IVF Consultation

We had our initial IVF consultation with Dr. NFB today. She is by far the best medical provider we have ever worked with.

Anyway, IVF is a lot of work. And expensive. And there are many needles. Worse, I have to give them to myself or trust Chris to do it. This makes me feel faint thinking about it. I wonder if she’ll give me a box of smelling salts to go along with this. Below are the notes we took and answers to the questions we asked. Of course all of this doesn't matter if we are lucky enough to be pregnant this cycle.

• My IVF protocol (exact schedule TBD)
• Attend an IVF class next week (9/29)
• Call CD1 and the IVF nurse will schedule some appointments:
• Blood draw for me: testing thyroid, prolactin levels, rubella immunity, blood type and, as required by the great State of Ohio, infectious diseases (HIV, syphilis, Hepatitis-B and Hepatitis-C). We have also elected to see if I am a carrier for cystic fibrosis and a muscular skeletal disease that I didn’t write down fast enough.
• Sonohysterogram: inject saline into the uterus and observe with an ultrasound. Checking for polyps, fibroids, or anything else that could cause problems with implantation. Easier to pronounce and MUCH less involved than the HSG which was done in a hospital with contrast iodine and continuous x-ray.
• Trial transfer: Dr. NFB performs a transfer but with no embryo. It is to make sure the needle will work and that she knows exactly where to put the embryo(s) when the time comes.
• More tests for Chris – no details yet, but will probably include an antibody test. Stop reading this bullet if you don’t like details. Basically, the body can launch an attack on itself. Semen can actually damage or kill its own sperm. The lab adds a substance to a sample of sperm and checks to see if it binds to the sperm (binding = bad).
• Blood draw for Chris: apparently the State of Ohio also requires the male to be tested for infectious diseases (HIV, syphilis, Hep-B and Hep-C). If my test results come back as a carrier for cystic fibrosis or the other disease then Chris will also be tested.
• IVF nurse draws up detailed medication schedule
• Start birth control pills on CD3, take for 3 weeks
• Start Lupron subcutaneous injections – will overlap with BCPs and injected daily until egg retrieval
• Stop BCPs, continue Lupron alone for 4 days
• Suppression check: ultrasound to make sure that my ovaries look ok and are quiet. Blood test for something (I think estradiol levels)
• If all looks ok, start stims: Follistim and Menopur subcutaneous injections until retrieval (still doing Lupron injections. Daily injection count = 3)
• During stims, appointments every 2-3 days to monitor follicle growth via ultrasound and to check estradiol levels via blood draw
• Once follicles reach ~20mm each, hCG intramuscular injection. I have had these before, but never had to do it myself!! It has to be done 36 hours before retrieval, so that will be ~8:00-10:00 PM. The office is not open at that time to stab my ass for me.
• Egg retrieval (ER) and 1 day of bed rest
• Start progesterone-in-oil injections (PIO) on day of retrieval. TEARS! Daily intramuscular injections based in oil, not water. These will continue for 2 weeks. If I’m pregnant, then they continue for 2-4 more weeks depending on how fast the placenta starts producing it on its own. I’m not going to be able to sit. I’ve already volunteered Chris to give these to me. Good thing he has played darts before.
• Embryo transfer (ET) on either day 3 or day 5 post-retrieval. Abbreviated 3dt or 5dt. If we have several good quality embryos, they will let them continue to grow in the lab for the extra days so they can isolate the best of the bunch for transfer. If we only have a couple good embryos then they do a 3dt. She thinks because of my age we will have a 5dt. Three days of bed rest. 
• Two weeks later: beta check
• I seemed to stop responding well to Clomid – does that cause any concerns for my response to Follistim?
• No, completely different drug
• Will we work primarily with you throughout the whole process?
• Yes, the IVF nurse will do her best to schedule everything so that we see her for most checks and for the ER and ET
• Any reason we should take a cycle break before starting IVF?
• No, there is no difference in the pregnancy rates so it is totally up to us
• Given we are ‘unexplained’, any concerns about my uterine lining or anything that might cause implantation problems?
• No, even with the Clomid, which can cause thickness problems, I produced a thick enough lining and from the looks of the all the ultrasounds I don’t appear to have any polyps or fibroids. Will take a closer look with the sonohysterogram.
• Will I be awake during the egg retrieval? (what I really wanted to know is if the sedative is a truth serum – not that I have anything to confess, but I would like to just not say anything while Dr. NFB and the nurses have needles where sharp objects should never be stuck)
• No, while it is not a general anesthetic, it is a heavy sedative and will cause me to sleep. I might be able to respond to direct commands, but that’s about it. Plus the sedative contains an amnesiac. This sounds like what they gave me when I had my wisdom teeth extracted. My poor Mum. “How long was I in there, because I swear it was only like 2 minutes? Wait, how long did you say it took? Did I cry? No, oh, but how long was I in the room? And did I cry?” NO!
• Do you recommend ICSI (intracytoplasmic sperm injection)? This is where they fertilize the eggs directly.
• No, she doesn’t see any reason to recommend it. But, we will authorize the embryologist to make a game time decision if he doesn't think the eggs and/or sperm look like they will work well on their own
• How often will we hear about the progress from retrieval to transfer:
• They can tell us how many follicles they aspirated at the retrieval. Later that day the embryologist will call with how many eggs are mature. At the end of day +1 he will call with a fertilization report. On average, about 75% of mature eggs will fertilize. End of day +2 will call with whether we are doing a 3dt or 5dt. End of day +5 will tell me how many they will freeze (we are hoping for at least a couple).
• Do you recommend acupuncture?
• Whatever I want to do to relax is fine, but if I want to do acupuncture I need to start now because all those needles can cause more anxiety for some people. She does not want my first acupuncture treatment around when I start stims.
• Can I stop taking bromocriptine (aka Kryptonite)? It's a hangover without the party.
• No, not until I get pregnant. Damn.

I like to understand everything that is going on, so I tend to research things on my own. Here is what I found out about the medications:

• Birth control pills – nothing anyone doesn’t already know. The point in an IVF cycle is to start suppressing ovulation as the doctor wants to control that process
•  Lupron – stronger ovulation suppression drug. It acts as an agonist at the pituitary gland receptors and causes a reduction in estradiol and testosterone levels. Also noteworthy: it is used to treat the symptoms of prostate cancer. At least my prostate will be in good order...
• Follistim - synthetic FSH (follicle stimulating hormone) stimulates the ovaries to produce more follicles. Dr. NFB prefers this brand over Gonal-F because it is easier to self administer
• Menopur - equal parts FSH and LH (luteinizing hormone) to stimulate the ovaries to produce and mature more follicles. Dr. NFB wants to use this in conjunction with Follistim because she believes it helps with egg quality
• hCG - chorionic gonadotropin to trigger the final stages of egg maturity, will cause ovulation which is why it is important to time this injection exactly as directed so they can retrieve the eggs before ovulation
• Progesterone-in-oil - prepares the uterus for implantation and decreases the maternal immune response to the embryo. Need injections because the cells that naturally produce progesterone are aspirated during the egg retrieval.