Welcome to Cycle Day 1

It's like deja vu all over again. Goodbye, IUI #5; Hello, IUI #6. Originally, my beta was scheduled for Friday. Now that appointment has been changed to a Day 3 Monitoring (BW/US) appointment.

Shocking, I tell you, simply shocking. Do you think it was my husband's high fever on IUI day? Or my high fever for 7 days after IUI day? Or the terrible fall I took in my laundry room? Yeah, I don't think it was any of those things either. I think it was the fact that IUIs have abysmally low per cycle success rates, which is why I'm ready to be off this IUI train. One more and then I move to IVF.

I can't say I'm particularly thrilled about moving to IVF, except that the per cycle odds are somewhat higher than with IUI and at least it will feel like I'm doing something instead of marking time in my calendar until the next cycle.

Still, I'm quite tired of this whole game.

yowie yow yow youch!

I'm 12 days post-IUI, which is where I was when I found out I was pregnant last cycle (in july/august). I've had a lot of odd cramping and spotting, identical to the weirdness that I had last time. As of yesterday I was vaguely considering the possibility that maybe this IUI had worked. As of today, I'm pretty sure it didn't. I think today might be CD1, or maybe that will be tomorrow, but holy cow am I all kinds of crampy right now. And while I know that I had a lot of bleeding last time and it turned out I was pregnant... I find it really hard to believe that it would happen that way twice.

Le Sigh.

Beta is Friday. I do not expect good news.

IUI #5

Not having many positive thoughts about this morning's IUI. S woke up wretching this morning, having apparently caught J's stomach virus. Poor thing. We almost called the whole thing off, but S said if I could drive him, he'd do his best. And do his best, he did. Smallest count on record (6.5 million as opposed to last time which was closer to 30 million), but Dr. Amazing said anything over 5 million is great.

When we first arrived at Shady Hell, I thought that Dr. Evil was going to do the IUI, and I was decidedly unhappy about that. He's rarely at the Rockville office, which is a blessing to me, because I really can't stand him one bit. Fortunately, it turned out that Dr. Amazing came down to do the IUI, which was great. Still, I don't think the odds are particularly high considering how sick S was this morning (he's sleeping now). I'm fairly certain that I will get sick soon too, since it's gone through J and S already. Fortunately, it will be too eary for even ME to delude myself into thinking it's pregnancy-related nausea.

Do you know how sick I am? I'm vaguely considering peeing on a stick since the hCG shot is probably still in me just so I can see those two lines ONCE this cycle. Yeah, I'm a sicko. I'm not going to do it, but I was seriously considering it. Then I realized I've done that before, but never gotten a positive pee-stick just from the hCG trigger. Is that odd? Well, whatever. I'm definitely odd, so I am probably asking silly questions.

Either way, my beta is 1/26. Perfect timing to ruin my birthday, which is 1/29. No problem, since, like I said, I'm not particularly counting on a positive result, no pun intended.

IUI Tomorrow

I rarely receive anonymous comments on my blog (for that matter, I don't get that many comments at all, but I love the ones I do get), but I did get one today. It reads:

I'm thinking good thoughts for you. May your level-headed expectations be rewarded with the best outcome. The conflict with work has got me wondering: What actually is the statistical difference in a situation such as yours between an IUI and well-timed intercourse?

I don't actually know the answer to this. As far as I can figure, for most problems, IUI doesn't raise the odds very far above well-timed intercourse. I suppose in cases where there are issues with not having EWCM, the IUI makes a significant difference, since it bypasses the cervix. I know that in normal, healthy, fertile couples, with well-timed intercourse, there is about a 20% chance per cycle of successfully conceiving a child. I also know that the odds of IUI working in any given cyle are about 20% per cycle. Further, this is even true in women with no fertility issues... 20% odds per cycle, period.

So what does IUI actually get me? Well, for one thing, it guarantees the timing. There have been a number of medicated cycles that we've had where we wouldn't have been able to make the timing had we been relying on "the old fashioned way". Most notably, we almost missed out on the timing this cycle because I didn't think I'd get to mikveh in time.** In a non-medicated cycle, I simply don't ovulate, so that doesn't help either. So there's that. The guarantee of timing.

Other than that? Not a whole heck of a lot, actually. It just gives a bit of peace of mind, I suppose. I suppose this is one of the reasons I'm not terribly interested in continuing to do IUI for much longer. On the other hand, over three years of trying the old fashioned way, even with Clomid assistance, yielded no results, but 8 months of IUIs yielded a pregnancy, albeit a short-lived one. So I suppose in the long run, IUI has been good to us, comparatively speaking.

That being said, tomorrow is IUI day, and for whatever reason, I wouldn't want to rely on getting our own timing right, and I'm just as happy that S was able to get his work schedule to accommodate. I'm actually beginning to wonder if we ought to have a, um, you know, sample cryopreserved... just in case we have another conflict, but one he can't wriggle out of. I dunno. I mean, I suppose there's always the chance that it will be a moot point, right? After all, it's theoretically possible that I could get pregnant this time. Right? Stop laughing! Okay, I can't stop laughing either, but after I peel myself off the floor, I'll consider shooting my doctor an email to see if it would be a complete waste of time and money to have a back up plan, so to speak.


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**Mikveh is... well, it's hard to explain. Jewish law mandates that a Jewish couple separate for a minimum of 12 days starting the first day of a woman's menstrual cycle (well, the first day she sees blood, which may, or may not, correspond with the medical definition of CD1). At the conclusion of their separation, the couple does not resume relations until after the woman has immersed in a ritual bath, called a mikveh. That's the short story. If you want the longer story, I can point you to some links.

CD14 - The end is near (I think)

This morning I had follicles at 18.5 and 14.0. Lining was 11.6. I will, in all likelihood, trigger tonight and have an IUI on Thursday. This is about as bad as the timing could get, because S is staffing on Thursday and I feel awful asking him to find someone to cover him, but there's really no way around it. Unless the bloodwork comes back completely contrary, we can't really push it off, so there you are.

I've never had a follicle that big, so this is kind of cool. Still not expecting it to work, but it's still nifty. Will update this entry once I get my hormone levels.

Update: Trigger tonight. No big shock. I didn't even ask what my E2 was. Maybe I should have, but I didn't even think of it until we got off the phone. Poor S.

CD13

I don't normally blog about every single monitoring appointment during a treatment cycle. But I also usually have one or two real-life friends who are in on the fact that i'm cycling who I talk through these things with. I've been very closed about this cycle with anyone I know personally. People know I've had appointments at Shady Hell but they don't know why or really even when. And anyway, it's MY blog, so I can blog all the gory details I want. So here are today's details:

Right Ovary (always the overachiever): 16.1mm and 14.4mm (up from 14.6 and 13.6)
Left Ovary (with a surprise comeback!): 13.8mm
Endometrium: 11.16 (I've never had an endometrium this thick at this point in my cycle, so yay, I think)

Today's sonographer (my beloved Margaret) suggested that the two follicles on the right were just waiting for the Left to catch up a little bit so I could have THREE follicles come trigger time. Um. Triplets? I hope not! (I do realize that there is absolutely no possibility that I'm going to end up pregnant at all this cycle, let alone with triplets. But still...) Margaret also pointed out that on Friday it was the doctor who did the measuring and sometimes doctors aren't quite as skilled at using the equipment, since they don't do it all the time. So three different people doing my ultrasound in three different visits yielded three very different results. Not terribly shocking.

The doctor didn't know quite what to think about me, but said we'd wait to see where my estrogen was today before making any judgments. This particular doctor is usually pretty decisive, but he sure doesn't seem thrilled with the way this cycle is developing. Frankly, I don't blame him. Because although each individual visit seems to have good news, the overall trend is a little odd. It happens that I'm anal, so I keep a simple spreadsheet of every cycle and this is by far the weirdest. Thanks to the joys of Google Docs, I now have it accessible online: IUI Cycle #5.

All I can do at this point is wait and see. I'm still pretty early in the cycle, so I'm not worried. I make sure to remember that my second IUI cycle lasted over 30 days (triggered on day 31, IUI on day 33, CD1 on day 45 or so). It's just been a very weird cycle, because on Wednesday I was told I'd probably trigger Friday or Saturday, on Friday I was told I'd probably trigger Saturday, but was later called back and told to come back Sunday. On Sunday I was told I'd probably come in on Tuesday and trigger Tuesday or Wednesday, but I was called and told to come in today. Today the doctor didn't even try to take a guess on either when I'd trigger or even when I should schedule my next monitoring appointment. He just said to wait for the estrogen level to come back and we'd figure it out from there.

I probably wouldn't even be tense about it, except my husband has to staff in the Shock Trauma unit on Thursday, which would be really hard for him to get out of if I end up triggering tomorrow and needing an IUI on Thursday. We'll obviously work it out one way or another, but it's still making me tense. I'll update later when I get my status call from my nurse.

UPDATE: E2: 121 LH: 1.89. No one seems to know why my E2 is plateauing. This is a new wrinkle that I was not prepared to deal with, and I am beginning to believe this cycle is a complete waste of time. Why is this suddenly not working? I've been known to have slow cycles, but even those had predictable/appropriate rise in hormone levels. Phooey.

More Info

I'm just Posty McPostyson today!

Just got a call from Shady Hell. My estradiol is 118 (this is not amusing me, since last Wednesday it was 103, and had apparently gone down a little bit on Friday, though I don't know Friday's number).

My estrogen NEVER gets as high as the nurses seem to think it should, but I've asked my doctor about it before and she said it's not surprising in PCOS patients, and that she really doesn't care as much about the raw number as she does about the comparative levels from visit to visit. My preliminary web research suggests that my doctor was being diplomatic, as it appears to be specifically excess weight that can result in lower estradiol numbers (which is weird, since fat cells produce estrogen, so you'd think it would be elevated, but I suppose there are different kinds of estrogen, so maybe that's why).

My LH is 1.6 which doesn't make any sense to me. Everything I've found suggested that the LH surge should show >20 mIU/ml, so I'm thinking they're using a different scale (so maybe this is really a 16 on that scale?). I also find this completely unamusing. But I'll just sit, smile, and nod and do anything they tell me.

In this case, anything they tell me includes going in tomorrow instead of Tuesday (as I'd originally been told). Since I'm making the appointment at the last possible second, the only appointment they have for me is 8:15, a full hour than I usually like to be there. I much prefer the 6:45 or 7am appointment, but 7:15 is usually my last resort. 8:15 is all manner of inconvenient, but at least I'm still working fairly close to the Rockville office. I'll likely be changing jobs at the end of the month and THEN it will be much harder to manage with an 8:15 appointment.

Mystery Solved

I went in for bloodwork and ultrasound (again) this morning before the crack of dawn (no kidding... the sun wasn't up when I arrived at the office), and the mystery is solved. My hormone levels had sort of leveled out and weren't where they expected them to be given a 16mm follicle on Friday. This explains bringing me back for more monitoring today instead of triggering last night.

Now I have 2 follicles on the Right: 13.6mm and 14.6mm instead of one 16mm follicle. How could this be? The sonographer thinks that there were probably two follicles developing so close together that the septum was difficult to visualize. And, she said, the bonus is that I now have two good looking follicles, which is great.

So that's where I am.

Odd...

Weird. I'm told to increase my dosage by 18 IUs tonight and tomorrow and return for monitoring Sunday. How weird is that? I'm not sure what to make of it, but I couldn't get any more specifics because my nurse called while J was throwing a bit of a hissy fit. So I didn't hear any useful information, but I can only assume my estradiol or LH wasn't where they wanted it to be yet.

CD10

I had bloodwork drawn and an ultrasound done this morning. My beautiful 14.7mm follicle is now 16mm. Lining is 8.9. Doctor wanted one more day and then have me back tomorrow to check before probably triggering tomorrow night.

Except I can't come in on Saturdays, which the tech remembered and pointed out. I wasn't planning to say anything about not coming in on Saturday, I figured I'd work it out with my nurse when she called with my E2 and LH levels and instructions.

If I absolutely had to have an IUI (or in the case of IVF: retrieval or transfer) on a Saturday, I'd do it. There's a hotel within walking distance, and the clinic knows how to handle patients who have to come in on Friday to show ID and sign paperwork if necessary. But for a monitoring appointment, my Rav, while willing to say I *could* go if there were no way around it, doesn't love the idea (and neither do I. It's a lot of trouble for not a lot of gain). This is my fifth IUI cycle. My body is pretty predictable.

Fortunately, the doctor agrees that it's not entirely necessary (though possibly preferable). After he gets a look at the E2/LH levels, he'll confirm, but his suspicion is that we'll give that beauty of a follicle another day to ripen before it hatches so that it's around 18mm when it's released. So that means no more monitoring appointments, but a trigger tomorrow night and an IUI Monday.

I would have preferred a Sunday IUI, but I can live with Monday. Can't be too picky, after all. Plus with my mother out of town, I don't know what we'd do with J if my husband and I both needed to be at Shady Hell on Sunday (though I suppose he could go and come back and then I could go, but I'd be cutting it really close for my appointment if we did that)

This is the fastest cycle on record for me. Triggering on Day 11, if that's what happens, is unprecedented. My previous IUI was on Day 16, which was already super-early for me (but it worked, so I'm not complaining). I'm all for this cycle being over, though... the discomfort on my right side has turned into quite considerable pain. Not debilitating, obviously, but enough to make me want it to go away.

CD 8

5 days of Follistim under my belt, and it was back to Shady Hell to see what was going on. Here are the basics:

Right Ovary: 1 follicle measuring 14.9mm; 7 follicles under 10mm.
Left Ovary: 1 follicle measuring 11.7mm and on measuring 10.3mm; 6 follicles under 10mm.
Endometrium: 8.7mm (is that good? they seemed all excited about it)
E2: 103 (again with, is that good?)

Two more days of Follistim at the same dose, and back on Friday. I have this feeling that I'm going to end up triggering on Friday (CD10) and having an IUI on Sunday. That's the fastest cycle on record (for me). Shocking.

Oddly enough, I'm having some pretty noticeable pain on my right side, enough that I notice it and I've got a pretty high pain tolerance. It's not debilitating or anything, but it's definitely distracting.

Also, I realized tonight that I've been taking the wrong dose. I was supposed to take 66IUs per night, but I accidentally have been going one more click on the pen than I should and have been taking 75IUs each night. Obviously nothing horrible has happened as a result, and it's not a big difference, but I feel a little sneaky. Except, well, I wasn't being sneaky, I was being careless. Well, anyway, I'm not going to revert to 66 (particularly since it's working and I didn't have some scary alarming response that made everybody worry), but I imagine I ought to mention it to my nurse anyway. Sigh.

CD Whatever

So, here's the thing. Wednesday could easily have been described as "full flow" making it CD 1. And then most of yesteday? Almost nothing. Today? Full flow is definitely a good description.

So is this CD1 or 3 or whatever?

Well, whatever it is, I went in for CD3 monitoring this morning. They managed to draw my blood in just one try today, which is nothing short of miraculous since Dracula had the day off. And I got to see my beloved Margaret, the super sonographer. My one bright spot in this whole ridiculous ordeal of having to do this all over again is that I get to see Margaret again. M is responsible for my blog name, you know. She always refers to my ovaries as "perky" because they're always full of antral follicles, which, yes, I get is a good thing, but it was, for a time, disconcerting to hear my ovaries referred to as perky. They felt slightly mocked at first, you see, which is (I'm certain) why the first IUI didn't work (though it doesn't explain why the 2nd and 3rd didn't work... surely by then they were used to the good-natured ribbing?).

MY POINT... if I ever had one in the first place, is that I adore Margaret. So while I wasn't entirely PLANNING to see her again until April or so of 2008, I'm happy to see her now, even if it's because my body sucks.

Anyway, today was no terrible shock. My ovaries, true to form, are definitely perky. I couldn't count the number of antral follicles even in one single view, let alone by seeing it all the way through. So I think it's safe to say that I've got good ovarian reserve. Shocker. Also that if I were to do IVF I'd be a super responder. Another shocker. But it does rather accentuate why it is that IUI is such a dragged on process for me. With that many eager follicles, they've got to be careful to bring just one or two to the front and ditch the rest. So teeney, teeeney, teeeeney doses of follistim for me. (More than last time, though, 66IUs) Assuming, of course, that my E2, P4, and Beta all come out indicating that it's appropriate to start stims. And they had BETTER come out saying so, because I just spent scads of money on Follistim. Which brings me to the one surprise of the morning:

I stopped at the pharmacy on my way out to pick up my Follistim. I'm fairly certain that I have a vial at home, but I'd hate to get home and find out it was no good or had been misplaced, or had expired, or whatever after I got home. Shabbos comes in at 4:30 today, so there wouldn't have been time to find a more local pharmacy to take care of it. So I stopped to pick up a vial just in case. Anyway, my insurance had rejected the Follistim because it didn't "match the existing authorization." My insurance has paid for probably 30 vials of Follistim in the last year, but I think the problem is that there was an intervening order for Gonal-F back in November, which I decided against using, because it's such a pain in the neck for non-standard dosing.

I'm certain the insurance will pay for it once it's resubmitted, but in the meantime I had to pay out of pocket for it. Not the end of the world, fortunately, but not inexpensive. Since I'm taking such a tiny dose, one vial should get me through about 5 days, possibly 6. And that one vial cost me $300. I know people who take 5 vials PER DAY for IVF cycles (I'd never be allowed to take that much for fear of OHSS). That's $1500 PER DAY. If they take stims for the standard 12 days, that $18,000 in drug costs alone for an IVF cycle. Actually, that's $18K for JUST ONE of the many necessary medications. Holy Schmoly! Suffice it to say, I'm thrilled that I have generally good health insurance and that it covers the medications as well, despite this temporary hiccup.

(I do know that the pharmacy I use heavily discounts their Follistim for out-of-pocket IVF patients. They didn't discount it for me, because they know that the insurance WILL cover it in the long run and because it was "only" one $300 vial. So at least I know they give a lot of folks a bit of a break, but even so, I can't imagine how devastating the costs must be for someone with no insurance coverage in need of that high a dose of stims! Ugh!)

So, um, let the fun begin!

Fun Times Ahead

So I had 11 vials of blood drawn today. First, I went to Ye Old Fertility Clinic to have a blood draw to see if I could start taking Provera today. I have to admit I had these silly romantic notions in my head of not needing the Provera. I had this weird feeling last week that maybe I was ovulating (like I would know what that feels like? Duh! I told you it was a silly romantic notion!) . And well, not that you need that much detail, but it seemed like a good time for my husband and me to spend some quality time together. And gosh wouldn't it be funny if ... ?

Yeah, see, I knew you'd think it was ridiculous.

Ahem. Back to my story.

During my "lunch" break this afternoon, I went to Ye Old Phlebotomy Lab to have another 10 vials of blood drawn for the thrombophilia panel that Dr. Amazing wants done. While I was at Ye Old Phlebotomy Lab, my doctor called. But not Dr. Amazing. I mean Dr. T., the original Dr. Wonderful. She called to let me know that I could start Provera tonight. Yeah, definitely no ovulation occurring naturally. So much for my ridiculous romantic notions. Oh well.

She also said she was very sorry to have to talk to me again so soon, and that even though she knows I'm really an optimist (I am? Really? Huh?) that it isn't easy to have such a loss. She asked if I had any questions for her about the plan Dr. Amazing had laid out for me in her absence and I don't really. I did want to hear her opinion about it, since she knows me best. She agreed with Dr. Amazing's assessment, and said it would be a good idea to have the thrombophilia panel done (good, since I'd just had 10 vials of blood drawn from me), and she agreed that the risk/benefit ratio of taking metformin in the first trimester shifts if there's a history of miscarriage (in other words, she agrees that it's worth it to stay on the metformin if I get pregnant again). All in all it was a very good conversation.

At any rate, it was the first time I'd talked to Dr. T. since I was eight weeks pregnant. But she's officially back from maternity leave though she is transitioning primarily to the Columbia office. I'm faced with a decision I don't really want to make. I can keep Dr. T. as my primary doctor and just deal via phone consult if I need to talk to her directly (this doesn't happen very often), or I can change to having Dr. Amazing as my primary doctor. This really doesn't make a huge difference either way, since the doctors rotate the monitoring appointments and they work as a team for the most part.

I love Dr. T. Completely. I adore her. She listens to me, she takes my concerns seriously, she gives me serious answers to all of my questions and she always makes me feel as if she's got all the time in the world to talk to me, whether in person or over the phone. I also really like Dr. Amazing. I think they are both fabulous doctors. I think they both listen to me as if I'm a real person and not patient number 333687 (yes, I really do have my patient ID number memorized, and no, that's not the real number). While I do like the idea of having my doctor physically accessible in Rockville... does it really make a difference? I don't have consults very often... really only when things aren't going right. And Dr. T. works just fine via phone (and she will be at the Rockville office once a month and Columbia isn't THAT far away).

I dunno. I think I'll just get through this next cycle and go from there.

Yeah. That sounds about right.

Meanwhile, beware! I'm taking Provera, and it ain't gonna be pretty. IUI #5 (for real this time) here we come!

IUI 5.0

I am officially starting my fifth IUI cycle. I was supposed to start an IVF cycle if the fourth didn't work out, but I looked at my September calendar and realized I'd be in Phoenix for a critical week, so one more IUI it is. My poor husband.

It's kinda getting boring. I mean, I know the routine. I can practically self-medicate. I hardly even need the doctor to tell me what to do anymore. And the end-result (BFN) is just so darned predictable. There's got to be a way to make this all more interesting.

I know! We could make a drinking game out of it!

• Time for an injection? Take a drink!
• Time for an invasive ultrasound? Take another drink!
• Abnormally obnoxious migraines? Take two drinks!
  Snapped at your husband for breathing too loud? Another drink for the lady!
• BFN? Congratulations, you get to drink the whole bottle!
• BFP?? Well, the makers of this game don't actually believe that BFPs exist, but if they did, I'm sorry, you'd be out of the game because you'd have to stop drinking all together, so hey! It sucks to be you! (er... I think my perspective may be skewed here)

Anyway, in other fun news going through another cycle is that I have a new, but slightly used, excuse to yell at my husband whenever I feel like it. "Oh, sorry, honey, it's the hormones, you know. Can't be helped."

It's fun to yell at him. Well, fun for me. I'm betting it's not fun for him. Okay, it's not really fun to yell at him, but it is hysterically funny after the fact when I look back and realize exactly how stupid I was being. Also, it's a tiny bit fun to have carte blanche to be evil and be able to blame it on all those darned hormones. "Gosh, Honey, I'm so sorry I called you that, but I'm the one who has to stab myself with needles every night, so you have to put up with it, okay?"

(I'm exaggerating, of course. I only yell at my husband when he deserves it. He just seems to deserve it more when I'm all hormonal and cycling... hrm. Nah, it couldn't just be me, could it? Nah, couldn't be... that's ridiculous!)

Ahem. And now back to your regularly scheduled life.

CD1

Not that it's a shock or anything, but IUI number 4 failed. Today is Day one. That's slightly surprising, as it's a little early, but I can live with it. I called my nurse and left a message asking her to call in my script for BCPs so I can prepare for an IVF cycle. But now I'm being schizophrenic. I looked at my calendar and realized I have to be away for the second week of September (I'll be in Phoenix for training), and that could make things more difficult.

So when my nurse calls me, I'm going to apologize for being schizophrenic, and I'll ask if we can just do one more IUI cycle (which was the original plan anyway). I'm sure it will be fine, and I'll need to pick up more meds, but I can do that on Friday, when I'll have to be there for monitoring anyway, if we make this an IUI cycle.

Right. See, I had decided NOT to chicken out on the IVF cycle. I had decided to suck it up and deal with the PIO IM shots. I had decided to stop being a baby. I had decided that getting pregnant was more important than my irrational fears. And then my calendar got in the way anyway.

I'm not having fun anymore.