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.

Like a Butterfly Emerging from a Cocoon

I'm alive!! This stork has not fallen off the face of the Earth, nor been run over by a bus, never to be heard from again. No, it was not some ill-fated adventure or injury that has kept me from my blog, but rather a tiny little wombmate that has been sucking all of the life energy from my entire body for the past 8 weeks.

As you may recall from my last post, we had very strong positive home pregnancy tests, and the transfer appeared to be successful. We had only transferred a single, PGD-normal, male embryo, so our dark lines on the home pregnancy tests gave us the impression that he was snuggling in nicely. Around that time, the pregnancy exhaustion hit me with full force, and has only given me a couple of reprieves since. The morning sickness came with it, although the nausea was quite predictable; arriving late-afternoon each day and hanging around until sometime into the night. I would wake each morning feeling well rested with a calm stomach, just long enough to be productive for a few hours and get some food into my system. By the time 2:00 pm rolled around, I had to close my office door for a brief siesta just to get myself through the afternoon, and any chance of productivity was shot for the day. But today is one of those blessed reprieves, so I'm taking full advantage of it to fill you all in on how things have developed over the past couple of months.

At our first blood draw 10 days past transfer, my beta-HCG (human chorionic gonadotropin - pregnancy hormone) result was 221 mIU/mL, which is a great starting number. With the goal of doubling the amount of HCG in my system every 48 hours as a healthy embryo should do, we tested again at 12 days past transfer where our result was 542 mIU/mL. Far better than doubling, this little bean was really taking off in there. The clinic scheduled the first ultrasound for the following week when the pregnancy was 5 weeks and 2 days along. Mandy, Wes and I knew that we wouldn't be able to see much on that ultrasound other than a yolk sac, as the fetal pole doesn't develop until the end of week 5 and the heart doesn't start beating until early in week 6. Much to our surprise, the bean measured 5 weeks and 4 days (2 days ahead), and had the beginning of a fetal pole forming. It was great to see we were right on track with a little overachiever on board.

Our next ultrasound was scheduled for the end of the following week when we were 6 weeks and 5 days. I was surprised when I showed up that morning with quite a flutter of nerves in my stomach. It felt like the weight of the world rested on this ultrasound and whether the bean was able to get that heart beating or not. As the sonographer lit the screen up, she immediately moved past the bean and there on the screen was the undeniable flutter of a fetal heart. My eyes leaked a little as I was so relieved and awe-inspired by the work that we had done to get that point. I immediately sent Mandy the pictures, which elicited the expected exuberance that also made my eyes leak a little. Aside from what I predict will be an amazing feeling when they hold their baby for the first time, this was one of the greatest moments of this journey. To help these wonderful people to finally be able to achieve something that they have dreamed of for so long breathed pure happiness into my soul.

The final RE ultrasound was scheduled for 8 weeks and 1 day, and again showed the bean growing like a weed, still measuring 2 days ahead. The nurse coordinator emailed me to say that everything looked perfect, that I was to transition to my OB, stop my progesterone shots that day and start progesterone suppositories for 13 days until I was 10 weeks pregnant. After 2 days of the suppositories, I was deeply regretting the switch and wishing for a nightly injection of progesterone into my backside. The suppositories caused some irritation and light spotting, as is common for many women that use them. Mandy and Wes, however, were panicked by the spotting and requested that I see the OB. I was able to get a quick view on ultrasound to let them know that the bean was still doing fine with a perfect heart rate, and we set our first regular OB appointment on the Monday after we hit 10 weeks.

The first OB appointment was great fun. Mandy and Wes are not currently stateside, so they likely won't be able to attend many appointments. Such was the case with this first one. The nurse, the OB and the staff all seemed to really enjoy having a case that's a little new and different. We joked around and had a great time, as well as running through the usual first appointment information. We got yet another peek at the bean on ultrasound, where he was still outperforming expectations. Our next appointment is set for August 31 when we'll be 14 weeks. We're now 12 weeks and 1 day, and I'm just starting to emerge from the exhaustion and nausea cocoon of the first trimester. Here's to increased energy and keeping the blog updated!

One Week Later

It's been a full week since the transfer, and things are looking good. I've been experiencing some nausea off and on, although nothing that's actually brought a meal back up, thank goodness! I'm also feeling very tired throughout the day and lacking in motivation. Both are great signs, but as any IVFer can tell you, the meds can play serious tricks on your mind by mimicking pregnancy symptoms. Waiting it out and testing is the only way to get a clear answer, which is why I have peed on a stick daily for the past three days. Here are the results:

Indeed, things are definitely looking good! Mandy and Wes are over the moon excited, and I couldn't be any happier for them. We have our first blood test on Monday, which I presume will be followed by another on Wednesday. Here's hoping this little bean is nice and comfortable and stays put for the duration.

Lights, Catheter, Action!

Surrogacy can turn you into a professional wait-er. Even when there's a lot of fun stuff going on, the in-between is filled with more waiting. We're currently in one of the most difficult waits: The embryo has been deployed and everyone holds their breath until the bean signals back that it has accomplished it's implantation mission. With this being my third transfer, I am definitely handling the wait differently than I did after the first two transfers. Maybe it's the acupuncture; maybe I'm just getting older and developing a touch of the patience, but I'm really feeling a lot more zen about it, and the days are passing at a more normal speed.

Last Thursday, I packed up and flew out to the East Coast. It was a pretty easy travel day with no difficulties or delays. When I landed it was already evening, so I was able to grab a little dinner and settle into bed early for the 5 am wake up call that was coming the next morning. Although I didn't quite make it to the clinic at 6 am as planned (wrong clinic, Google!), I was able to quickly get my last pre-transfer blood work and ultrasound done, and head back to the hotel for a nice breakfast. The clinic called me back just before lunch to tell me that my labs and ultrasound looked perfect, and that we would be transferring at 1:00 pm. When I arrived, they made me comfortable in a procedure room, the acupuncturist came by to work his magic and somewhere around 2:00 pm, the RE and crew rolled in with an ultrasound machine and an incubator with this adorable little embryo. About 10 minutes later we were done and everyone rolled out as quickly as they rolled in. The acupuncturist came back to do a second round of sweet relaxation goodness, and I was out the door. The nurse gave me the usual instructions (assume you're pregnant, don't do dumb things), but I was pleasantly surprised to receive instructions for walking activity throughout the afternoon. With all of the recent research that strongly indicates that post-transfer bed rest is counterproductive, I'm very happy to be working with a clinic that is so responsive to the research data. After a leisurely afternoon of shopping and exploring the area around the hotel, it was back to bed in preparation for another full day of travel.

Saturday morning was very easy paced as well because my flight didn't leave until 1:30 pm, but I decided to get to the airport a little extra early to allow plenty of time for any TSA shenanigans that might come my way like the last time. Instead, I breezed right through security and to my gate an hour and a half before my flight time. As luck would have it, on this one isolated incident of my prompt timeliness, my flight was delayed due to a faulty aircraft. The airline had to find a different plane for us and kept pushing our flight time back until they were able to locate one. In total, we ended up being 3 hours late. To my advantage, it was a direct flight for me, so I didn't have a connection that I was missing due to the delay. I spent quite a bit of quality time with my Kindle and Hulu; thank goodness for technology.

It's now been almost 3 days since I got home; 4 days since the transfer, and we continue to wait. I have moments that I feel certain the transfer was successful, and just as many moments where I feel absolutely nothing at all. That is the true torture of the post-transfer wait. It helps to know that we'll have a clear answer in 6 days, and yet, it will only bring on another wait. This is the life of a stork, a professional wait-er.

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

Stork 951, This is Ground Control, You're Cleared for Take Off

I think I've kept you all in suspense long enough. A month ago I was on the fence between the local IPs through the agency or the independent match IPs on the East Coast with the picky clinic. After much discussion with Scott and the East Coast clinic, I decided that the independent match was the way to go, and the medical screening date was set. The IPs, Mandy and Wes, already have 4 frozen PGD tested embryos, so once we traverse the gauntlet that is screening and contracts, we'll be ready to transfer.

After a thorough review of my records, the clinic called to schedule the medical screening. Scott and I flew out there last week with 3 of the 4 kids in tow. We met up with Mandy and Wes on the first night that we arrived and had a wonderful dinner together. This was the first time meeting in person, and they were as sweet and wonderful as they were over Skype. I'm really quite happy to be working with such a wonderful couple. While still in their early thirties, they have had multiple unexplained early losses that led them to visit a few reproductive specialists who determined that several auto-immune factors were to blame for the losses and that Mandy would not be able to successfully carry a pregnancy. That prompted them to act quickly to locate a surrogate to carry the embryos that they had already created. Those efforts led us all to the clinic last week where their RE did a saline sonogram of my uterus, took 7 (yes, SEVEN) vials of blood, and we all sat down for some psychological evaluations and group discussions. It really was an interesting day, and we all enjoyed seeing each other again. As we left, Mandy gave me a box of the medications that she had been sent in preparation for her own transfer prior to learning the results of her infertility testing.

When we got back to the hotel, Scott asked me how we were going to get the box back with us because it was full of needles and we had only traveled with carry-on luggage. I decided to ship it rather than deal with it at the airport - seemed simple enough of a solution. After printing the shipping label and preparing the box for shipment, we took off for the airport. Not being natives of the East Coast, we were unaware that we really couldn't get off of a turnpike once we got on it, and this particular turnpike dropped us at the airport. No problem, there had to be some FedEx drop box somewhere in the airport, right? Wrong again. At this point, we only had a little over an hour until our flight left, so my options were to carry it on or check it. The airline counter was swarming with passengers checking bags, so I asked if I needed to check it based on the needles, or if I could carry it on. They told me that I could carry it on as long as there were prescription labels on the medications. Great!

Off to security we went with 5 rolling bags, 3 kids and a suspicious looking box. At every opportunity, I told the TSA agents "I have medications including needles, how do you want me to proceed?" They were all great, said "No problem" and scanned everything as usual. We passed through the metal detectors to the swabbing area where everything that was swabbed was normal except the box of medications that lit up their machine like a Christmas tree. The agent, again, very nice, did a full pat down on me, swabbed me and the box again, and came up with the same electrifying result. Awesome. She then tells me that the protocol dictates that they call in the explosives expert who arrives about 10 minutes later. He goes through the course of events with the TSA agent, explains to her that there are certain medications that will produce a false positive, then tells me that he has to do a full search of my luggage and person.

While he removed and photographed every item in my bag, the TSA agent did a very thorough body search, then they sent every item through the scanner again. Interestingly enough, they never opened the box of meds and actually looked inside - only scanned it twice. Once he had everything documented, he thanked me for my time and sent me on my way. We ran for the gate where we saw the last few passengers boarding. Whew, we cut it close on the time, and am I ever glad that I did the online check-in the night before!

A week later, we're home and back to our regular routines. The clinic called a few days ago to say that everything came back negative/normal, and we're ready to go once we have a signed contract. Lest I bore you all to death with the tedious details of the contract process, suffice it to say that Mandy and Wes' attorney doesn't have the same sense of urgency with the contract drafts as the rest of us do. We finally decided that the best way to make progress was for the three of us to have a long conference call to make all of the final decisions on the modifications that had been proposed, and then send them to their attorney to incorporate as the final draft. We did that 3 days ago, and are now waiting for her to send it back to all of us for final approval and signatures. 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.