PREPARING FOR ASSISTED reproductive technology (ART) can be mind-boggling. The appointments, medications, and ultrasounds are enough to make anyone feel inept. Couples who elect ART may experience a range of feelings that lie anywhere between optimistic and apprehensive.
Putting Your Money Where Your Heart Is
Cesar and I had quite a lot saved, and we knew we could either have a life—because the fertility treatments put our life on hold emotionally and financially—or we could try again. We discussed how we needed a new home, a new car, and even an extended vacation, but in the end we listened to our hearts. We tried again.
—Christine, 32, human resources specialist
It’s not uncommon to find yourself torn between feeling hopeful on one hand and tentative on the other. Why? It’s hard to postpone buying that home, car, or going on that dream vacation just so you can pay for something that might not happen, especially when it should happen naturally for free. This $8,000-plus wager is enough to give seasoned gamblers sweaty palms.
To combat any prepurchase indecision, take a moment to consider that everything in life is a gamble: from choosing your career to choosing your spouse to walking out your front door. But the good news is that in vitro fertilization (IVF) technology has contributed to the births of over 5 million babies worldwide. Since its inception researchers have significantly reduced the number of couples who don’t achieve pregnancy. As parents of IVF children, we can’t think of any reason not to try.
ART is the ultimate weapon available to your doctor to defeat your infertility. It refers to any fertility treatment that involves direct manipulation of sperm and egg. Simply put, ART involves surgically removing your eggs from your ovaries, combining them with your partner’s (or donor’s) sperm in the laboratory, and returning them to your body.
There are three types of ART: in vitro fertilization (IVF), zygote intrafallopian transfer (ZIFT), and gamete intrafallopian transfer (GIFT). IVF is the most common and represents 99 percent of all ART cycles. If you’ve had a hard time finding fertility centers that offer ZIFT or GIFT, you’re not alone. Both of these treatments have fallen out of favor at most centers and account for less than 1 percent of all ART cycles. Many centers do not even offer them at all. Both are identical to IVF except for a few distinctions: what your RE puts into your body, when he puts it in, and where he puts it.
Table 8.1. Summary of steps for ZIFT and GIFT
Most of us would like to think that our reproduction rests in our own hands, which is why starting with a noninvasive procedure is often our first choice. But reality can intrude to let us know that it doesn’t. Sadly, sometimes two pairs of hands are not enough. This is when you need an option that can dramatically increase your odds.
IVF is precise and can bypass nearly every fertility issue you and your partner face. Used correctly, you can control how many babies you have by limiting the embryos you implant. This means that if twins are all you can handle, ask your RE to put in two embryos. As we mentioned on page 123, there is a chance that one of your embryos could split, leaving you with three. This is rare, but it’s a scenario you need to discuss with your partner before deciding how many is too many.
In IVF you undergo ovulation induction (see chapter 7), but in this case your RE surgically removes (aspirates) all the eggs your body has produced. An embryologist then combines these eggs with your partner’s sperm to produce fertilized eggs. These zygotes grow in the lab three to five days before your RE transfers them into your uterus. If all goes well, one embryo implants in your uterus and you’ll be pregnant.
When you meet with your RE to begin IVF he’ll likely give you a calendar highlighting all the medications, ultrasounds, blood tests, dates, and times for your cycle. This is your protocol, and it will be your bible for the next two months. Read it carefully, and make sure you follow it. If you have any questions that this book doesn’t answer, ask your doctor or his staff. Deviations from your protocol can destroy your cycle and waste your time, money, and stomach lining as a result of anxiety.
Jennifer’s protocol is included here and is a good example of the standard “long protocol” that some doctors call “long Lupron.” This is the most common type of protocol because it’s highly effective. Your protocol will differ only in that your doctor will tailor it specifically for your situation, but Jennifer’s is close to what you’ll normally see.
Figure 8.1. Jennifer’s protocol: A sample IVF calendar
The first step for IVF may leave you baffled. It’s natural to question your doctor’s judgment when he prescribes you birth control pills when you’re trying to get pregnant. After all, this is contrary to everything you’ve ever learned about trying to have a baby. But don’t put too much stock in this. What he may not tell you is that taking “the pill” weeks before your cycle helps you produce quality eggs and reduces your chance of developing ovarian cysts. All of this is important when you’re trying to have a baby. The pill also resets your cycle to a specific schedule, and this is important so medications your RE prescribes are then able take control of your reproductive processes for a short time.
No Question Is Dumb
Pay close attention to everything your doctor and his staff say. They say the same thing to couples all day long, so they might “gloss over” something. Ask as many questions as you need to, and if anyone seems insensitive or suggests your question is stupid, let the doctor or a senior staff member know. Mark and I did. This stuff is serious!
—Natalie, 38, real estate investor
Twelve to 21 days after you start the pill, you’re ready to begin the ovulation induction phase of IVF (see chapter 7). I started with daily Lupron injections. Your RE may also ask you and your partner to take a broad-spectrum antibiotic to kill any unwanted infections before they damage your cycle. Baby aspirin may enhance uterine blood flow and helps aid embryo implantation (but that’s not why we call it baby aspirin). And prenatal vitamins ensure that your body (and, ultimately, your baby) is getting proper nutrients. Be sure your prenatal vitamin includes folic acid, which reduces chances of spina bifida and other birth defects.
Ask for Prenatal Vitamins with Docusate Sodium
Besides folic acid, make sure your prenatal vitamin contains docusate sodium. This is a stool softener, and it will come in handy once you’re pregnant. High levels of hormones soaring through your body cause constipation, and iron in your vitamin makes this problem only worse. But docusate sodium, along with plenty of water and high-fiber foods like whole grains, beans, vegetables, and fruits, will counter your body’s tendency to slow the transit of food.
A few days after your menstrual period ends you’ll visit your RE for the first of many ultrasounds and blood tests. During this first visit your RE will do an ultrasound to look for ovarian cysts that might grow large once he stimulates your ovaries. If he finds one, he’ll likely adjust your protocol and instruct you to continue Lupron a bit longer. He’ll also check your estradiol blood level. This first test is to get a baseline for future tests. If you recall in chapter 7, we discussed that as your follicles develop, they produce estrogen. So the more estrogen (estradiol) in your blood, the more follicles you have growing inside you. With each subsequent test your RE will ensure that your estradiol level grows.
Prepare yourself for plenty of vaginal ultrasounds. There may be an occasion when you feel mild discomfort, but overall they’re relatively painless. Your RE will insert a specialized probe into your vagina. The probe emits high-frequency sound waves (well beyond our ability to hear or feel) and then receives them back as they reflect off tissues in your body. The result displays on a small computer screen as a video image. Your doctor can then see what’s happening with your ovaries, follicles, and, ultimately, (hopefully) your embryos.
Table 8.2. Other possible protocols
Although you probably never had your partner visit the OB/GYN with you, it’s helpful to have him come with you for as many of these appointments as possible. He’ll feel more involved in the process and will better understand what you’re going through. If you remove the mystery surrounding your doctor visits, you’ll both feel like you’re truly sharing this experience.
Assuming all is normal with your ultrasound and blood test, you’ll reduce your Lupron dose and start gonadotropins to prep your ovaries to work overtime. In Jennifer’s case it was Gonal-F and Repronex. Four or five days later you’ll return to his office for another ultrasound and blood test. This time your RE will ensure that your follicles are growing and will count how many he sees. Ask him to show you. Here is an example of what you might see:
Figure 8.2. Follicular ultrasound
When Jennifer saw this image, she saw a bear. Adam saw ET. But Dr. Potter saw follicles—a good example of one is the large circle in the center above the bright white patch.
About three days later you’ll be back for another round of tests. If he sees promising follicle development, then all is well. But if your follicles are not developing (or there are too many), he may change your gonadotropin dosage. This is one reason why most clinics suggest you administer your shots in the evening. If your dosage changes, you can easily adjust it at the next scheduled time; otherwise, you’ll have to wait an extra day.
If he hasn’t done one already, your RE will probably use this visit to perform a mock transfer. Guided by abdominal ultrasound, he’ll insert a small catheter through your vagina into your uterus. He’ll measure the depth of your uterus and note its position (tilted, straight, etc). This way, when the actual embryo transfer comes around, he’ll have all the information he needs to put the embryos right where he wants them. You might have some minor cramping, but otherwise this procedure is painless.
IVF as a Team Sport
You’ve got to go into this as a team. There will come a time when you don’t feel like giving the next shot. You’re tired of appointments. You’re tired of lab coats. You’re tired of the protocol. You’ve got to go into this 100 percent as a couple, and you need to realize that there’s going to be more times than not that your wife needs your support. I know Christine did, and she plows through everything without help.
—Cesar, 42, marketing director
During this visit your RE will review instructions for your retrieval and transfer. This is when you need to make sure you follow his advice to the letter. One thing he’ll certainly discuss with you is your hCG injection. This is key, as hCG is an artificial LH surge that causes your eggs to release into the follicular fluid. It’s sold as either a urinary preparation (Noverel, Pregnyl, hCG) or recombinant form (Ovidrel).
Based on your retrieval date, your doctor will give you a precise time (approximately 35 hours before) to administer your hCG shot. It may be—and often is—in the middle of the night. If so, set your alarm. Don’t miss this time, because if you do, you’ll ruin your entire cycle. Your RE is counting on your cooperation, so he’ll find your eggs waiting peacefully in your follicles. If your shot is too early, all your eggs will release before your retrieval.
The same day you get your hCG shot you may start Medrol, a steroid that temporarily suppresses your immune system and may help facilitate embryo implantation. Medrol comes in a “dosepak” with 21 pills in it: six for the first day, five for the second, and so on. Be sure to follow your RE’s advice closely to know how to take this steroid. He’ll also prescribe an antibiotic to prevent you from getting an infection during the retrieval.
While ovulation induction has only four distinct phases (see pages 128–129), your IVF journey adds three more. You should familiarize yourself with the medications your RE prescribes during each.
Figure 8.3. Key for full medication table
Table 8.3. Phase V: Egg retrieval Protects you during retrieval and prepares your uterus
Table 8.4. Phase VI: Implantation Stops ovulation to improve follicle development
Table 8.5. Phase VII: Pregnancy Stops ovulation to improve follicle development
Illustrator: Adam Hanin
It’s time. More than likely you and your partner got up before dawn (the anticipation that got you to this point probably made for a restless night’s sleep), and have made it to your RE’s office early. Both of you are ready. And that’s the mindset you need to have at this stage. You’ve had all the shots, taken all the medications, and managed through all the ultrasounds and blood tests. Now it’s finally time for results.
First, you both have to part with some of your gametes. Your egg retrieval is the main attraction for the day, but your partner is the opening act; he has to provide sperm that will ultimately fertilize your eggs. This process can be difficult for him, because there’s a lot of pressure riding on his sample. To help deliver the best sample possible, he should ejaculate and then abstain for two days, otherwise his sample will have too many dead sperm.
Most centers make it easy for him in a number of ways. They’ll provide him with a comfortable, private room. They’ll also provide racy magazines and videos to view while he’s producing his sample. And they’ll often allow you to join him. This is a good time for you to participate, as this is the only opportunity you’ll have for some semblance of lovemaking in this clinical form of conception. (Besides, do you really want your guy looking at some other hot chick when he’s fathering your child?) But keep in mind that you should not have any contact with his penis other than with your hands. We’ll let you imagine what you might be able to do to help.
Figure 8.4. Sperm after collection
And speaking of hands, he (and you, if you’re in the room) needs to wash his hands thoroughly with antibacterial soap. Just a small amount of bacteria can compromise his sperm sample. Typically, he’ll deposit the sample in a tiny cup (every drop counts), put a cover on it, and label it with his name. Then, after another hand washing, his contribution is complete.
Egg retrieval is a minor outpatient surgery. But there are things you need to be aware of. You should not eat anything after midnight the night before. And if you talk to any of the other couples fidgeting in the waiting room that morning, you’ll learn you’re not alone; most clinics do all their retrievals and transfers during specific weeks to make it easier on staff.
When it’s your turn a nurse will call your name. Once they give you the go-ahead, an anesthesiologist will give you a light sedation. Then your RE will use a long ultrasound-guided needle and insert it through your vaginal wall into your ovaries. The ultrasound helps him find each follicle, and he’ll use the needle to remove each mature egg and the follicular fluid around it. This procedure usually takes less than ten minutes from start to finish.
Figure 8.5. Egg after retrieval
In general your RE hopes to retrieve at least ten to twelve mature eggs. This is because IVF is ultimately a numbers game. From ten eggs, possibly eight will fertilize. Of those, maybe only five will grow to blastocysts. Of those five, embryologists may rate only two of them as top quality. And of those two, hopefully one will implant.
Once you’re awake and your head is clear from sedation, you’ll be free to go home as long as your partner or someone responsible is driving. Some women might find it difficult or painful to walk afterward, so take it easy on your way out. In fact, you should take it easy for the next day or so. You should also note any possible complications and notify your doctor immediately if you have significant bleeding or cramping. A small amount of bleeding, including pink-tinged urine, is normal.
Now, while you anticipate the transfer a few days away, the lab starts their most important job: making your baby.
FERTILIZATION: CREATING AN EMBRYO
Embryologists in your RE’s lab will waste no time getting to work on your eggs. They’ll carefully wash and grade each egg based on the embryologist’s opinion of its maturity and quality. Egg quality is not as important as embryo quality (unless you’re freezing eggs; see page 220), and some pretty poor-looking eggs have produced some beautiful children, but it does help if your RE identifies which ones are likely to produce healthier embryos.
Next an embryologist places your eggs in a Petri dish that they have already filled with a special culture medium to keep your eggs healthy. This medium provides nutrients for your eggs (and, ultimately, your embryos) so they will thrive for several days until your RE transfers them back into your uterus. Only in the past few years have embryologists produced media that allow embryos to thrive for five days—long enough to perform PGD (see chapter 13) and to grow to more mature stages before transfer. Day-five embryos have a much better implantation rate, but fewer embryos make it to day five.
While this is all happening, another embryologist is likely working with your partner’s sperm sample. Like IUI, she’ll wash the sperm and put it through a centrifuge to spin out a concentrated mass of the strongest swimmers. She then takes a drop (which will contain 50,000 to 100,000 sperm) and places it with each egg (although not always—we’ll discuss ICSI in a moment). Finally, she places all the dishes in a special incubator set to body temperature and leaves sperm to do their job.
If all goes well, in about 18 hours most will be zygotes—the first stage of embryo development. From here they’ll begin dividing. So by day three, when embryologists remove the Petri dishes, they’ll find a host of six- to eight-cell embryos. If these embryos continue to divide until day five, they’ll be blastocysts, with as many as 100 cells each.
Figure 8.6. Stages of an egg after fertilization
Embryos grow in nutrient medium for three to five days. During this time an embryologist will move your embryos to new culture medium once or twice and, depending on the lab and their requirements, will evaluate them under a microscope to document their development. The rest of the time your embryos sit in an incubator and grow.
Right around this time you’re probably wondering about security. Well, don’t. Security in IVF labs is very high. Labs are typically under a separate lock and key from the main facility. Often they’ll have security cameras and digital key-card access. And only on-site embryologists have access. Every container has a label on it. Most centers use a combination of color codes, numbering systems, names, conception dates, and storage locations. Everything you or your partner or your donor provides for the lab (eggs, sperm, embryos) is clearly labeled as yours. Generally, before any procedure, at least two embryologists sign off that they’re using the correct samples or embryos.
Your RE’s lab has to manage great challenges. Because they do not have direct contact with you, they have to trust the office staff to provide them with accurate information. They need to know that Mr. X’s sperm goes with Mrs. Y’s egg. They can’t watch a man provide a sample to ensure he labels it properly. And they can’t suddenly shut down when there are ongoing cycles. Their work is detailed, microscopic, and meticulous. Their science is still developing. And yet error occurrence in IVF labs is infinitesimally small. So if you have a chance to thank the talented men and women in your RE’s lab, do so. They’re the hidden heroes of your IVF cycle.
ICSI: REVERSING MALE-FACTOR INFERTILITY
Sometimes sperm does not penetrate an egg. This can happen if your partner has low sperm count or sluggish (poor motility) or irregularly shaped sperm (poor morphology) or sometimes because your eggs have a thick “zona” (mucous layer around them). In each case intracytoplasmic sperm injection (ICSI) solves the problem.
With ICSI, instead of placing a drop of concentrated sperm on each egg, an embryologist performs a much more delicate procedure. Under a microscope, he positions a thin glass straw (pipette) on one side of your egg to hold it still. Using a microfine needle, he collects a single sperm. Then, very carefully, he injects your partner’s sperm through your egg’s zona into the cytoplasm from the opposite side of the pipette.
Figure 8.7. Egg after ICSI
Now think about what you already know about eggs and sperm. Your eggs, though the largest cells in your body when mature, are still barely visible to the naked eye. And one drop of semen can have a million sperm cells in it—they’re the smallest cell in the human body. Consider the precision required for an embryologist to inject one immensely tiny cell into another tiny cell if your doctor recommends ICSI. Knowing this will help you understand why most clinics offering ICSI tag on an extra $1,000 to $2,000 per cycle.
ICSI reverses most male-factor infertility issues (see chapter 3). So it’s likely that 50 percent of all IVF cases will ultimately involve ICSI. And many clinics incorporate ICSI into all cycles. Although this may ensure fertilization of every egg, it also adds extra cost to some who may not need it.
ASSISTED HATCHING: CRACKING THE SHELL
The zona pellucida, or mucous layer, surrounding your egg hardens the moment your partner’s sperm fertilizes your egg so no other sperm can enter. As your embryo develops, the zona surrounds and protects it during its three-day journey down your fallopian tube. Once it reaches your uterus, the embryo has to hatch, much like a chick hatches from a hen’s egg. If it doesn’t, it can’t lodge in your uterine wall and implant itself there for the next nine months. A dislodged embryo would flush out of your body with your menstrual flow, and you would never know it was once growing inside you.
Enzymes in your reproductive tract help dissolve the shell-like zona as the embryo passes through. But these enzymes aren’t present in the culture media that your embryos grow in. Assisted hatching fills the gap (although technically, it creates the gap).
With assisted hatching, an embryologist makes a small hole in the shell so that your embryo can break free. The opening is not wide enough for the embryo to exit, but once in the uterus, uterine enzymes enlarge the hole. An embryologist makes this hole in one of three ways. He may make a small tear with a micropipette, use acid to eat away a small portion, or use a specialized laser to drill a precise hole. Whatever method he uses, he must be exact; a hole too narrow or too large will invariably make implantation fail.
Figures 8.8 and 8.9. Before and after assisted hatching
So far there is no evidence of significant risks from assisted hatching as long as the embryologist performs it properly. Some believe that assisted hatching can traumatize the embryo’s cells and force them to separate during division, thus creating identical twins. Although some studies show an increased risk of this, others show none. Your best bet is to ask your RE about his results.
Your entire cycle has led up this day. It’s perfectly understandable if you didn’t sleep well the night before. After all, you’ve gone through lots of appointments, shots, ultrasounds, money, and stress, and it all rides on how things go today. As John Gray (Men Are from Mars, Women Are from Venus) writes, “A women under stress is not immediately concerned with finding solutions to her problems but rather seeks relief by expressing herself and being understood.” Make sure you share your thoughts and worries with your partner. He’s in this as much as you are.
On your big day you’ll likely see the same people in the waiting room that you saw on your retrieval day, and you can bet they’ll be going through the same feelings you are: a mixture of anticipation, excitement, fear, and uncertainty. You might find that talking with them while you’re waiting helps free some of your butterflies; after all, it’s comforting to know you’re not alone.
This time your doctor will probably allow your partner in the room. You’ll want him there to hold your hand and share the excitement with you. You’ll also need him there because the first step involves a joint decision.
While you’re waiting, an embryologist is busy preparing your embryos for review. She’ll line them all up under a microscope and take a photograph. Then she’ll note how many cells are in each embryo and will assign a grade to each one to predict the likelihood of implanting and growing in your uterus. Different centers use different methods for grading. Some use number grades, some use letter grades, and some use percentages. But all grades use the same basic evaluations: number of cells, symmetry, size, texture/granularity, and fragmentation.
The more cells in the embryo, the further it has developed on its own. As an embryo passes each cell division milestone, it has a greater chance of surviving in your uterus. Symmetry refers to how even and round each of the cells are. An embryo with equally sized, perfectly round cells looks healthier and should have a better chance of success. Texture/granularity describes how the cells look—their membranes, cytoplasm, and so on. Fragmentation refers to little pieces of extra “stuff” in the embryo. In this case the less stuff, the better.
Most clinics transfer embryos on day three. Some transfer on day five. Some do both. Day-three embryos are really still dividing eggs; there is little unique information an embryologist can gather from looking at these embryos other than their grading factors. By day five, however, unique features begin to emerge that can help embryologists determine health and success potential for each blastocyst. So picking the best day-three embryos is like picking the winner of a marathon at the eighteen-mile mark. But getting embryos to survive in culture medium for an extra two days requires considerable skill and expertise. Many don’t make it. This is why day-three transfers are still the overwhelming favorite. There are also more embryos available to transfer at day three. But at day five, blastocysts that have survived will likely continue to grow.
The next time you see your RE, he’ll likely give you your “family photo.” Keep it in a safe place. This is a once-in-a-lifetime photo of your potential brood, so treasure it. After our transfer Adam and I sent copies to our parents, who framed them and looked at them every day to give us positive thoughts. We’ve provided a copy of our photo to help illustrate the process.
Figure 8.10. Jennifer and Adam’s “family photo”
Your RE will tell you how many eggs he retrieved, how many fertilized, and how many survived to your transfer day. He’ll discuss egg grading with you and help you decide how many and which embryos to transfer. You can see from our photo that we had nine embryos (out of fourteen eggs). Of these we had two embryos rated a 4 (the highest rating) with eight cells, three rated a 3 with eight cells, one rated a 3 with seven cells, one rated a 3 with six cells, one rated a 2/3 with 8 cells, and one rated a 2 with six cells.
We were lucky to have two top-rated embryos. Some couples won’t have any. But don’t worry too much about ratings. They’re guidelines and are fairly subjective. Besides, there are plenty of perfectly fine children in the world who, if under a microscope as an embryo, would have received a poor rating. Use the ratings only to help you select which ones to transfer. Once you’re pregnant, embryo ratings don’t matter.
With Dr. Potter’s insight, we took an aggressive route and transferred four embryos. We elected to freeze the remaining ones for future use (more on cryopreservation in a moment). You’ll need to consider a number of issues when you select how many embryos you’d like your doctor to implant: your age, results from previous IVF attempts, and your tolerance for potential multiple births. Your RE will consult with you, but ultimately it’s your decision. Some labs (and some countries) limit the number of embryos you can transfer, so familiarize yourself with these limits to avoid disappointment on transfer day.
Once you and your partner have selected the embryos you want your RE to transfer, you’re ready to begin. You’ll disrobe, and then you’ll need to try to get comfortable on the examination table. The doctor will have you put your feet in stirrups. At some point a nurse or embryologist will bring in a tray with a catheter and your embryos in a tiny syringe. If you ask, your doctor will show them to you—if you try hard, you might be able to see them.
Your RE will then insert a speculum into your vagina and clear away excess cervical mucous. Then, as she did during the mock transfer, she’ll insert the catheter through your vagina, past the cervix, and into your uterus. Using ultrasound, she’ll position the catheter end so it exits at the most advantageous location for the embryo. This part of the process is where ART really is art. The doctor’s experience is crucial because this is what she relies on to judge what has been most successful for patients like you.
Now, very carefully, she’ll inject the embryos through the catheter into your uterus. She (and you, if you’re watching) will be able to see them leave the tube and enter your womb. But while you might see the transfer occur, you won’t feel it—embryos are still so small that you’ll likely have no sensation of anything happening. The doctor will then remove the catheter and turn it over to an embryologist, who will examine it to ensure all embryos are inside you and not stuck to the catheter walls. If any did not make it the first time, the doctor will repeat the transfer with the stragglers.
That’s it. Your transfer is over, and your potential future baby is now inside you. The doctor will ask you to rest on your back for about 30 minutes. Sometimes she’ll allow you to stay longer, and we’d recommend that. From this point on, for at least the next three days, you should be on your back as much as possible. Why? Gravity. The more you stand and walk around, the easier it is for the embryos to flow out of your uterus and be lost.
Does Bed Rest Really Make a Difference?
Although bed rest after an embryo transfer is the standard recommendation at reputable fertility centers, empirical data has yet to prove its usefulness.
Plenty of people have heard the saying that a woman needs beauty rest to look her best. Well, after your embryo transfer you need baby rest to have your best. This is when your embryos attach to your uterine wall, so your doctor will expect you to stay on strict bed rest for at least 72 hours. This means no showers until you’re off bed rest. If this sounds gross, it’s time to pretend you’re camping. You can rest on your back, side or stomach as long as you remain in a horizontal position. Most REs allow you to have up to two pillows under your head and prefer that you elevate your feet.
Some women dread this downtime. But why not make the best of the next three days? Think of all you wanted to do during the last year but haven’t had time for. Obviously, bungee jumping and parasailing are out. But what about that novel that you’ve wanted to read or those movies you’ve had to skip? Or what about that journal you’ve wanted to start? Or if your partner is around, why not play your favorite card games? Any of these activities are permissible if you play by the following rules.
• Stay in bed with your feet elevated.
• Use no more than two pillows under your head.
• Sit up for meals only.
• Walk only to and from the bathroom.
• Avoid douching and sexual intercourse.
• Insert only prescribed vaginal suppositories into your vagina.
• Do not shower.
• Do not stop taking your fertility medications.
This is how your scenario is likely to play out after your transfer. Once the nurse releases you with aftercare instructions (which you’ll want to read in case your RE has other stipulations he wants you to follow), your partner (or someone reliable, if he’s not available) will help you into the car and lower your seat so that it’s flat as possible. You may even want to select your favorite CDs ahead of time so you can hear something soothing instead of tunes that make you want to break into song and dance.
Because embryo attachment is a delicate process, caution your partner not to hit the gas over any speed bumps or make any sharp turns. When you get home, he should help you upstairs (if needed) and escort you directly to bed. Many REs shoot for transfers on Fridays and Saturdays so your partner can be around for a couple of days to take care of you.
It’s a good idea for your partner to take a day or two off on top of that so he can share this experience with you. His job for the next few days is to be your nurse, chef, companion, and entertainment committee rolled into one. He needs to provide you with your prescribed medications, nutritious meals, snacks, plenty of TLC, fluids like water and juice, and diversions like books, DVDs, or games. Remember, your sole job is to stay off your feet.
Spotting or Cramping
Don’t become alarmed if you see clear or pinkish fluid in your panties (or urine) after your transfer. This is normal. You also may experience spotting or cramping afterward from the instruments your doctor used. Use Tylenol as needed for pain, but avoid any product containing Ibuprofen.
Your RE will request that you continue your medications according to your instructions. Keep taking whatever he prescribed until your pregnancy test (you’ll likely take these through the first trimester if your pregnancy test is positive). If you’re running low on medication, notify your pharmacy or RE in advance so they can refill it before you run out. This is important if you’re using a pharmacy that delivers so they have enough time to ship your refills.
Most REs allow you to use stairs once daily if you must change rooms but would prefer that you stay put for 72 hours. Keep in mind that the more you walk, the more you risk dislodging your embryos. The best way to approach this is to plan what bedroom you’re using ahead of time and stay there. It helps to use one with an attached bathroom or at least a nearby half bath.
If your partner must be away for the day, have him leave everything you need within arm’s reach. He can place anything that needs refrigeration in a small ice chest. If he plans to be away on an extended trip, make arrangements in advance for a responsible family member or friend to help.
You get the point. The more you stay off your feet, the better. Most REs will allow you to resume light activity 72 hours after your procedure, but if you’re like Jennifer, you might give it one more day for good measure. But no matter what, your RE will want you on restricted activity for the next four days (96 hours), prefer that you stay home the week after your transfer, and insist that you avoid strenuous activities for two weeks. Exercises like walking or swimming are ideal after that.
Once two weeks rolls around you’ll finally see your RE and get the news you’ve been waiting for: your test results! Many women can’t wait the entire two weeks without knowing, so they enlist the help of an in-home pregnancy test. Keep in mind that these tests are not as accurate as blood tests and may give you a false negative or positive. So it’s important that you visit your RE for a blood test. If bleeding occurs, you should notify your doctor immediately, but you’ll still want to visit her office for the test. More than likely your RE will have prescheduled the date (see your aftercare instructions) and may instruct you to call her office for a specific time. Most REs (or their nurse) will call with results that afternoon, so you might want to make a point of staying near a phone.
Waiting for the Call
It was a long day, but when they called and said my name, I could tell from the tone it was positive. From then on, every day was a new day.
—Claudia, 35, teacher
Sometimes your body lets you know you’re pregnant. In my case we were driving to Monterey Bay for a weekend of whale watching when my body threw me a few curve balls. Adam and I were listening to The Bell Jar, but I fell asleep at least four times during our seven-hour drive. At first we dismissed this as a sign that our audiobook was a bit slow. But by the time we arrived at the Monterey Bay Aquarium I craved protein. This craving, my bouts of exhaustion, and the fact that my stomach wasn’t cooperating let me know that I was probably pregnant.
Here’s a list of common early pregnancy signs you may experience.
• missed period
• nausea
• food cravings
• tender, swollen breasts
• darkening of the areola (area around your nipple)
• swelling
• fatigue
• constipation
• frequent urination
This is not to say that every woman will have signs and symptoms of early pregnancy. Some will have all of these signs and not be pregnant while others will have no signs and find that they are indeed pregnant.
Orgasms during Childbirth?
This may sound like a joke, but it’s not. A study conducted by French psychologist Thierry Postel confirmed in the journal of Sexologies that it’s entirely possible for a woman to orgasm while her baby sojourns though the birth canal. Postel surveyed 956 French midwives, and received 109 completed surveys from midwives who assisted 206,000 births. Of those surveyed, the midwives reported 668 cases where mothers felt orgasmic sensations while giving birth, 868 experienced signs of pleasure, and 9 mothers confirmed they experienced full-blown orgasms. As one mother surveyed put it, “When was the last time you had an orgasm with an eight-pound, 20-inch penis?”
Finding out your pregnancy test is negative can be devastating. The effort and discipline it takes to march through an IVF cycle is exhausting. Add this news to your hopes of becoming parents, and the letdown is huge. One of the most difficult aspects of IVF is not knowing whether your cycle will work, when it will work, and what you or your RE can do differently to make it work.
About two-thirds of couples who undergo fertility treatments become parents. This means you have every reason to believe that trying another cycle or two may do the trick. Ask your RE about prescreening tests like PGS and PGD found in chapter 9. But only you can know when you’ve had enough. You’ll want to consider freezing any high-quality eggs or embryos for a future cycle (see chapter 12). As long as your outlook is positive and seeking treatment is not jeopardizing your health or your relationships, there is no reason not to try again. If you catch yourself spending more time thinking about alternative solutions, talk with your partner and RE and see chapter 11.
When Four Times Becomes a Charm
Our fourth cycle was my highest point. My parents looked after our boys, so my husband and I traveled from Australia to California for two weeks together. It was like a second honeymoon. I was so relaxed and in love with my husband. Maybe that’s why it was so successful. It was a dream cycle. And now I’m pregnant.
—Sally, 38, critical care nurse
Need to Store Your Embryos?
Cryopreservation is a technique millions of people use to cool embryos, eggs, or sperm to subzero temperatures so they can preserve them for future use (see chapter 12 for more on putting embryos, eggs, or sperm on ice).
WHAT QUESTIONS SHOULD YOU ASK?
IVF has brought the joy of parenthood to millions of couples worldwide. Over its more than 35-year history it has evolved from the collaboration of two men, Robert Edwards and Patrick Steptoe tinkering in a laboratory, to a common medical procedure. If you and your partner can’t conceive, there’s a good chance IVF can help. But it’s not flawless. On average (not considering age or type of infertility) you have about a 33 percent chance that a given IVF cycle will result in pregnancy.
If your cycle fails, take heart. Your doctor learns from the results and will adjust your protocol to achieve success next time. And if you have multiple unsuccessful trials, there are still plenty of avenues to parenthood if you’re open to them. Besides adoption, there’s a whole world of third-party reproductive options available to you. We’ll discuss these in the next chapter.
Undergoing an IVF cycle requires considerable preparation from you and your partner. Ask yourself the following questions. If you answer no to any, discuss them with your doctor.
• Are you ready for a daily regimen of hormone injections?
• Are you willing to consider parenting multiples?
• Did you know that IVF involves a minor outpatient surgical procedure?
• Is your partner willing to undergo the emotional and financial stress that often accompanies IVF?
• Are you aware that IVF makes up 99 percent of all ART cycles?
• Is your partner’s semen analysis average or above?
• Have you and your partner discussed what you wish to do with remaining embryos after your transfer?
• Can you stay on strict bed rest for 72 hours or more?
• Are you ready for the phone call to hear your pregnancy results?
• Can you believe some women report experiencing orgasm during childbirth?
• If pregnancy did not occur, discuss other options and consider storing your embryos.
• IVF technology has contributed to nearly 5 million babies worldwide.
• ART involves surgically removing your eggs from your ovaries, combining them with your partner’s (or a donor’s) sperm in the laboratory, and returning them to your body.
• Your protocol is your IVF bible; it highlights medications, ultrasounds, blood tests, dates, and times for your cycle. Read it carefully and follow it.
• Your partner is an integral part of this process. Invite him to attend all of your appointments. He’ll have a better appreciation for what you’re going through.
• Egg retrieval is a minor outpatient surgery. Your RE will use ultrasound to guide a long needle through your vaginal wall into your ovaries. He’ll find your follicles and aspirate each mature egg and the follicular fluid around it.
• By making a small starter hole, assisted hatching gives an embryo a head start on its efforts to break out of its shell-like zona.
• Share your thoughts and concerns with your partner along the way. He’s as much a part of this as you are and needs to be involved.
• Although you may see the transfer take place, you won’t feel it; the embryos are still so small that you’ll likely have no sensation that anything is happening at all.
• Follow your aftercare instructions after your transfer. And remember that your partner’s main job is to take care of you, while your sole job is to stay off your feet.
• Two weeks after your embryo transfer you’ll visit your RE and get what you’ve been waiting for—your pregnancy test results!
