How To Make a Baby

Monday, September 21, 2015

Don't worry, this isn't "the talk" you got when you were a kid, although this information is just as important.

As my friend and fellow blogger, Becca, said recently, "Getting pregnant is supposed to be easy." Spoiler alert: It isn't always that easy.

When I was a kid and a teenager, it seemed like all we heard about was how we had to make sure not to get pregnant, as if sperm and eggs were just flying all over the place, willy-nilly, creating life. There were more than a couple of times in my adult life where I had a low fear in my belly; "Could I be pregnant?" (Forget for a moment that I was religiously on the pill and hadn't missed a period. I didn't say the fear was logical.) But the general idea was that if you weren't EXTREMELY CAREFUL ALL THE TIME, you would get pregnant.

Would Coach Carr lie to you? (I mean, the man couldn't spell chlamydia so... maybe.)
It turns out that each month, a woman only has about a 15-25% chance of conceiving, and that is if you time it perfectly, you or your partner have no health problems, you're not over 30, if the planets are aligned, and if it happens to be a Tuesday. (Okay, those last two probably aren't true, but I'm beginning to think they might be.)

I'm going to drop some science on you. (Yup, I did it again.)

In women of reproductive age who have no health issues that would interfere with her hormones etc, a woman will have a bunch of follicles mature and a single egg will ovulate each month. This maturation process begins on the first day of the menstrual period, during which the non-pregnant uterus sheds its old lining in preparation for a new cycle. After mensturation ceases, estrogen levels begin to rise, which makes the lining of the uterus grow and become thicker.

Meanwhile, the body is also producing FSH (Follicle Stimulating Hormone) which stimulates the ovaries (where the eggs live in their follicles) to produce a mature egg. There are many follicles in each ovary, and they each contain an immature egg. They all develop at different times, and typically, only one will be mature and ovulate each cycle. Eventually, the rising estrogen triggers a spike in another hormone called Luteinizing Hormone (LH). This "LH surge" is what causes the dominate follicle to rupture, allowing the mature egg to head towards the uterus via the uterine tube (AKA: The Fallopian tube. Because remember, everything in anatomy has at least two names.) This is ovulation, and it typically happens between Cycle Days 12 and 16 (CD 1 = First day of the menstrual period). After ovulation occurs, the follicle begins to produce yet another hormone: Progesterone. This hormone is what supports a pregnancy (it's right there in the name!) and once a fertilized egg implants and begins to grow, the placenta will take over in the progesterone department. Until then, it's up to the follicle.

So, the ovum floats down the tube to the uterus, and hopefully along the way, a friendly sperm will meet it and fertilize it. This usually happens in the tube itself, which is why the number one location for ectopic pregnancies (pregnancies outside the uterus... no bueno) to occur is in the fallopian tube. The egg will live for about 24 hours once it has left the ovary, whereas the sperm can live in the female reproductive tract for 3-5 days. The fertilized egg will head towards the uterus, which has a nice, cushy  lining in which the zygote (fertilized egg) will implant, grow, and make a baby. Once the fertilized egg implants (usually about a week after ovulation), the body produces another hormone: hCG, or Human Chorionic Gonadatropin. This is only made during pregnancy, and is the hormone that is detected by tests. If the egg remains unfertilized, progesterone levels fall, the body realizes that hey, we don't need this stuff in the uterus this month, and menstruation begins again.

The miracle of life. Or whatever.

Clearly, there's a lot going on there, and since the egg only lives for 24 hours after ovulation, there are really only a few days during each month when conception can occur (the few days prior to and including the day of ovulation). It's a miracle that anyone gets pregnant at all! And yet, people do. Every day. But not everyone.

Infertility: Not Just a Lady Problem

Infertility is defined as the inability to conceive after one year of having unprotected sex, or 6 months of unprotected sex if you have a health issue or are a woman over 35. Infertility can occur for many reasons, at each of the steps involved in making a baby. It can happen to men and women; a recent study showed that among infertile couples seeking reproductive assistance, 18% of men were diagnosed with a fertility issue. If you'd like to read about the multiple infertility issues that can occur, check out the CDC's Infertility FAQ (where a lot of this info is coming from).

For me, the issues are multifold. I was diagnosed with endometriosis in 2005, PCOS in 2011, and an autoimmune disease in 2013. This means that my uterine lining grows where it shouldn't (outside the uterus), which can cause blockages and scarring, that my hormones are imbalanced and therefore I might not ovulate or have good-quality eggs, and that my body attacks itself, causing all sorts of inflammation and other uncool things. Basically, none of that is good for pregnancy.

My Intro to Fertility Treatments

I've talked about how losing two babies in a row was heartbreaking. What I haven't talked about is how after my first miscarriage, people kept saying, "At least you know you can get pregnant!" and after I got over wanting to set them on fire, there was a small part of me that was amazed and hopeful. My body had finally done something that it was supposed to do. I was (foolishly) convinced that since we had been so fortunate to get pregnant after 4 months of trying without intervention, that we would have similar luck when trying again. There were even a couple of people who said that they had always heard that after a miscarriage, women are more fertile than other times. (This, by the way, is a total lie.) When I didn't get pregnant right away, I was devastated. Every month, it was the same thing.

Focus. Anxiety. Hope. More anxiety. Devastation when each month, a big, fat, negative pregnancy test appeared.

I knew that if I called my reproductive endocrinologist and said that we wanted to try some low-tech interventions, I wouldn't have to fight for it. For some reason though, I just... didn't want to. I tried to talk through it in therapy. Before I had ever gotten pregnant, I was 100% gung-ho for heading towards fertility treatments, including IVF if we had to and our insurance covered it. I had never expected to get pregnant, miscarry, and then not be able to get pregnant again. My body did it by itself once, why couldn't it do it again?

But it wasn't doing it again. I didn't know if I was ovulating. My ovulation tests were negative, and I had no idea if I was just missing the LH surge that the test detects, or if my body wasn't doing it. I had no idea what my hormones were doing. With a history of PCOS, not ovulating and having hormonal imbalances is always a possibility, and endometriosis and autoimmune disease definitely weren't going to help the situation. And yet I resisted moving on to even low-tech interventions like oral medications to induce ovulation. It just felt like "giving up," and I wasn't ready to admit that yet again, my body had seemingly failed to do the most basic thing its programmed to do. After lots of crying and frustration, talking to Ken, and running through all of these thoughts in my brain, we decided to try IUI, or intrauterine insemination, and we did our first cycle in July.

How to Make a Baby: IUI

More science time! In case you don't know, an IUI is when the semen/sperm is taken out of the male partner (or donor), processed and spun down in a centrifuge to concentrate it, and then injected into the uterus of the female partner (or surrogate) via a tiny catheter inserted through the cervix (the part of the uterus that connects to the vagina).

When you sign up to go down the path of an IUI, you don't just randomly show up on any old day to get it done. If I hadn't been obsessed with my calendar before this, being on fertility treatments would have made me obsessive. There are very specific times during which blood needs to be drawn, the uterus and ovaries need to be imaged via ultrasound, and drugs need to administered. Usually, there's baseline blood work to check hormone levels and an ultrasound to count developing follicles on Cycle Day (CD) 2, 3, or 4. If that's normal, ovulation induction medications (like Clomid or Femara) are given on CD4-8. Then on CD12, another ultrasound is done to take a look at the follicles, and if one is the right size (18-20 mm is the sweet spot), then later that night at a particular time, an injectable medication called a "trigger shot" is self-administered to force the follicle to mature and the egg to ovulate. 36-38 hours after that, it's back to the office for, ahem, sample collection, and then two hours later, during which the sample is processed cleaned up, and concentrated, it's go time. 

The actual process for the woman is a bit like a slightly longer pelvic exam, and for me, it has never been painful. Some women report cramping when the catheter is inserted, and if they have to clamp the cervix, that is definitely not a great feeling, but they never have clamped mine to stabilize it (at least not for this procedure, thank you God and all that is holy, because that single-tooth tenaculum is AWFUL. By the by, that link is totally safe for work, it's just a picture of the instrument. No body parts.) After the insemination, the doctors ask you to lay on the table and wait for about 15 minutes. If you're like me and like statistics and numbers, in 2009, the British Medical Journal published the results of a randomized controlled trial comparing women who had remained lying flat for 15 minutes post-IUI to women who were allowed to get up immediately following the procedure. In the group randomized to 15 minutes of rest, pregnancy rate was 27%, whereas the pregnancy rate in the control group was 18%, which was found to be statistically significant. If all of that made zero sense to you, that's okay. I have a plan to do a basic stats primer for people who want to be able to read journal articles and at least kind of know what is going on. (I know, it sounds super exciting.)

Patience is a Virtue... Just Not One of Mine

And then we wait. For two weeks. This isn't any different than a non-medicated, non-IUI cycle, as there is always the dreaded "two week wait" (TWW) between when you might have conceived and when you will find out. It's essentially the longest two weeks of my life. Every. Damn. Month. The only added "bonus" to an IUI medicated cycle with a trigger shot is that you definitely cannot trust an early test if you test before you've missed your period. This is because the injection that is used to trigger ovulation is hCG, which is the very same hormone that is detected by pregnancy tests. And I think the only thing worse than a negative pregnancy test is a false positive that turns into a negative. Really, testing early is generally not suggested for a variety of reasons, not least of which is preserving your sanity because if you get a faintly positive test and then your period shows up, it's just not a good time. (That being said, I am the worst at not testing a day or so early. But that's what cheap pregnancy tests are for, right?)

You might think that after over a  year of actively trying to get pregnant, I'd be better at going with the flow or chilling out. You would be very wrong. I will say that I am beyond grateful that NJ is one of the 16 states with mandated infertility coverage in its insurance policies. Otherwise, the option to do IUI's would be completely off the table, and we couldn't even think about IVF if we have to go that route. The fact that infertility treatments and assisted reproductive treatments are not covered by most insurance is another post entirely for another day, but it makes me really upset to think about, so I'm not going to go there now.

(deep breath)
Okay, I've calmed myself.

I hesitated writing about this because it is really personal, and it might make some people uncomfortable, but those people don't have to read my blog, and it's all medical information anyway. Plus, I talked about what I wanted to do with this blog, and educating people about science and medicine is part of that. One of the things that I've heard when I've talked about this in real life is that so many people have no idea what fertility treatments entail, and even fewer understand the basic biology that occurs in almost all women of reproductive age. By sharing my story, hopefully people will learn some useful info, and more importantly, other couples out there going through something similar might feel less alone. 

So that's what I've been up to. I am currently in the middle of our third cycle, and we thought we'd be doing IUI #3 this past weekend, but biology had other ideas, and so the meds and ultrasounds continue. If you have any questions about any of this stuff, please don't hesitate to ask them! If I don't know the answer, I will find the answer for you, or at least point you in the right direction. 

Thanks for reading, and for being on this wild trip with me.

Full disclosure: Some of the links in this post are affiliate links for which I will receive a very tiny amount of money if you click on them!

The Joy that Was and the Joy that Wasn't

Tuesday, September 8, 2015

Wednesday, August 26th, was quite a day.

It was the original due date for the baby we lost in January.

It also was the day that I found out that I was pregnant again.

Talk about a lot of feelings, right?

Obviously, Ken and I were over the moon excited about the fact that yes, we were going to have a baby! We decided not to tell a lot of people because it was so early, but we did tell some close friends. I called my doctor and they told me to come in for labs on Thursday. My first HCG level (HCG = the hormones that indicates pregnancy) came back at 126. The number itself kind of means nothing, other than yes, I was definitely pregnant. What matters is that in early pregnancy, the HCG should double every 48 hours or so. I had my labs redrawn on Monday, 96 hours later, which meant that my HCG should have been roughly 500.

It was 277.

I had been waiting all day for the phone call that would tell me that our baby was growing, growing, growing! I felt good. I was feeling the early signs of pregnancy; I was exhausted, my boobs hurt, I wanted to eat the couch, that kind of thing. I was surprisingly not anxious, given what happened the last time I was pregnant. In fact, I was really proud of myself for not being a neurotic disaster about all of the untoward things that could possibly occur during a pregnancy. The fact that my HCG would not double did not even cross my mind. This baby would be fine. Statistically, there was a very low chance that I'd have a second miscarriage. And come on, the universe owed me this after the shitshow of last winter, right?

When I heard the news from my nurse coordinator, who by the way, I am convinced is an angel on earth, it felt like a punch to the gut. This baby was not okay. Or, we didn't think it was okay. There was no way of knowing until the next HCG level was drawn, but my nurse was honest and told me that it wasn't looking good. My numbers had not even increased 50% every day, let alone doubled every 48 hours. I would just have to wait and see. I got this information shortly after leaving the house to go out for the evening, so I didn't turn around to go tell Ken. Instead, I sobbed for 20 minutes and then drove to Philly. Given the situation, I ended up having a really good time that evening, but once I got home, my exterior shell crumbled when I told Ken what was happening and I spent the rest of the evening in bed.

So, against my better judgment, I took to the internet to do some research. Surprisingly, the internet had a lot of good, happy, stories about women whose HCG was wonky who then went on to have totally healthy, normal, babies. Also, I learned that HCG doubles every 48-72 hours in only 85% of pregnancies. I did and redid the math. If I had doubled every 72 hours instead of 48, my 277 would be okay! And 277 was well within a normal range for a very early pregnancy, even if it hadn't doubled. And it had gone up, so that had to be reassuring. By Wednesday, I had convinced myself that yeah, this baby was totally fine. I'd be due in early May, right after the school year ended for me. I wouldn't have to be pregnant all summer. It would be great.

I had my blood drawn on Wednesday morning and then proceeded to menacingly stare at my phone, willing it to ring for the rest of the day. I knew that my nurse wouldn't call until after 3, but by 3:00, I felt like I was going to throw up, pass out, or pee. I did none of the above, and my phone finally rang in the middle of a lecture about infectious diseases and antibiotics that I wasn't really paying attention to anyway. I went into the hallway.

"Alison, I'm so sorry. Your HCG dropped to 134."

I crumpled into a chair in the hallway and tried to remember to breathe. I felt like my body went numb, or that I wasn't a part of it anymore. The nurse said a lot of very kind things and I just kept saying, "Okay," because even though it wasn't okay at all, it was all I could think to say. She told me that I had to come back on Friday. I hung up the phone, walked back into lecture, quietly packed up my things, and left. Then I got to my car and burst into tears.

I just couldn't believe that this was happening again, and I couldn't believe the insane pace at which it was happening. And I also couldn't believe that after the initial grief and shock, I felt... fine? Not fine. Calm. Semi-numb. Sad, but functional. Well, semi-functional. I spent the entire day in bed on Thursday. After my lab draw on Friday, I came back home and went back to bed for hours. My life plan at that point was hour-to-hour, and was generally take a Klonopin, fall asleep, wake up a few hours later, take another Klonopin, repeat. I also kind of forgot to eat unless Ken put food in front of me. So yeah, semi-functional.

My only hope and wish at this point was that my HCG would continue to drop precipitously, so that my not-very-long-national-nightmare would end quickly and that I could get on with my life. I knew that I could not handle another protracted miscarriage in which I had to have two D&C's, separated by a dose of misoprostol. See also: The longest few months of my life, during which I may as well have been in some kind of fugue state because I don't really remember anything between January and April. When the call came on Friday that my HCG was down to 39. I had instructions to come in this Friday if my period hadn't returned. Fortunately, I won't have to do that, as it seems that my reproductive system has decided to at least cooperate a tiny bit this time.

Like I said, the 26th was a big day. The week that followed was a whirlwind, a roller coaster, a crazy experience that ran the gamut from the ridiculous to the sublime. I'm sad, I'm frustrated, I'm scared. I'm in disbelief, but not denial. I'm concerned. My biggest fear is that I will continue to get pregnant, only to lose our baby, over and over again. My fear is that no one will figure out what is wrong, or even worse, that there's nothing specifically wrong or fixable. It's just shitty lucky.

My gut is telling me that there is something we can do. Something to be discovered. Clearly, I can get pregnant, and I am so grateful for that fact. The trouble seems to come after that part, and the medical community at large knows far less as to why that happens than it does about getting people pregnant in the first place. I know that my history of PCOS, endometriosis, and autoimmune/inflammatory arthritis certainly aren't helping things, but since we know so little about all three of those things affect pregnancy, aside from the fact that all three increase your risk of miscarriage, making the leap to some kind of cause is difficult, if not impossible. Because I'm me, I went into triage mode and made an appointment with a reproductive immunologist in north Jersey for the beginning of October. Maybe, just maybe, he'll have some ideas. (At the very least, he's a DO, so I know he'll be awesome.)

It is incredibly exhausting to carry so many diametrically opposed emotions. I was so sad at the thought of my original due date coming and going and not having a baby to show for it. I was overjoyed when I found out that I was pregnant again. I was devastated when I learned that once again, I wouldn't be bringing this particular baby home. And now I'm relieved that I don't need extensive medical interventions to let this extremely unfortunate event pass. The joy and sorrow, intertwined, reminded me of this poem by Khalil Gibran called Joy and Sorrow, one of my favorite poets, authors, and thinkers. My favorite line is this:

The deeper that sorrow carves into your being, the more joy you can contain.

That is keeping me afloat. At the end of this, I will be overfull with joy.

Revamp, Rethink, Re-evaluate

Wednesday, September 2, 2015

Last week, I had the opportunity to meet up with some of the awesome women of PHLBloggers to talk about social media and blogging. My friend Chrystina started the group last year, and she's done a great job setting up really cool programming for us! Of course, thanks to med school, I have been to approximately 2 of the events, but I knew that I wanted to go to this one, and I am so glad that I was able to actually make it.

Besides talking about the various types of social media and how we can maximize its use for blogging, the session gave me time to think about my blog and what I want for this space. I have a lot of questions that only I can answer, really.

What is my niche?

Ah yes, the elusive "niche" question. When I started blogging (waaaaay back in the day on OpenDiary... I just dated myself there), my online journal was just that: a journal. It was pretty much exactly like my paper journal, but online. It wasn't very interesting to anyone who didn't know me, and I didn't really have anything earth-shattering to say. I moved to LiveJournal in college and there was more of the same. When I started blogging her, I had just gotten married and was working, and for the most part, wrote about life, the universe, and everything. As I started reading more blogs, I felt a distinct lack of direction for my own. In fact, I hestitated to even call myself a blogger, because I couldn't define my blog. It definitely wasn't fashion, food, or business related. I didn't have a product, or a brand new idea, or a super cool job. I wrote about marriage and mental health, my cats and some traveling we did. It was totally random. Chrystina said that maybe it was a lifestyle blog, so I went with that. Yeah, a lifestyle blog. Whatever that means.

I decided that I wanted to get serious (or at least more serious) with blogging when I hired Jenn to redesign my blog, and it was really the first time I invested real money into this space. I love the redesign and it made me feel so much more "legit" as a blogger. Since then, I've kind of tried to trim my content, but I still wasn't sure what I wanted to write about. I decided that I needed to consider two things: What do I know, and what are my passions?

What do I know? What are my passions? Where do they intersect?

I know a little about a lot of things, and a lot about a couple of things, some of which aren't very interesting or blog-worthy. I was able to group the good ones into a few categories:

Medical school/grad school
Communicating well
Cats (okay, maybe this one doesn't count)

Then I went to my passions and included some goals in there as well:

Helping people
Talking and writing about and destigmatizing mental illness
Writing/talking/communicating in general
Educating people
Making people laugh
Cats (okay, maybe this one also doesn't count)

Fortunately, some of these things overlap! Which left me with:

Depression/anxiety/destigmatizing mental illness
Communicating/educating people about the above topics
Cats (or... not)

Based on these results, I need to write a blog that focuses on medical science and mental health, with a primary focus on communicating to large groups of people and hopefully educating them. Also, I'd love to be able to make you laugh if I can.

So now what?

Excellent question. What do I want to do with this space? What is my pie in the sky goal? Well, I'll tell you. I mean, it is Wednesday, which used to mean confessions.

My big goal?

I want to write a book. A book about depression, anxiety, and mental health in general, focusing on the medical school and physician populations. I want to drag this subject out into the light, in a real and meaningful way.

I used to think that this was a stupid idea, because who the hell cares what I have to say? I guess that could still be true, but mental health is so personal that I feel like if my story can help even one other person, I want to tell it.

So there it is. I'm going to reshape my blog in order to get my brain into a setting where I can write this book. I don't know when I'm going to write the book. I don't know how one goes about writing a book. But the idea is out there in the universe now. There you go.

I guess a good place to start would be to post on some kind of regular schedule. I'll... get right on that.

What do you think of the new blog idea? The book idea? And has anyone out there ever changed their blog name successfully? Let me know!

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