The Finish Line

At approximately 10:30pm on Wednesday 24th February, at gestation of 37 weeks and 4 days, my water broke. As it was late in the evening, and everything appeared normal, I did not phone my midwife until the next morning. This is standard practice so that they can be at their best when they need to be later in your labour, as they are likely not needed until at least the next day. The advice if early labour starts at night is to try and rest, and monitor any contractions. While I didn't get much sleep due to my brain running overtime, I did not experience any contractions overnight.

After speaking to my midwife on Thursday morning, and them learning that my water had broken but I still had not felt any contractions, they asked me to meet them at the maternity ward of the hospital for an examination. On arrival they hooked me up to a monitor consisting of probes strapped to my stomach, one that measures the baby's heartbeat, and one that detects contractions. After 20 minutes of continuous monitoring, no contractions were noted, and the heartbeat was healthy. My midwife then performed an examination of my cervix, which was still closed, and took swabs of the fluid still leaking to confirm that it was amniotic fluid and that therefore my waters had broken (apparently sometimes urinal incontinence can confound things, but thankfully that hasn't been an issue for me). The initial swab test came back as a weak positive, and subsequent a test confirmed this. The concern with the water breaking before labour commences is that the amniotic fluid is sterile, and is what protects the baby from infection. If the baby is not born within 24hrs of the water breaking, then IV antibiotics are administered to the mum to protect the baby. I was advised to return to hospital that evening if nothing had changed, to be admitted to receive antibiotics and to begin the process of inducing contractions.

Upon admission to hospital, I had an IV inserted and a midwife performed another examination of my cervix, and assessed my readiness for labour (I wasn't; cervix still closed, baby not in position, but still leaking amniotic fluid). She applied a prostaglandin gel behind my cervix, the purpose of which is to help soften the cervix ready to thin and dilate for birth. This alone can sometimes be enough to bring on labour, but more often is used as a precursor to a synthetic oxytocin IV drip, oxytocin being the hormone that drives labour. The next morning, after being seen by the obstetrics team and discussing the plan, I was moved to a birthing room and once again hooked up to the monitor. Following a continuous half hour of monitoring to check on the baby and confirm there were no contractions yet, at around 11:30am the midwives looking after me began the drip. I was also given the first dose of IV antibiotics, which were to be given every 4 hours until the baby was born. As the monitor showed no contractions, and I wasn't feeling any, the oxytocin dose was increased every half hour.

My midwife, who had been busy with another woman she was caring for, popped in and established that even though I couldn't feel anything, if she palpated my abdomen she could actually feel that I was undergoing some contractions that the monitor had not been picking up. With some adjustment they managed to get the monitor to work, and even though I felt nothing I was apparently having  6-7 mild to moderate contractions per 10 minute period. This was not ideal, as this can be indicative of hyperstimulation, where the contractions were too many and too small to actually progress labour, and can begin to cause distress to the baby. Thankfully my baby was not showing any signs of stress at all. The decision was made to reduce the oxytocin dose again, with the intention of reducing the frequent contractions before increasing the dose to hopefully bring on fewer, stronger contractions to dilate my cervix and bring about labour. After nothing really changing despite reducing the dose for a couple of hours, the midwives upon consulting with the obstetricians decided that since there were no signs of distress to the baby, to just continue ramping up the oxytocin dose for a few hours to see if they could just bring about bigger contractions. During the course of the day, I was advised not to eat, and to limit fluid intake 'just in case'. After several fruitless hours, and a further check confirming no change to my cervix, at around 7:20pm the call was made to perform an emergency caesarean section. The baby was still not in distress, but since it had now been almost 48hrs now since my water broke, they had to get her out somehow! Thankfully my lack of pain and the fact that the baby was still doing well meant that I wasn't feeling particularly stressed about how things were going, just getting frustrated at the long day of waiting to see when and how my baby would arrive.

The anaesthetist and obstetrician both met with me briefly to go over the procedure, risks and consent paperwork. Since I hadn't required an epidural, I was to have a spinal for the c-section, where anaesthetic and morphine was injected into my lower back, bathing the spinal cord and numbing my body from that point down. We were prepped for theatre almost right away, and at 8:17pm on February 26th 2021 our beautiful baby girl was born. My abdomen was obscured from my view with a curtain during the surgery, but they showed her to me as soon as they pulled her out, all shrivelled and purple, before briefly taking her aside to perform checks, and let Dave cut the remaining section of umbilical cord. They administered a vitamin K injection, which is standard procedure as babies are born with low vitamin K, which can put them at risk of a bleeding disorder. They put a nappy on her, then placed her on my chest for skin to skin contact and covered her with a blanket. It sounds cliché, but the moment she was given to me, I had the overwhelming feeling that everything was going to be ok. My heart rate, which had increased when they announced they were ready to start the surgery (mostly because it finally hit me that we were about to have a baby), immediately dropped to closer to normal as I relaxed. 

Dave and I could not be prouder or happier that two years since starting this journey, our baby girl is finally here. Perfect, healthy, and free of the SCA3 gene.

Our wee family of three

Nerves (not that kind)

 Incredibly, today marks one year since my egg collection procedure, and I am now 37 weeks pregnant. While estimated due dates are set for the 40 week mark, a baby born any time from 37 weeks onwards is no longer considered premature, and is full term. 

Over the last month, I have continued with the routine fortnightly midwife check ups, including one where I met my midwife's practicing partner, in case she ends up being the one on duty when I go into labour. At 36 weeks I had a follow up blood test, and now that I am taking supplements daily, my iron levels are now within the normal range. Dave and I also attended a weekend of antenatal classes, which both consolidated information we aleady knew and provided further information around pregnancy, labour, birth and caring for a newborn. 

Following recommendations from the antenatal classes and my midwife, I have also attended a brief group training session with a physiotherapist at Nelson Hospital to learn how to use an obstetric TENS (Transcutaneous Electrical Nerve Stimulation) machine so that I can hire one should I want to use it during labour. Basically, this device emits an electrical signal through each of four adhesive electrode pads that you stick in position on your lower back. The idea is that the electrical signal confuses and helps ease the pain signals from the contractions, particularly during early labour. I have hired one from the hospital so that I have one available should I choose to use it - it's only $30 and this is just to cover the cost of the adhesive electrodes which are replaced between each patient.

The TENS machine and wrist splints on loan from Nelson Hospital

I have also had another appointment with a physiotherapist, this time because I have developed pregnancy-induced carpal tunnel syndrome. While this presents the same way as those who develop it from overuse (tingling and numbness in the fingers and hands, shooting/burning pain up the arms), pregnancy-induced carpal tunnel is caused by the build up of excess fluid in the wrists pressing on the nerves, rather than swelling of the tissues around the nerve. I often wake up being unable to flex my hands properly until the fluid has a chance to redistribute as I move around. The good news is that it should hopefully rectify itself in the weeks or months after birth. The physiotherapist has also given me wrist splints to wear overnight, which should help keep my arms in a straightened position, limiting the build up of fluid, as it's usually worst at night and first thing in the morning. The bad news is that it can take months to resolve after the baby arrives, so I may have to care for my newborn without the full function of my hands. Fingers crossed it dissipates quickly.

All in all, besides the carpal tunnel syndrome and feeling increasingly tired, I still feel pretty good and think I am thankfully getting off lightly so far.

Perfectly Average

This week I had another routine midwife visit, with the usual measurements (blood pressure, urinalysis, foetal heart rate) all checking out as normal. Routine checks with my midwife have now progressed from monthly to fortnightly as my pregnancy advances. My midwife is now also measuring my fundal height (length from the top of my bump down to my pubic bone) each visit to help track the growth of my baby. Fundal height should roughly correlate with the gestational week. Last visit my measurement was slightly above average - 30cm at 29 weeks. This week I am 33cm at 32 weeks - so still a little above average in measurement, but growing steadily at ~1cm per week, which is ideal. Overall, my midwife seems happy with my progress.

Diagram illustrating measurement of fundal height.
From: https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/multimedia/fundal-height/img-20008049

I also had my 32 week scan, which was primarily to check position of the placenta relative to my cervix, as it was quite low in my 20 week scan. Today it was deemed to no longer be low-lying, which is good. They also checked the level of amniotic fluid, and took several measurements to check on the growth of the baby. Everything is thankfully looking very normal at this stage, and the baby's weight is currently estimated around the 2 kilogram mark, which is perfectly average for this gestational age. As the ultrasound technician pointed out - this is one of the times you actually want your child to be average! She is currently positioned with her head down, her back along my right hand side, and her backside up near my ribs. This explains why I tend to feel the most movement in my lower left abdomen - that's where her limbs are as she moves them around.

During my next midwife visit I will meet with my regular midwife's midwifery partner, so that I can get to know her in case she ends up being the one attending the birth. We also have antenatal classes coming up, so we are already getting used to much of our time already revolving around the baby - a sign of things to come.

Testing, testing

Nothing much to report (at this point no news is good news), but I thought I'd write a bit of an update of the appointments and tests I've had lately.

Midwife checkups
Routine 4-weekly appointments with my midwife have been thankfully uneventful, with my blood pressure, urinalysis, and the baby's heart rate all checking in as normal each time. They use each appointment to discuss any concerns, pass on information on what to look out for during pregnancy, when to call them, and when to arrange any upcoming tests. From here, my next appointment is 3 weeks following the previous, and then the checkups will move to fortnightly as my pregnancy is further along.

Anaesthetist
Four years ago I had a serious of four surgeries on my lower spine within the space of about five weeks; the first to remove a piece of prolapsed disc, and the subsequent surgeries to address complications I experienced. I mentioned this to my midwife, particularly since I was wondering if the scar tissue I likely have would affect my ability to have an epidural or spinal should I want or need one during the birth. They referred me to the hospital to discuss this directly with an anaesthetist. Incidentally, when I arrived at my appointment the doctor was the same one who oversaw my anaesthetic for my first spinal surgery. They asked me some questions about the surgeries, my recovery and current health, and performed a quick examination of my back to assess how easily they could feel and visualise my vertebrae. They had no concerns regarding administering an epidural or spinal should I require either, and discussed the risks and benefits of each as is routine before such a procedure.

Physiotherapist
A few weeks ago I was experiencing some referred sciatic pain in my leg, which while a very common pregnancy symptom, is also a sensation I am all too familiar with from the prolapsed disc I mentioned above. This time thankfully I only experienced the pain intermittently for about two weeks, but during that time I asked my midwife if I should see a doctor or physio, especially given my history of back problems. They referred me to the physio team at the hospital, and I had a very reassuring and helpful session with a physiotherapist who showed me some stretches that can help alleviate sciatic pain, assuming I'm likely to experience it again during my pregnancy as the baby grows and shifts around. I also experience some fatigue in my back at the base of my shoulder blades most evenings, and she gave me an elastic body bandage that I can wear around my middle for extra support to alleviate this.

Diagram explaining sciatic pain caused by pregnancy from https://www.cantrellcenter.com/is-your-baby-getting-on-your-nerve/

28 week antenatal blood test

At just over 28 weeks I had the routine 28 week blood test, which includes a complete blood count (CBC), iron levels, and glucose tolerance test. The CBC was normal, but my iron was low so I have started taking supplements prescribed by my midwife. My glucose was high, so I had to take the subsequent test which checks for gestational diabetes, and requires a fasted blood sample followed by another sample taken two hours after drinking a 75mg glucose solution. For this you have to remain in the waiting area for the full two hours, and as my appointment was just before christmas, the staff were playing christmas songs and singing along the whole time! Thankfully the subsequent glucose test came back normal. 

What's next?
At 32 weeks I'm due my next scan, which is to check the position of the placenta relative to my cervix. In my 20 week scan it was quite low, so they usually scan again at 32 weeks to check for placenta praevia, where the placenta lies across the opening of the cervix, and can get in the way during birth.

Otherwise, so far I'm feeling pretty normal, just tiring easily. My belly is getting bigger, and I can feel the baby as she is moving on and off all day. I'm still working part time, walking the dogs daily and swimming laps a couple of times a week. It remains to be seen how long I can keep this up.

It's a...

 A couple of weeks ago I had my latest midwife appointment. Once again they checked my blood pressure, conducted a urinalysis and used the doppler to listen to the baby's heartbeat. Everything checked out as completely normal, and this time they found the baby's heartbeat the moment the probe was placed on my stomach, where in the previous visit it took a few moments of moving it around to pinpoint the sound. They asked again how I've been doing, and I was able to tell them that I feel pretty normal these days, which is a welcome change from feeling sick. I did have a question about a muscular-type pain I felt in my abdomen one night when I tried to roll over using my stomach muscles. I wasn't too worried as the pain subsided the second I stopped, and used my whole body to roll over rather than just my stomach muscles. I said that I suspected from my online research I just over-stretched my round ligaments - these are the ligaments that wrap around your uterus, and so are very tight as it grows with your baby. My midwife agreed that it was most likely muscle or ligament pain, as these are very common throughout pregnancy. I have already had a flu vaccine this year, but I was advised that any time between now and 38 weeks I need to have my whooping cough vaccine, so that the baby will have some protection passed on from me until it can have it's own vaccination at 6 weeks of age. We then booked my next midwife appointment for early November, and my next scan for mid-October.

So today at 19 weeks and 2 days we had our next scan, which they term the 'anatomy scan' as they continue to check and measure many aspects of the anatomy. It is also the earliest scan at which you can learn the sex of your baby, if you would like. I found the scan really fascinating, it was amazing the level of detail they can see over the course of about half an hour. We were able to view and measure the heart, including visualising the four chambers and you could even see the valves moving as it pumped blood. They checked each of the blood vessels entering and leaving the heart, as well as several blood vessels elsewhere in the body including to the lungs, brain and kidneys. Measurements were taken of areas of the brain, including the circumference, the cerebellum and of the ventricles in the brain that secrete the cerebrospinal fluid. They looked at the hands and feet counting the digits - four fingers and a thumb on each hand, five toes on each foot, and counted the number of bones in the arms and legs. The stomach was measured, and we looked at the spine to check for normal shape. What we could see there looked normal, but unfortunately the baby was fairly uncooperative once again, and had by this time rolled from their side onto their stomach, where they were essentially curled into a little ball  upside-down with their bum sticking up. This meant the sonographer could not complete their measurements/check of the spine, nor could they check facial features (they check the eyes, nose, lips and profile) so we are going back for another appointment later in the week. They were able to get a look at the genitalia of the baby though - we're having a girl!

Stock photo of 19 week old foetus from: https://www.gettyimages.ae/detail/photo/my-babys-19-week-scan-royalty-free-image/139538366

They assured us that so far, everything they could see looked normal, and measured within a normal range. The only except to this was that the placenta is still sitting fairly low close to my cervix, so they will do another scan at 32 weeks to check it's position again. This does not affect her development, but can affect the birth if the placenta lies across the cervix (a condition called placenta praevia) as it can essentially get in the way, and also increases the risk of bleeding. They re-scan at 32 weeks because as the uterus stretches, the placenta may move away from the cervix and this self-rectifies the problem. If it was still low towards the time of birth, my understanding is that a planned caesarean section would be advised to minimise the risk to me and baby. This is not something that worries me, as at least it is something they can monitor closely, and they can then take appropriate steps to keep us both safe.

Update from follow-up scan

I had the follow-up anatomy scan at the end of the week. They were able to see the baby's face this time, and check her eyes, nose, mouth and facial profile. They were also able to see her lower spine. Everything looks normal, so my next scan will be at around 32 weeks to check the position of the placenta.

Wiggly little fish

 At the end of August, at 12 weeks and 2 days we had our 12 week scan. The purpose of a 12 week ultrasound is routine screening to check the baby is developing normally. Together with a maternal trimester 1 blood screen, the scan is used to assess the risk of chromosomal abnormalities such as Down Syndrome (trisomy 21), trisomy 13, and trisomy 18. 

The sonographer had a little difficulty getting a clear view of the baby, saying it was quite deep in my abdomen. After positioning and re-positioning the probe, we managed to get a few grainy views where he was able to take some measurements including length (61mm), heart rate (150bpm) and checked the position of the placenta. During this time, the baby was very active - more so than I knew they could be at this age. They kept moving up and down like they were swimming, wiggling about like a little fish! They were also on a slight angle, which meant that the sonographer couldn't take one key measurement - the nuchal translucency. This a a measurement of a fluid pocket at the back of the baby's neck, and is one of the factors used to assess the risk of Down Syndrome. After asking me to repeatedly move positions and get up and walk around to try and move the baby (unsuccessfully) they rescheduled us for a follow up scan the next week.

The day before my next scan I had my next midwife appointment. They asked how I was doing, checked my blood pressure and we were able to hear the baby's heartbeat through a doppler (151bpm). They also conducted a urine test to make sure I wasn't passing an excess of protein or glucose, which can be indicative of health issues. Everything checked out as normal, and my next midwife appointment is to be at 17 weeks.

At the follow up ultrasound at 13 weeks and 3 days, the sonographer was able to find the baby more easily and images were much clearer - but this time the baby was upside down! After repositioning the probe a few times, they managed to get a clear view and were able to skillfully take the nuchal translucency measurements upside down. At 1.9mm the measurement was well within the normal range - anything less than 3mm is no cause for concern. Our next scan is to be at 20 weeks.

Stock image of 13 week old foetus. Ours looked more-or-less like an upside-down version of this.
From: https://www.sciencephoto.com/media/79609/view

When the risk assessment results came in from the scan and blood test, they reported that the chance of Down Syndrome is 1 in 4500; trisomy 13 1 in 100 000, and trisomy 18 1 in 100 000. The reference given for all of these was that the cutoff is 300 - so a chance of 1 in 300 or greater would indicate high risk. The analysis concluded that there is a low chance of our baby having any of these conditions. (the chance of Down Syndrome is only higher because it is a more common condition than the other two, these results are well within the range of normal and low-risk).

At 10 weeks, I was able to wean off both my Progynova and Utrogestan over 4 days. At 12 weeks, folic acid supplements are no longer necessary. The only thing I am currently taking is the daily iodine supplement. After consistently feeling pretty sick up until around 13 weeks, I am now mostly feeling a lot better, with the odd period of nausea becoming less frequent. I'm still generally exhausted, but I've had my busiest couple of months work/study wise, and should be able to get some more rest soon which will hopefully help. In the meantime, we will look forward to our next scan.

A Little Lizard Thing

It's been a busy couple of weeks! The week following my last post we met and signed up with a midwife, who sent me for my first antenatal blood test. While we will be in contact and I can get in touch if I need anything, we will not need another visit until after our 12 week scan.

Later that week we had a bit of a scare, as I discovered I was bleeding. I called Fertility Associates, and the nurse assured me that some spotting/light bleeding can be very normal at that stage of pregnancy, and for someone who has gone through the type of treatment cycle I have. Regardless, they ordered a blood test to recheck my hCG. It came back at 24300, so had still been at least doubling every 2-3 days, suggesting that everything was still ok. The bleeding also stopped after just a couple of hours, which was reassuring. I had been feeling a little nauseous, and that also hadn't changed, so it looked like we were still on track. Bleeding at this stage of pregnancy can be caused by the embryo implanting into the uterine lining, so hopefully it was just making itself at home.

Over the last couple of weeks I have found that instead of feeling hungry, I start to feel sick. While I haven't actually been sick yet, it's not a great feeling. I also find I get hungry a lot, so I'm basically feeling sick on and off most of the day at the moment. Nothing debilitating, but not fun either, especially as I'm also feeling tired most of the time. Also helpful is that I am experiencing the heightened sense of smell that often accompanies pregnancy, as well as food aversions. Some days I feel sick at the thought of certain foods, the next day it's one of the few things I can face eating. I can barely keep up! At least I can eat I suppose.

Today we had our 7 week scan. They advised me to go with a full bladder, but they couldn't get a very good view through the external probe so they asked me to empty my bladder so they could use the internal one. They were able to get a good look at our embryo, and take some measurements. We could see the embryo itself looking like a little lizard thing, and the yolk sac through which it receives its nutrients until the placenta forms. Normally, for non-IVF babies, the measurements from this scan are what they can use to calculate the estimated due date from. Today, known to be 7 weeks 3 days of age, it measured 13mm long and was calculated to be 7 weeks 4 days based on the length, so the measurements are pretty accurate. We could see its heart beating, and the ultrasound technician recorded it at 150 beats per minute, which they said was within the normal range for this stage. Since our appointment was late in the afternoon today, I expect Fertility Associates to call and discuss the scan with me tomorrow. If they're satisfied, they will discharge me into the care of my midwife.

Stock photo of an 8 week ultrasound. This is more or less what we saw (once again not posting our images out of respect for any potential future person).
From :https://www.itnonline.com/article/fetal-pictures-ultrasounds-gallery

While things are still very early, it was reassuring that things are looking ok so far. The appointment today helped things feel a bit more 'real', and it was nice to confirm that there really is something growing in there.

Player Two is Still in the Running

Today I had a blood test to measure my hCG (human chorionic gonadatropin), which is the hormone produced by the cells that surround a growing embryo. This is the hormone that is used in tests to confirm pregnancy. Ideally, I would have had this test over the weekend as this would have been 10 days following embryo transfer, but it was scheduled for today (Monday) so that we could get a same day report of our results. Just before 4pm today Fertility Associates called me, and after checking my identity details, gave me my results. Had the test occurred on Saturday, they would have been looking for an hCG ≥50, and the reference doubles each day, so by today they were looking for hCG ≥200. My level today was 410! So I am currently 4 weeks and 2 days pregnant, with very encouraging levels of hCG. 

We still have a long way to go!
From:https://www.healthline.com/health/pregnancy/pregnancy-week-4#your-body

I am to continue taking the Utrogestan and Progynova, and have a follow-up blood test on Wednesday to check my hCG is still climbing at an appropriate rate. If things are still looking good, I am to continue my medications until around 12 weeks, all going well. I am also to continue taking folic acid, and to start taking 150μg of iodine per day. I was also advised to contact a midwife, as although visits wouldn't start until around 7 weeks, they can book up really quickly. Pending a good blood test result on Wednesday, I will have an early scan at around 7 weeks (so in late July) to check how things are going. 

We are relieved and excited, but also mindful that things are very early (most people would not yet have announced) and we have a long way to go yet.

8/7/20 Update:

Today I had my next blood test, and a Fertility Associates nurse rang me early this afternoon to report my results. My hCG today was 1350, which is very encouraging given they said it should be doubling every 2-3 days at this point. They then checked the medications and supplements that I am taking, and organised to courier me some more Utrogestan. They sent through a referral to Pacific Radiology, and I have since arranged my 7-week scan for the end of the month. Until then, we're just crossing our fingers and taking it one day at a time.

Player Two Has Joined The Match

Last Thursday, my blood test results again came back showing that I was on schedule for embryo transfer. Yesterday we traveled to Christchurch in preparation for the appointment today. After finding that my bladder wasn't full enough last time to visualise everything properly on the ultrasound, I made sure I drank close to two litres of water over the course of the morning. By late morning when our appointment time arrived, I was very uncomfortable!

As before, on entering the clinic and being taken to a private room, I was asked to confirm my name, date of birth and address, before the nurse advised us that our remaining embryo had survived the thawing process and was ready to be transferred. They gave me all the paperwork and lab forms for aftercare and the next blood test I would need. I changed into a gown, and they led us back through to the theatre to the waiting nurse and specialist doctor. Dave was again seated on a chair just at my shoulder. This time, they had no trouble finding my bladder with the ultrasound, (if anything it was a little too big!), but they were able to visualise my cervix and uterus. Having a full bladder apparently helps move other organs such as your bowels out of the way, and flattens and straightens out your cervix and uterus into positions that are easier to see with the probe. They had no trouble inserting the speculum and threading the catheter through my cervix, and could see it on the ultrasound - the catheter shows up as a thin white line in the grey distortion. Again, this was a little uncomfortable, but not painful. When they were happy with the position, they indicated to a third nurse who handed them the embryo contained in a syringe from the lab. The embryo was then passed through the catheter and into my endometrium (uterine lining). The doctor waited a few moments before withdrawing the catheter, allowing the embryo time to 'settle'. The fluid from the syringe that contained the embryo could be seen as a small dark spot on the ultrasound. Once the embryologist double-checked the syringe to ensure the embryo had been transferred, we were set to go. We are hopeful that things going more smoothly this time is a good start.

Diagram showing ultrasound-guided embryo transfer.
From: https://www.youtube.com/watch?v=BSYkjZR4xmE

The next step is a blood test in just under a fortnight to see if this one takes. In the meantime, I am to continue taking the Progynova, Utrogestan, folic acid, and my probiotics. And on it goes.

Here we go again!

At the start of this week, I called Fertility Associates to notify them of day 1 of my cycle, and started taking the Progynova (estradiol) tablets again. After checking the usual details (Have I been consistently taking folic acid? Have I been well in myself? etc) the nurse entered my information into the system, and I waited for the embryologist to call me with a plan.

I'm back on the Progynova. Three times a day, every day.

The plan: the same as last time, more or less. I am to have a blood test late next week to check my body's response to the Progynova. This time they haven't requested a scan, most likely as last time they were happy that the results of my blood test were a good enough indicator of how thick my endometrium (uterine lining) is. All going well, two days later I'm to start the Utrogestan (progesterone) pessaries again. Then on the 25th of June we have an appointment in Christchurch to have the remaining embryo thawed and transferred into me. They have emailed me another set of consent forms (we must complete more for every cycle), a copy of the plan/timeline, and a request form for the blood test. Let's see how we go this time!

Maybe next time

At 8:00am this morning I had a blood test to check my levels of human chorionic gonadotrophin (hCG), which is the hormone produced by certain cells that surround a developing embryo. This is also what many home pregnancy test kits detect. At 4:20pm Fertility Associates called me (after I had already called and left a message since I hadn't yet heard anything) to say my hCG was less than 5mlU/ml, which is a negative result for pregnancy.

Table from Wikipedia showing reference ranges for hCG from last menstrual period (LMP)
https://en.wikipedia.org/wiki/Human_chorionic_gonadotropin#Testing

We are fine as we hadn't allowed ourselves to become particularly emotionally attached to anything yet. At this point, we're mostly feeling frustrated about the logistical side of things dragging out even further. The plus side is we still have one frozen unaffected embryo, and we can go back to Christchurch next cycle to try having that one implanted. In the meantime, I am to stop taking the Progynova and Utrogestan, and to call Fertility Associates on my next day 1. All going well, we could potentially have the remaining embryo implanted in a month or so. Onwards and upwards!

Implanted

Having travelled to Christchurch yesterday in preparation for our appointment, today we went to the Fertility Associates clinic. I was told to arrive with a full bladder, and was previously advised by the nurse that a good way to ensure this was to empty my bladder approximately one hour before my appointment, and then have two large glasses of water. A full bladder is easy to find via ultrasound, and helps position your uterus for viewing.

On arrival, the receptionist issued us each with a face mask (covid-19 level 2 precautions) and took us to the waiting area for the laboratory. After a couple of minutes the nurse called us through into a separate private room, went through the usual identity checks (full name, date of birth, address) and then gave us a run down on what we needed to know for the appointment, and for the days following. They said that of our two unaffected embryos, the five-day old one (the best one) had been thawed ready to be used. They also gave us a USB card with footage of the development of each of the two unaffected embryos from the TiMI (Time lapse Morphometry Imaging) incubator we used. They then gave us space for me to change into a gown, before we were taken through to the theatre whether another nurse and the specialist were waiting. One nurse was assisting the specialist, the other was on standby ready to pass the embryo from the lab, and Dave was seated next to me. They used an ultrasound probe (on my stomach this time) to try and visualise my bladder as a reference point, and then my uterus. Despite drinking water and feeling full, apparently my bladder was still so small it barely registered on the screen. They tried inserting the speculum, and tried threading the catheter through my cervix, which can sometimes help improve visibility and also help them 'feel' what they're doing. This felt a little uncomfortable, but not too bad. After a few minutes, the specialist decided they weren't confident enough they were in the right place, so they asked me to go back to the private room and drink some more water in the hope that a bigger bladder might improve visibility on the ultrasound.

The card given to us containing footage of our embryos. If you look closely, you can see embryonic development depicted on the card.

Around one litre of water and 10 minutes later, they took me back through to try again. My bladder was bigger, but my uterus still wasn't clearly visible, though the speculum and catheter showed up better on the ultrasound this time. The specialist explained that sometimes the position or the angle of the uterus can make it harder to see, or even some days it can be easier to see than others, depending on what your bowel and bladder are doing. They were satisfied that the catheter threaded through my cervix into the right place, and decided to implant the embryo 'by feel', which they explained was how they always used to do it before ultrasound technology was good enough to assist. They'd prefer to see via ultrasound as well, but it isn't imperative. The embryo was passed from the lab in a small (1ml) syringe that the specialist attached to the catheter, which was used to transfer and implant it into my endometrium (uterine lining). The nurse then double-checked the syringe to make sure the embryo had been transferred.

A stock photo of a blastocyst embyro similar to the one implanted in me today. For privacy reasons, we have decided not to post a picture of our actual embryos. You know, in case one of them is a person one day.

So now we wait. I am to have a blood test in approximately two weeks time to check to see if this implantation results in a pregnancy. In the meantime, I can go about my normal activities, though I will be making mindful choices about consuming pregnancy safe food and drink, just in case. Cautious optimism from here on.

T-minus 7 days and Counting...

On Thursday I had an early morning blood test and internal ultrasound to check whether my body was responding to the Progynova (estradiol) tablets that I am currently taking three times a day. The blood test measured my levels of LH (lutenising hormone) and progesterone to see if the levels in my body will help provide the right environment for an embryo transfer. The ultrasound examined and took measurements of my ovaries, cervix and endometrium (uterus lining).

At lunchtime, a nurse from Fertility Associates called and said my blood test results look good, and as of Thursday, my lining was 6mm thick, which is enough for the transfer to go ahead as planned next week (though I'm not sure what the reference range is). I'm to start taking the Utrogestan (progesterone) pessaries from Saturday, and continue the Progynova. I will also continue taking folic acid, and the oral probiotic supplement I have been taking aimed at supporting urogenital health through healthy flora (which I obviously cleared with my doctor prior to the start of my treatment cycle).

The current cocktail, since I'm off the booze.

We will drive to Christchurch next week for an appointment on Thursday to have one of our two frozen embryos thawed and implanted in to me. This is apparently very straightforward, and we should be in and out of the clinic in about half an hour. We are now at Covid-19 alert level 2, so Dave will be allowed into the clinic with me. Although this doesn't make as good a story as "Dad waited in the car outside while mum got pregnant", it does feel right to have both prospective parents in the same room at least when pregnancy hopefully begins.

Aaand we're back

At the start of this week, on April 28th 2020 New Zealand downgraded our Covid-19 alert from level 4 to level 3. This takes us out of complete lockdown, and allows more businesses to operate provided social distancing and appropriate non-contact measures can be taken. Fertility Associates sent an email and posted a general advisory on their website, which stated which treatments they are currently able to conduct. This includes manufactured embryo transfer cycles, which is the category that we fall into. 'Manufactured' refers to the process of using medications to generate an artificial menstrual cycle, ensuring my body provides the right environment for the transfer of embryos. I called to confirm our eligibility to continue treatment, and also to check this included permission to travel from Nelson to Christchurch. I was advised that we can go ahead, and that Fertility Associates are considered an essential service so we are permitted to travel there.

In preparation, I made an appointment and had my copper IUCD removed by my GP, since my previous appointment had to be cancelled as we started moving towards lockdown. I then called Fertility Associates on day 1 of my cycle, and after going over a checklist of questions with me, the nurse advised me to immediately start taking the Progynova (estradiol (E2)) tablets three times a day. I already had the prescription, but they will send another to make sure I have enough as I will need to be taking it for several weeks. As I mentioned in an earlier post, E2 is the main estrogen hormone usually released by developing follicles, and one of its purposes is growing the endometrium (uterine lining), which in this case will prepare my lining for the embryo implantation. 

The embryologist then called to go over the details of my plan for this cycle, which they emailed with a lab request form for a blood test, a letter declaring Fertility Associates to be an essential service (for when we travel), and a consent form for us to sign for this treatment cycle. I am to have a blood test and a scan (in Nelson) on May 14th to check how my body is responding to the Progynova. They will call with the results, but all going well, on May 16th I will start self-administering Utrogestan (progestone (P4)) vaginal pessaries. This is another hormone normally made by a follicle once it has secreted its egg, which maintains the endometrium so that the embryo can implant and cause a pregnancy. At this stage, the tentative date anticipated for embryo transfer at the Christchurch clinic is May 21st. Two weeks later I will have a blood test to see if the implantation has successfully resulted in pregnancy. 

Locked Down, but not Out

Since I've had a few people ask, I thought I'd let anyone wondering know that the next step in our IVF treatment will be postponed until the COVID-19 emergency is under control, and normal routines and services can resume. For those reading this overseas, as of 11:59pm tonight (Wednesday 25th March 2020) New Zealand is going into complete lockdown, with the exception only of essential services. For most people, this means remaining in their homes with the exception of trips to the supermarket/doctor/pharmacy if necessary, and we are allowed out to walk in our neighbourhoods for 'fresh air', provided we maintain social distancing from others of at least 2 metres.

Following the Prime Minister's announcement on Monday that we would be progressing to COVID-19 alert level 4: Lockdown within 48hours, a generic email was sent out from Fertility Associates. It provided a case-by-case list of what the plan would be for people depending on what stage of treatment they were at. As I have not yet started medications for my embryo transfer cycle, or been given a date for transfer, it will happen at a later time. We had figured over the last week or so that our cycle would likely be postponed, particularly since our next step, embryo implantion, would involve return travel from Nelson to Christchurch. We are feeling pretty relaxed about it, and feel fortunate that our cycle is at a good natural stopping point. As things stand, we have two healthy, unaffected embryos safely frozen, where they can stay for weeks, months, or even years if necessary. When society is able to return to normal, however long that takes, I can start the hormone medications in preparation and be implanted then. In the meantime, we will hunker down and wait this out with everyone else (from a socially distant proximity). I also figure now probably isn't the best time to get pregnant given the strain already placed on healthcare, and presumably maternity facilities will be extra busy in nine months time given the extra alone time many couples now have!

Stay safe out there everyone.

The Odds are Even

I had a missed call on my phone while I was at work yesterday, which I frustratingly didn’t see until after the Fertility Associates clinic would have been closed for the day. The specialist left a message saying they had our results (already!), and after some back and forth I was finally able to speak to them this afternoon. Of the four embryos biopsied, two were affected by the SCA3 gene, and two were unaffected. A textbook 50% transmission rate! We are super happy that we have two healthy, unaffected embryos so that we can have one implanted and one in reserve. It’s also great that the results were clear and that none came back inconclusive, as that could have required further testing and more agonising waiting. Both of the unaffected embryos were ones that were graded AB, so are also two of the higher quality embryos.

Autosomal dominant conditions like SCA3 mean each embryo has a 50% chance of inheriting the gene.

So within the next couple of weeks, I am to arrange with my GP to have my IUCD taken out some time before my next cycle starts. We will be using a ‘manufactured cycle’ to prepare my body for implantation, which means I will be taking more hormone medications to simulate what my body would be doing naturally had we conceived the conventional way. I am to call the clinic on my day 1, and they will advise me to start taking Progynova (estradiol (E2)) tablets. E2 is the main estrogen hormone usually released by developing follicles, and one of its purposes is growing the endometrium (uterine lining), which is what I’ll be taking it for. Fertility Associates will also make me an appointment for approximately 10 days later for a scan and blood test in Nelson to check my body’s response to the Progynova. They will also dispense Utrogestan (progestone (P4)) vaginal pessaries. This is another hormone normally made by a follicle once it has secreted its egg, and maintains the endometrium so that the embryo can implant and cause a pregnancy. An appointment will be made for approximately six days after the scan and blood test at the Christchurch clinic for an embryo to be implanted. Two weeks later I will have a blood test to see if the implantation has successfully resulted in pregnancy. From there, if I’m pregnant the risk factors will be roughly the same as a naturally conceived pregnancy, and so hopefully everything will progress normally from there. 

This is all starting to feel very real!

Four on Ice

On Wednesday, the embryologist from Fertility Associates called with an update on our embryos. To be eligible to be biopsied (sampled) for PGD, they need to develop to the blastocyst stage of development. This generally occurs around day 5 or 6 of development, at which point the embryo is comprised of approximately 200 cells. They said that of our nine embryos, one was developed enough to biopsy for PGD so far, and so had been biopsied and would be frozen that day. Four more embryos were looking promising for biopsy the following day. The remaining four weren’t looking as good, and while it is likely they wouldn’t continue to develop, they would continue to monitor them and make a decision regarding their viability the following day. On Thursday, three more embryos had been biopsied and frozen, and one more was still ‘trying’, so the embryologist said they’d give it until Friday to see if it too reached the blastocyst stage, and would call then to let us know.

Development of a blastocyst embryo

Today, the embryologist called to say the final embryo didn’t make the cut, which leaves us with four embryos in total biopsied and frozen, a great result. For each embryo, there is a 50/50 chance that they do not have the gene for SCA3, and will be suitable for implantation. We are cautiously optimistic that four embryos gives us a reasonable chance of one with a clear result. They sent the samples to the lab today for the genetic testing, and advised us that the results will take between 2-6 weeks. 

Further information
Blastocyst embryos are graded A-C according to their appearance and rate of development. They contain two groups of cells, one that develops into the foetus (the inner cell mass), and one that develops into the placenta (the trophectoderm). Embryos are given one grade for each of the two groups of cells. I asked how ours were graded, and three of them are graded AB, which is very good, and one is BC which isn’t as good, but embryos with that grade can still develop normally. The trophectoderm is the part which is sampled for PGD.

Diagram showing biopsy of the blastocyst's trophectoderm for PGD

Harvest

At 10:30pm on Wednesday night I gave myself the Ovidrel trigger injection as instructed. I worked out this was the last of 41 injections I have administered to myself in total (Ovidrel was the 41^st) in the 29 days between 22^nd January and 19^th February. When I woke up on Friday morning I drank lots of water up until two hours before the procedure (8:30am) when I had to go nil by mouth. The exception to this was the three paracetamol I was instructed to take with a sip of water one hour before egg collection. We reported to the laboratory at Fertility Associates just before 10am, and delivered the semen sample Dave needed to provide. The embryologist was actually the one who received the sample from us, and once Dave had completed the submission forms for the sample they took us straight into the day clinic and got us set up in a small room with a big chair in the centre. Here they went over all our paperwork, re-confirming my details and the medical history I had previously provided. I was then instructed to change into a hospital gown, and shortly afterwards a nurse came to take my observations (check blood pressure, heart rate and dissolved oxygen). My doctor then inserted a cannula into my hand ready to receive intravenous medication. They explained that I would be given a cocktail of midazolam and fentanyl for the procedure.

Once I was all set up, they showed us through to the theatre, where a team of six staff comprised of nurses, doctors and the embryologist were busy preparing. I was seated on a big chair with stirrups and surgical drapes were placed over my legs and abdomen. Dave was seated in a chair slightly behind and to my left, able to watch the procedure. I was given a nasal cannula providing oxygen, a dissolved oxygen monitor was placed on one hand and a blood pressure cuff on the opposite arm. They then injected the sedative medications into the port in my hand. The doctor used an internal ultrasound probe to guide a needle which was used to collect the eggs from my ovaries, which took around ten minutes in total. While I felt really light-headed and woozy, I was surprised to find that I was fully conscious for the whole procedure, and I think I can remember most of it. The medications obviously did their job though as I felt no pain or discomfort throughout the egg collection. I recovered really quickly from the sedation. They provide tea and toast before you leave to aid recovery, so after this and two glasses of water I was a little light-headed but ready to go after half an hour. After lunch, I just went about my day as normal and felt no further discomfort than the same slight bloating I’ve had for the last week.

Diagram showing how egg collection is carried out

When they were finished the team were really pleased to announce we had collected ten eggs in total, which is a great result! They will fertilise them in the laboratory later today using the ICSI method, where an individual sperm cell is injected into each egg (https://www.fertilityassociates.co.nz/media/1699/updated-fertility-facts-icsi-and-ssr.pdf). While this method is often used where sperm motility is an issue, in our case it helps ensure no additional sperm adhere to the outside of the egg or zygote (fertilised egg), which could confound the results of the genetic testing later. After discussion with our specialist we had previously decided to pay an additional $975 to use Time-Lapse Morphometry Imaging (TiMi). For this the embryos are placed in a special type of incubator that photographs them every 10 minutes as they develop (instead of removing them from the incubator to track progress), which can help embryologists detect which ones are developing most normally and identify the highest quality embryos (https://www.fertilityassociates.co.nz/about-us/latest-technologies/time-lapse-morphometry-imaging-timi/). This will hopefully help ensure we have as many embryos as possible reach the point where genetic testing can be carried out.

The lab will call us early tomorrow morning to let us know how many of the eggs have successfully fertilised. On Wednesday and Thursday next week they will call us to update us on how many embryos are developing well enough to be biopsied for PGD. On day five of growth they will then perform the biopsies on any suitable embryos and freeze them while we await the results of the genetic testing.

22/2/20 Update:

The lab called this morning, of the ten eggs collected, they were able to inject sperm into nine of them. And all nine have fertilised! They will develop them all to Wednesday/Thursday next week and call us each of those days to update us on how many are developing as they should. We are feeling cautiously optimistic. 

Thinking Fecund Thoughts

I managed to get my Puregon doses from the pharmacy in Nelson during the 9am-10am window on Sunday without incident. From Sunday/Monday I’ve been feeling a bit uncomfortable and bloaty in my abdomen – like I’m tight/full from eating too much but in a slightly different place. This is a common side effect from the ovary stimulating medications. Yesterday I headed down to Christchurch in time to collect my next Puregon dose from St George’s Hospital (they are associated with Fertility Associates but are open a little later). They only dispense as much medication as you need as they cannot accept returns due to them being refrigerated products, and they are very pricey. A Puregon 900 injection pen (contains 900 units, my dose was 300 units so three injections for me) costs $1035. While it has been quite stressful trying to make sure I had each dose in time, at ~$345 per dose I can see why they only dispense what you need, as you need it!

An image from my scan today. This is one view of one ovary. The dark, round objects clumped together to the centre left are follicles, each which should contain an egg.

First thing this morning I had another blood sample taken, and an appointment for a scan at Fertility Associates in Christchurch. My scan showed several follicles in each ovary that were measured and met the size criteria to have egg collection this week, as well as a few smaller ones. From what I could tell, ideal size is 18mm or larger in diameter, and a few of mine were at least 20mm, some around 18mm, and a few around the 13-14mm mark, although several overlapped each other so were a little difficult to get an accurate measurement. All in all, they seemed very happy with what they saw, and there were enough suitably-sized follicles to go ahead with collection this Friday. In preparation for this, a nurse dispensed to me the trigger injection Ovidrel, which contains human Chorionic Gonadotrophin (hCG) and is used to trigger ovulation. They talked me through how to use it – it’s another injection pen similar to the Puregon. It’s pre-loaded with the medication vial ready to use, all you need to do is dial it to the 250iu dose. They advised me that Fertility Associates would phone me this afternoon when they had received the results from my blood test to advise me when our appointment on Friday will be, and when to administer the Ovidrel – it needs to be 36 hours before egg collection. In the meantime, I do not need to inject any more Buserelin or Puregon. 

The tools of the trade. From top: case with Puregon injection pen with vial and needles, Buserelin vial with syringe/needle, Ovidrel injection pen.

The nurse called at 3:30pm, and advised that I need to have my Ovidrel injection at 10:30pm sharp tonight, in preparation for egg collection at 10:30am Friday. I am not allowed to eat anything for six hours before the procedure, and can drink clear fluids for up until two hours prior. I am also instructed to take three paracetamol one hour before the appointment, and Dave must provide a fresh semen sample for the appointment on Friday too. Interestingly, we are not allowed to wear perfume or anything overly strong-scented (though deodorant is ok as long as not too strong) as the eggs and embryos are very sensitive to chemicals and strong odours.

In the meantime, I'll just keep thinking fecund thoughts as we hope for a successful collection procedure yielding a good number of healthy eggs on Friday.

Our First Rollercoaster

It’s been a bit of an odd week. On Wednesday I had a blood test as scheduled to check my body’s response to starting the Puregon (FSH) injections the Friday before. I had my blood drawn first thing in the morning as instructed, and a Fertility Associates nurse called me just after 2pm that day. They let me know that my blood test suggested my ovaries weren’t really responding to the FSH injections, as my oestradiol level was only at 189, and they would hope it would be in the late hundreds or early thousands at this point. They said it’s looking likely that we wouldn’t achieve egg collection this time as the blood test indicated that I wasn’t producing or maturing any or many follicles, and we might need to try again with a different medication regime. She double-checked that I was administering the medications correctly (I was) and said to continue with the same doses and they would refer me for a scan and another blood test on Friday to see if anything had changed. Apparently, sometimes it can take the ovaries a little longer to respond to the FSH injections for patients on what they refer to as the ‘long cycle’, which is IVF treatment cycles like the one I’m on where they start with the Levlen (or equivalent) pill for several weeks before a few weeks of Buserelin.

We felt a bit deflated and disappointed, but not devastated. The injections haven’t been too taxing on me as I don’t mind self-administering them and I haven’t experienced any side-effects so far except for bruising on my poor stomach. This wouldn’t count as one of our two funded IVF cycles, as a cycle is only considered complete once an embryo has been implanted (unless they have to call the whole thing off for medical reasons). It was frustrating, but we started coming to terms with trying again next time.

A stock photo showing a follicle in an ovary. (I'll try to get photos of mine next time)

I had my blood test done Friday morning as instructed and had my scan (internal ultrasound) done later that morning. The technician measured my ovaries, and then measured and counted any follicles they found in each ovary. They found 3 larger follicles that they said ‘met the criteria’ in one ovary, plus several smaller, less developed ones. There was another larger follicle and a few small ones in the other ovary. The technician couldn’t tell me what this might mean for my treatment, so I had another long afternoon waiting to find out.

My stomach after 30-odd injections over the last few weeks (it doesn't feel as bad as it looks).

Finally a nurse from Fertility Associates called later Friday afternoon. They wanted to give my follicles a little more time to develop and wanted me to keep giving myself the injections. I am to travel to Christchurch in time for a blood test and scan there first thing Wednesday morning next week, with a view to egg collection on the Friday. We are relieved to hopefully still be on track after all. 

To add to the excitement, the pharmacy that Fertility Associates sent my Puregon prescription to (I need more to get through to the appointments and MUST inject it daily) is closed over the weekend. In desperation I approached a neighbouring pharmacy, which while they didn’t stock Puregon were able to tell me the other one is open for one hour 9:00am-10:00am on Sunday as a methadone clinic. The pharmacist even knew someone who worked there and was kind enough to call them for me and confirm that I’d be able to collect my prescription during that window.

It’s going to be a busy week.