I've been combing over the protocols from my last two IVF cycles to try to see what could have made the results so different despite being roughly the same antagonist protocol.
These differences somehow lead to the following differences in IVF results:
1. Fewer eggs retrieved
2. Fewer mature eggs
3. Lower fertilization rate
4. Lower survivorship to day 5
5. Lower quality
I'm waiting for my next period to start our next cycle (or that I am miraculously pregnant naturally). That should be around the beginning of March. By then- I want to be able to know what to do differently the next time around. The only thing my doc wants to change in slightly lowering the initial stims so that my estrogen doesn't increase as much/so fast.
Here's what I come up with when I compare this cycle (bad) to my last cycle (good):
1. NCCRM vs University of Michigan- UM is a university hospital, and NCCRM is a private clinic. I used to get frustrated with UM because their protocols were so conservative, but I'm beginning to think they knew what they were doing. Not to mention their IVF facilities were more state-of-the-art and sanitary/sterile than NCCRM. Either way- neither of them managed to get me pregnant but the embryo results were so much different. So- could the different outcomes be from facility practices?
2. Roughly 1 year later (Dec. 2013 vs Jan 2015)- can your fertility (or what's left of it) really change this dramatically in one year? From age 28-29? With a sample size of 2, this also could be "normal" cycle to cycle variation.
3. Shorter suppression phase with birth control- This is a red flag for me, and really is one of my top two candidates for why this cycle went so poorly. At UM, after 24 days of birth control suppression, my blood estrogen levels were still high (52), so they continued suppression for 8 more days (totaling 32 days) until my estrogen was below 12. At NCCRM, they only tested my estrogen levels 4 days after they had already taken me off birth control. Estrogen was 71, and after another day of waiting went to 69 (not statistically significantly different in my book). But NCCRM cleared me to start stimulating my ovaries. I'm worried that in those 5 days being off birth control, my follicles started growing- and because they didn't all get whopping stims early, there was probably uneven growth that created early lead follicles. Maybe I needed longer suppression to make sure estrogen was low and follicles would grow more evenly.
4. Higher doses of follicle stimulating hormones (Gonal, Follistim, Menopur)- theoretically, higher doses should lead to more eggs retrieved, but it didn't. Why? I think that because there were early follicle leaders from being off birth control that the increased stims only worked to make the big follicles bigger.
5. Stimulated follicles longer amount of time- At NCCRM, I was given higher doses for a longer time than at UM. Again, shouldn't that have increased egg yield? But it didn't. I think if they had triggered 2-3 days earlier, they would have ended up with about the same eggs as I got in my previous cycle. This is in my top two suspects for this cycle's failure but hindsight is 20/20.
6. Antagonist added later- I don't know how much this matters, but the antagonist is supposed to keep you from ovulating. It was added later in this cycle than my previous one.
7. Estrogen levels higher at trigger- This past cycle at trigger, I don't even know what my estrogen levels were because NCCRM didn't test them in the last three nights of stimulations. If it didn't plateau, I think it was between 3-4 thousand. At UM, my estrogen stalled out at about 1,000, which prompted them to trigger. At the time, the said stalled out estrogen is bad for egg quality. So- I'm wondering whether my estrogen levels stopped rising this cycle.
8. Lupron trigger vs HCG trigger- I think that Lupron is a weaker trigger than HCG, but that is just from internet searches. NCCRM claims that they trigger all their infertility patients and donors with Lupron.
9.Took DHEA and CoQ supplements- I'm going to come right out and say that supplements don't work :/ I didn't take any for my "good" cycle and had more mature eggs, higher fertilization, higher quality and better survivorship. But I'm going to keep taking them anyway just in case (grumble, this is how people are making money off of infertiles).
10. Can you think of anything else? I have no thought whatsoever that SuperUterus had anything to do with our failed cycle. Her lining was perfectly fluffy, and welcomed our little embie with love.
I got the most kind and gentle email from Super Uterus- telling us that every test she took had been negative and that she was so sorry to tell us. We had prepared for a negative- expected it really. I was glad for it to be over- the wanting to hope but not wanting to be hopeful. The worst part for me was having to tell my loved ones that it didn't work. I don't know exactly why it is so upsetting for me- seeing as I just group texted them. But it was like I was letting them down- in the face of all the support and hopes they had. Another failure that I had to admit. There is definitely part of me that wishes that I could go through all of this without telling anyone- JUST to avoid having to tell anyone it failed. again. It makes me feel so desperate. It makes me question why I am trying so hard to have a child in the first place. Is it worth all this pain, money, time, and risk? Most people say that it is "worth" it. And they would know because they have the kids to prove it. But I think maybe in some cases it is not. I'm getting a better understanding of my good friends who have chosen to live "child free" instead of pursuing a life of one failed infertility treatment after another. That being said- I'm not there yet. We are not quite sure about what the next step is but we will keep you posted. How lame would this surrogacy blog be if we never get pregnant?? It had better work.
As things started going downhill during the follicle stimulating phase, The Manager and I said things like "We only need three embryos" "One out of 3 transfers should work" "It probably won't work the first time". I embraced good luck charms this cycle to try to get me through it. It's something that I could do differently than in past cycles- maybe it is what would make it work this time. I painted my nails green all throughout the cycle. I tried to wear green as much as I could- and did quite a nice job of integrating green into my wardrobe. It isn't a color that I wear often!
Luck only seemed to be on my side for scheduling with retrieval and transfer. In the lead up to the main events (retrieval and transfer), The Manager and I were so worried that the surgery or transfer would fall on days that would be really bad for our work-life. But luckily- retrieval happened on a decent Monday. The Manager dropped me off and Super Uterus picked me up and tucked me in at home after it was done. I went into retrieval with a population of follicles that was over mature and a population of follicles that were under mature (see chart below). At my "WTF appointment", the doctor would tell me he was "hoping" that small ones would catch up and he could still work with the larger ones. I woke up to hear that they only got 4 mature eggs :/
By day five (transfer day), only one embryo was still growing but it didn't have a high quality score- so that's about when I gave up completely. It was really hard getting this news with Super Uterus. It was time for her to be really hopeful about the embryo transfer, but it was just really bad news. We wouldn't have any embryos to freeze to try again if this transfer didn't work.
Perhaps the coolest and creepiest thing about this clinic is that the embryologist- Stanley- literally brought the embryo from across the hall into the transfer room to an incubator similar to the kind used for NICU babies. We all got to have a look at it sitting there in it's little petri dish in pink media. It all seemed very unconventional to me as my old clinic in Michigan just had tiny window from the embryology lab into the STERILE transfer room. The window opened when everyone was ready and the doctor loaded up the embryo in a syringe to transfer. Dr.Toma was not even in scrubs and we were in a normal ultrasound room. Super Uterus wrote in more detail about the transfer over at her Part-Time Uterus blog.
I told Super Uterus that I didn't want to know any of the results from her home pregnancy tests (HPTs) until the morning we were to get blood drawn two weeks after transfer to see if she was pregnant (this is called a Beta HCG test, or Beta for short). The reason I didn't want to know- is that there are, sadly, many times you can become pregnant transiently, technically- but then a few days later, the pregnancy ends. I didn't want to get my hopes up at all at any point only for them to be crushed at the Beta test. During the two-week wait, I realized that at some point- Super Uterus was going to have a pretty good idea of how it was going based on the results of her HPTs. If they were bad, I was so worried about her being upset, and having to go through it on her own because she was keeping this part of her journey largely private so that I didn't find out. I know how awful it is to try your hardest to do everything right- and to not understand or accept that the tests are negative. By 9 days past the embryo transfer, many of the people that I was cycling with (women who had IVF retrieval and transfer on the same days that Super Uterus and I did) were already having their Beta test results. I felt like it was a good time to ask for her results, as they were not likely to change by the time we went for the Beta test. They were, of course, negative and we are ready to think about what is next for these two uteri.
Many thanks to two Super Uteri for helping our site be beautiful and for documenting our journey. Sandra Paa created these awesome Super Uterus graphics. They are so powerful, fun and united- they represent so much how we would like to be on this adventure in infertility. When you think of me- fighting the good fight- I hope you see me as the feirce red uterus in the middle- I have claimed her as my icon too. Also we are very thankful for Rachel Campbell for coming to our transfer and photographing these important moments. Her professional photos are sprinkled throughout the site now (photos above in this post), and the one on our home page of me and Super Uterus was taken by her. They are all amazing, but this one below is my favorite: me and Super Uterus doing what we normally do.
The Phoenix - rising from the ashes of infertility. Super power- extreme worrying.