IVF Diary Vol III: 31 Mar – 02 Apr 16

Medication(s) administered and dosage(s). Stimming phase: day 1 PM: Gonal-F 375 iu & Menopur 75 iu injections. AM Lupron 0.5mg (5 units) injection

My doctor has decided to increase the Gonal-F and reduce the menopur for this cycle (Gonal-F being the more expensive drug, of course!!).  I hope I respond well to this change!!!

Medical procedures undertaken. Baseline monitoring vaginal ultrasound and hormone blood tests.

ultrasound

What are my symptoms?  I have experienced few symptoms, except for mild tummy bloating and a lot of farting!!! I also have what seems to be a cold, although it is pine pollen season so perhaps I am experiencing the effects of the icky yellow goo that spreads itself around this time of year.

How do I feel today? I am feeling perfectly chilled out right now.  I have had two nights in a row of sleeping through the night 🙂 But I’ve had a few bad dreams 😦  We are feeling a little bit emotionally lost about this IVF cycle.  It has been hard to get really excited.

I am planning some fun things to get us through this cycle.  I will be spending some of the two week wait away in DC so I am going to have to do these progesterone injections myself.  The nurse mentioned that if I do get a positive result then my doctor might be OK with me taking turns doing suppositories and injections.  But not until I get that positive!!!

Chris and I had a little walk to the beach and took our solo cups of wine because the weather was nice and warm.  It was our last alcoholic drink to mark the start of our IVF cycle!

Any results?  Estradiol level 20.9 pg/ml. Uterine lining perfect.  Ovaries – nice and quiet with some follicles sitting nicely ready to be stimulated!!

What’s next? Monday morning is my next monitoring appointment, meanwhile we keep taking those wonderful stimming injections!

Weight. I still haven’t got on the scales yet!

Waist. NSTR.

Boobs. NSTR.

The Final Countdown!!!

160402_IVF3_Calendar_Countdown.jpg

*Notes.  I take First Response Reproductive Health multi vitamin gummies (pre-natal), 5mg Melatonin at bed time and CoQ10 200mg gummies daily.  NSTR = Nothing Significant To Report.

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IVF Diary Vol III 21-30 Mar 16

Medication(s) administered and dosage(s). Lupron 0.5mg (10 units) injection AM.

Somehow I have managed to take all my medications at the correct time despite all the time zone changes (Belgium was 5 hours ahead and the UK was four hours ahead at the time). I have taken the Lupron injections in  some strange places, including in the airplane toilet.  I had alarms set on my phone so I could remember to do it because taking the pill and doing the injection were both at random times of the day!  Quite frankly amongst everything that has been going on I am impressed with myself for managing to figure it all out!

Medical procedures undertaken. Nil.

What are my symptoms?  Actually, I haven’t really experienced any symptoms in particular.  I still have a mild upset tummy, it was doing much better before I left for Europe, but I think everything got screwed up after everything with the attack.  I’ve had a few random bouts of tears, but I can’t tell whether they are a result of the hormones or not.  Who knows! I’m kind of getting used to this happening now.

How do I feel today? I went back to work on Tuesday and it wasn’t too bad.  I did have a little bit of a shaking episode after I had recanted to my Brussels story the nth time.  I was just overwhelmed (in a positive way) with how many people told me they are pleased to see me in one piece!!!  I was also overwhelmed with the sheer number of people who actually read my blog post.  People who I have never spoken to at work before had read it and came up to me to tell me how amazing it was…even all the senior bosses had read it.  Basically pretty much everyone I work with now knows about my blog.  I’m pretty sure most people didn’t take much notice of the infertility part of my blog, rather were just interested in the Brussels story, but when my friends and family asked if it was OK to share it, I really had no idea how far it would be shared.

I’m not doing well at sleeping, but I guess that is to be expected…and with the hormones I am not sure how much is contributed by events vs the medications.  So I am a little tired.  But the good news is that I have taken some time off work!  Woohoo!!! Relaxation…chilling…are all that is scheduled for me during the stimulation phase of this cycle! A complete contrast to last time.  I have even discovered a new yoga place that has opened up near my house.  Overall, I am excited that we have another chance at IVF, but a little niggly part of me thinks I shouldn’t get my hopes up because it will be a long way to fall down from this time around.

Any results?  Nil

What’s next? I have my first baseline monitoring appointment tomorrow morning.  Hopefully it will all be go go go for cycle 3! Fingers crossed this Lupron has done its job nicely.

Weight. I still haven’t got on the scales yet!

Waist. NSTR.

Boobs. NSTR.

The Final Countdown!!!

160330_IVF3_Calendar_Countdown.jpg

*Notes.  I take First Response Reproductive Health multi vitamin gummies (pre-natal), 5mg Melatonin at bed time and CoQ10 200mg gummies daily.  NSTR = Nothing Significant To Report.

Good plan batman

First of all, let me say a big thank you to everyone who showed us support by commenting on my last update.  It has been a really difficult weekend.  Full of emotional roller coasters.  Chris and I have been brought to the edge with our sadness and confusion about our second failed IVF cycle.  I couldn’t reply to your comments without crying.  I am sure some of you who have been there have felt that overwhelmingness.  I read each and everyone one and they mean a lot, so thank you for your support.

Today we had our follow up appointment.  Chris and I prepared for the meeting the only way we know best….by making a list.  We wrote a list of all possible scenarios for ways ahead on this pudding club hunt.  And then we individually wrote down what we felt about each scenario and exchanged our thoughts.  We discussed where there were differences.  It was difficult and emotional to do as we realised that we agree in some situations, but not in others.  It’s OK at this stage that we don’t agree or have the same point of view, but it was bloody hard and we had some very raw and honest conversations.  We used up a few boxes of tissues 🙂  But what was good about this exercise is that we were ready to come to this follow up appointment prepared for whatever the doctor was going to suggest doing next.

When my doctor spoke to me on the phone to tell me the bad news that our IVF cycle had failed she mentioned poor egg quality, I took away bad things from this when I needn’t have.  This was just my doctor’s first impressions report, she hadn’t really looked into my case in detail or reviewed my history.  But this is what she did at today’s appointment.

Our doctor was very positive and believes that our best chance is to try again.  We expected that, but she ruled out egg or embryo donation for us or the necessity for genetic testing.  Our chances are still high more than 50% success.  We will make a couple of minor adaptations to our next cycle with my medication protocol by switching from antagonist protocol to Lupron (Down regulation) protocol.  I am a good responder to stimulation so she believes this may help improve the egg quality.  We will also carefully review our Day 3 v Day 5 transfer options at the time.  I had some excellent Day 3 embryos this time around, similar to my first cycle when I got my positive.  May be my embryos don’t do as well in the culture afterwards.

But before we go into another round of IVF, I need to have a hysteroscopy.  This is a small surgical procedure where the doctor inserts a camera through my cervix to look at my uterus and fallopian tube opening closely to check for any potential damage from my suspected ectopic pregnancy, scarring or inflammation as well as checking for endometriosis and taking a small biopsy for further testing.  So I am scheduled for my procedure in two weeks time!

We have a plan we are both happy with.  I felt a huge relief off my shoulders because our doctor was genuinely positive for our next round of IVF – and we pushed her about it too (well Chris did!!) – there was no BS-ing!   So all things going well after the hysteroscopy, we are looking at an April IVF/ICSI Cycle:-)

Thank you all for sticking with us through this, it has been hard, but you make it all the better!!  XXX

butterfly

IVF Diary Vol II: 25 Jan 16

Medication(s) administered and dosage(s). Some cocktail of anesthesia drugs, x2 tylenol the nurse gave me before the Egg Retrieval procedure.  I have avoided the pain killers so far.

Medical procedures undertaken. The Egg Retrieval!!! My appointment was at 0630 AM, so we got up nice and early at 0500, I actually slept quite well, I thought it might be a bad nights sleep with nerves, but it wasn’t.  The nurse picked us up from the waiting room, she exclaimed “Oh I know you guys!!!! You are French!!!” (We thought she was teasing, but I found out later she wasn’t and she actually thought we were french).  She said “Oh I am supposed to be just bringing the patients up today….but….I’ll sort you guys out!!”  She took over from the other nurse so she could be with us.  Haha, I think she actually just loves Chris 🙂  She was very sweet.  Anyway, we were number 2 into the surgery room this time (out of 5).  I was feeling pretty relaxed about it all, knowing vaguely what was about to happen.

The nurse got the Intra-Veinous drip into the back of my hand with no problems (because my hand has nice straight veins!!), it didn’t hurt at all.  It was cold in the ward, I was wrapped up in lots of blankets but my right hand just wouldn’t get warm because of the drip running through it.  We waited about 40 minutes or so, and even got a game of cribbage in.  I was made to go pee.  Chris was called to do his part for the day, and then it was my turn – the anesthetist gave me something that started to make me feel woozy, I was a lot more aware than last time around, so I tried to take a good look around.  I was shuffled over to the operating table and was given something else, then zzzzzzzzzzzzz I was asleep.  I don’t think I was awake for getting my legs into the stirrups this time!!!  30 minutes later I was waking up with the nurse asking me lots of questions.  I was talking random crap about how nice they were.  The nurse continued to monitor my vitals (blood pressure and heart rate), I was made to sit up, then finally I was made to go to the toilet to pee for her to check it.  There was a teeny bit of bright pink blood, but not much.

Chris helped me get dressed and I was taken to my car in a wheel chair.  I was feeling woozy, but no where near as much pain as I experienced last time around.  In fact I was wondering if the local anesthetic was taking longer to wear off.  I am sat here now 6 hours later, and I have some pain, but not half of what I felt last time.  However, I do have a very very drippy sore nose.  I think the oxygen tube must have damaged my nose somehow, or the anesthesia drugs have caused this.

What are my symptoms?  Really not too bad apart from the runny, dripping nose.  I am taking it easy on the sofa, but I haven’t needed to snooze yet and my tummy is tender, but not extremely painful.  So overall I’m grateful!

How do I feel today? Super relieved to get today over with, I’m feeling very positive!!!

Any results?  14 Eggs retrieved!!! That is really much better than I expected.  Last time we got 9 of which, only 6 were mature.  So I am hopful for 9 mature eggs this time 🙂

What’s next? We will receive our fertilisation report tomorrow morning.  Then hope for a 5 Day Transfer – this is our goal.  But of course we will do a 3 Day Transfer if things aren’t looking promising.

Weight. Not even looked at it.

Waist. Continually growing.

Boobs. NSTR.

Hours of Sunshine 🙂 None.  I’m tucked up on the sofa, hopefully tomorrow I will get out for a short walk.

*Notes.  I take First Response Reproductive Health multi vitamin gummies (pre-natal) and CoQ10 200mg gummies daily.  NSTR = Nothing Significant To Report.

IVF Diary Vol II: 4 Jan – 14 Jan 16

Medication(s) administered and dosage(s). Ovulation Control Pill (OCP) Reclipsen 0.15MG-30MCG x 1 per day – Last pill taken Monday 11 Jan 16

Medical procedures undertaken. Baseline monitoring appointment was today – including blood work and vaginal ultrasound!!! As the nurse said to me – you know the drill!

ivf2_baseline.jpg

Baseline Monitoring Appointment DONE! We are go to start IVF 2.

What are my symptoms? I continually spotted whilst taking the birth control pill and as soon as I stopped taking it the spotting has stopped.  I was concerned this morning because my period had yet to start.  I recalled from last my IVF cycle that when I went in for my monitoring appointment I was bleeding, so I worried that everything would be cancelled!  But then I discovered that my monitoring appointment this time around is one day earlier than last time, so I was worrying over nothing!

How do I feel today?  Surprisingly chilled and relaxed.  Even dare I say, excited to be getting this cycle underway.  I went to my local Resolve support group monthly meeting last night and we talked about the new year and our goals…it got me inspired!!!  So I am feeling pretty good after that meeting.

I spent a lot of time at the clinic today waiting around and so I ended up being really late for work – I didn’t get in until 1230.  I told my boss I would be late in, but even I didn’t think it would be that late!  Oh well.  My best laid plans to work from home have been thwarted a little because of tech issues with email.  I am trying desperately hard to not get stressed from trying to fit everything in before the egg retrieval.  Work is closed on Monday next week because of Martin Luther King Day which just adds to shortening timescales to get things wrapped up!

Any results?  8 Follicles ~5mm in Left Ovary, and 9 Follicles ~5mm in Right Ovary.  That’s 11 more than last time!  My uterine lining is also good to go. Oh I have beautiful ovaries apparently, never turn down a compliment!  Blood test results come throughto my account a day later, but I have been given the go ahead to start stimulation injections tomorrow evening. So it’s GO GO GO IVF 2!

What’s next? Starting injections tomorrow evening and next monitoring appointment is on Monday.

Weight. I mentioned in last diary entry that I was 10lbs heavier than my last cycle…well with a bit of P90X3 in the mornings and cutting out the crappy food I have lost 4.5lbs over the last two weeks, which is quite incredible!

Waist.  NSTR

Boobs. NSTR

Hours of Sunshine 🙂 Ughhhh NONE.  Have to change this status over this coming weekend.

Fun Activity to keep Dani from going insane. This is going to be a new feature to my diary – basically I realise that I need to have little mini exciting goals, things to look forward to to keep me from going insane and letting IVF consume my head.  Thanks to everybody’s help with my previous post (you have no idea how much you helped), Chris is going to take me on ‘surprise’ date and I am going to relinquish all my desire to take control and plan things!  He doesn’t know it yet – but it will be a test to see if he fully reads my blog posts ;-p Haha just kidding. He does read them, and I love him so much for supporting my blogging.

*Notes.  I take First Response Reproductive Health multi vitamin gummies (pre-natal) and CoQ10 200mg gummies daily.  NSTR = Nothing Significant To Report.

A discovery – How far are we willing to go?

Whilst on our epic South West USA road trip, Chris and I had lots of time to talk to each other.  You could almost say we lived in each others pockets for two weeks…some couples might break…but for Chris and I we kind of thrive on it, and it brings us closer together.  I think we only had one small ‘argument’ on this trip, but you could probably describe it as more of a strongly heated debate rather than an argument as such.  Anyway, the point is, we had lots of time to talk about some of the bigger things in life.  Surprisingly, we didn’t talk about our future as prospective parents for several days.  It wasn’t until I received a phone call from our fertility clinic that we got around to talking about it again.

The topic of conversation was how much more can we deal with all the infertility treatment?  Can we deal with another miscarriage or ectopic pregnancy?  The likelihood for another ectopic pregnancy almost doubles after you have had one.  What about dealing with a negative result?  We discussed whether to transfer our one frozen blastocyst or to go for another round of IVF/ICSI.  Yes, a frozen transfer would require injections, but I would avoid the egg stimulation and egg retrieval process which, for me, was very painful the last time around.  Chris wants to avoid me being in pain as much as possible.  He hates seeing me in that way.

I understand his point of view, it is hard for a partner to see their loved ones in pain over which they have no control.  But I feel differently, I feel like I know what to expect, how to better deal with the symptoms and feel overall less anxious (although I think I was pretty cool in my attitude about the first IVF cycle).  I feel ready to get some embryos frozen into reserve.

I am 32 about to turn 33.  If we go for the frozen transfer and we succeed in a pregnancy (!!!!! That would be awesome!!!) then I will be 35 by the time we are ready to have a second go at it for child #2 – my egg quality is likely to reduce and we could be facing an additional factor to our unexplained infertility.  So I figure it is best to do one more IVF/ICSI cycle now and we have one in reserve.  Perhaps I sound a little greedy in this respect – we are lucky to have one frozen right now!  I don’t mean to be – but I am an operational analyst after all, so I can’t but help try to figure out the optimal solution to a problem.

I explained to Chris my reasoning for going ahead with another round, and he gets it.  He admitted he hadn’t thought about age related factors for the future.  So we have both agreed that tomorrow we will ask our doctor about going ahead with a new round of IVF/ICSI.

But this isn’t really where the story ends.  I think Chris and I have different ‘lines’ to draw under how far we are generally willing to go to get our own baby in our arms.  How many times is enough to say we gave it our best shot?  How many times can we deal with sadness?  Will we ever become numb to it?  Depending on the nature of the outcome for round 2 will create different visionary paths in our heads for each of us, we discovered that they are not aligned at the moment.

This isn’t an easy topic to talk about without accidentally hurting each other with words that first come to mind…. so we are going to try writing down our feelings on paper and swapping our ideas so that we can understand each other’s perspectives.  I don’t know whether it will work, I hope it will help us at least gain a respect for each other’s feelings.  Love and marriage is unconditional, but feelings can easily get hurt when we are talking about something so passionate as becoming parents and how to do it.  Infertility knocks you for six when you discover that you can’t become a parent the ‘normal’ way.  So I think it is healthy to have this exploration of feelings and keep things open between each other.

Perhaps we will share these letters to each other on the blog at a later date, but for now we just need to focus on getting to the same place together.

I always say it’s never over ’til the fat lady sings….predicting a successful pregnancy outcome

fat_lady_singing

I always say it’s never over ’til the fat lady sings.  But that doesn’t mean I can’t see that fat lady getting ready to get on stage…I can also hear her warming up, running through a few scales too.

So, my suspicions were pretty much confirmed about why I didn’t get my results yesterday.  My results were not good.  And let me point out here that these are not my words, but the words of my nurse.

My hCG levels last Weds were 49 –  just a bit lower about where they should be, but were not overly worrisome…

My results from Tues this week, however, were 126.  They went up!!!! But those of you who are familiar with hCG levels and where they should be by now will know this is not a great number.  hCG levels should double every 2 to 3 days.  What does this mean?  Well my doctor wants me to keep taking my progesterone and estrogen, just in case – there is always a small chance this pregnancy is still viable!! But I have to go in for another beta test on Friday to double check that this pregnancy is, in fact, over.

I can safely say I am no longer feeling cautiously optimistic….I am feeling pessimistic as hell and sad.  If you would like to hold onto hope for us, I gratefully take your strength and thank you for helping to hold us up, but quite frankly when the nurse tells you it is not good, it’s not good.  I understand she is preparing us for the worst.

BUT!!!!! I decided to do a bit of research on what all this really means, what are MY chances?  You know I had to do it, as one of my colleagues told me today – GTS!  (Google That S#*% !!!).  OK, I’m going to get a bit technical here….hang in there if you have in interest in hCG levels (the beautiful pregnancy hormone!!)….


I found a very useful study* that looked at the predictive values of hCG levels for a viable pregnancy 13 days after a 3 day Embryo Transfer (I took my first beta test 14 days after my 3 day Embryo transfer).  My result of 49, according to their model, gives me the following chances of outcome: 45% successful singleton pregnancy, 31% miscarriage, 13% bio-chemical pregnancy, 9% ectopic pregnancy, 3% successful multiples pregnancy.  Well I am glad they didn’t tell me what my hCG levels were last week!

According to these researchers’ analysis, they decided that the cut-off level for predicting a viable pregnancy was an hCG level is 76 IU/I (80% sensitivity)….although this is considerably higher than some other researchers have reported (for example other studies have found the cut off at a similar sensitivity to be: 42 mIU/ml (Qasim et al., 1996); 55 IU/l (Bjercke et al., 1999); and 50 IU/l (Sugantha et al., 2000)).

Wow guys, 76 seems to be a whole lot higher than the others….so do they have credibility in their research?  Well from what I can ‘statistically understand’ and in understanding their research design, it looks solid; their sample size is excellent, some of the best I have seen in articles about artificial reproductive technologies….but I am not a medical professional, so I am totally relying on my knowledge of stats and may be there is something ‘medically awry’ that I cannot see.

If I use any of these models, and consider my hCG level of 49 from last week, these researchers would have told me my chances of a viable pregnancy were always going to be low.

However, there was one interesting point that came out from this study that caught my eye:

In subjects with unexplained infertility, ICSI may result in lower than expected HCG levels (Gold et al., 2000)….The explanation for this was not clear.  Although the early embryo cleavage is delayed in ICSI-derived embryos and the fragmentation of embryos is increased the implantation potential is comparable with IVF-derived embryos.

Even though my numbers have not multiplied nicely….in the back of my mind I am holding onto this slither of hope….holding on that we are the ones in that 5% extreme quantile who defy the norm, and it is because we are unexplained and our embryo was ‘ICSI-ed‘ that my hCG numbers are much lower.

Until Friday…………. :-s

*Pokkeus, P., Hiilesmaa, V. & Tiitinen, A. (2002) Serum HCG 12 days after embryo transfer in predicting pregnancy outcome. Human Reproduction 17(7):1901-1905. Available at: http://humrep.oxfordjournals.org/content/17/7/1901.full

How to get the most out of your doctor

It took me about 24hrs after it was confirmed that I am pregnant to realise I do not know how to be pregnant.  This might seem very weird considering we have been talking about this moment for more than two years now.  Once we started trying to conceive I just of buried my head in the sand.  I didn’t want to jinx our chances by buying a book about it, and I started to avoid all pregnancy related websites and apps after 6 months of failing to succeed in our quest to make a baby.  I know the basics, like smoking is a big no-no, drugs are dangerous, avoid raw meat and reduce caffeine, but really, that is the limits of my knowledge.  So yesterday we went to the book store and bought two books on pregnancy.  One was the standard text book “Great expectations: Your all in one resource for pregnancy”, and the second was “Expecting Better”, beautifully demonstrated in this picture by Sushi:

Sushi, my book keeper

Sushi, my book keeper

This second book interested me because I have always wondered whether Japanese women stop eating sushi, or French women stop eating brie when they are pregnant.  Really?  I don’t think so.  I hope that this book will enlighten me to what the conventional wisdom really means.  But when I started reading the first chapter I didn’t need to go much further with it to be completely satisfied with my purchase.  Why?  Well the author, Emily Oster, is not so different from me, she was not happy with what her doctor was telling her.  I realised that my experience with my fertility clinic’s doctors and the feeling I had that there was a poor lack of communication.  All of this was because I was not asking the right questions.  I didn’t know I needed to ask them.  And this is silly because all along I had the key questions in the back of my mind…I use them everyday at work!!!

In my job I help leaders make decisions every day…I do this by presenting the evidence, the facts – for and against a decision – I do some analysis on the data that supports the decision, I try to be unbiased and objective in my analysis, and then I present a recommendation to the leader on the best course of action.  The leader doesn’t always go with my recommendation, but I have presented them with the facts and figures to make their own mind up.  Sometimes I feel a bit hurt, but then I remember, I am not the one taking the risk.  So when it comes to our healthcare and doctors, WE are the decision makers.  We need to be presented with the arguments for and against, and be told what the supporting evidence is.  WE are unique in many different ways and the decisions we make will be unique, blanket guidelines are not always appropriate for everyone.

I think a good example of this is when we were told we should do ‘ICSI’ because of our unexplained infertility.  We didn’t ask the questions:  What are the pros of ICSI?  What are the cons of ICSI?  What are the improved success rates with people like us? (i.e. what’s the supporting evidence/data?)   We were not armed to make a decision, we just went with what the doctor said, and in the back of my mind I felt like I had not been given a chance to make a decision.  I did actually do a lot of this research myself, but it would have been better if my doctor would have told me – after all I am not the medical professional, I just have the fortunate ability to interpret statistics from studies and experiments.  So although I was finally happy with the decision to do ICSI after my research, something inside me was niggling about our doctor’s communication.

Another example is when it came to our embryo transfer.  We were told that it is the standard practice at the clinic to transfer 2 embryos on day 3, unless there were over 6 fertilised embryos then maybe we would be a candidate for waiting to Day 5 to transfer 2 blastocysts.  We did not ask the questions: what are the pros of us waiting to Day 5? What are the cons of us waiting to Day 5?  What are our personal chance of success with 4 fertilised embryos compared to if we had had 6? (i.e. what’s the supporting evidence/data?).  Again, I did a lot of this research myself.

I could go on with other opportunities throughout our infertility treatment where I could have asked these three simple questions that would have revealed the knowledge I needed to feel like I was in control of making a decision.  We rely on doctors to make the decisions for us…and most of the time I am happy with that fact, but there were times that I felt like we should hold that responsibility for a decision.  When it comes to my pregnancy I want to be able to ask these questions to my doctors and nurses so I can take the responsibility for making some of the big decisions such as prenatal testing or birthing plans.

Emily Oster suggests reading the book “Our medical mind: How to decide what is right for you” by Jerome Groopman and Pamela Hartzband.  I think I might try it, and I’ll let you know how it goes.  Has anyone read this one?

In the meantime my friends, next time you are in a consult with your doctor, remember these three simple questions to help you make the best decision, for you, and get the most out of your doctor….

  • What are the pros (for me)?
  • What are the cons (for me)?
  • What is the evidence/what are the chances (for me in particular)?

Reflections on the future – using someone else’s ten lessons learned on Infertility

A friend of mine recently sent me a link to a Huffington Post Article “Ten things I would tell my past self about infertility”, written by Kathryn Kefauver Goldberg (she has written other posts too).  Not only was it an interesting article, but my friend told me “I can be your number 9”.  Number 9 in the list of ten things was:

9.  Find one person to whom you can talk uncensored.  Check in with yourself about what and who feels good.  This might be a friend, a counselor, a support group — anyone who can support you unconditionally and isn’t invested in the outcome.

Well of course, my friend already is my number 9 🙂  I’ve got this one nailed already!  So what about the other 9 suggestions in the list of Ms Goldberg’s lessons learned?

1.  Recognise that the limbo of infertility puts you in an impossible situation.  This is something we are totally dealing with right now, with the added limbo on whether we stay in the US or move back to Europe.  Fortunately, one of those limbos has been taken away – I have been offered an indefinite contract, so I don’t have to leave the US in December!  We have choices.  But we don’t have choices when it comes to whether we get pregnant or not!  So we are handling it OK right now, better than last week.  We will just take one to two weeks at a time.  It’s pretty hard work on the abdominal muscles all this limbo business, but you get a good work out, and your muscles only get stronger as time goes on.

2.  Feeling sadness will not define your path.  I have had a pretty tough few weeks on this front, and I have questioned my ability at work, if I am coping.  I even asked myself if I was depressed.  I don’t believe I am depressed, but just sad.  Being sad is OK.  How do I know I am not depressed?  Well I just googled it, and I am not depressed, I don’t fit the descriptions.

3. Define and honor your limits.  Here Ms Goldberg talks about pressure to try everything on the medical front.  It can be quiet easy to go far without questioning medical treatment, for example agreeing to ICSI, agreeing to freezing embryos, agreeing to participate in research etc.  We have made sure we talk about it together, but I am not sure Chris and I have the same feelings on how far we go on our path.  I think I will feel what I will feel, in the future and I can’t predict that right now, so I don’t want to put a maximum number of attempts, money or time on our path.

4.  Listen to your doctor and trust your gut.  I’m not very good at questioning a doctor, after all they are supposed to be the qualified ones, right? But I do get gut feelings about people and I have a positive gut feeling about our doctor, even if she seems a little crazy sometimes.

5.  Have rote answers prepared for nosey questioners.  I have talked about this on two occasions recently, but I think it depends on the situation.  It’s a careful balance.  This week I caught up with some friends I haven’t seen for a year, and I totally lied to them about what we are going through (I didn’t lie directly, I just avoided the opportune moment to talk about it) and I wish I had just been honest because I know they would have been great about it.

6.  For every medical procedure you go through, find a soothing activity for your body.  Ahhh a couple of massages I think might be scheduled.  Maybe we need to think about this more.

7.  Take care of your heart.  This is more about protecting yourself from emotional overload moments, like going to baby showers.  Well I have decided to tackle these head on.  Infertility doesn’t define the me and the type of friend I want to be to my friends.  I won’t let it, and it’s worked so far.  I will take care of my heart, but I know Chris has got me on this one too.  He’s like my cod liver oil or what ever is good for your heart – he is my added protection layer for my heart.

8.  Invent a project.  Well I have decided to take another online course starting in a week.  This will be my project.  It will be a useful distraction, I hope, rather than be an added stress.

10.  It will be OK, though your definition of OK will change.  I tell myself this a lot. Everything is going to be OK.  And if I ever doubt this, all I need to do is listen to Chris’s playlist of movie’s all time greatest dramatic soundtracks, like the one below.  And everything is going to be OK again.  This is my future.

The ethics of ICSI – Intra Cytoplasmic Sperm Injection

ICSI for unexplained infertility

I felt pretty well versed and comfortable in the ethical debate behind IVF, well, so I thought until we came across ICSI.  Intra-Cytoplasmic Sperm Injection (ICSI) was recommended by our doctor because we have been diagnosed with unexplained infertility.  She explained that this procedure is worth trying because in our case of unexplained infertility there could be a chance that there may be something in the fluid surrounding my eggs preventing fertilisation.  ICSI overcomes this potential problem by injecting a sperm directly into the egg, avoiding the fluid.  It is important to note that with unexplained infertility there could be many other reasons unknown to us why we have not been able to get pregnant yet; we just can’t pinpoint the exact cause at this moment.  By performing ICSI (for a few thousand dollars more) it slightly increases our chances of success.  I have been looking into the evidence behind unexplained infertility and ICSI and the jury is out on whether it is worth while or not.  Despite the mixed reports on the internet, I trust our doctor, and as our fertility clinic is attached to a medical school I like to think that they are up to date on these things.

I hadn’t thought much about ICSI previously because Chris’s sperm is pretty good, I didn’t think it was on the table.  So I hadn’t read much about the procedure.  As I began to read up on the procedure, I started to think more about the ethics and morality of it.  Selecting the ‘best looking sperm’…is it any different to selecting the ‘best looking egg or embryo’ as would be the case for normal IVF?  And so I decided to look into it a bit more to understand what ICSI really is, and the considerations for and against this artificial reproductive technology procedure.

This post is just me putting ideas out there and exploring the issues, I do not necessarily agree with everything written here.  I may have been unintentionally selective or biased in some of my arguments, there are probably many more arguments for and against ICSI, so please feel free to comment and add at the bottom of my post.

What is ICSI?

ICSI – Intra Cytoplasmic Sperm Injection is an in-vitro fertilisation procedure that has been in use since 1992.  Fertilisation is achived by the direct injection of a single sperm into the cytoplasm of the egg.  The sperm can be extracted from fresh or frozen ejaculate, as well as being extracted directly from the testes (yikes, sorry guys, doesn’t sound fun at all).  The egg is prepared to facilitate penetration of the sperm.  The preparation of the egg includes enzymatic treatment and micro dissection of the cells which surround the egg.  Injecting the sperm bypasses the normal interaction it would have with the egg upon first encounter.  The deliberate selection of sperm for the procedure involves an assessment of selection criteria including: size, form and mobility of the sperm.  Despite the selection criteria, there is no guarantee that the sperm is actually ‘normal’ and therefore, there is no guarantee that fertilisation will occur.  It is even possible to select X or Y sperm to select gender, but only few fertility clinics offer gender selection for when it is necessary to avoid a known genetic disorder being passed.  I have also read about some fertility clinics offering gender selection if the family has one child already, and they want to ‘complete the family’ by selecting the opposite gender of its sibling.  This totally blows my mind.  After the sperm is injected into the egg, the egg is placed in an incubator and checked the next day for fertilisation.  If fertilisation is successful, the embryo is left for 2 or 3 days and then a decision is made whether to transfer the embryos back into the woman’s uterus for the next stage implantation.

Statistically speaking, there is evidence that ICSI slightly increases the pregnancy rate (but not statistically significant) compared to normal IVF.  The spontaneous abortion rate with ICSI is slightly lower, but this maybe as a result of the younger age of the mothers and the absence of female-related infertility.  The frequency of multiples is about the same (probably because the policies for number of embryos transferred remains the same).  The statistics for randomised trials of normal IVF v ICSI show that there is no significant difference.  Some researchers suggest that ICSI should only be reserved for the use of severe male factor infertility.  However, the use of ICSI is on the rise and becoming the new normal as infertility clinics like to reduce the risk of failure for the patient.  I can understand why that little extra % chance all adds up.

Ethical and moral considerations of ICSI – the arguments pro and against.

All ethical debates relating to IVF still apply to ICSI.  But ICSI may be considered effectively as a further layer of ethical debate  because we are potentially further ‘messing with nature’ by selecting one single sperm.  Often Pre-Implantation Genetic Diagnosis (PGD) will be part of ICSI, where there is a screening of cells of pre-implantation embryos for the detection of chromosonal disorders before an embryo transfer.  We are not doing PGD.  This can also add a further level for debate.

I will start with what I have found regarding the pros of ICSI, and other Artificial Reproductive technologies, followed by the against arguments…

Pro ICSI: The right to procreate.  To want a child is probably the most legitimate need in the world.  The right to found a family is one of the most important human rights as declared in the Universal Declaration of Human Rights (948, Article 16.1)  ICSI enables and supports this right.

Pro ICSI : Genetically related offsping. Before ICSI was possible, couples with male infertility would likely have resorted to donor sperm, or due to religious or personal beliefs would have rejected the use of a donor and remain childless.  With ICSI, it is possible for couples to have a child that is genetically related to them that previously was not possible.

Pro ICSI: Reducing the risks to the couple. If natural IVF was chosen over ICSI the woman may be unnecessarily putting herself at increased risk, physically and mentally for both partners.  For instance, if natural IVF were to fail first time round, ICSI may have prevented failure.  There are no guarantees, but as a couple puts themselves through multiple rounds of IVF, the physical and mental stresses increase, including the financial burden.

Against ICSI: The risks to the child itself.  There is much debate about the use of ICSI in male infertility and associated genetic abnormalities.  Chris does not have male infertility, so the risk of genetic abnormality is supposedly lower.  But the case for natural selection is negated with ICSI, there is no competition as would be with natural fertilisation, the chosen sperm may be a factor in genetic malformation.  There is also a risk of choosing a sperm that is immature and may interfere with the process of genetic imprinting and could result in growth retardation and functional disorders.  However, there has been little evidence to support these concerns.  Having said there is little evidence, ICSI has been around only since 1992, so children born from ICSI have not reached far into their adulthood and so studies are limited on the long term health related issues of ICSI born children.  Not to say the least, that the long term generation effects of ICSI on the population overall are not well understood and are only theorised.  For example, will infertility be passed? In itself, will ICSI simply contribute to further medicalising in the future?

Against ICSI: Multiple Embryos.  With IVF, to give a couple the best chance for a pregnancy multiple embryos are produced, grown, and then implanted into the uterus.  Some embryos may be discarded if they aren’t of good enough quality to present a healthy chance of pregnancy.  ICSI increases the likelihood for the generation of surplus embryos.  For some people, each embryo represents a life and so the disposal of embyros is considered in the same light as abortion.

I found one eloquent and well articulated argument that explains why some people are against multiple embryos “Where doubt exists on the level of fact, the integrity of conscience requires that the presumption be in favour of the life.  There is a classic example, if a hunter hears a rustling noise in the bushes, and is unsure whether it is a deer or another human being, he must assume it is a human being until such time as he can establish that it is not.  Similarly we may accept the argument that there is scientific uncertainty as to the precise moment when an individual human life begins.  That uncertainty, however, does not remove the obligation of care and respect for what certainly has the potential to become, and may already be, a distinct human individual.”

Against ICSI: Human Error. I have read about people worried about sperm/eggs getting mixed up in the laboratories.  We learned that sperm is dyed a certain colour for each patient so there is no confusion – this was why Chris’s sperm was purple!!  But to err is human after all and so are we potentially increasing the risk for a morally complex problem?

Chris's purple sperm

Chris’s purple sperm

Partial ICSI – overcoming some of the issues at hand?  Partial ICSI is where some of the eggs are left to fertilise ‘naturally’ in the petri dish as with normal IVF, and the rest of the eggs are injected with individually selected sperm as ‘back up insurance’, just in case normal fertilisation does not occur naturally.

There are many different valid and understandable viewpoints about assisted reproductive technologies like IVF and ICSI.  I am the type of person who respects others’ viewpoints and tries to understand as much as possible all sides of an argument.  I am an analyst by profession so I like to think I am good at that.  We have decided to do IVF and ICSI knowing these issues.  I just hope that others can equally respect our decision for IVF and ICSI.  But I now feel suitably versed to think about some of the important ethical and moral issues surrounding these artificial reproductive technologies.


Other notes and interesting references

On a side note, I found an interesting statement as I was researching that I wanted to share with you, it is about IVF and women’s rights in general.  Mary Anne Warren, (a philosophy professor who wrote a lot about abortion and criteria for personhood) wrote:

“If women’s right to reproductive autonomy means anything, it must mean that we are entitled to take some risks with our physical and psychological health, in the attempt to either have or not have children.  Neither abortion nor many forms of contraception are entirely safe, but women sometimes reasonably judge that the alternatives are even less desirable.  Having a wanted child can be as important a goal as avoiding an unwanted birth.”

Other references which discuss some of the more interesting medical facts than I am not willing to describe in my blog as I am not a medical professional or just interesting…

Potential Health Risks Associated to ICSI: Insights from Animal Models and Strategies for a safe procedure, Front Public Health. 2014. 2: 241.  Accessible here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235077/

Ethics of Intracytoplasmic Sperm Injection: proceed with care, Wert, G.M., Human reproduction, 1998 vol 13 (1)  Accessible here: http://humrep.oxfordjournals.org/content/13/suppl_1/219.full.pdf

Dealing with uncertainties: ethics of prenatal diagnosis and preimplantation genetic diagnosis to prevent mitochondrial disorders, Human reproduction update,  2008, vol 14 (1), Accessible here: http://humupd.oxfordjournals.org/content/14/1/83.short

Ethical issues in Assisted Reproductive Technologies, a presentation by Effy Vayena: http://www.gfmer.ch/PGC_RH_2005/pdf/Ethics_IVF.pdf

Ethical issues arising from the use of Assisted Reproductive Technologies, Dickens, B.M., Accessible here: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.195.8966&rep=rep1&type=pdf