Wednesday 25 January 2017

Reality is a bitch

But who can retrieve hope out of a 10 foot deep pit toilet? Who, you ask?

Me, that's who.

January is almost over. I'm fairly sure I'll survive the rest of it. I have almost finished the things I absolutely have to finish. I am still standing; I have most of my wits; and I feel strong: albeit a little smeared by the shit of circumstance.


Ah, let me back up a bit.

We had our follow up appointment with Dr. Cotter. I always have a sinking feeling anticipating these appointments, and it didn't help that I had to drive across the city in winter weather. I felt crazier trying to figure out the parking machine at the clinic than I ever felt while taking any fertility drugs. I narrowly restrained myself from cursing a blue streak at it and the bystanders behind me for the insult of existing and making demands on my stressed mind.


That was my mood going in, but I was quite prepared thanks to the detailed charts and notes I kept during my Clomid cycles, and the fact that I blogged about the matter and received some helpful comments.


Dr. Cotter chose, uncharacteristically, to open with a positive: "You ovulated several times!" (with reference to the first three Clomid cycles). She followed this with "We received some new information from the latest semen analysis." I allowed myself to briefly fantasize that this new information was good, even though I knew it wasn't.


Mr. Turtle's last SA (September 2016) showed a drop in numbers from 17 million (2013) to 1 million. That moves him from the "moderate" male factor infertility category to "severe."

Dr. Cotter was quick to add that "men's sperm counts go up and down like the temperature in [Western prairie-steppe city that has huge temperature fluctuations due to the Chinook phenomenon]. "Men can go from zero to millions in a few days," she elaborated, and said that this was true for men of all ages, including men in their 20s.

"With those sort of numbers," she continued, we would usually go to IVF, but we know you didn't produce any eggs on [very high dose of follicle stimulating hormone]. And you were three years younger then, so....[pause]."

"It does seem unlikely that we'd get a better result now," I mutter at Dr. Cotter and the indifferent universe.

"So the question is...." [pause to lean forward and make intense eye contact] "How aggressive do you want to go?"

There is another pause while some part of me registers that the last time I heard about aggressive treatment, it had to do with my dad's esophageal cancer. Also that at the moment I feel not very aggressive at all, but maybe this is one of those times that you fake it till you make it.

"Would you consider donor egg? Would you consider donor sperm?"

I stare at Mr. Turtle. "It's not off the table. But we haven't talked about it lately." Mr. Turtle adds, "Yes, we'd definitely have to have more conversations about that." He then steered the conversation back to his SA and recurrent lymphedema as a possible reason for it.  Mr. Turtle has Crohn's disease and is immuno-compromised because of the drugs he takes to manage it. Anytime he is fighting an infection, he gets a lot of swelling in the genital area which increases body heat, probably killing sperm or causing them to not develop properly.  We talked about how at the time we conceived AJ, Mr. Turtle had been doing lymphatic massage for drainage. He didn't think that at the time it made any difference, but maybe it had? Also his perception was that he was in worse health overall at that time than at present - but still managed to conceive a child, which is interesting. Dr. Cotter looked up his medical records on her computer, corroborating what he was saying with what his other doctors had observed.

Her recommendation after this discussion was to repeat the sperm analysis twice more, to see if there are any changes or if the low numbers seen in September continue. In between the analyses, Mr. Turtle can try what he can to reduce the lymphedema. He also has follow up with other doctors to get more opinions. So that's all good.

After we talked about that, I felt like I should bring the conversation back to my issues, although for a change, I was (sort of) the receiver of good news. I asked:

Assuming Mr. Turtle's sperm counts improve, would Dr. Cotter suggest trying Clomid again or look at something different?
Dr. Cotter reiterated that she feels Clomid is the logical treatment, because I did ovulate on it, it has been used for a many decades, and because "we know that Clomid at low doses works for women at the end of their reproductive lives." She seems quite positive on this point. She also implied that considering the one anovulatory cycle, she might increase the dose. She also talked about Femara/Letrazole as a possibility, but noted that it works in "a very different way" and she could not judge if it would be better than Clomid or not.

I asked if there was an advantage to going off Clomid for a while before trying it again, and she said yes, you need to take a break every four cycles. If we do try Clomid again, I will want to ask more questions, such as the short luteal phase on the ovulatory cycles and in what circumstances she would consider additional things such as a trigger shot/progesterone supplementation. But that conversation can wait till we know more about what's going on with the sperm and if improvement is possible.

I asked if there were any risks to taking DHEA over an extended period of time, and she said not that we know of, and agreed to give me a prescription for it for another few months. It shouldn't do any harm and it might do some good.

And then because I felt I should, I asked what were the options for donor egg should we choose to go that route.

Most of the donor egg information I already knewfrom asking the same questions three years ago. Two options:  fresh cycle with an (unpaid) egg donor, 38 or younger. Since we don't want to recruit a donor this isn't likely an option for us. Option 2, we can buy frozen eggs in batches of 6 from a US egg bank. The cost is $10 000 plus $1000 shipping cost, plus the cost of the IVF cycle. The donor eggs would need ICSI and assisted hatching as the freezing process makes the eggshells tough. (She actually said eggshells).  As Dr. Cotter was talking, I couldn't help thinking of all the things that could go wrong during this process.  Another wrinkle: Dr. Cotter said the egg banks might refuse to sell eggs to a couple with a low sperm count, because they would worry about it affecting their pregnancy rates and that's how they market themselves.

And what about donor sperm? Dr. Cotter had floated the idea of donor sperm with Clomid and/or an IUI as an option.

Dr. Cotter told us that "donor sperm is expensive" although the numbers she gave were in the hundreds of dollars, not thousands which is less expensive than eggs, at least. She then went off on a tangent about how sperm costs more or less depending on the race of the donor: Caucasian sperm is the cheapest, and Black/Hispanic sperm goes up in price with Asian sperm being the most expensive. Asians have low sperm counts and sperm donation is not a cultural norm. "There is literally one Asian donor in Canada and he is in high demand."  I don't know why she thought all these details were necessary since we are obviously white and not likely to seek out a different race donor but what do I know. She told us how sperm and eggs are flown all over the world and that is normal. At the end of this informative disclosure all I could manage was "It's an interesting world you work in."  "Oh yes, very interesting,"Dr. Cotter said breezily, as though she had quite enjoyed discussing professional business with us. Maybe this is her way of testing if people are really serious about "aggressive" treatment.

It's an interesting word, aggressive. A google search of "aggressive treatment" brings up this definition : "Aggressive care describes a particular approach to a life-threatening illness or condition. A patient receiving aggressive care will receive the benefit of every medication, technology, tool and trick that doctors can devise to treat his or her illness."  "Aggressive" usually (to me) has a negative meaning, such as a person who wants to pick a fight and threatens with words or actions.

But in the context of illness, aggression sounds kind of positive: Imagine soldiers of medicine fearlessly fighting the enemy disease! If you are aggressive, you must really be doing something. No more talk, all action! It seems cowardly to say, well shucks, maybe I don't feel like being aggressive. It rather reminds me of times in my life (mostly as a child) when well-meaning people kept telling me to be more assertive, maybe even more aggressive, with the stated or unstated implication being, if I didn't, the aggressive people were going to win or get all the good stuff. By the time I was in my 20s, I felt I had proven that I could have a good life without being aggressive, i.e. something I wasn't.  But the notion they planted still lingers in my thoughts: if I'm not aggressive, I'm not really serious about what I want, and I won't get it.


The thing is, at least with regards to infertility, I see aggression as illogical. Aggression implies an opponent. But who or what is my opponent here? My own body. So aggression means two things: I'm fighting my own body, or, I'm asking doctors to fight my body (while I passively watch? how is that a thing?). Neither possibility makes a whole lot of sense to me. Maybe the key piece here is self-image: I see myself/body as fundamentally good and beautiful. My body is not so much my property (I didn't ask for it and I don't get to keep it) as a sacred trust. To harm it or hate it feels deeply wrong and always has. In so far as "aggression" means harm or hatred, I can't go there. At all.


But you might say, it's just a word. Why not focus on the treatment options, not the words.  Well, because I think words actually do mean something. Words tell us truths about how we and others think, if we listen attentively. The words we use are not coincidental or accidental. They have histories. The histories tell the story of real things and real people. Real bodies. When Dr. Cotter calls DE/sperm IVF "aggressive treatment," she's telling a real story with real world consequences.


And whether I have another child or not, all my life I'll be telling my story. More than that, I'll be telling my child(ren) their story. What kind of a story do I want to tell?


That's where my thoughts are at. Not whether I can conceive naturally or whether DE IVF or some other treatment will "work." Those are valid questions, but I won't be able to answer them until I try, and when I get the answer, it may well be too late to do something differently, and thus the answer itself will be useless. So truthfully, none of those questions or their hypothetical answers will actually determine our course. The one that will is, What kind of a story do I...do we....want to tell?


So back to retrieving hope.


I'm actually feeling quite good. January is almost done. The days are getting longer. My daughter is beautiful and my husband walks with me on this path. We don't have to go back to The Fertility Clinic for another four months (after the second SA) and I'm quite happy about that. We can cycle unassisted. Or not. But we probably will.  We can talk about DE IVF and the other options Dr. Cotter floated. Talk is good.


Basically, I'm not being aggressive. And I feel just fine about that.

Tuesday 17 January 2017

I need some suggestions

January is more than half done, hallejulah. I don't want to wish away a day of my life but January isn't my favourite month. It feels like everybody is making New Year's resolutions in December and my only thought is: please can I just get through January.


Anyway. We are at a turning point/checkmate/stalemate (I can't metaphor right now) with regards to trying to conceive #2. I'm not feeling very optimistic at this point, not going to lie. But optimistic or not, we still have to decide to do something, or nothing, which is still a decision.


We have completed our 4 cycles of Clomid, 100mcg. No pregnancy achieved. According to progesterone levels, I ovulated the first three cycles (levels were 11.3, 18.9 and 22.1 respectively). All 3 ovulatory cycles had a relatively short luteal phase, according to the charts I kept (about 9 or 10 days). Other than that though I was encouraged to see my charts looking mostly the way they are supposed to for a fertile person. My temperature was low prior to ovulation, then rose, with the highest point about 7 days after ovulation. From there it would plummet. I had one or at most two positive OPK's in each cycle (I stopped testing after BBT rise).


I did not ovulate on the fourth cycle. I didn't ask the number for this one. My BBT chart is basically flat and low, no temperature rise. I had positive OPKs starting day 9. They were positive for about eight days, went negative for three, went positive again. I have never had this happen before. I finally gave up because it was too frustrating. I had various kinds of cervical mucus throughout, some of which looked fertile but as previously noted there was no evidence of ovulation at any point. This cycle lasted for 34 days and finally ended with what looks like a pretty normal period. I was glad that I at least did not need to use the Prometrium to induce a period which wasn't something I wasn't anxious to do. I am now unmedicated for the first time since October. What I notice so far is that my BBT (follicular phase) is lower by 3-4 tenths of a degree than it was when I was taking the Clomid. (I didn't chart prior to taking Clomid so no idea what it was before).


We have the follow up appointment with Dr. Cotter this Thursday. I'm trying to think of what I should ask her / talk about. I don't know if we will be offered any treatment options after Clomid. Maybe she will interpret my 3 ovulatory cycles positively and be willing to try something else, maybe not. I'm also so busy this month I haven't had much time to research or think about things, and it's still hard to think past the disappointment.


From the little I've had the time to read, here are some possibilities I found for when Clomid doesn't work:
  • Keep trying Clomid at same or higher dose (we were given four cycles, but surveying the internet I see that some people have had it prescribed for up to a year ...!!!... )
  • Clomid with a trigger shot
  • Go off Clomid, go unmedicated or take birth control pills for a couple of cycles, try again with Clomid
  • Femara
  • "Injectibles" - not totally sure what those are....needles??
  • IUI (we were not previously considered candidates for this because of male fertility issues)
Does anyone have any ideas of what else we could ask about?


We will also get the results of Mr. Turtle's latest semen analysis. I mainly focus on the female side on the blog, because it's easiest to write about myself, but we are a double infertility diagnosis. So that could be very important information going forward.


I haven't officially been given the results of my salinohysterogram, either, but unofficially I was told everything looked good and I had follicles growing.


I plan to ask if there are any negative side effects to continuing to take DHEA/COQ10 and if not whether Dr. Cotter can refill my prescription for that. I don't feel terribly hopeful right now about "trying naturally." But neither do I feel ready to make the decision to stop.


There is also the donor egg option. Since I wrote this post and this post, donor egg IVF has not become any more appealing to me. I definitely don't have the desire to start that process right away; at the same time I can't yet shelve it permanently.


I took the day off of the appointment. I wish I could spend it relaxing, but I will be busy with individual program plans and report cards which are due this month. The nicest thing I can probably do for myself is get that work done so I don't have to do it on the weekend.


Any ideas to kick start my tired thought process are welcome!!


Monday 9 January 2017

Microblog Mondays: This Child

I feel like I've been living a dual existence lately: caught up in the process of trying to make a second child (I'll update on how that's going another time: basically, Not Good), while being riveted by AJ and how she is growing.

She really isn't a baby anymore. Of course, I still call her Baby Girl, and probably will when she's 20 if she'll let me. There are moments where I fleetingly see the newborn in her (a certain sleepy, secretive smile, the shape of her head and way her ears stick out when looked at from the back, the way her face crumples up when she cries). Will I also still be seeing those flashes of the newborn when she's 20, I wonder? But most of the time, she's busy reminding us over and over again she's Not a Baby.

I have four photo collages up in the dining room, two big rectangles with 12 photos apiece and two smaller ones, 8 photos each. In theory these are supposed to be updated every year; in reality this job is procrastinated because sorting, printing and displaying photos is a terribly time consuming and therefore difficult and stressful. So the photos have not been changed since shortly before AJ's first birthday, and they are all of her in the first year of life. Lately, I'm thinking I really have to change them up, because she Does. Not. Look. Like. That. Baby. Anymore.

I don't know; those (not so) old photos have somehow brought it home in a way that everything else, even all the developmental milestones, haven't. The baby is a child.

In a way it's therapeutic: As AJ grows into an individual, she grows away from the whole process of conception and pregnancy and even birth and infancy. It's nice to be reminded that life is evolving and surprising and meant to flower beyond its (amazing) beginnings. Her growth and change is a reminder that the future is unwritten and could be very different from the past and from the future I imagined in the past. And that's.....sad and delightful and frightening and liberating all at once.

I savour the moments that I have with this child, this totally unique life.

Also here is the Susan Aglukark song with the same name as this post. Because.



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