Fertility health care

My husband and I were only “infertile” for a few months, but that was scary enough.  I read in the Impatient Woman’s Guide to Getting Pregnant that the man should get a semen analysis right away so that there would be time to fix things if necessary.  We tried to follow that advice, but it was really hard to find a semen analysis anywhere.

The ironic part is that our fertility issue (other than our ages) seems just to be something very cheap to fix:  a $150-200 semen analysis + some blood tests + Clomid for him.  The imaging study that I had that month may have helped to clean things out either physically or with 3 days of antibiotics.  And knowing my exact ovulation date almost a week in advance also helped.  Regardless, much cheaper than ART.

First, I had to figure out where to find a semen analysis.  I tried calling the in-network lab for my insurance company, but their in-person locations were either far away or didn’t do semen analyses.  It took some googling to figure out that urologists were the type of doctor to see.  I called several urologists in our neighborhood and my husband’s work neighborhood, and made appointments, but appointments were more than 6 weeks out.

Second, I realized that I should probably find good urologist, not just a convenient one.  One urologist at a medical school faculty practice wouldn’t accept insurance for a semen analysis, so we put off that appointment.  That’s the urologist that my husband ended up seeing in the end, and we paid $157 out of pocket for the semen analysis even though we got semen analyses at REs for just a $20 copay.

Third, once I made an appointment with a reproductive endocrinologist, the RE would do the semen analysis, but only AFTER I went to see the doctor.  Even though my appointment wasn’t for a month, they couldn’t allow my husband to come in for the semen analysis before I saw the doctor.  My husband ended up getting one semen analysis there, but the RE didn’t refer us to a urologist.  I would have appreciated that option in case we wanted to switch from the current urologist that charges out of pocket for semen analysis.

We switched REs from one big-name university RE clinic to another big-name university RE clinic — the first had suggested unnecessary surgery, and had incredibly unhelpful office staff — and the second RE did their own semen analysis.  By that point, my husband had already seen his urologist 3-4 times, so we said we didn’t need a referral.  The main purpose of this semen analysis was to determine that we needed ICSI.

All together, my husband had 3 semen analyses:  2 at REs and 1 at a urologist. All showed the same diagnosis — morphology on the low side, but possibly made up for by other parameters — but only the urologist offered treatment.  REs are trained as gynecologists before their fellowships, so perhaps they aren’t allowed to treat males, but I would expect a closer alliance with urologists so that male partners can get treated at the same clinic.  I was very happy with our 2nd RE, but neither RE made sure that my husband was receiving adequate treatment for his diagnosis or that he had a good urologist.

About 1/3 of fertility problems are male-factor, so this situation is hardly rare.  We got pregnant naturally the month after an IVF cycle during a month before an intended frozen cycle.  While it’s rarely that extreme, it seems that health insurance companies should do more to encourage these linkages between REs and urologists to make sure that semen analyses aren’t only done for making the decision about IVF/ICSI.

Or maybe REs aren’t that interested in helping natural conception because the chances are so much lower than for IVF.  We were lucky in that our RE told us that we could definitely get pregnant on our own, but it might just take awhile.  That was reassuring to hear.

Others at the same clinic were not reassuring.  The nurse told us at the IVF class that we would have to take the month off if we did not get pregnant.  When I asked if a fertility monitor still worked normally in the month after an IVF cycle, the nurse looked at me quizzically.  She said that a fertility monitor would work, “if you still want to give that a try.”  She was clearly trying to be encouraging, but I think she thought that I was engaging in wishful thinking.

Doctors face a tough balance between pragmatism and hope.  Much has been written about this.  In some cases, though, there’s cheap treatment to be had, like a simple semen analysis and my husband’s Clomid.  If we could have done semen analysis as soon as I read about it, we might have gotten pregnant several months earlier and saved our insurance company the cost of a round of IVF/ICSI.

Update

I got married, so we are glad that my eggs are in reserve to be used.

I also got pregnant, naturally, after just over a year.  I’m end of 1st/early 2nd trimester.  We’ll see how it goes.

After 6 months of trying, my husband and I both went to doctors:  him to a urologist and me to a reproductive endocrinologist.  What seemed to do the trick was the medication that his urologist gave him (Clomid).  We got pregnant 3-4 months after he started the Clomid.  What a reversal that the guy takes Clomid, right?  I also had an imaging study that month (an SSH:  saline sonohysterogram) that probably helped my fertility by washing out my uterus and putting me on antibiotics for the 3 days around the SSH.

We did a round of IVF also.  The single-embryo transfer didn’t work, but we put some embryos in the freezer.  From that round, I learned two things:

• I responded much better this time to the drugs at the same dosage, and I made more eggs than in my egg freezing cycles even though I was 2-3 years older:  20 mature eggs.  Maybe it was because I got the American drugs that got shipped overnight on ice (paid for by my insurance company.  So grateful!), maybe it was the small amount of HCG in the trigger shot (egg freezing cycles used only Lupron) (I had to pay out of pocket for the trigger shot $175), maybe it was that I was following directions more closely.  Who knows.
• I was doing the injection sites wrong in my freezing cycles.  For some reason during the freezing cycles, I thought that I could inject anywhere in the U shape below the belly button, even 3 or more inches away.  For the IVF, I was at a different university clinic that emphasized that it had to be exactly 1 inch away from the belly button, no more, no less.  I followed that exactly.

This pregnancy happened the old-fashioned way.  If old-fashioned includes getting told at the ultra-sound-guided SSH procedure which day you’re going to ovulate 5 or 6 days ahead of time, so we knew to have sex for the 3 days beforehand. The Clear Blue fertility monitor didn’t give me so much advance notice.

The old-fashioned part of the pregnancy is a blessing, both to know that we can do it, and because I had fewer restrictions in the first trimester than I would have with an IVF pregnancy.  With an IVF pregnancy, they don’t allow swimming, bathtubs, or sex, and I had to take estradiol 2 times a day and insert progesterone 3 times a day.  Inserting progesterone wasn’t so bad, but what goes up must come down, and it’s frothy white and stains, so I was going through a lot of cloth pantyliners.

Hoping that the pregnancy goes smoothly, but also a bit scared because I haven’t been in for 5 weeks.  NT scan on Friday.  Hope that there’s still a fetus there, and that it’s healthy!  This paper reassures me that the risk of miscarriage after a normal first trimester visit is less than 2%.

Pictures of meds

When I was ordering drugs, I had no idea of what I was doing and the differences between European and American drugs, especially since some had different names. I was fortunate to get some of the drugs for free, so those are the American ones, and the European drugs are the ones I paid for. I also had no idea about what each injection used and how it worked.

Here are pictures that I took of the materials that I used for many of the different injections: I put down a kitchen towel, the needles, syringe, and the bottles. And some pictures show both the American and the European. The captions on many of the pictures are only visible if you hold your mouse over the picture. Sorry about that.

Ampoules of water differ, and no Q-cap for the European.

April egg retrieval

I did another cycle of egg freezing. This time, I had Bravelle, not Follistim, and it took longer. I think part of the longer time and lower yield was that I didn’t know until the end that Bravelle doesn’t dissolve automatically into the water, and I could feel it stinging when it went in, which apparently happens when a drug isn’t fully dissolved.

Injections 1-5: 300 Bravelle + 150 Menopur. That’s 6 vials total!

Injection 6-7: 150 Bravelle + 150 Menopur + syringe Ganirelix. (2 separate shots.)

Injection 8-10: 1 Bravelle + syringe Ganirelix. It was supposed to be Menopur, but I was out since I had ordered just enough for last time, but the injections lasted 3 days longer, but they said that I could substitute Bravelle. I wonder if that’s part of why I didn’t have as good results as before. Lesson learned. Wish I didn’t have to learn from mistakes so much.

Injection 11: Lupron at 10 pm.

Day 12: Nothing

Day 13: Retrieval. They got 17 eggs, of which 14 were mature to freeze.

Disappointed that they got fewer. Maybe next time I will get follistim even if I have to pay for it myself. I have looked around, and the study results don’t find a difference between the two drugs in the clinical trials, but I wonder whether the mechanics of transferring drugs between 4 Bravelle vials results in losing more than just pushing out 300 units of Follistim. And then the dissolving issue.

Discovered that the reason for my post-retrieval nausea was that they put a narcotic in the IV, and the narcotic makes some people nauseated. Apparently I don’t drink enough alcohol to be able to metabolize it well or something. Anyhow, they suggested putting anti nausea drug in addition to the narcotic, and I asked if they could just leave both of them out. And that was fine. So all my pain relief came from Tylenol and a heating pad. Both of which I definitely needed, but no narcotics needed, although I had the same bottle of Percocet that I picked up last time (and didn’t use then either.) And no Tylenol needed the day after retrieval, although I’ve been sleepy.

The other piece of pain relief came from an unexpected place. The nurse (same as before) asked whether the guy who brought me was the same guy as last time. I said that he wasn’t since we’d broken up. She said, “Oh, good! I was wondering at the time whether I should say anything, but he didn’t seem good for you.” I asked what she meant, and she said that he seemed angry and not very nice, and being a woman in her 50’s, she has seen a lot of couples, and just knows what is a good relationship. And he just didn’t seem nice enough for me. And maybe he had some issues and needed counseling for them before he could be a good relationship partner. And I’m sure that since she sees so many couples going through a stressful time, I know that she must have a particularly unique perspective. And that was the best thing anyone said to me all month, and completely cured my heartbreak that I’d been feeling for just over a month. Which was lovely.

Weight changes

The other egg freezing blogger mentioned that her weight went up by something like 10 lbs during her process.  It sounds like that may be associated with the ovarian hyperstimulation, which she later had symptoms of, and which is also characterized by fluid retention and bloating.  My weight did not change at all, as far as I can tell. My normal weight range is about 5 pounds, and by the end of the process I was at the higher end of that range, but I never went outside that range, and usually I stayed within the limits, not at the highest weight in that range.  And a few days after the retrieval, no symptoms at all.  My digestive system took a day to go back to normal after the retrieval, but I think that’s normal consequence of the anaesthetic, not from the hormones.

Summary of the process

Here’s what the process was, from beginning to end.

12 days before what turns out to be cycle day 1:  ordered drugs from online (abroad), based on what the nurse told me to order.  (30 Bravelle, 20 Menopur, 8 Ganirelix.  I got 10 Bravelle free and I had 5 Ganirelix and some Follistim left over from last time.)

Cycle Day 1:  drug order arrives, along with my period. Oh, and a small snowstorm.

Cycle day 2:  Morning:  ultrasound scan and blood work.  Midday:  go ahead to start the stimulation medication.

Cycle day 2 is Injection day 1, 4 pm:  300 Follistim, 150 Menopur.  Used Follistim pen + 1 syringe + 1 needle.

Injection 2, 4:45 pm:  300 Follistim, 150 Menopur.  Follistim pen cartridge is running out, so I injected the first part of the 300 into a syringe and then put in a new cartridge and injected the rest into the syringe, to avoid doing 2 injections with the Follistim pen.  So pen + 2 syringes + 2 needles.

Injection 3, 4 pm:  300 Follistim, 150 Menopur.  1 syringe + 1 needle.

Injection 4, 4 pm:  300 Follistim, 150 Menopur.  Lost some saline before there was medication in it, so used a second bottle of saline.

Injection day 5:  morning appointment shows E2 1360.  Medication reduced.  Injection at 4:20 pm: 75 Follistim (the very end of the pen), 75 Bravelle, 150 Menopur, 1 syringe Ganirelix.  A total of 3 injections, then, used 2 syringes + 2 needles. The Ganirelix I put in a new syringe type, the German ones that came with my German-packaged Bravelle, and it was a 27 gauge needle which left blood, the only time I bled from an injection.

Injection day 6, 4 pm:  150 Menopur, 1 syringe Ganirelix.  Used 3 syringes + 3 needles because first mixing syringe was too short (only 1 ” so didn’t reach to bottom of bottle, not 1.5″ which does reach to bottom of bottle).  Also, the distraction made me forget to release the fat when I injected the Ganirelix, so I had one glistening drop outside my skin sitting there.  I think this was also the injection where the syringe was different, so I had to stop the injection with fluid left in it and then clean another spot and finish it in another spot.

Injection day 7, 3:20 pm:  150 Menopur, 1 Ganirelix.

Injection day 8 (which is cycle day 9).  Early morning appointment shows sufficiently high E2, so 10 pm injection of Lupron (20 units, I think, but they just gave me a syringe). Changed out the needle they gave me for a 30 gauge needle.

Cycle day 10:  Nothing.

Cycle day 11: Retrieval at 9 am.  Took 6 extra strength acetometophin (Tylenol) and used 1 thin pad over the course of the day.  Feel back to normal by 6 pm that day, well enough to do several loads of laundry.

Cycle days 12-18:  5 mg provera.

Cycle day 19:  Period is predicted to start.

Sum total of materials used:

Medication:  Equivalent of 18 Bravelle, 14 Menopur, 3 Ganirelix. Over the counter Tylenol.  7 tablets of Provera (generic version, covered by my regular insurance).

Materials:  12 3 cc syringes, 14 small gauge needles, 1 empty powerade bottle for sharps disposal, 1 clean dish towel for putting on the table under all the medication, a few dozen alcohol prep pads, a couple panty liners.  If I had used Bravelle the whole time, it would have been the same because it would have gone in the syringe with the Menopur.

Ways it changed the pattern of my day:  I left work early and made sure to be home every day by 4 pm so that I could do injection at the earliest possible time.  No idea if that helps, but I figure it doesn’t hurt, and I was also more awake at that time so probably made fewer mistakes.  Also, the cat is sleepier at 4 pm than 6 pm, so when I got home, I would wait a few minutes until he went back to sleep before starting everything, and he never jumped up curious about the injection.  Which he did last time.

Lessons learned for next time:

Syringes and needles:  Order a box of 100 3 cc syringes with 1.5 inch needles + a box of 100 30 gauge 1/2 inch needles from a medical supplies store so I don’t need to worry about running out or the syringe changing.  When you change syringe type, you have all kinds of surprises come up such as discovering a larger gauge needle that makes you bleed or the syringe feels different in your hand, so you have different amount of control over the medication.  For $10 you can get a box of syringes or needles. Syringes should be 3 cc not 1 cc because the 1 cc is harder to use, in my experience:  the syringe is so narrow that the surface tension is much higher and plunger feels “sticky” from the extra friction.

Medication:  medication from abroad is fine, certainly for the stuff that doesn’t need refrigeration like Bravelle and Menopur and Ganirelix.  Need to order 2 weeks in advance.

Clinic location:  I was thinking about going to the NYU clinic, and I’m glad that I didn’t.  This clinic was just over an hour drive from both my home and my work, and that was a manageable distance to do for the few times that I needed to go there, even for a 7:30 am appointment, and it reduced the stress that I didn’t need to pack an overnight bag or change my day much to do this.

Refrigeration of Follistim:  I kept it in the fridge because that’s how I got it.  I later read that it doesn’t need to be refrigerated if you are planning on using it in the next few days, so I could have left the pen out all the time, so that it would be room temperature so more comfortable to inject.

Retrieval

On Thursday, I went in for a blood test and ultrasound, and they said that I had done so well that I would do the trigger injection that night.  I’ve been dreading that darn pregnyl with the long needle, but I dutifully brought it along.  I was traveling that day for work, so wouldn’t be sleeping at home, so I had to pack all the medications that they might possibly tell me to take.  In the end, none of the medicines I brought were used:  they gave me a syringe filled with Lupron, with a trigger time of 10 pm.  So I did it at 10 pm on the dot, subcutaneous, just like the others.  It didn’t feel good, but I was glad to be done with it.  And Saturday was the day of retrieval.  So again I got to skip the pregnyl.  And now I have 24 vials of Bravelle, 9 vials of Menopur, 3 shots of Ganirelix (1 may be refundable if I manage to get it back to them), and the pregnyl left over.  And some needles.  And that is not even counting that I gave a box of 5 Bravelle back to the clinic since they gave me 2 boxes of 5 when I started the cycle.

This morning was the retrieval.  My boyfriend stayed over and was such a good sport.  Something woke him up at 3 am, and he didn’t fall asleep again until we left the house at 6:30 am to make it to the surgery part of the clinic for 8:15 am, for 9 am surgery.  I woke up at 4 am and puttered around.  We got there by 8:05.

Everyone kept asking me whether I knew what to expect.  I did, sort-of, but each time I said “no” in hopes of getting more information since I felt like I was flying blind.  I’ll just say the things that I wish that I knew ahead of time.

0.  When I woke up at 4 am, I drank a lot of water, a cup of tea, and 8 oz of milk.  I reasoned that I would not be able to drive safely for over an hour while dehydrated (my boyfriend does not like to drive), and that it would clear my system by 9 am.  As far as I know, it did, because I was super thirsty when I got to the clinic, so clearly I needed more fluids than I had.  I wore cardigan sweater, which made it easier to take off from under the gown.  I wore a short-sleeved t-shirt, which was perfect.  I also decided to take off my bra, which was more comfortable.  I was wondering whether I would be uncomfortable wearing jeans afterwards, so I brought along a skirt, but I was perfectly comfortable in my jeans.  It was useful that my jeans were loose in the waist so I could stick the heating pack that they gave me into them.

1/2.  Once I was in the gown with IV and everything, they asked if they should bring in my boyfriend.  I didn’t want them not to bring him in, but I didn’t feel particular separation anxiety either.  But I also kind-of felt silly in the gown with all the machines, and I wanted someone to see me like that.  So I said sure.  Plus it never hurts to do the rituals of this type of thing.  And he comes in, and he reassures me that it’s a short thing, and not a big deal.  Which I knew, but somehow, I felt better doing the ritual of the boyfriend (or whoever) coming in.

1.  Bleeding is normal afterwards.  It seems like just some pantiliners are necessary, not a heavier pad. I kept asking them what kind of pads I would need since I normally don’t have them in the house, and I wanted to know whether I needed to go buy some. I didn’t really get a good answer, but the nurse did give me some extras from their supplies.  They were the thin type — not the bulky diaper type.  So far, even that wasn’t even necessary.  A pantiliner would have been fine. 

2.  I drank lots of water afterwards.  That was really important.  I brought my own food and munched on some grapes afterwards.  That was a good choice.  Nice and sugary and easy to digest.  I had also brought yogurt, but I had no interest in that.  I also had some peanuts.  I think protein of some kind would have been welcome, but I didn’t have anything other than the yogurt.

3.  The clinic nurse (i.e., an IVF nurse, so a different nurse than the nurses at the surgery center) and one blog that I read said that they keep you until you pee, but I felt rushed out the door.  I opened my eyes a few times and the nurse said to rest a bit more.  But I wanted to look around a bit, and eventually she told me how many eggs they got which was a good number but not so many that I would hyperstimulate, she put my clothes on the bed, and before I knew it, she was walking me out and left me in the waiting room, and that was it.  That was around 10:30 am.  In spite of drinking tons and tons, I didn’t pee again until 3 pm.  When I did pee, the urine looked like I had just eaten some beets, but it didn’t hurt, as some bloggers said it did.  It felt a bit uncomfortable, but not so much.  I wonder if it hurts more if you do it right away.  This way, I had a few hours to heal up.  I wonder if the delay between all the liquids I drank and peeing was because my system got slowed down by the anaesthesia.  Or if my body was using all the liquid.

4.  Afterwards, I felt dizzy and nauseated walking.  I went to the Target pharmacy to fill the painkiller prescription, and I had to sit down.  At one point I thought I might vomit.  I didn’t. As long as I was there, I wanted to buy a few more things like a heating pad, and it was walking to get the other things that I felt bad.  And in the car, I felt really nauseated.  I closed my eyes a lot, turned on the A/C, opened the windows to let in the winter air, held a bag in my hand in case I needed to vomit which thankfully I didn’t use, and listened to classical music and some soothing pop music.  Even things that I normally love, like a certain radio program, bugged me.  But soothing music was lovely.  And air conditioning.

5.  I felt much much better when I got home and ate some protein.  I no longer felt nauseated.  I had pictured myself on jello and clear fluids, and instead I ate a piece of cold chicken with skin, and that was exactly what I needed.

6.  So far I haven’t used the prescription painkiller, just my extra strength tylenol and heating pad.  And I’m fine.

I actually feel better than fine.  I want to do laundry, but that would probably be too much.

Darn needles

I have been using the same needles from the pharmacy and my doctor was so nice to give me needles instead of a prescription, and I didn’t notice until it was too late that they were 1″ not 1 1/2 ” needles, so I couldn’t get all the Menopur from the vial.  Seriously?  I’m going to waste medicine because I didn’t have the right length needle?  Fortunately I had a 1 ml, 1 1/2 inch syringe to try that came with the Bravelle, but I think I lost some in the transfer between the different syringes, and I really wish I didn’t have this issue.  I have one of the old syringes left.  I will use it for both injections, and then I will have to get new syringes when I visit the doctor on Thursday.  But really, this is absurd.

Non-drug factors: Food and sleep

Last night I slept about 10 hours.  I went to sleep around 7 and woke up around 5:30, with some wake-ups in the middle of the night due to my cat deciding to purr loudly in my ear as he settled in on my pillow.  Today,  I have a total brain fog, and I am feeling better as I read others’ stories about their similar experiences.  This blog is particularly funny and also very positive with good tips: the post that I linked to was her story, but there’s a lot from that first month of the blog that’s really relevant.

One thing that I read today on the fertility forums (I hate when people put an “in-” in front of that word.) is that fat helps develop strong eggs.  Also, I’ve seen a study that associates low fat diets with lower fertility. I’m a strong believer in fat.  I drink whole milk, I eat red meat, I eat peanut butter (the just peanuts kind).  So I ate half an avocado, and by golly, I did feel better.  And then I had a bowl of homemade chicken soup.  And now I feel fantastic.

What I’ve been doing with diet is what I normally do:  no processed foods, lots of produce, meat, dairy, protein, beans, no limits on fat, and limited starches (only when I feel that I need it, so not every day). But having read that about the egg quality being helped by fat, I am even happier that I drink whole milk.

Needles

When I was given the shopping list for needles, I had no idea what it meant, and there were so many different parameters:  the gauge of the needle (30 gauge for injection, 21 gauge for mixing the drugs), the length of the needle (1-1.5 inches for mixing, 1/2 inch for injection), the volume of the syringe (3 ml for injecting because sometimes there is more than 1 ml of fluid.  Most diabetes needles are 1 ml.)

When I shopped online, I noticed that some needles were called “diabetes needles” and others weren’t.  I went to lots of drug stores, and I eventually discovered that only the fertility-specialty ones had the right needles, and they cost reasonable amounts:  15 cents per needle and 25 cents persyringe.

Today I came to a new appreciation for needles.  Ganirelix comes in a pre-filled syringe.  It’s quite pretty, actually:  pure glass, with the needle built-in, like the old-fashioned kind you see from 1950s movies.  The last time, I just put all the drugs in one syringe, per my doctor’s instructions, but this time, I was instructed to keep them separate.  So for the first time, I tried to inject myself with the pre-filled syringe.  And it just wouldn’t puncture my skin.  Not that I tried too hard, but I wasn’t going to jab at myself with it until it worked.

So I opened the needles that came with my Bravelle, and I filled the syringe with the liquid, topped it with the needle, and injected it.  When I withdrew, there was a bright bead of blood, the first time I’ve seen blood when I hadn’t made a mistake.  (The other time I saw blood was during the previous cycle when I hadn’t released the fat that I had pinched.)  I checked the needle gauge:  27 gauge.  All my other injections have been 30 gauge, so 3 sizes smaller.  That’s why they don’t hurt.  Follistim uses a 29 gauge needle, and that seemed about the same as my 30 gauge needles.  So I called up the drugstore and ordered more 30 gauge needles.

I’m amazed what a huge difference it makes to go through this process with 30 gauge needles.  If I only had the 27 gauge that came with the Bravelle, I wouldn’t know any different and it would be more painful each time.  Thankfully I was prescribed 30 gauge in the first place!