if I ever bring you triple-chocolate brownies again.)

I told SuperDoc after the transfer, "I swear to you, if this single blastocyst splits twice and I end up with monozygotic triplets -"
"-I'll shoot myself," he finished for me.
"You might have to fight me for it."
"And if we only have one gun and one bullet, we might have a problem!"

After my allotted period of "rest" my nurse came in and looked at the picture of George (my blastocyst) and said, "Oh look, they transferred both of them! That's great!" I almost decked her. Watch out there, or I might change your pseudonym from NurseAwesome to... well, something else. She went over my discharge instructions, and took some brownies (which I distributed all around, I took another for J (Marketing Supervisor Extraordinaire), and sent the rest to SuperDoc's office (see? I don't hold a grudge!).

I brought a brownie down to J's office and bid him adieu. "I'm not back here until the 18th! What will I do without you, Marketing Supervisor Extraordinaire?"
"Oh, I'm sure we'll be emailing."
"Aren't you sick of me yet?"
~dramatic pause~
"Of course not!"
(I'm kidding, there was no dramatic pause, but go with me here, it's more interesting my way, right?)
"Well, maybe I'll make my appointment for my beta late enough in the morning that I can bring you cookies."
"Oh no! I don't know how I can stay friends with you! I'm going to be 400 lbs!"

I'm thinking snickerdoodles... Yeah, 'cause those are low fat. Ahem.

I mean, there is the theoretical possibility that I'll get pregnant this cycle and he'll be rid of me. Right? RIGHT?

Yeah. Um. Seriously? I still can't say that with a straight face.

Another Episode of: You've Got Questions - I've Got Answers!

I know, I know, ever since my recent media appearances, it's been hard to escape my adoring fans, the ruthless paparazzi, the constant phone calls, the text messages, the overflowing mailbox, the neverending emails... It's a hard life, but someone has to live it, right? At least I can say that stardom has most definitely NOT gone to my head.

So you, my adoring fans, have questions. And, it turns out, I have a couple of answers. . .

Q: What time will your transfer be tomorrow?
Well, I'm glad you asked. Because I just got a call from my nurse answering that very question! I'm scheduled for 11:15 tomorrow morning. Be there at 10:45 with a "moderately" full bladder and instructions not to use the bathroom upon arriving at the office. Now, I find this incredibly hilarious. Have you ever tried to exactly provide a "moderately" full bladder? Yeah, it doesn't happen. Either you end up with an empty bladder, or you're sitting in the waiting room absolutely DYING and eventually a nurse says, "Okay, you can pee, but only THIS much." And really, have you ever tried to pee just, say 30ccs with a completely overflowing bladder?? Yeah, it doesn't actually work that way. So good luck with that. (I will say that the serious advantage of having had HOMs is that I never had to have bladder-filled ultrasounds in my pregnancy... that would have been sheer misery)

Q: But what about Shabbos preparations? How will you manage?
Fortunately, I'm not the only super-hero in my household. My husband, darling man that he is (see? I can say that now that I'm not on Lupron!), can totally handle Shabbos prep all on his own. That, and I'm going to cook as much as I can tonight so that it doesn't ALL fall on him.

Q: How long will you be on bed rest?
My clinic, apparently, is "East Coast Conservative" on this issue. There have been several studies done on the benefits of no bed rest after transfer vs. 24 hours vs. 48 vs. 72 etc. So there's some benefit to bed rest, but 72 hours seems to (maybe) be overkill. So we're a 24-hour clinic. Look at me, referring to the clinic staff as "we". Yeah, I'm there so much I feel like I work there. I assure you, I don't. Though for all the free press I give them, I ought to be on the payroll.

Q: If you have 3 good embryos and they implant 1 and you freeze the other two and the first embryo takes and results in a successful pregnancy what do you do with the other two embryos?
Well, first I'm going to nitpick here a little - Doctors can't implant embryos. They can only transfer embryos into the uterus and hope that it implants into the uterine wall. Implantation = pregnancy (though no guarantee of ongoing pregnancy). If doctors could implant embryos (and who knows? Maybe someday they will be able to!), they would always implant a single embryo in all IVF cycles - because it would be a 100% initial pregnancy rate. The media, for WHATEVER reason has never been able to keep these terms straight. For crying out loud, the frickin' New York Times can't even get the term right. If they can't, who can we expect to get the term right? The problem with getting the term wrong is that it causes the general public to have a skewed view of the reality of fertility treatment. It makes the general public believe that IVF is more of a sure thing than it is. While IVF success rates have skyrocketed in the last several years, it is still not a guarantee. And when the general public perceives that every cycle is a guarantee that each embryo transferred equals a guaranteed baby, they think that women who come out of fertility treatment with multiple babies had it coming. And frankly? That's unfair. So I'm on a mission to blot out the misuse of the term implant.

But I digress, because I didn't actually get to the heart of your question, did I? You want to know what I'll do with any leftover embryos should I have any frozen and should I get pregnant on my first go-round.

Well, I imagine the author of this article would have you believe that having any frozen embryos from this cycle would be an irresponsible consequence and rather poor planning on my part. And, further that the only morally acceptable choice for any remaining embryos that we have would be to enter into an embryo adoption program. But... that author probably never went through IVF himself. I daresay he actually never spoke with an actual IVF patient. And, further, probably never actually spoke with a reproductive endocrinologist or fertility science researcher. No, I'd guess that he never read beyond the abstracts of the studies he cited or the party lines of the political think tanks he references. Instead, he proudly waves the banner of prochoice moralism and dismisses any opinion other than his own, woefully uneducated one.

Right. Off soapbox now (but for a brilliantly written soapbox on this very article - I highly recommend Akeeyu's post!)

Clearly, I didn't have the luxury of telling my doctor to make sure to only create one embryo and make sure there were no others that survived. (I mean, that very well may still happen - but if it does, that's Darwinism in action, not anything pre-planned). I certainly wasn't going to tell him only to fertilize one egg and hope THAT one was the one that lived. (Don't worry, I don't think you, my reader, were suggesting that I should have done so. I'm just still so pissed off at that article... which, by the way, I read over a MONTH ago and my blood is still boiling). So, sure, I ran the risk that I would make more embryos than I needed for my planned single embryo transfer.

But, then again, we also knew that I wasn't *quite* the ideal candidate for eSET... and so we knew that I wasn't looking at the standard 67% odds on an eSET cycle that my clinic has. I was looking at 40-45% odds going in, which SuperDoc revised to...oh, 30% about halfway through my cycle. So clearly, having some back ups? Good thing. (again, still don't know that I'll have any back ups...)

So what if I get 3 blasts by tomorrow? We transfer one, freeze 2. And then, let's say, I get a BFP? (Hah! I can't say that with a straight face yet. But for the sake of argument...) What then?

Well, we'll start with the knowledge that I've already had one late miscarriage, so a BFP for me does not necessarily equal an ongoing pregnancy. So I'm not holding my breath, first of all. But... if I do get and stay pregnant and deliver my (healthy? Please God) singleton baby (9? Please?) months later... what then?

Well, I'm not promising our family is complete with one more baby. Maybe it is. But I don't know yet. We know that right now, we want at least one more baby. And that probably is it for us. But not because we want to be done, but because of the financial hardship of having more after that point... we're already stretched financially, so one more? Sure. But two more? Probably more than we can handle. But option one is we hang out for a while until we are certain our family is complete. And that IS the current plan.

After that, our choices are between my husband and myself, and those decisions are up to us for the moment. We do have a plan, and they are documented in our consent forms with Ye Olde Fertility Clinic (though they'll have to be revisited at the end of a specified period of time). But it's our plan, and ours alone. (I will say that Jewish law is pretty complex in this area, so there isn't a lot of choice involved, but regardless, our plan is documented)

Sorry for the long answer to a seemingly simple question.

Q: What happens to those embryos that don't make it to freezing or transfer but are still considered viable?
This question came from an anonymous commenter. I'm not entirely certain that I understand this question. Honestly, if by Day 6 the embryos haven't made it to a stage suitable to freeze, they aren't really all that viable any more. I'll check with Ye Olde Fertility Clinic, but I assume any non-suitable embryos are discarded in a respectful manner.

Q: All this fine-tuning seems sensible and makes me wonder how the Hatchery does those batches when obviously tailoring to individual response is needed.
This is from the same anonymous commenter. Yes, YOFC has been doing very sensible fine-tuning, which is fantastic considering that YOFC is an enormous clinic. Other clinics in the area accuse my clinic (without naming names, of course) of being a "revolving door of doctors" and tout themselves as being able to individualize care in a way that the "bigger clinics cannot". I'm here to tell you - YOFC individualizes every patient's care and treatment plan. They don't just have one set protocol and squeeze each patient into it. They have been extraordinarily flexible with my protocol, recognizing that the fine tuning is where the success will come from.

As for The Hatchery - they do batch their patients for the start of their cycles (every two weeks), but they almost have to do so because they have one doctor and one doctor only. This gives him the ability to have one retrieval weekend and one transfer weekend per month on average according to his nurse. But he, too, has built in flexibility. And because he sees fewer patients, he's able to individualize care plans very easily as well. For example - though they have never done an elective Single Embryo Transfer, and he wasn't totally comfortable with the idea of having his hands tied on that issue (me saying that under no circumstances would I allow him to transfer two), he was willing to work with me on that. He never takes his patients to blast and always transfers on Day 3. Why? Because when he was doing blastocyst transfers, he found that he had a much higher pregnancy rate, but no more babies. His ongoing pregnancy rate didn't change with blastocyst transfer. He couldn't figure out why, either. However what he did say was that with me and me alone he was thinking that to do an eSET, what he'd probably do would be to take me to blastocyst before transferring. So he was definitely flexible in terms of the protocol and the timing, etc.

Obviously, with the batching, there is occasionally some overlap of patients, but it is kept to a minimum for him this way.

Any other questions??

Day 6

No transfer today. Moving to a Day 6 transfer (tomorrow).

I, personally, think this is really all rather rude. I was waffling this morning about moving my afternoon meetings. If I moved them, for sure I was going to end up rescheduled, right? If I didn't move them, I was going to end up with transfer staying on today's schedule and having to cancel my meetings at the last minute. So, at 6:45, I rearranged my calendar, just in case.

And then, on my way in to work, my nurse called.

"Hi Perky One..."
"Oh this can't be good."
"We're moving you to tomorrow."
"Oh for the love of Pete." (I admit I may have been, um, slightly less delicate than that)

Turns out, things are actually growing for a change (maybe we'll even have something to freeze? Did I just say that?), but they're growing slowly and unevenly and nothing's made it to blast yet.

So... we'll see what goes down tomorrow...

Oh Yeah, and that other thing

I kinda left you all hanging about the embryology report didn't I?

While I was at Ye Olde Fertility Clinic today, I ran into SuperDoc and he told me we are likely a go for tomorrow for transfer, but no promises. It will probably be a last minute call, but for the moment I'll assume we're a go for 1:15 tomorrow afternoon.

There's at least one little embryo who could. Possibly another. Whether they'll be blasts by tomorrow remains to be seen.

I don't care if it only takes one

Yes, people, I know it only takes one. I get that. But the cliche isn't helping me right now. I have a right to wallow for a few hours in my less-than-stellar news, and that's precisely what I'm going to do now, because today's news was even less promising than yesterday's news.

Let's Review:

Going into Retrieval: We were expecting 4-6 eggs (not stellar news, but at least we were expecting not stellar news)

Retrieval Day: 10 eggs retrieved! (Double what we expected! A great number, all things considered)

Day 1 Fert. Report: Of the 10 eggs retrieved, 9 were mature (1 post mature) and all 9 fertilized and were 2 celled embryos (unbelievably good news! I was stunned and overjoyed by this news!)

Day 2 Embryology Report: 1 didn't make it at all, 6 2-celled embryos still (1 with no change; not a good sign), 2 6-celled embryos (with 10-15% fragmentation, not good). Not a good enough report to warrant a 5 day transfer. Transfer scheduled for day 3 at 2pm. Disappointing news at best as with Single Embryo Transfers, they always try to go to blast in order to find the cream of the crop when possible.

Day 3 ... (Today):

I'm on my way in to work and the weather is crappy, my head is pounding, my tushie is sore from the PIO shots, I'm cranky. You get it, right?

I'm walking out of my parking garage on my way into my office juggling my keys, my briefcase, a couple shopping bags (I bought candy to re-fill the candy jar I keep for people to snack on in my office), and my phone rings. I'm fumbling for it, but I have to pull off my glove (did I mention it's snowing?) to get it open and turn it on; I almost miss the call. It's my nurse at Ye Olde Fertility Clinic.

"Hi Perky One*, it's NurseAwesome*. SuperDoc wants to talk to you."
"Yeah? All right," I sighed.
"You okay??"
"Yeah. Yeah, I'm fine." I said, knowing that this just wasn't going to bode well.
"Okay, hang on, here he is."

Why the man couldn't have just dialed the phone himself is beyond me. Because that introduction is exactly what gave me the anxiety I had, you know. But whatever. I do love him, and I know he has my best interests at heart. And for all I know it was NurseAwesome that wanted to make the call to me so that she could guage how I was doing, since she knows how pissy I've been all cycle. (Update: It turns out that SuperDoc did call me directly himself - but he called me at home and left a message at 8:45. Of course, I wasn't home - I was on my way to work. NurseAmazing knows better, and she knows me well enough to know that I probably wouldn't have been okay with just hearing a voicemail on my home number ... which I may or may not have checked before I went in for my appointment this afternoon, by the way ... so she probably said, "Yeah, no, we're going to call her cell phone now." That's why I love her.)

So he said he took a look at the embryos with the embryologist this morning and what I've got is a 7-cell, a 6-cell, a 5-cell, and 2 four cells. If I were any other patient, with their normal criteria, he'd be recommending a two-embryo transfer today (day 3), but he does NOT recommend that with my history. With HOMs at home, and with my pregnancy history (e.g. not good) and with my need to ensure I do not get pregnant with twins (unless, you know, they're monozygotic, in which case, we just had no way of controlling that risk), he is wholly opposed to a 2-embryo transfer. Which is good, because I am also opposed to it. My exact words were "absolutely not." And he responded, "We are on the exact same page, don't worry, I'm not recommending it - I would caution against it."

My embryos look pretty crappy. They do not meet the criteria to go to a 5 day blast, but given the choice between picking a crappy single embryo for transfer today as planned or trying to grow one to blast by Thursday or Friday, he thinks our chances are better if we wait. He believes we are likely to have one at the blast stage if we wait.

So what happens if we don't have any blasts by Thurs/Fri? We transfer whatever the best we've got is. And what if there's nothing? We scrap the whole thing and start over. After all, we were all set to cancel this cycle last week before we got to retrieval, remember? It's really no different, except that now we've been through a lot more hell than if we'd canceled ahead of time. But at least now we've got more information, right? What I don't know is whether this would count as a full IVF cycle for insurance purposes if we don't make it to transfer. My guess? Once you get to retrieval, it counts. That being said, my doctor is confident that we'll have something to transfer either Thursday afternoon or Friday morning, it's just a question of quality.

And so it goes.


*Note, she did actually use our real names... she doesn't refer to herself as "NurseAwesome" though she'd be perfectly justified in doing so.