Treatment Protocol

Here is my treatment Protocol as I currently understand it:

1. Firstly, I’ll need to call the FA nurses on day 1 of my next period (which I have been doing anyway to track my cycles). The week following they will courier me the medications and paperwork that goes with them, including more specific instructions as to the timeline and what is to happen when.

2. Approximately 2-3 weeks later, I will start injecting myself with a drug called Buserelin, which is a Gonadotrophin Releasing Hormone (GnRH). This is a modified version of the hormone my body produces to stimulate the release of Follicle Stimulating Hormone (FSH) which stimulates the follicles in the ovary to grow. These follicles are what develop into eggs during ovulation. Injecting the Buserelin will cause my body to adapt and stop secreting it’s own GnRH, effectively ‘switching off’ my ovaries. This is called ‘down-regulation’, and stops my normal hormones from interfering with the IVF process.

3. Approximately two weeks after starting the Buserelin, I will be told to take a blood test to ensure it’s done the job, and that my ovaries are ‘switched off’. Assuming this is the case, I will be advised to now start another injection, Puregon, which is a Follicle Stimulating Hormone. This Follicle Stimulation Phase is to stimulate my ovaries to start producing follicles and keeps them growing in preparation for egg collection. During this time, I continue injecting the Buserelin as well, but at a lower dose than before.

Flow diagram from Fertility Associates' 'Pathway to a Child' booklet

4. Approximately a week after starting the Puregon, I will be advised to have a blood test and potentially a scan (vaginal ultrasound) to track how many follicles there are, and how they’re growing. This can be done in Nelson, and depending on what this shows, I may need a follow up scan and test 2-3 days later.

5. The last scan I will need to travel to Christchurch for, and they will give me a final injection to administer that night. This will be Ovidrel, which is a copy of human Chorionic Gonadtrophin (hCG) hormone which will trigger ovulation. At this point I will be advised to stop the other two injections, and will again insert a vial into an injection pen to administer it into my stomach.

6. 36 hours after administering the Ovidrel (trigger injection) I need to be back at the Christchurch clinic for egg collection. For this procedure I will receive a narcotic sedation, and cannot drive for 24 hours following. At this point Dave will also need to provide a semen sample, which they will use to fertilise any suitable mature eggs that are collected from me.

7. The day following, they will call us to tell us how many eggs have successfully fertilised, and so how many zygotes (early embryos) we have. These are then incubated until they are 5 days old.

8. At day 5, they will let us know how many high-quality (viable) embryos there are (it is expected that some will not make it to this stage). These will each have a tiny sample (10-20 cells) lasered off and sent to the lab for genetic testing. The embryos will then be frozen to await results.

9. FA will contact us after 2-3 when the results come back, and if there is a suitable, high-quality embryo that tested negative for SCA 3, they can replace (implant) the embryo.

10. Again, on day 1 of my cycle, I contact FA, and they will advise me to start taking Progynova tablets 3 times a day. This contains Estradiol (E2/estrogen) which will help growing and preparing the lining of my uterus (endometrium) for implantation.

11. After approximately 10-12 days, I will have a vaginal ultrasound.

12. At day 12-14, I will have a blood test to check my progesterone level. When this is at the right level, they will advise me to start using Utrogestan vaginal pessaries 3 times a day. These are Progesterone (P4), which maintains the lining of the uterus so that an embryo can implant and cause a pregnancy.

13. Five days after starting Utrogestan, they will thaw and replace (implant) the embryo.

14. Ten days after transferring the embryo, I will have a blood test to find out if I am pregnant.

There’s obviously a whole lot more from here, but that gets us to a potential pregnancy anyway.

All Systems Go

This week we had our first series of appointments at the Fertility Associates clinic in Christchurch, which they helpfully scheduled these all for one day knowing that we’d need to travel.

Semen analysis
We started with Dave submitting a semen sample for analysis – this was the first one done by Fertility Associates, the one from the start of the year was organised by our GP. This was booked for 10am, and we had the option of him utilising a room at the clinic to produce a sample, or collecting a pottle prior to the appointment and bringing the sample to the clinic within an hour of collection. They also provided a page of instructions including how long to abstain for prior to collection (which depends on what the sample is to be used/tested for), and how to exercise basic hygiene to minimise contamination of the sample. Dave opted to drop a sample off, to the disappointment of his friends who wanted to know what ‘material aids’ may have been supplied at the clinic. We were directed to their lab by the reception desk, dropped the sample off, filled in the brief submission form and returned to the waiting room for our next appointment – we’d receive the results later.

Counsellor
Our second appointment was with the FA counsellor. She explained that due to being referred to FA for PGD, we’d sort of landed straight into treatment compared to a couple who had been receiving fertility advice often for months or years before treatment. This appointment was for them to get to know us and to get a feel for what our understanding was of the IVF treatment process, how it works, and (reading between the lines) how we would cope. We explained what we knew of the process we were about to go through, and discussed SCA 3 and the effect it has in Dave’s family. She asked whether we are talking to anyone about what we’re going through, and we told her about our belief in how important it is to discuss these things. We said that we are being open with our family and friends about starting treatment, even to the extent that I am writing this blog. She seemed satisfied with our conversation, and after making sure we knew we could contact her or other members of the FA staff at any time should we have questions or need additional support, concluded our appointment. Though an hour had been allocated, this appointment only took around 30mins as I guess she learned all she needed to from us in that time. We had a couple of hours until our next appointment, so headed out and came back in the early afternoon.

Drug education
The third appointment was with one of the nurses, to go over the regime of medications I would need to take as part of the IVF treatment process. 

The medications are provided in either a vial where I will be drawing up a dose into a syringe for injection, or in smaller vials which are inserted into an injection pen, which you fit a needle to and have an adjustable dial that you use to set it to your dose. I will be injecting myself daily, and the injections must be done at the same time each day. They are administered into the flab in my stomach in a line below my belly button. The nurse showed me an example of the vial, the syringe and needle, and gave me the opportunity to practice inserting a needle into my stomach. I gave it a go (figured best to do any trouble-shooting while there!) and it was easy, the needle is so small I actually didn’t feel it at all. This is where I’m glad I have no problem with needles, and am not at all shy of medical procedures!

Drug taking 101

Appointment with the specialist
Our final appointment for the day was with the fertility specialist overseeing our treatment. First they gave me a vaginal ultrasound, viewing my uterus (with IUCD in place), and both ovaries. They commented that everything looks normal and is in a normal position, so it should be a routine enough egg collection when the time comes. In my right ovary we could see one large follicle and 2-3 smaller ones, indicating that I am likely to ovulate from this one this cycle. In my left there were 3-4 smaller follicles.

After the scan, they checked the results from Dave’s sperm analysis from that morning, which were perfectly normal. This was all very reassuring, knowing that there are no surprises so far with each of us that could affect treatment.

We then went over the consent forms for treatment, one for IVF in general, one for this specific cycle, one from FA for the PGD, and one from the lab for the PGD. During this they mentioned again that they will use Intracytoplasmic Sperm Injection (ICSI), injecting an individual sperm into an egg directly, rather than just adding semen to the eggs. In this case, this ensures there are no other sperm attached to the outside of the egg, which could affect the results of the genetic testing. I also enquired about Timelapse Imaging Incubation (TiMi) which I had read about. During this process, instead of removing the embryos briefly from the incubator to observe and photograph their progress every couple of days, daily images are taken without removing from the incubator. They can even make a video of the embryo development. The articles I read suggested that the daily monitoring of development can help them better select which are the highest quality embryos. I asked whether they thought this was worth doing, if it could be part of our treatment program, and if it cost extra. The specialist said it is worthwhile doing, but more as they felt the incubator was better and therefore any more sensitive embryos were more likely to thrive. It costs $975 extra if we wanted to opt for this, which we are leaning towards doing. 

So now we wait for my next cycle and go from there. I have made a summary of the next sequence of steps as far as I understand it, and will make this a separate post as I've included quite a lot of detail.