Since a TON of people have asked me various questions about IVF and the process, I thought I would break it down for you guys here and also highlight how my particular program is handling our procedure vs. how other programs may do it. Before I get in to all the nitty gritty of what IVF is and how it works, I just have to give an update about how amazing my week has been!
Boy, have I been loved on this week! FIRST, my sweet, amazing, loving friend and veteran, Shelly set up this awesome thing for me and Tim:
I mean… we were both in tears! Shelly, along with many others, have been so supportive! They have listened to me complain, called to rejoice good news with me and Shelly took it one step further and THE SAME DAY she set this up, she broke into my house and filled my fridge full of IVF diet approved foods. Like…. yall… I CAN’T EVEN! Even more than that, you guys have even actually donated!!! I am SO humbled!! THANK YOU! If you haven’t seen this post from Shelly and also feel led to contribute to our journey you can click this link and I will continue to regale you with my hilarious and sometimes heartbreaking stories. I mean, I’ll keep up the blog regardless, but it will definitely last longer if we can pay off that scary balance!
Next most awesome love I received this week:
My beloved Hernando Animal Shelter featured my sweet family on their Meet Us Monday segment! Y’all, all the comments and love showered on me from this post has completely lifted me up this week! It’s been a crazy month and this seriously recharged my battery! And look how precious we are, gosh I just can’t wait for these kids to get a two-legged sibling.
Ok, moving on!
I am going to try to be as concise as possible, but lets be real, this is a complicated process, so bear with me through some of these tedious steps. Someone asked me today “So, what’s the process? I don’t understand” to which I internally responded, “I only have a basic grasp, too!”
Get a diagnoses! …or not.
This is a vital step. There are many, many OTHER options out there before you consider IVF. Timed intercourse, ovulation tracking, time in general, IUI, diet changes, medication, endometriosis surgery and holistic treatment are all things you can and should consider before doing IVF. I can’t imagine any doctor suggesting IVF if the first problem is “We want to get pregnant, have been trying for two months and no joy” unless you already know you have some major complication. Many of these things we tried before being lead to IVF by both medical doctors and our hearts. This step cannot be diminished. The time it takes to explore these options, implement these treatments and being referred around is agonizing, especially if they are not effective. Typically, you should try to get pregnant, with or without intervention, for at least six months before an OBGYN will even see you to intervene. Usually, the next steps are drug interventions, like Clomid or Metformin, that are typically prescribed by an OBGYN. Some doctors will suggest you keep trying for a while longer. Here is where your path may diverge. For us, we were treated with Clomid and I had monthly blood test to confirm ovulation and my dose was consistently increased until I passed that test. Some people get pregnant at this point. I have a good friend that had fraternal twins this way (whom I love and adore)! Maybe this doesn’t work for you. At this point, we sought a different OBGYN who would be willing to either help us in a different way or refer us to a specialist. In our case, we were referred to what’s called a Reproductive Endocrinologist (RE), a fertility doc. Remember, we are still at step one!! Many people have to wait quite a while to get a referral or if they do get one quickly, have to wait months to get in to a busy practice. That was certainly the case for us. When we scheduled our first appointment with our first RE, we had to wait almost six months from the time of that first call til we actually got in to see her! Once you get that appointment, you undergo a complete battery of tests that escalate in invasiveness and depth if the prior ones come back with no abnormal result. Normally, the first tests are blood and urine tests to measure the levels of specific hormones and compounds in your body and vaginal ultrasounds to examine your uterus, ovaries and follicle counts, all to be done at specific times in your cycle. For me, all the blood work except one pesky test was completely normal. My AMH (antimullerian hormone) came back extremely low. Normal levels in women my age are between 4 and 11. Mine was 0.236. My uterus was determined to be normal and healthy and my antral follicle count was off the charts at 39 on one ovary and 42 on the other. Normal is about 12. It was an anomaly, so we escalated to more invasive testing to get to the bottom of this issue. Up next was the sonohysterogram. Sonohysterography is an ultrasound exam where your cervix is dilated with a small balloon catheter (I PROMISE it does not feel small AT ALL) and fluid is pushed into the uterus. An ultrasound probe is then used to create images of the lining of the uterus. The fluid helps show more detail than when ultrasound is used alone. Again, normal. Next up, hysterosalpingogram. This test uses a real-time form of x-ray called fluoroscopy to examine the uterus and fallopian tubes for blockages. It can help investigate miscarriages resulting from abnormalities within the uterus and to determine the presence and severity of tumor masses, adhesions and uterine fibroids. Hysterosalpingography can occasionally open blocked fallopian tubes to allow the patient to become pregnant afterwards. Again, normal. At this point, many women learn they have PCOS, endometriosis, poor ovarian reserve, blocked tubes, thyroid issues or any other myriad of “explanations” of their failure to become pregnant or stay pregnant. Originally, I was diagnosed with PCOS due to my high antral follicle count. However, after several consultations with other providers, it was determined that was definitely not the case due to my very consistently low AMH. While other women at this point are receiving a diagnoses of infertility due to XYZ, I received a diagnoses of unknown infertility, likely due to unknown autoimmune issues. I also tested barely positive for the antiphospholipid antigen, which won’t directly effect getting pregnant but will certainly be very relevant in staying pregnant. It was pretty awful. Don’t forget, your husband or partner will be going through a couple of tests as well! Mainly blood work and a semen analysis, they get off so easy! In our case, Tim’s sperm was within normal range for motility and volume but his swimmers are just like him, big heads, short tails (in science terms, he has a morphology issue). So, for us, IVF is the next logical step because of our combined issues. There are many a steps to take AFTER if IVF isn’t successful for us, but that is the step we are on now. So, step one, get a diagnoses (or not) and decide the next logical step. It might be IVF, it might be surrogacy, it might be adoption OR (as Dr. Brezina always reminds us), do nothing. I’ve blown my concise story on step one.
2. Find a provider and consent to IVF
This sounds straightforward, but there is a lot to consider once you’re ready to explore this option. Do I want to proceed with IVF at my current clinic? Do I want to undergo genetic counseling? Do I want to influence the sex of my child? Should I do PGS/PGD testing? Assisted hatching? Do we need to use donor eggs, sperm or embryos? How many embryos will we transfer? It’s a lot to consider. The first question (Do I want to proceed with IVF at my current clinic?) will sometimes determine many of the answers to the following questions. Many clinics have strict protocols they will not deviate from regardless of the circumstance. Some clinics do everything on a case by case basis. If I had my choice, I would have stayed with Dr. Brezina through every single step of the way. Personally, he is caring, thoughtful, smart, discerning and incredibly communicative. I adore him and his clinic has been an absolute Godsend. As it were, that is not what we are doing, though any subsequent FET’s (frozen embryo transfers) will take place at his clinic. Walter Reed’s program is a more-successful-than-the-average-clinic IVF mill, so their policies are far more strict and rigid than the personal experience we had with Dr. Brezina at home. For example, Walter Reed WILL NOT under any circumstance transfer more than one embryo into an under 42, healthy, never been pregnant, never had IVF person. They transfer ONLY 5 day blastocysts. All persons will be put on progesterone following transfer and they perform assisted hatching as a matter of routine on all blastocysts. After knowing all of this, do you still consent? We absolutely did.
Virtually zero insurance companies cover any type of fertility treatment. Neither TN nor MS have state laws requiring insurance companies to cover any cost of infertility treatment. So, most ART (assisted reproductive technology) clinics operate on a “self pay” (it’s a nice way to say “all cash, all upfront”) basis. And yall, this is big business! We are talking very, VERY expensive procedures. For the services we needed at our Memphis clinic, we were looking at roughly $23,000 for ONE complete cycle ending in ONE transfer. At Walter Reed it is about $10,000 and we can only access this benefit while Tim is deployed or retired. There is a wide range in pricing at IVF labs across the country, but as a loose rule, the cheaper it is, the more restrictions you will have to face. Cost does not equal efficacy, but there are things to consider about price. Regardless of the price of your procedure, you have to pay for it up front. In my case, before I will even be informed of my cycle start date.
4. Receive your protocol
Your protocol is the treatment plan for your cycle to include such determinations as drug type and dosage, trigger day selection (the day in which you give yourself that big intramuscular shot to make your eggs ready for collection), when to transfer, if you require embryonic genetic testing, if you require assisted hatching, etc. We have not yet received this. And we won’t until after we pay, at which time we will also be given the exact dates of our cycle.
5. Down regulation
Down regulation consists of taking a birth control pills 7-14 days prior to your baseline in order to prevent you from menstruating. This will set your ovaries up to properly grow and mature multiple eggs at once with stimulating drugs instead of maturing one egg at a time for normal ovulation.
This is the OFFICIAL cycle start date! We have come a long way, huh? On this date, you will have a blood draw and ultrasound to measure the baseline (creative, huh?) of your body to measure against after stimulations (or stims).
Over the next 8-12 days (depending on your body) you will take medications to stimulate your ovaries to grow and mature all of the eggs within the follicles of your ovaries at the same rate. Some clinics will have you come in every few days for blood work and ultrasounds. At WR, I will be released for 6 days after the baseline and will report back on day six to start daily (yes, daily – at 0645 precisely each morning) blood work and ultrasounds to measure my ovaries progress. Just remember, at any point during this time your protocol could be changed all the way up to and including cycle cancellation. Ovarian Hyperstimulation Syndrome (OHSS) and other such issues would be grounds for cycle cancellation. For me, this will mean daily or twice daily injections, yuck! On a personal note, at this time, I will be feeling pretty lousy. I could be so bloated I look pregnant (as many women do), the medication could make me feel tired or nauseous (my biggest fear of pregnancy). Its hard work growing my half of new life! Sweet thoughts at this time are preemptively greatly appreciated.
8. Trigger Shot
A trigger shot is an injection of synthetic human chorionic gonadotropin (hCG), which is a hormone medication used to stimulate the maturation of follicles and trigger ovulation. This must be administered 36 hours before the egg collection as it will cause the follicles to release the matured eggs. FUN FACT! If I pee on a stick after this shot IT’LL SHOW A POSITIVE FOR PREGNANCY since hCG is the hormone home pregnancy tests screen for! It won’t mean I am pregnant, but I just might have to do it so I can say I have at least once in my life had a positive after I peed on a stick!
9. Egg Retrieval
Ok, here’s where it gets serious folks. This is a no joke, knock me out with propophol surgical procedure. It is outpatient and I should be right back to normal in a few hours but this is a BIG deal! After this procedure, we will be able to, for the first time, actually see my eggs. This will also serves as a diagnostic test for me because there is much question surrounding my egg quality because of my unknown origin low AMH level. The doctors will use a long needle guided by ultrasound to “aspirate”, a fancy word for remove, all of the visible, mature eggs from each of my ovaries. While I am hoping for a big number, I am way more concerned with quality over quantity. I want nice, normal, mature eggs. Just remember it only takes one. With that being said, IVF is a numbers game. Numbers will reduce drastically as the process continues forward. I am not sure if anyone ever ended up with as many live births as eggs retrieved or even as many AA blastocysts as eggs retrieved. Statistically, the more eggs that are retrieved, the greater the chance of me having a pregnancy to live birth. BUT, it only takes one.
After the egg collection, each mature egg will be fertilized with sperm. For some people, simply isolating each egg and surrounding it with sperm will result in fertilization. Remember Tim’s big headed swimmers? That probably won’t work for us. We have opted to have our eggs and sperm undergo a process called ICSI where each egg is isolated, an embryologist picks out the best looking sperm in the vat of 7 million and injects that sperm directly into each viable egg. At that point the embryologist will leave them to incubate in a cozy lil petri dish for a few days, checking in on them regularly an documenting their progress and eventually grading them. Some will fail to fertilize. Some will grow and then arrest at some point between day 1 and day 5. But some… some will continue strong cell division, rapidly growing in size from two little cells into hundreds over the course of just 5 days. Those… those will be our kids. And my photographer heart DELIGHTS that I will get pictures of each and every one of them. One day, I will be able to tell them truthfully that I have seen what they are made of and witnessed their growth from literally day one. Each one of these mass of cells are mine and Tim’s children. We will cherish each one, we will be proud of each one, we will honor their life and force in this world and we will mourn them if they do not grow to their birth date because this is the moment we become parents. At Walter Reed, they will be allowed to grow to day five before the next phase of our journey.
11. Assisted Hatching
This ones hard to explain, so I’m going to link a pretty informative vid. My clinic does this as a standard procedure.
This is also thought to explain the 25% of IVF patients that develop identical twins.
12. Embryo Transfer
After the embryo’s have developed for five days and undergone Assisted Hatching, its time for transfer day!! This is where the embryologist picks the very best looking embryo and he or she is transferred from his or her petri dish into my uterus. After this procedure I will be officially “pregnant until proven otherwise” or PUPO. YALLLLLLLLLL! This is it! Also, all of my remaining developing embryos will be carefully frozen and stored for future use.
13. The Two Week Wait
The dreaded two week wait. This is how long I will have to wait to find out if I am pregnant or not. This will be the hardest wait I will have to endure. Please, please, please… for my sanity, don’t ask during this time. I promise I will update the blog with the outcome when I am ready and after I tell Tim the results. Instead, take me out! Keep my mind off the time. Call me to catch up. Come over for dinner. Invite me to the zoo. Help me come up with an epic way to tell Tim if it is successful. While I know I will have a little devastation if the first time isn’t successful, we are prepared for that outcome as well. Hopefully we will have other viable embryos and will be able to do another transfer with them.
So here is the long and short (HA!) of IVF 101. Hopefully that will help to frame my future posts once we get into the nitty gritty of our actual cycle. As a disclaimer, there is a large amount of variation from woman to woman and this may not represent YOUR cycle and certainly is not the end all be all of IVF explanations, but this is relevant to MINE.
Next up for us: Pay.