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!

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