A Tale of Two Clinics

There are two large fertility treatment centers in the large metropolitan city in the neighboring county. The first is affiliated with a large teaching hospital, and the second is a private fertility clinic. Their ranking in most areas is the roughly the same, and the price of treatment is also similar. I am insured by two excellent PPO insurance carriers, (who probably won’t be sending me holiday cards this year) but neither plan offers fertility coverage.

My initial fertility work up and first round of IUIs were done at the large teaching hospital, mostly because my primary care doctor belonged to the IPA affiliated with the hospital. There are a lot of good things to say about that center- the staff physicians were excellent, the lab was excellent, and a wide range of specialists collaborated with the center to provide ancillary tests and analysis. As I progressed through treatment, however, I encountered some issues that were so serious that my husband and I decided to leave the large hospital and pursue treatment at the private center. Specifically:

Teaching hospitals have a dual purpose: to treat patients and to train physicians, (also to conduct research, more on that in another post) and those activities generally amount to the same thing, as far as patients are concerned. You know the doll who gets yanked off the shelf for the community CPR class? Congratulations, you’re that doll. And while I am the first person to appreciate that physicians have to start somewhere, my personal experience, as a CPR doll was, how to say not exactly, exquisite. Here were two problems that could have been avoided:

- I researched my Reproductive Endocrinologist (RE) a lot, and luckily enough, she accepted me as a patient. So far, so good. However, she was not the clinician who performed most, or any, of the actual procedures, and probably more importantly, she was not the physician who monitored my progress. Or, at least, not until I developed multiple cysts after several months on Clomid- cysts that should have been monitored prior to every procedure, and were not.

- There’s a new commercial for a pregnancy test (I have no idea if it’s a new pregnancy test), with the byline “1 in 4 woman can misread a traditional pregnancy test.” Ok. Fair enough. I suppose that under the right circumstances, 1 in 4 people can misread nearly anything, so I’m not going to deconstruct that statement. But the Ovulation Predictor kits suggested by my RE….good lord. Now that was rocket science. I need to devote an entire post to explain why this was so. But in any case, it is for this reason that the private clinic doesn’t use them at all, instead relying on ultrasound monitoring to appropriately time IUIs. Also, the private clinic uses ultrasound monitoring to look for the development of cysts. Also the private clinic uses ultrasound monitoring to ensure that CLomid hasn’t decreased the ovarian lining to a thickness that would not be conducive to implantation. For those three reasons, my IUIs at the teaching hospital were pretty much pointless. I think I should devote another blog post to why exactly one probably doesn’t want to go through pointless IUIs, with the adroitly named TomCat catheter.

The Big Box of Needles and Drugs

The Big Box of Needles and Drugs arrived today. I cleared out a drawer in the refrigerator so the drugs would not get mixed up with the arugula and the milk.
Here is what is in the box:
Follistim
HCG
Repronex
About a million needles and syringes
Packages of individually wrapped alcohol swabs.
One container of very large capsules of antibiotics.
One container for disposing of needles and syringes.

I called American Express to confirm that they had accepted the charges for the doctor (nearly $9,000) and the latest shipment of medications (over $3000).

I do not want to swallow those pills. I do not want to give myself those injections. The puppy, barometer of my emotions, has retreated to his crate.
But, for the chance of having a baby before I am 38 years old, I will do it. I am committed.

fertility work-up: the second time is twice as nice!

Nearly three years have passed since I last went through a fertility workup, and I am due for a repeat. The standard workup consists of a battery of tests. All things being equal, in terms of number of tests, simple blood analysis make up the majority. I couldn't give you an exact number, but I have learned that it's best not to count the number of vial labels that the lab tech exchanges for the lab requisition slip (one label per tube, at least three tubes per work up). Also-note that the pre test instructions are not theoretical. During my first work up, in my mid twenties, I made the mistake of having an FSH analysis (I think it was an FSH analysis, anyway) shortly after taking a dose of Clomid. I wouldn't recommend that particular course of action unless you are the bizarre sort of comedian who wants your ob/gyn to think you are a candidate for premature ovarian failure.

Certain other tests, including follicle counts with the craftily designed transvaginal ultrasound, (in the interest of not getting booted off Blogger, I’m not going to include a link) do not exactly rank high on the fun list, but can be gotten through. Others, such as the HSG, are rather unforgettable and I will in no uncertain terms drink bleach if I am made to repeat that particular test again. I will say, with regard to the HSG, that I object to the idea far more than the actual procedure, which was uncomfortable but not painful. Luckily, the only tests I need to repeat are the labs and the follicle count.

Because no test has ever indicated a definitive cause of infertility, there's not a good reason for me to worry about the results, which doesn’t mean that there aren't plenty of other shoddily constructed and weakly articulated reasons. I'm one of those people who subscribes to the idea that if you don't believe in the principle of induction, (not to be confused with a similarly named step in the IVF procedure) the principle of induction doesn't apply to you, much like ghosts for children or hell for athiests. I am absolutely aware that people who go around verbally articulating these things are irritating to be around, but by God, I've earned it, what with the rare cancer lottery and all. So just because a test has come back normal five out of five times, doesn't mean that, say, the sixth time, it's not going to indicate that I am not only in full-blown premature menaupause, but have contracted liver flukes and will any day now express a latent gene for supernumary teeth, because I've always had sort of questionable orthodontia.

All this is to say that I’m not having the tests re run until my next appointment with the endocrinologist, which will be in approximately 33 days +/-.

Will Someone Die Every Time I do IVF?

As you may recall, my father was diagnosed with stage 4 pancreatic cancer just after I went through my embryo transfer for IVF. And, as I started this process again, and tried to articulate the particular strands of trepidation I was feeling, the thing I was not telling people was that I was wondering whether someone would die every time I did IVF. To be clear, even though I am an only child, I don't really believe that everything in the world revolves around me. But I know about the circle of life, both from the Lion King and from that movie where death takes a holiday, and I know that usually, someone, somewhere is leaving this mortal plane when someone else is arriving via birth. Really, God, I get it. It does not have to be illustrated for me with such a direct connection as it was in the spring.

But apparently God, or the Powers that Be, or the Great Narrative Arc of my life feels otherwise.

Because I started my Lupron shots on Friday night, and today I have learned that another loved one is dying of cancer in the very near future.

Last Thanksgiving, while my parents were visiting us in California, we found out that a close friend of theirs, Virginia, was diagnosed with lymphoma. She had started treatment, but, with a variety of pre-existing conditions (including congestive heart failure), no one thought she had long to live. When I started IVF and my father was diagnosed, my mother and I were really not able to call or help or even really think about Virginia's condition. Luckily, she has a nephew who really stepped in. While my father was on life support and in his final days, the nephew moved Virginia to an assisted living facility near his house.

Now, Virginia has not had an easy life. Her first husband was a fighter pilot, and was MIA in Vietnam. She remarried a squadron-mate of his, and they had a son. When their son was 8, he was killed by a drunk driver on the sidewalk in front of their house. We met them a few years after this, and Virginia and her husband Bob took an instant liking to me. They took trips with us, to Hawaii, and the Caribbean and France. They wrote cards and called and spent holiday after holiday with us. And then, in 1991, when I was caught up in the whirlwind of college, Bob died of cancer. Virginia was alone. She did not have any siblings. She had lost both of her parents. Really, her nephew was her only relative. And we were the next closest thing.

A week after my father's funeral, I drove my mother down to see her. We had a terrible dinner in her assisted living facility, but she was happy to see us. She complained about her room; she complained about the food; she complained about how old and boring and lifeless her new house-mates were. Honestly, she didn't even seem sick anymore. She sent us out to buy some bottle of wine and some Doritos. And then my mother and I drove back up to my mother's house to continue the strangely sad and technical work of executing my father's estate, writing a new will for my mother, and preparing for the other major life transitions I was about to go through (including a surgery and a move to a different state.)

And now, just as I've started the long Lupron protocol for IVF, Virginia has moved to a hospice. There is a tumor in her spine and possibly one in her brain. She told her nephew that she is not afraid of dying, she is only afraid of dying alone. And he has promised her that he will be there for her.

And I will continue my protocol. I will not make plans to fly across country to see her, because, as my Reproductive Endocrinologist reminded me, I am not as young as I was six months ago.

And if Virginia does die alone, I will always feel I have failed her.

Comrades in ART(s)

Two years ago, I started trying to get pregnant. And then, because I was 35, about six months later, I started fertility treatments. In January, I amped up the intensity of that project by starting an IVF cycle. This is an intense thing, with lots of shots and appointments and nausea, and maybe that’s why I was able to ignore the frequency with which my mother was taking my father to doctors to address his fatigue. Maybe.

In March, the doctor retrieved a bunch of eggs, and my husband made his contribution, and then, like magic, there were these embryos sitting in a cryopreservation facility in San Jose California. My parents were thrilled. They talked about their hypothetical grandchildren as long as I can remember. Three days after the creation of these embryos, I went back down to San Jose and the doctor transferred two of them back into my uterus. A week later, while waiting to find out whether I was pregnant, my parents told me that my father had stage-four pancreatic cancer. He had between six and nine months to live. I was devastated. I was also, unbelievably, pregnant. Nine months, I thought. Nine months for my father to live. Nine months of gestation for his grandchild. Could I beat that deadline?

I spent the next few months in Florida with my parents. I went with them to the doctor appointments. I went with them to chemo. And one day, I drove myself to the emergency room and found out I was probably having a miscarriage. I went into the hospital for three days, because it was not a normal, routine miscarriage. And then the normal terrible series of events of cancer unfolded. My father died on May 31. I did not beat the deadline. I did not give my father the grandchild he had talked about all of my life.

And now I have started round two of IVF. Is it a sad, tragic time? Is it a hopeful adventure? I have no idea. What I do know is that in the books and blogs on fertility, they like to talk about a Fertility Journey, which makes it sound a lot more like a Carnival Cruise than the malarial jungle trek that it has been for me. Which bring me to the top three reasons for writing this blog, right here, right now, with Erin:

1. I am a Compulsive Information Gatherer: When I started IVF the first time, I went on Amazon and purchased a whole bunch of books. I did random internet searches, and scared the estrogen out of myself with those. I kept hoping to find the source that would tell me exactly how to give myself the shots, exactly what they would feel like, exactly when it was okay to feel hopeful, and exactly when it was okay to be annoyed that I have to go through all of this crap. I read all the books, and they gave some modicum of information about the process, but Erin was really my go-to person. As a bonus to her natural intelligence and writing skills and her personal experience with fertility treatments, she also has a medical background, so she actually knows how things work.
2. Erin is Entertaining: I find conversations with Erin to be endlessly witty, informative, and fascinating. Other people should have the opportunity to be entertained by her posts. Especially women going through IVF, who need all the entertainment and understanding they can get. And especially, especially women who are going through IVF after the recent loss of a parents, because, well, life just kind of sucks for them in a very particular way.
3. Comrades in ART(s): When my father was dying of cancer, I started to get the feeling that I didn’t want to be around people who hadn’t gone through a tragedy. Not that that there weren’t lovely, empathetic people who supported me through my first round of IVF and then through my miscarriage, and then again through my father’s hospitalizations and death. I was blessed with an amazing set of friends all through all of that. It’s just that the people who had lost a loved one, they really knew. It made me understand why people who go through war together have such a bond, because no matter how empathetic or well-read or a good listener, no one else really understands. And to add to that the Big Crazy that can be a result of Assisted Reproductive Technologies like IVF, well, it makes Erin my comrade in Assisted Reproductive Technology and Grief, it puts me in her elite Special Forces Unit of Fertility and Mortality.