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.