Second Trimester: The part where the waters are calm and sailing is smooth

Let the flogging commence: This blogger has seriously neglected the duties required of the position. Let me see if I can make up for it by penning a thoughtful and (hopefully) somewhat humorous update of what life has been like while incubating the fetus since my last update.

We left off at 12 weeks 1 day with the anticipation of our 14 week regular OB appointment on the horizon. The appointment seemed to come up quite quickly on the last day of August, with the new OB and I having another engaging 15 minutes while she checked out my little belly buddy. All was well with the little guy, and she scheduled me for the next routine appointment 4 weeks later. Almost in passing, she also mentioned that she hadn't told anyone yet, but she was going to be leaving at the end of October, so I should probably start thinking about who I might want to switch my OB care to. I tucked that little nugget of information away to process later for a couple of reasons. First, I was really disappointed because I had so enjoyed the appointments that I'd had with her over the short 6 months that we had a doctor-patient relationship, and I loathed the idea of trying to find another OB that I would have the same rapport with. In the 11 years that I have been seeking and receiving OB care, I have found that there are a small handful that I have loved, several that met the needs but didn't knock my socks off, and another handful that should consider a career change. Aside from the tedious nature of trying to pin down a new OB love, my second reservation was that I didn't want Mandy and Wes to stress about the change. This is the first baby and their first ride on the OB merry-go-round, so I didn't want this news to be upsetting to them. So with 60 days to go before I had to do something about it, I thought it best to just put it on the shelf temporarily. Next appointment was set for the last few days of September. In the meantime, one of my co-workers delivered a beautiful baby girl at 40 weeks and 6 days. She kicked off the year of babies in our department. There are 4 of us that do the same job; she delivered her baby the first week of September, I will deliver the bean in late February, and one of our other teammates will deliver her first baby in early April. Needless to say, we have no shortage of estrogen flowing in this hallway! *Cue all of the "there must be something in the water" jokes. With Babypalooza in full swing, along with it comes an almost steady stream of maternity leave. So September through the end of November have been packed even more full of making sure all of the projects are properly managed and moving forward.

Along came the end of September and our 18 week regular OB appointment. By this time, Mandy and I had been having a conversation about the hospital and our delivery plans, which provided a perfect segue to relay issue of the pending OB transition. Letting her know about it was the easier of the two tasks; actually identifying and committing to a new OB was a job that I still wasn't ready to tackle just yet. Instead, I just showed up at the appointment and went on with the usual routine. Lovely Outgoing OB did her usual assessments of the babe, determined he was doing great, right on track, and set me up for an appointment 4 weeks later. Falling at the end of October, this would be the last one where we would get to see her, but she let me know that any of her partners would be happy to take on my care. I tried to probe a little further with her to see if she had some insight that would help me make a solid match with one of her partners, but she just gave a me a sweeping "they would all be great and do a good job for you" statement. Still, I had another month to figure it out, and an anatomy ultrasound coming up in between at 20 weeks, so I didn't dwell on it too much.

The big ultrasound day arrived a short 2 weeks later in mid-October. Although feeling a bit buried by the amount of work I had been juggling, I was very excited to take a quiet morning to spend with Mandy and Wes (albeit over Skype) for the ever-anticipated anatomy scan. I enjoyed being able to share the experience with them, although, admittedly, it was a bit anti-climactic. Everything measured perfectly, even about a week ahead (recall that this little guy has been an overachiever all along). The technician confirmed, decidedly, that belly buddy is, in fact, a boy. Mandy and Wes watched and listened throughout the scan without saying much. I was hoping that they were enjoying the glimpse of their little man. We had a nice long phone call after the appointment where they told me they were relieved that everything looked good, and we talked about the 3D/4D ultrasound that we scheduled for the first week of December where they would get a really good look at his face, features, and adorable little toes. They now had even greater anticipation of seeing him on that upcoming scan. They also asked me about scheduling a fetal echocardiogram, as is common in IVF pregnancies. Seemed easy enough, right?? Famous last words...

I called the OB's office the following week to inquire about the fetal echo. The nurse (medical assistant? not sure...) that I spoke with told me that they don't routinely do a fetal echo on their patients, so I shouldn't worry about it. Now, maybe it's the pregnancy hormones, but there's something about the way this conversation went that drives me bananas. If I call a professional's office with a professional question that is decidedly outside of the norm of their day-to-day activities, I expect a professional to weigh the question and respond based on their acquired skills and knowledge in their field of practice. I don't expect (and don't even want, in fact) one of the paraprofessionals on the team to dismiss the question without due consideration. In this case, I more explicitly asked the person on the phone to discuss it with Lovely Outgoing OB. A week went by without a response, so I called again. This time the person on the phone seemed very annoyed to be asked a second time, but said she would call me back with an answer. Five minutes later she called to say they were not going to order it and that we didn't need one. I asked why they don't order them if it's common practice for IVF pregnancies in light of ACOG's support of fetal echos at 24 weeks following IVF based on statistically significant increases in heart disease and heart conditions in IVF babies versus naturally conceived. Again, I got annoyed stuttering and an "I'll call you back". Ten minutes later she called back and this time seemed to relay Lovely Outgoing OB's irritation with being questioned. She told me that the request was specific to IVF and if we wanted it done we should get the RE to order the echo. Ouch. I hung up, sufficiently hormonal, unsure what to do with that response. First, I let Mandy know what they said, then I went to work as I always do when I need to gather solid information: a review of scientific literature. I was happy to find, among the plethora of documentation of rationale for doing a fetal echo around 24 weeks for IVF fetuses, a study of several hundred IVF pregnancies that showed that although that is true, there were no findings of cardiac irregularities in patients that first had a normal anatomy scan. So that's to say that all of the IVF babies with cardiac disease or abnormalities also showed those on the 20 week scan prior to the fetal echocardiogram. With that information in hand, Mandy and I talked it over and decided not to push the issue further based on the bean's normal cardiac findings on the 20 week anatomy scan. Whew... crisis narrowly averted. On the other hand, I had to go back to see Lovely Outgoing OB in a couple of weeks, and I wasn't entirely sure what her demeanor would be like when we were face to face.

Two more weeks rolled by and we were back to see Lovely Outgoing OB for our 22 week appointment. She started by asking me what we decided on the fetal echocardiogram issue. I was impressed that she just jumped right in with that, and that she acted like we somehow had a choice. Definitely not something that her office staff relayed to me over the phone a couple of weeks prior. Regardless, ready to move on, I told her we were good with the anatomy scan results and were not planning to pursue the fetal echo. She gave a long, detailed explanation of her lack of experience in RE medicine, but that she felt the push for echos on fetuses that demonstrated a normal 20 week anatomy scan was motivated more by RE's and Maternal Fetal Medicine specialists that are so accustomed to visualizing their patients through ultrasound that they get into a rut of thinking they need it when sometimes they don't. Fair enough. I appreciated the professional opinion and rationale rather than "the answer is no and if you don't like it, get someone else to order it for you." Both content, we went on with our usual business; a few questions, a little measuring and a couple of jokes to round out our final appointment. When she measured my fundal height, she noted that it was a little big for our dates. I asked by how much and she said "1 cm... I could call it 2, but I don't want to freak you out. It's about 1.5 over the 22 cm we're expecting." I filed it away, knowing that I had a gestational diabetes test coming up at the next appointment and secretly praying that I wasn't measuring big because I had GD making the baby larger than normal. To wrap up the appointment, she asked me who I would like to see for my next appointment. I had decided to switch to one of her partners that I had heard good things about and had great online reviews. They scheduled me for an appointment with Partner OB for 4 weeks later at the end of November, although that appointment would be scrapped before we ever even got close to Thanksgiving.

More Monitoring, More Results

We've progressed to pre-transfer monitoring, round 2. At this point, we are 16 days into the medication cycle and exactly a week after the last monitoring appointment. We will have one more monitoring appointment in 3 days, and then we'll transfer in a week and a half (June 12).

As with each monitoring appointment, they drew a vial of blood and did another ultrasound this morning. The things that have changed since our appointment last week are that I finished shedding old lining, the RE cut my Lupron dose down to 5 units per day instead of 10, and added oral estradiol at 1 mg twice a day. After the first three days of that change, he upped my estradiol to 2 mg twice a day. The effect that we hoped to see at this appointment was increased estradiol levels in my blood, my endometrium starting to thicken up (goal thickness at transfer is > 8 mm) while the ovaries should still be quiet (no follicles over 10 mm) and progesterone levels should still be low.

Results
Endometrial thickness: 9.3 mm
Right ovary: 6-7 follicles < 10 mm; 0 follicles > 10 mm
Left ovary: 8-9 follicles < 10 mm; 0 follicles > 10 mm
Additional findings: Small pocket of fluid in the uterine cavity
Estradiol: 228 pg/ml
Progesterone: 0.5

Things look great. My lining is already past our goal and we have no rogue follicles trying to impede our progress, so we're in great shape. We're going to keep plugging along toward our next monitoring appointment on Friday. The RE didn't say anything about the small pocket of fluid, but I'm hoping that it'll be gone by the time we do the next ultrasound.

Sneak Peek

Today was our first pre-transfer monitoring appointment. This is an aspect of IVF that I really enjoy and look forward to in each cycle. When couples are trying to conceive naturally, there are a lot of days that pass with no news or no indication of what's going on down in the land of babies. The two week wait is notoriously excruciating because of the lack of information. In the IVF process, however, doctors are getting all up in our business on a pretty regular basis, so I'm very up to speed on how things are progressing during each cycle. I like knowing things. In spite of the magic wand they have to use, this state of knowing things makes me happy.

The routine is pretty much the same at each pre-transfer monitoring appointment. They draw a vial of blood to be tested for the pertinent hormones of the week, then I head to the ultrasound room for a quick look at my inner girl bits. First stop on the magic school bus ride is the uterus where they measure the endometrial thickness (lining) and look for any pockets of fluid. Next they head on over to one of the ovaries, count the number of immature follicles (less than 10 mm), document and measure any developing follicles (greater than 10 mm), and check for any cysts. They repeat that procedure on the other ovary and we're done. I put some pants on and head back to work to await the results.

At this first appointment of the cycle, the goal is a thin lining (around 3-5 mm), two quiet ovaries (no follicles over 10 mm) and low estradiol and progesterone levels.

Results
Endometrial thickness: 5.9 mm
Right ovary: 6-7 follicles < 10 mm; 0 follicles > 10 mm
Left ovary: 8-9 follicles < 10 mm; 0 follicles > 10 mm
Additional findings: None
Estradiol: 34 pg/ml
Progesterone: 0.6

And We're Off, Like a Herd of Turtles

It's that time again: Another month has passed, and the blog needs an update. If you've read any of the older entries, you'll notice a pattern of posting where there's a longer pause between updates during these contract and preparation periods, and more of a flutter of blog activity as we get into some of the more exciting surrogacy events. There are two main reasons for this. First, the contract and preparation periods are tediously long and rather boring. Second, as you may know by now from this blog, I am not a patient person, so I don't take the long, slow waiting as well as one might hope. More frequent updates from me during this period may come out as "Still no *@^$*# contract yet," and no one wants to read my constant Debbie Downer frustrations without some good news to help wash it down. With that said, brace yourself for a flurry of blog excitement on the horizon.

Exactly a month ago, I closed with "Here's hoping we have a signed contract next week. If so, we'll be right on track for a transfer in the last week of May." And then the gods laughed and laughed. T'was not meant to be for an end of May transfer. We experienced two major hiccups to the plan. First was that Wes and Mandy's attorney *must* get paid by the hour. I can't think of any other explanation for why someone would hold onto this document for days and weeks on end without signaling forward progress. Holy buckets! I have never seen someone work so slowly in my life. Working with her has led to me the conclusion that if I ever find myself in the situation of doing another stork contract and the IPs select her as their attorney, it's an automatic deal breaker for me. I have also decided that I would rather be subjected to an angry hoard of starving fire ants with no route of escape than to wrap myself up in another several month long contract negotiation, especially with that attorney or any others like her. But I digress. There was a secondary hold up as well.

Back in early April when we all visited the RE, Mandy and Wes also had to have blood drawn to meet FDA testing requirements for transferring the embryos to a third party (me!). Normally, IPs will have this done at the time of egg retrieval and/or sperm collection, but Mandy and Wes did not intend to use a surrogate at the time of their embryo creation, so the RE had no reason to run those tests at that time. Now that we're getting ready to start cycling, they need those results on file before we can get started. It was about two weeks after the results for Mandy, me, and Scott had come back that everyone started to question where Wes' results were. After some digging into it, the answer was that the lab lost his blood sample. This is quite problematic, as Wes is working an out-of-country job assignment, so he doesn't have access to lab to get another sample drawn quickly. It took about a week to get another sample drawn and submitted, but alas, the contract still wasn't done, so we waited patiently for the results. About a week ago, as we were all trying our hardest to pry the final draft of the contract out of the attorney's death grip, we got an email from the clinic saying that one of the infectious disease markers on Wes' blood panel came back positive, and that we would need to do some additional steps before proceeding. The positive result was for a relatively inconsequential virus and indicated a very old exposure that Wes had fully recovered from. Still, I had to have an antibody titer done to assess my immunity to it, meet with an infectious disease specialist to talk about the risk of contracting the virus from the embryo (highly improbable) and sign an FDA form stating that I assume that risk in moving forward with the transfer. Amazingly, I was able to whip through all of that in two days AND put some ink on the signature line of the contract last Tuesday. It was like some kind of post-Mother's Day miracle! Still holding the wet pages with a look of shock and awe on my face, the box of medications arrived on Saturday in order for me to start my first Lupron injection today.

We're cooking with gas now! We may still be a month away from transferring, but we have some dates to look forward to in that time span. I'll start Lupron tonight and my first monitoring appointment will be May 26, with two more monitoring appointments on June 2 and June 5. Then I'll fly out to the clinic on the 11th for our frozen single embryo transfer on June 12. This stork is officially no longer on standby; let the oven pre-heat begin!

Round 3 - Ready, Set, Go

It's that time again - needles, syringes and vials by the fistful. I started the third round of meds this past Monday, so today is day 5 of Lupron. The last time it took about a week before the side effects kicked in, so we'll see in a few days if the hot flashes, insomnia and weight gain will return with this cycle. Today I met a brand spanking new side effect that didn't pop up last time; nausea. To be fair, nausea is my catch-all 'something's off in my body' symptom. Some people get headaches, I get nausea. Especially when hormones are involved; even your run-of-the-mill birth control pills will make me nauseous on a daily basis. When we did the first round of meds in July and August, I was actually pretty lucky that the nausea side effect didn't show up until we added the Estrace and then it was pretty intense. I cursed the Estrace a bit for it, but I guess there's a chance that the Lupron was equally to blame. On the bright side, I didn't need to hold onto those extra calories I ate at our office holiday lunch anyway.

So we're about a week into the cycle with exactly 4 weeks to transfer. I'll go in for a baseline monitoring appointment next Wednesday and if everything looks good, we'll start the Estrace on Friday and work on building a nice thick lining for the next monitoring appointment in December. Scott and I are going to sneak a nice little Caribbean getaway in between to get some rest and relaxation in before I get called up for stork duty. We're now 2 weeks away from vacation, and I'm looking forward to a fruity drink in my hand and some sand in my toes. Here's hoping that the tropical sun will help clear my hormonally-induced pukiness.