Friday, 21 October 2011

Part 3: Reflection on the Birds and the Bees (ICSI IVF Style)

There was a point during our cycle of IVF when I joked to someone that if we were lucky enough to have a child, that I would really look forward to telling my child all about the birds and the bees. Well, you see, darling, it all starts with needles...

...lots of them.  Now some people breeze through this part of IVF without a backward glance but if you happen to a bit needle phobic, like me, then you are in for a bumpier ride.  Just to put all of those needles into context, IVF breaks down into the following basic stages for a woman:

- egg production (in my case this took approximately 27-28 injections, 8 blood tests and 8-9 vaginal ultrasounds);
- egg retrieval (IV plus the whopping needle used to hoover out my eggs);
- egg fertilisation (well that involved a needle but thankfully it was not stuck in me); and
- embryo transfer (I think that this was needle free, but it was certainly not catheter free).

I should say at this point that I have a tendency to faint when people brandish a needle at me so I have to tell you that I am very proud of myself for surviving all of the above without passing out and bruising my forehead on a piece of hospital furniture.  That, in itself, was a miracle.

I should also say at this point that having read up on IVF, the processes, procedures, choices and paperwork before we started our cycle of IVF, it was my ideal scenario to go through the above process, produce a bumper crop of eggs (of course) and have at least 4 of them fertilise.  This would give me the option to use two embryos in this IVF cycle and freeze down the other two for a second 'go' later.  Either if the first cycle failed or if we were successful and decided to try for a second child later.  Really.  Ok, you can stop laughing at my naivety now.

I really should say that this is a very long blog post.  Sorry about that.  It's just the way that it turned out.

Egg Production

Once I was a couple of days into the process (only 1 injection per day for the first two days, which the nurses handled in order to demonstrate how and where the drugs should be injected), I was supposed to inject my tummy or upper thighs with two drugs per day to stimulate egg production and manage my cycle - FSH and Buserelin. 

Being a logical person, I decided to use one side of me for one type of drug and the other side of me for the other.  As you do.  What did tickle me (this is from my very unscientific packet reading and internet research) was that the two IVF drugs - well, one was made from hormones extracted from the urine of post menopausal women and the other's primary use is in the pallative care of men with prostate cancer.  Isn't that quite the party?

The only problem was that I was supposed to inject myself with these drugs and I just couldn't do it.  I tried and I failed.  The Fella tried and he failed.  Neither of us could do it.  I sat at our dining table, drugs and syringes laid out in front of me like some kind of serious drug addict and I could not overcome 40 years of needle phobia and neither of us could overcome our conditioning not to hurt ourselves (or anyone else) on sharp, pointy objects.  Either we would think that we were pushing the needle in but it turned out that we were not (as it wouldn't go in, just created a dent in the skin) or it would just pierce the skin with a sensation that felt (both to me and the Fella) like a ballpoint pen being pushed dully through a piece of clingfilm.  Whereapon we'd either recoil in panic (dropping the syringe on the floor, contaminating it and wasting our drugs) or not be able to push the rest of the needle in.

I phoned the hospital and explained our problem.  Luckily, the nurses have come across people like us before.  So I had to go into the hospital every afternoon for the remainder of our IVF cycle to get a nurse to do my jabs for me.  Pathetic but true.  Personally, I found that the drugs stang after they were injected.  By the time I reached the egg harvesting stage, my abdomen sported a whole constellation of scattered injection bruises, my hormonal balance had been so upset I was a raging basket case and my ovaries felt like they were trying to bulge rudely (and uncomfortably) out of my pelvis.

On top of the injections, from Day 3 of the IVF cycle onwards, I had to be at the hospital at 8am every other morning for a blood test and a vaginal ultrasound.  The Fella nicknamed this 'The Breakfast Club'.  I didn't really speak to any of the other women that I met in the Breakfast Club blood test corridor or ultrasound waiting room.  Other than the odd smile and nod of recognition, we were all very quiet.  Towards the end of the cycle, this became a daily appointment.  The blood tests were just more needle misery that I pretended to be stoic about and the ultrasound became affectionately known in our household as the 'light sabre treatment'.  I have to be honest, it was silent, but somehow it really helped me to imagine the light sabre noise in my head as I could feel the ultrasound probe swinging first to the left and then to the right in order to scan my ovaries so that the specialist could count how many egg follicles they were producing.  By helping, I mean that it distracted me from the fact that I was reclining on a chair, knickers off, socks on, covered in a modesty sheet, being probed by a piece of hospital ultrasound equipment.

After every blood test, I had to ring the hospital at noon to find out my blood test results and whether my drug dosage was being altered.  After which, I would go hang around the pharmacy to buy more drugs and take them into the hospital for a nurse to do the jabbing honours.  Rinse, repeat for 14 days (in my case).

This was quite a stressful, emotional time for us as a couple.  Apart from the fact that my hormones were completely messed up, I did not respond to the drugs either as quickly or well as the hospital expected.  I didn't realise there was a problem until about halfway through the IVF cycle when a doctor I had not met before did my ultrasound and commented, effectively, that my body needed to buck up its ideas and try harder because only 5 egg follicles were starting to look viable (I started with 9 or 10 but they did not all develop).  As a result, I was starting to look borderline in terms of whether there was any point moving onto the egg retrieval process (the hospital will not go to egg retrieval for anything less than 4 follicles).  They ramped up my FSH drug.  I fussed very badly because there was absolutely nothing that I could do to 'buck up my body' or control how my body responded to the drugs they had instructed me to take.  They ramped up my FSH drug some more, the IVF cycle dragged on but no more egg follicles matured.  I felt very despondent.  We reached the crunch point where we really needed to either proceed to egg retrieval or cancel the cycle. 

You see, despite the drugs you take to control your cycle, the IVF egg production process does have a clock ticking.  It gets to the point in an IVF cycle where you have to act, retrieve the eggs, fertilise them and get embryos back in before the uterus lining starts to prepare itself to shed.  There is an optimum window for embryos 'to stick' and if you miss it, the IVF cycle is very likely to fail.

We had a difficult conversation with one of the specialists about whether we should or should not proceed to egg retrieval.  She was honest but very careful to tell us that this had to be our decision - our case was not optimal, I did not have many egg follicles and we were really pushing my cycle, so the odds of us being successful were diminishing fast.  She estimated that the chances of us becoming pregnant had dropped to around 20% from 30-35% so we were very likely to need another cycle of IVF if we wanted to become pregnant.

However, she also warned us that we needed to be aware that this might be just as good as it ever gets - what would we do if there were fewer eggs next time?  She'd had cases where there were lots of egg follicles but the eggs turned out to be very poor quality.  She'd had cases where there were very few egg follicles but the eggs were all very good quality.  With us, she pointed out that there was no case history established for us that identified whether the number of follicles in this cycle was typical and no data on whether my eggs were any good.  If it was a question of finances, then we could cancel and try again in another 2-3 months time and hope for a better outcome.  However, the way that she said it, left us both with the impression that we should consider continuing.  She had to leave in order to do a procedure for another couple. 

We sat with one of the IVF nurses and hashed the problem backwards and forwards, looking at the pros and the cons of going to egg retrieval.  I would be lying if I said that finances were not a big part of that discussion. By that point, we were at least $5,000 into the procedure (hospital treatment and drugs).  If we continued, the remainder of the cycle would cost a further $5,000.  So really, the question was whether to proceed so that the hospital could build up a full cycle case history on us or bail and put the $5,000 we saved towards another, potentially better cycle with better odds.  It was a very miserable and upsetting discussion. 

In the end, we decided to continue.  We made this decision on the basis that it would give the hospital a full case history on us, which might improve our chances in the future.  We also made it on the basis that having two full attempts at IVF for $20,000 had to be better than one and a half attempts for $15,000.  After all, if we were successful, even if our odds were very low, we wouldn't need the second cycle.  Also, I have to acknowledge that there was a part of me that did not want to have gone through such an expensive, exhausting experience and walk away, mid process.

Also, notice how we were committing ourselves mentally to another round of IVF if this one failed? After starting this whole process by saying that we would give it one single go and if it didn't work out, that we would get on with our childless lives and not get sucked into further cycles of treatment?  I think that this is how it happens, how people are drawn in and how doggedly determined they can become about having a baby at any cost - the hope extended by IVF can be a cruel, expensive thing.

Egg Retrieval

This took place at about 10:30am on Sunday 30th January 2011.  We showed up at the hospital, I donned a hospital gown, gave my music to the nurse to play during the procedure (Amplified Heart by Everything But The Girl), sat in a chair and freaked out quietly about the IV needle in my hand.  I made them put tape over it so that I couldn't see the needle poked into my skin.  The Fella had to vanish into a little room to well, you know, do his part!  Once he returned, they took me through to the procedure room where I climbed onto the bed and put my feet into the handy holders (in my trademark black ankle socks), lay back, tried not to dwell too much on what was about to happen and held the Fella's hand like it was my anchor to the earth.  At that point, they started some kind of happy, relaxant drug in my IV and once that kicked in, I didn't care at all about what was about to happen. 

A new specialist that I had not met before did the procedure and he was both quick and efficient.  After injecting something to numb the area, he used a whopping great needle to stab through the walls of my vagina into each egg follicle on my ovaries.  He proceded to suck out each egg.  How do I know this?  Well, he had positioned a screen so that I could see what was going on via the ultrasound image.  It might sound biazarre but it really helped to see what I could feel going on 'down below'.  It wasn't painful, I could just feel the jiggling around.  The lab staff came into the procedure room, took my eggs away and confirmed an egg count.  Six eggs - one more than we expected!  I was so relieved (as sometimes, they cannot reach all of the eggs) that I burst into tears.  Once the procedure was over, I had to spend an hour in recovery, then go home and take things easy. 

Egg Fertilisation

The lab fertilises your eggs on the same day that they remove them.  They prepare the eggs and sperm and in the case of ICSI IVF, they inject individual sperm into each egg.  They leave them and wait to see if any embryos develop.  Depending on what IVF process you are following, embryos are implanted back into your uterus either on Day 3 or Day 5.  In our case, we were due to be implanted with our embryos on Day 3.  We had to wait for a phonecall from the lab on Day 2 to tell us if any of our eggs had fertilised and how many embryos we had suitable for implantation. 

As I am 40, the hospital would have agreed to implant up to three embryos, to give me the best possible chance of conceiving.  Under 40, they tend to implant a maximum of two embryos.  If you recall, we had already decided that we would only implant two embryos and save any others for later.

This all turned out to be a very moot point.  When the phonecall came through, it turned out that only three of my six eggs had been mature.  The lab cannot inject immature eggs, so in a matter of seconds during this phonecall report, our six egg count halved.  Sadly, of my three mature eggs, only one had fertilised.  So we only had one embryo.  A single, lonely, only embryo.  Bang went my secret hope for twins and bang went my hope of having a second 'go' from one round of egg production. I made polite noises to the nurse and hung up the phone.

Then I realised.  Don't be stupid.  Just think how close you just came to having been through all of that and ending up with no embryo to implant at all.  I rang my dad in the UK, gave him a progress update and with his usual good humour, he immediately named our lonely little embryo, 'Bob Hope'.  If you are British, you will probably get the joke, 'You've got two hopes...and one of them is Bob Hope!'  (The other is no hope.)

Embryo Transfer

This was very straightforward as well.  It happened for us at about 10:30am on 2nd February, 2011. We were scheduled to have our embryo implanted after another couple had had their eggs out.  I only mention this because their music was left on in the procedure toom during our embryo implantation.  Again, I donned a hospital gown.  This time, no IV was needed.  The same specialist who had removed my eggs did the embryo transfer.  He inserted a catheter into my uterus, measured it and told us that he aimed to pop our embryo into my uterus, not quite at the back, so that it wouldn't float back up into a fallopian tube.  He used ultrasound while he worked out what was what but then advised us that the procedure itself is done blind as ultrasound waves are not good for an embryo.  A lab tech strolled in and advised us that our little Bob Hope was a grade 3, 10 cell embryo.  We must have looked a bit worried as it was very hastily explained that the hospital had had successful pregnancies from grade 5 embryos.

There was a short delay and the lab technicans walked in with what looked like a clear plastic tube.   I held the Fella's hand and stared at the ceiling while there was some jiggling around at my lower end.  The previous couple's music was still playing and it was some kind of light music being played on what sounded to me like traditional Chinese orchestral instruments.  As little Bob Hope was transferred I realised that I was listening to an instrumental cover of 'A Whiter Shade of Pale' by Procol Harum.  It's odd what you notice at times like this.  With great ceremony, the lab technicans took away the plastic tube, checked it and announced that the embryo was no longer in the tube.  Pretty much, that was it.  I looked over at the Fella and said, "I love you darling but you really need to work on your foreplay."

After the procedure, I was wheeled out to recovery and told to rest for an hour.  After that, advice conflicted slightly.  The hospital paperwork suggested bed rest for two days but the specialist told us that this wasn't really necessary.  I hedged my bets, took things easy for a couple of days and lounged about on our bed reading a lot.  I have no idea whether my fear was in any way rational but I was just terrified that the embryo would simply fall out.  After all, what was there to keep it in?!

After IVF

Once you've completed IVF, you wait.  You have to eat, drink and behave like a pregnant woman (both during and after the cycle) but you do not know if you are pregnant.  You have to wait 14 days and then go for a hCG pregnancy blood test to see if the embryo has 'stuck'.  If the results are either positive or ambiguous, you have to go for another blood test  at 21 days to either confirm the results and/or verify that your hormone levels are rising in a way that suggests a viable pregnancy.

It was a very long two weeks.  We waited, continued to eat and drink according to all of the pregnancy rules, told Bob Hope that it was well worth sticking around for the family grub and tried very hard not to fall in love too much with the idea that we might be pregnant while behaving exactly as though we were pregnant in case we were not pregnant.  It's actually a lot harder to do than it sounds.

On the day of the blood test, I was at the lab early.  The hospital told me that they would phone through the results at about 2:30pm.  I waited in for their call but it didn't come.  I phoned them.  The lab results were not yet in.  In BC, there is an online service that enables you to get your test results as soon as the lab publish them.  Although I had wanted the hospital to tell me the test results, in case I interpreted them wrongly, I went online and spent about two hours constantly hitting the refresh button on the blood test report.  Finally it came through.  I opened it....and I wasn't sure what it meant. 

It sort of looked like it might be positive news but I was terrified that I was interpreting it wrongly.  I phoned the Fella at work and explained the problem.  Together, we looked online for what different hCG levels meant but neither of us were certain and neither of us wanted to get our hopes up artifically.  I hung up the phone and it rang immediately.  It was the hospital.  The nurse said, "Well, it seems that I have nothing but good news for you today.  Congratulations, you are pregnant!  You have to go for another blood test in 7 days time to verify that the pregnancy is viable."

That folks, is how we found out that we were expecting our baby.  We were lucky enough to learn that our pregnancy was viable at the next bloodtest.  Then, once we'd seen our tiny embryo at our 6 (8) week scan, our little only, lonely Bob Hope officially became Spud.  We waited a long time to announce our pregnancy because we were terrified about the prospect of a miscarriage and once that danger was past, we had to have a series of tests to make sure that the baby was low risk for chromosomal problems (due to our ages).  

We know that we were extremely lucky with our IVF treatment as our chances of getting pregnant in that cycle were so low. I have since met a couple who have just had their first baby after 8 years of failed IVF treatment. I just cannot begin to imagine the heartbreak, misery and disappointment that those eight years brought them and what strength and determination it must have taken for them to continue their quest for children.

So now - I am almost 40 weeks.  Spud is due.  In fact, because of my age, viewed as being overdue.  If the baby doesn't trigger a spontaneous exit very soon, the hospital will want to induce me (due to fears about how quickly the placenta can deteriorate in women over 40 after Week 40).

On one hand, it's been a very long haul with lots of anxiety about the pregnancy and lots of worry about whether Spud is okay.  I suspect that a bit of extra worry is natural for people who have been through the mill of IVF.  I sort of feel like I have been pregnant and worrying about this baby forever. 

Quite needlessly, probably.  We seem to have had a very straightforward pregnancy.  We've been exceptionally lucky with our prenatal care as our OB has given us an ultrasound every month, so we've been able to 'have a visit' with our baby, see how it is developing and see what it is doing when it bumps around inside me.  This has been fantastically reassuring for us.

On the other hand, it feels like this year has whizzed past and I can hardly believe that this wriggly creature inside me is due to come out.  I really want to meet Spud - I really want to see, hold and pat my baby's wriggly bottom. 

So come on Spud, we're waiting - whenever you are ready, love.


grannypurple said...

Wow, Gabrielle--I've never heard such detail of this procedure before. A young relative-by-marriage of my husband's once told me that it was a great big science project that she never wanted to repeat, so their younger daughter came from China.. May you have relatively smooth sailing from here on in, at least until Spud reaches puberty! And, thanks for sharing.

Anonymous said...

What she said. Thanks for sharing – I reckon it could be very helpful for other wouldbe mums to hear all this detail. What an enormously stressful time you've had! Almost done now – sending very best wishes that the last stage goes as smoothly as the pregnancy so far.

Roobeedoo said...

Oh sweetheart! One thing is certain - you can tell this Baby that s/he was very much a wanted child! Nobody could go through all that unless they really really wanted it to happen! I don't think I could have coped with so much... intervention.
Hugs from afar!