Waiting on CD1

We had a phone consult with our doctor on Friday.  He was very impressed with our egg and blastocyst count.  His exact words were “hall of fame.”

I asked about the 50% DNA testing failure.  He confirmed it was a high rate of abnormal blasts for a young donor like ours which lead him to believe that the sperm were contributing to the anomalies.  The clinic has seen this scenario before, where a repeat donor has different rates of abnormality with different male partners.  (This also likely explains why we had such a low number of embryos with the first donor–three–and perhaps why none of them were successful–we didn’t test them.)

That said, he is thrilled with the number of blasts we have (10) and assured us that they are all equally good quality.  He said repeatedly that we have more blasts than we will ever use.  Then he asked if we had a calendar, and I had to say no because we’re still waiting on cycle day 1.

Waiting on cycle day 1 (CD1–the first day of a woman’s menstrual cycle) is a contentious topic for infertile couples for a lot of different reasons.  For some women, CD1 is evidence of yet another month of failure, spiraling them into another bout with disappointment-induced depression.  For others, it’s a shining moment of joy because fertility work revolves around CD1, so it’s arrival signals the beginning of a hopeful timeline.

When we were trying naturally, CD1 didn’t really upset me.  I understood from the start that it was very unlikely that we’d conceive right away.  Most women don’t. And at my age, I knew it would take some time.  So, we just kept trying and waiting.  Then we started calculating and tracking, and CD1 became the marker for planning and scheduling.

When it became clear that we weren’t going to conceive on our own, CD1 took on another significance.  It became the basis for taking medications and making appointments.  When the clomid didn’t work, CD1 was evidence we needed to find an expert.

For the last couple of years, CD1 has been the marker for testing, medication, and procedure schedules.  This month is no different–except I screwed it up.

I don’t quite remember what all was going on last month, but I do know that I was busy and stressed and quite frankly didn’t care much, so I failed to note the date of August’s CD1.  It didn’t really matter because our donor’s CD1 was much more important.  On my CD1, I do remember thinking that I wasn’t too far behind our donor, and I think I made a note about the approximate date a while later.

Unfortunately, my poor record keeping now means I don’t know the projected date of September’s CD1.

It’s now September 22.  According to my inaccurate note, I’m late by over a week.  I’m fairly regular, but it’s not unheard of for my cycle to go long by up to a week once or twice a year.  But I have no way of being sure where I’m really at now.

Part of me, like all infertile women I know, wonders . . . what if?  Should I test?  Most of me–the vast majority, in fact–knows that I shouldn’t waste my time or energy.  While I cannot say that it’s completely impossible that I could be pregnant, it is extremely unlikely.  Frankly, I don’t want to be pregnant.  If I was, between my poor egg quality and whatever is going on with my husband’s sperm, the pregnancy would most likely end in miscarriage, and it would just mean more wasted time before we can transfer.

Ultimately, though, my poor record-keeping doesn’t matter much.  We can’t do anything until CD1 anyway, and there’s not much do to but wait.

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Grading the Blasts

To recap, the retrieval yielded 29 eggs of which 24 were mature.  Twenty-two fertilized, and 18 made it to the blastocyst stage on Day 5 or 6.  Those 18 were biopsied, removing just enough DNA for Comprehensive Chromosome Screening (CCS). The embryos that were correctly formed were then graded.

First, the blastocyst stage is graded 1-6.
stage 1

Stage 1
Early Blastocyst:
Blastocoel (fluid filled cavity that results from the splitting of a fertilized egg) is less than half the volume of the embryo.

 

stage 2

 

Stage 2
Blastocoel is more than half the volume of the embryo.

 

 

stage 2-3

 

Stage 2/3
Blastocoel completely fills the cavity, but the ICM and trophectoderm are undefined.

 

 

stage 3

 

Stage 3
Full Blastocyst:
Blastocoel completely fills the embryo.

 

 

stage 4

 

Stage 4
Expanded Blastocyst:
Larger blastocoel and thinning zona pellucida is seen.

 

 

 

stage 5

 

Stage 5
Hatching Blastocyst:
Trophectoderm is herniating through zona pellucida.

 

 

stage 6

 

Stage 6:
Hatched Blastocyst:
Blastocyst has escaped from zona pellucida.

 

 

For blasts graded as stage 3 to 6, the Inner Cell Mass (ICM) and the trophectoderm are also graded.  The ICM will become the fetus, and the trophectoderm will become the placenta.  Both are graded on a letter grade scale: A, B, C.

ICM Grading
A: Tightly packed, many cells
B: Loosely grouped, several cells
C: Very few cells

Trophectoderm Grading
A: Many cells forming a cohesive epithelium
B: Few cells forming a loose epithelium
C: Very few cells

Our blasts were also classified as day 5 or day 6 embryos (identifying the day they reached blastocyst stage).  Last week, we got the report card.

Embryo Report Card:
#1: Correct: Day 5: 4BB
#2: Correct: Day 5: 5AB
#3: Correct: Day 5: 5AB
#4: Incorrect
#5: Correct: Day 6: 6AA
#6: Correct: Day 6: 6AA
#7: Correct: Day 6: 5AB
#8: Incorrect
#9:  Did not fertilize
#10: Did not fertilize
#11: Did not fertilize
#12: Did not fertilize
#13: Correct: Day 5: 4BB
#14: Incorrect
#15: Correct: Day 5: 5AB
#16: Incorrect
#17: Incorrect
#18: No result: Day 6: 5AB
#19: Correct: Day 6: 5BA
#20: Incorrect
#21: Incorrect
#22: Incorrect

Of our 18 blasts, 9 were incorrect, 1 had no result, and 9 were correct.  The incorrect embryos had an anomaly in their chromosomes–likely lacking a chromosome (or part of a chromosome) or having additional copies.  These embryos were discarded.  The no result for embryo #18 was because not enough cells were extracted for testing.  We have the option of having it retested or transferring it without testing.

Day 5 embryos are better quality than Day 6 (they grew more rapidly).  Likewise, higher stages are better than lower (but both Stage 5 and 6 are good), and A’s are better than B’s which are better than C’s.

Our best three embryos are Day 5: 5AB: #2, #3, and #15.  The next best two are Day 5: 4BB: #1 and #13.  Then we have two more from Day 6: 6AA: #5, #6 and an additional two Day 6: 5AB: #7, #18.  Finally, we have one Day 6: 5BA: #19.

As part of the chromosomal screening, the sex of each embryo is also known.  Of our 10 embryos, 6 are male and 4 are female.  We did not find out which embryo is which gender.

We have a follow-up with our doctor on Friday to discuss our results and which embryo(s) to transfer.  Once, we hit cycle day 1, we’ll have our calendar and be on the countdown to transfer again.

Embryology: Day 6

Last Wednesday was our egg retrieval.  That day, 29 eggs were retrieved, and 24 of them were mature.  On Thursday, we got our first update.  Of the 24 mature eggs that were fertilized using ICSI, 22 showed signs of successful fertilization.

Since then, our embryos have been hanging out, hopefully continuing to grow and divide, reaching the blastocyst stage on day 5 (or 6).  In “natural” conception, the eggs are typically fertilized in the Fallopian tubes and continue their descent to the uterus.  They usually arrive around day 5 or 6 after fertilization and are ready to implant.  In IVF, the blastocyst stage is when embryos are transferred (placed in the recipient’s uterus) or are frozen.

Today, the embryology lab called to report that 8 embryos made it to the blast stage on day 5 and an additional 10 were blasts on day 6.  That means we have a total of 18 blastocyst embryos.  Today, they each had DNA extracted and then were frozen.

In 10-14 days, we’ll get our testing results. In short, the chromosomes from each embryos are “paired.”  Each embryo should have 23 matching pairs of chromosomes (one half of each pair comes from each “parent” cell: the sperm and egg).  The testing is checking for missing or extra chromosomes.

selectccs-diagram

For example, there might be three copies of chromosome number 21.  This is called Trisomy 21 and is the cause of Down Syndrome.  In addition to known disorders, chromosomal anomalies can result in embryos failing to continue to develop or arresting at a certain point in development (resulting in a miscarriage).

In the meantime, I have a doctor appointment tomorrow for (yet another) annual physical, pap smear, and labs.  Once these preliminary tests are completed and our testing results come back, we should be ready to set a timeline for our transfer.

Embryology Day 1

Today, the embryology lab called.

The man on the phone was upbeat (I think everyone at our clinic has to pass a “chipper phone voice” test to be hired).  When he asked how I was doing, I said I was nervous.  I think it took him by surprise which is silly because all of us dealing with an embryologist are probably nervous, but I guess we just don’t say it.

He said there was no reason to be nervous; it was all good news.  Then he gave me our Day 1 report.

Yesterday, they retrieved 29 eggs.  Of those, 24 were mature.  They used ICSI to inseminate each of them.

day 0 egg

Day 0
Mature Egg
Day of Retrieval
Fertilization Occurs

 

 

Approximately 16-20 hours after insemination, the eggs are checked for signs of fertilization.  So our embryologists were looking for eggs that are 2pn which stands for two pronuclear.  Essentially, they are hoping to see two pronuclei, one from the nucleus of the egg and one from the nucleus of the sperm.  (The nucleus is the control center of the cell.)  As development continues, nuclei break down and cell division begins.  Of our 24 fertilized eggs, 22 were pronuclei today.

day 1

 

Day 1
Fertilized Egg
2 PN

 

 

 

 

 

Over the next few days, the embryos should continue to develop and divide.

day 3

 

Day 3
6-10 Cell Embryo

 

 

On Tuesday, we’ll get the next phone call with the number of embryos that have developed into blastocysts.

blast

 

Day 5
Blastocyst
This is the stage where an embryo can implant in the uterus.  Typically eggs are fertilized while still in the Fallopian tubes and continue their journey down to the uterus, arriving around day five or six.

 

That day, they’ll extract DNA from each remaining embryo to test and freeze all the embryos while we wait for results.  When the results are returned, we’ll know how many viable embryos we have.  For comparison, with our last donor, we began with 12 mature eggs, 11 fertilized on day 1, 10 continued to grow but only 3 made it to blasts.

The Anxiety of Infertility

Tomorrow, our egg donor will have her (our) eggs retrieved.  In yesterday’s post, I outlined the process.  What I didn’t write about is the anxiety.

The moment the nurse called with the retrieval information, my stomach began to gnaw at itself.  We spent months getting to this point, failing twice, picking yet another donor, setting a schedule, funding medication cycles, and waiting and waiting.  Then, suddenly, everything happened all at once. And the anxiety crashed over, nearly drowning me.

anxiety 2I’m not the one undergoing the surgical procedure after weeks of body-and mind-altering drugs.  I’m not the one being repeatedly punctured with a tiny needle.  I’m not the one facing anesthesia-induced nausea, limited physical activity, and possible complications.  I’m not even leaving home.  But I want to throw up.

There’s an element of hopefulness (and if you’ve read my past posts, you know what a complicated relationship I have with that particular feeling) overshadowed by a stronger cloud of fear. I’m twitchy and can’t sit still.

Our donor is proven.  She had great numbers, and her eggs resulted in a successful pregnancy last time.  But the what ifs crawl around under my skin, making me involuntarily writhe and flinch: What if we don’t get many eggs? What if they don’t fertilize well?  What if they don’t divide and grow?  What if they don’t pass testing? 

These what ifs are the easy ones though.  They’re the surface what ifs; they’re easy to scratch.  As long as we get some eggs and some fertilize and some make it to embryos and through testing, we’re fine.  And the odds are really, really good that that will be the case.  But with our past experiences with “odds,” I’m reluctant to believe our results will be noteworthy.

But we should still have some embryos.

So the next wave of  what if’s crash:  What if it works?  What if we get pregnant and have a child?  Or two?  What if we’re the lucky ones?  What if it all finally works out? 

But these what if’s conceal the darker ones lurking behind.  These what ifs are the parasites deep in my gut, sapping my energy, whispering unfortunate truths: What if the embryos don’t stick?  What if we wasted all this money, again?   What if it sticks but then doesn’t?  What if we have a pregnancy but miscarry?  What if we fail?  What if we never have a child?

Please don’t tell me to think positive.  Please don’t tell me that I can’t control any of this, so I shouldn’t worry about it.  Please don’t tell me everything will be okay.

 

Please.  Just.  Don’t.

 

Because for those of us with infertility, every . . . single . . . step is in the company of the what if’s.  Experience has taught us we always walk in the shadow of fear.

 

 

Countdown to Trigger

At 6:15 my phone rang.  I assumed it was a colleague also working at home, trying to finish up a report or project.  That was, until I looked at the caller ID.

It was our clinic calling.

Our ever happy nurse (and, amazingly, she’s not annoying happy but sincerely, cheerfully, happy), said that they are triggering our donor tonight.  That means sometime tonight, she’ll take the “trigger shot” which tells the eggs to finish maturing.  Retrieval occurs approximately 36 hours after triggering.

So, her retrieval is scheduled for Wednesday.  My husband checks in at the clinic at 9:15.  He’ll have blood drawn for yet another round of STD tests (because it’s been another six months since the last ones), and then go to the lab to make his “contribution.”

Meanwhile, our donor will likely already be checked in and resting in a room on the surgery floor, preparing for retrieval. Once she is sedated, the doctor will retrieve the eggs.  Guided with ultrasound he will insert a needle with an attached catheter through the vaginal wall into each follicle where he will “suck out” the egg.

egg retrieval

In the embryology lab, the eggs will then be fertilized using ICSI.  The embryologist will hold each egg on the end of microscopic tube and, using a tiny needle, insert a single sperm into each.  Then we wait.

ICSI

On Thursday, I will get an update from embryology with the number of eggs retrieved, the number that were mature, and an initial fertilization report.  On Day 5, we’ll get another update with the number of embryos that made it to the blastocyst stage (when an embryo is compromised of approximately 100 cells).  Then, they’ll extract DNA from each embryo and freeze them all.

The DNA will be CCS tested (Comprehensive Chromosomal Screening).  Embryos that are euploid–those with the correct number of chromosomes–will be available for transfer.  Embryos that are aneuploid (those with an abnormal number of chromosomes) will not.  Aneuploid embryos contain chromosomal anomalies which make them unlikely to continue to grow and develop normally.  These embryos may not implant or may implant but stop growing (resulting in a miscarriage) or may be viable but result in the child having a chromosomal anomaly and lifelong effects of it.

While we’re waiting for results, our nurse should draw up my transfer calendar, and I should be able to start my medications to prepare.  Once we receive the CCS test results, we’ll know how many embryos we have available for transfer.

We’ll know how many chances we have at a baby.

When You Hear about a Recall

I haven’t blogged much lately.  I’ve been busy going back to work (last week was packed with trainings and prep, and this week, classes began).  Even with all the busyness, I’ve been thinking about our donor every day.  In a week to ten days, she’ll be checking into the clinic for the egg retrieval.  That means she’s currently on a spectrum of medications including injections.

recall

And then, amidst the chaos of today, I checked my phone to find a facebook message from my mom.  “Is this the one you take?” she asked before forwarding the news release about a thyroid medication recall.

I skimmed the article.  Unfortunately, it was.  Of course, my mind went a million places.

Should I call my doctor now and get a prescription for something else?  Does my doctor even know about the recall?  How complicated is this going to be?  Am I going to have another office call?

Shit, I really don’t want to switch meds right now.  How long will it take the new one to get build up enough to work?  This med took six weeks before I could test.  What if there’s a gap in the effectiveness?  We’re on a countdown to transfer here . . . I have thyroid blood work at the end of the month.  If the numbers aren’t good, they’ll push back our transfer.  I can’t afford any gaps in effectiveness.

The article says the manufacturing facility was out of compliance with new rules, and at the last inspection (under old rules) was fine.  AND . . . it’s a voluntary recall out of an “abundance of caution” with no adverse effects being reported. So, maybe, it’s no big deal.

BUT . . . what if that doesn’t mean there wasn’t contamination, and there aren’t adverse effects that aren’t readily noticeable . . . like to your uterus . . . the last thing I need is another reason not to get pregnant.

Maybe I should read more about this.

So I found another article with the link to the FDA website with details about the recall, including the DNC and lot numbers effected as well as the medication strengths.  It also explained that the first recall notifications went out yesterday to the highest level distributors.

Maybe I should talk to my pharmacist firstBut how long is it going to take for our local pharmacy to get notified?  They clearly aren’t at the highest level or even the next highest level.  How many layers of notification are involved here?  But maybe they track the lot numbers on the meds.

In the hopes that my awesome pharmacist (the woman who gave me her personal cell phone number, so I could text her pictures of my meds, so she could pre-order them before my prescription came in) could give me more information, I opted not to call my doctor and instead went to the pharmacy after work.

And my favorite pharmacist was not working.

Instead, the pharmacist who sits behind the computer and doesn’t interact with the public at all was. As I stood in line, I debated leaving and coming back tomorrow.

When I finally got to the front of the line, a tech greeted me.  I told her I was there about the recall.  She said they hadn’t gotten a notice yet and that typically I should get a letter and the pharmacy should as well, and they would make calls.  I asked how long that would take.  She didn’t know.  I pressed, reminding her that with my fertility work, I couldn’t afford to spend weeks waiting to see if I was effected by the recall.  But she couldn’t tell me what she didn’t know.

At the last minute, I asked her to look up my prescription.  (I didn’t have the bottle on me.)  She looked me up (I love pharmacies where they know you by name).

I’m on 25 mcg.

And just like that, I’m safe.  I’m not taking one of the recalled doses.