As I sit here writing the third and final part to our fertility journey, it is the first day of the third (and final!!) trimester of our pregnancy. We’ve had a lot of highs and a lot of lows, but ultimately this is a story of hope and joy. Continued from Pt. 2, I’ll dive deep into the IVF process we experienced, but know that every person’s journey is different.
The egg retrieval
After we completed our initial consultation and workups (see Pt. 2 for details), we were ready to roll! Shortly after Christmas in 2020, we started our first round of meds (gonadotropins) to begin the ovarian stimulation process (also called “stims”). This step is crucial – the attrition rate through IVF is very high, and so you ideally want to start with as many mature eggs retrieved as possible to increase your chances of success. The gonadotropins stimulate the ovaries to grow many follicles at once and at approximately the same rate. The follicles in the ovary are where the eggs are housed, so theoretically more follicles = more eggs. During any given month of a normal menstruation cycle, women are generally growing multiple follicles, but only one matures fast enough to lead to ovulation.
Throughout this part of the process, we were going in to the office every couple days to monitor follicle growth via transvaginal ultrasound (fondly described as having a date with “Wanda” in the infertility community) as well as bloodwork. Looking back, I have to laugh at how difficult I thought this first step was, in comparison to all the rest that would come. We were doing multiple shots a day, but they were all subcutaneous (in the abdomen) and I experienced minimal bruising, if at all (this is not often the case).
This process lasted about 2-3 weeks before the actual retrieval itself. In the final days leading up to the egg retrieval, the ovaries are so large from carrying so many mature eggs that it starts to be very uncomfortable. You are advised not to bend or twist at all to prevent ovarian torsion (which I had already experienced prior to my surgery in Singapore and did not want to experience again – see Pt. 1). You also start some “suppression” medications in those last few days, to ensure that your body does not ovulate all those beautiful eggs you just spent all that time growing before they are ready. Finally, when the RE deems that enough follicles have reached the right size, you add one final medication – the trigger shot, which triggers your body to “mature” those follicles/eggs so that they can be ready to ovulate, or in this case, be retrieved.
I don’t actually remember much of the retrieval. They gave me “happy juice” when I arrived to the surgery center and it knocked me right out. It was a low enough dose of anesthesia that I did not need to be intubated and by the time I woke up 30 minutes later, it was already done. I spent that day resting at home, but overall recovery was pretty quick for me (again, not always the case for others).
Burjis was told after the procedure that the doctor retrieved 26 eggs! The general target is 15-20, so we were stoked about the news. But here is where the kicker comes – not everything in IVF is as it seems. We were called the next day – of our 26 retrieved eggs, only 20 were mature. Of the 20 mature eggs, only 15 fertilized (did I mention while I was in the OR, Burjis had to give a semen sample?). Much of IVF is a waiting game, so we would need to wait til Day 3 post-op for our next update. At that time we found out that 14 embryos were still growing from the 15 that fertilized and made it to the “cleavage” stage. At the next and final call (day 6 post-op), we were told that the final number of fertilized embryos that made it to the “blastocyst” stage was 7. Seven out of the original 26 that were retrieved!
We had also opted in to genetically screen our embryos (called PGS) to ensure that any that would be transferred would be genetically normal. This would reduce the chance of miscarriage and potential birth defects. After the results of that came in another week later, we were left with THREE genetically normal embryos. Three chances* for the family we always dreamed of having.
*Note: While the attrition is very high in this part of the process and we were hoping to have more than three embryos in the end, we do consider ourselves to be very lucky. Many couples do not even make it this far or end up with no viable embryos and need to restart stims again. As I’ve mentioned before, you can pay all the money in the world, go to the best doctors, but with fertility there are simply no guarantees.
The first transfer
The next step of the process is the embryo transfer, in which one of your “embabies” is transferred to the uterus through a catheter in the hopes that it will implant or burrow into the lining of the uterus. The transfer can be “fresh” (happens right after the retrieval) or “frozen” (embryos are frozen and then thawed when you are ready to transfer) and consist of either cleavage stage (day 3) embryos or blastocyst stage (day 5-6) embryos – with the highest success rates shown for a frozen transfer (FET) with a blastocyst stage embryo. Because we opted for the genetic screening / biopsy, we were automatically candidates for the FET with blastocyst embryo, as time is needed for the results to come back before scheduling the procedure.
There was a solid month or so gap before the next round of meds, so that my body could return to its natural state after all the harsh stims meds. Finally, we began a protocol of estrogen and later on progesterone (pill, shot and suppository form), which are the main hormones that support early pregnancy development and enable to uterus lining to grow nice and thick and cozy for the embryo to snuggle into. This part was literally… the WORST. The shots were muscular injections which means they now went into the glute instead of the abdomen. Yes there was bruising. Yes there was bleeding. I was able to do the abdomen ones myself but I could not bring myself to do the glute ones.
There was more monitoring to determine when would be the “right time” to transfer in terms of my window of receptivity. Five days before the actual transfer, in addition to progesterone we added in antibiotics (to prevent infection), steroids (to prevent inflammation) and baby aspirin (to improve blood flow). While the meds were more painful, the actual procedure for the transfer itself was a breeze. You are awake the whole time (but loosy goosy due to the Valium they give you upon arrival) and your partner is able to be in the OR with you. You can actually see the procedure via ultrasound as it’s happening and take home a magnified image of your embryo with you. A lot goes into choosing which embryo to transfer first and we opted for our best graded embryo which so happened to be male (we had 2 M, 1 F, so we could still have a gender “choice” next time if this transfer failed).
And then we wait. Yet again. The beta HCG blood pregnancy test is performed 10 days after the transfer, though you can of course test at home if you are a Nervous Nelly like me. We did test at home and found out we were pregnant! When we went in to the office on Burjis birthday, this was confirmed by the doctor and we were thrilled. At four weeks pregnant, we told both sets of our parents and everyone was overjoyed at the news.
Because biochemical pregnancies are so common, the RE always repeats the pregnancy test 48 hours later to make sure the HCG numbers are trending in the right direction (they should at least double). Our second test numbers were less than thrilling – still “passing” by those standards and the doctor called us to prepare us for a potential loss. We tested again two days after that and by some miracle the numbers shot up again! We went for our first ultrasound the day after that (at 4 weeks, 6 days) and everything was on track. One silver lining of IVF is that you get monitored via weekly ultrasounds from weeks 4-10, whereas most women won’t have their first OB appointment until 8-10 weeks (and then each subsequent appointment is every 4 weeks).
On our 5 week ultrasound, the doctor was looking for two markers – a gestational sac and a yolk sac. He saw the gestational sac but not the yolk sac. We were again prepared for a potential loss, but were told there was still hope that the baby perhaps was just a slow grower. I can’t tell you how horrible it feels to continue taking medications three times a day to support development of a baby that might never come. At six weeks – it was confirmed that there was still no yolk sac. We had what was called a blighted ovum – at some point, our precious embryo had stopped developing and I would eventually be having a miscarriage. Because of the early stage, we were encouraged that this may just happen on its own, but by week seven my HCG numbers were still rising (and I was still feeling more and more pregnant) so an intervention was needed.
We scheduled a D&C (dilation and curettage) surgery in which the tissue would be removed from the uterus and sent off for biopsy. I was intubated this time and under general anesthesia. I woke up in the surgery center empty. And in pain (on multiple levels). And with a ghastly amount of blood. I took the week off the recover but it honestly wasn’t enough. But I wasn’t sure when it would ever be enough, so begrudgingly I returned to work and returned to some form of my normal life. This was April 2021.
The second transfer
We were baffled at our loss as the tissue biopsy came back as genetically normal. By May 2021, my HCG numbers still hadn’t returned to zero, and so we headed to the surgery center again for a hysteroscopy. There was still excess lingering tissue that the doctor removed as well as some polyps, but besides that everything looked “normal”. We would be at least physically ready to try again. One crappy thing about the US healthcare system is most insurance companies won’t allow you to do additional screenings to determine potential other root causes of miscarriage until you have had multiple recurrent losses (multiple being 2-3). And so we continued on our path.
We went through all the similar steps as the previous transfer but with a few tweaks – we did a different medication protocol and different methods to deliver the estrogen to the body. We also added in blood thinners to help further improve blood flow and hence nutrients to the uterus. Though we were battered, we were not defeated, and we were hopeful that this would be it. We chose our one female embryo (I had always wanted a girl so this felt like our time) and proceeded with the transfer. The date for the beta HCG blood test ironically fell over Father’s Day weekend in June 2021, and we had to push it out a few days as we would be in Galveston with Burjis’ parents and brother.
As previously established, I am a serial home tester. I need to know the information as soon as it is available. And I don’t want to hear the news from someone else. Especially if it is bad news. Before our trip to Galveston, we had gotten another positive pregnancy test! But by the next day the line seemed to be getting fainter. I had been here before one year prior, and it was then I started to freak out. I was doing home tests three times a day over the course of our vacation weekend (despite knowing that the best results are with the first morning pee) and by the time we drove back home to Austin, it was all but confirmed in my head that this was another biochemical pregnancy. There would be no baby. The doctor confirmed the news the day after Father’s Day.
The third transfer
At this point we really had no idea how to proceed. We had only one embryo – one chance – left to start our family. How naive we had been to think that our three embryos could cover the two-child family we had envisioned! Now we were hoping just to even have one child. Where could we even go from here? Should we switch doctors and get a second opinion? Should we give up treatment for a while and just try naturally? In the end, we decided to give this final round “all we’ve got” so to speak.
Since we now fell into the category of “unexplained recurrent pregnancy loss”, other testing options opened up. We performed an ERA (endometrial receptivity array) to make sure my window of receptivity aligned with the timing of the transfer. We did an autoimmune panel to rule out any underlying autoimmune disorders that could be affecting fertility. Both came back normal. I started going to acupuncture – if western medicine was failing me, maybe I could find some answers in eastern medicine. I did a complete overhaul in our house of the cleaning and beauty products we use to remove phthalates and threw out all plastic food items to remove BPAs – switching to glass and steel where possible. I changed up my diet to a more fertility friendly diet and started taking daily collagen as well as CoQ10 supplements. I modified my workouts to be less intense and more fertility friendly. I reduced my dairy and gluten intake, just in case I had inflammatory reactions I wasn’t aware of. I largely cut out drinking except on rare special occasions. And saddest of all, I cut out coffee entirely and switched to low caffeine teas like matcha. When we finally started our medication protocol, the doctor also added in hydroxychloroquine (autoimmune suppressant) in addition to the blood thinners, “just in case”. Following the transfer, I succumbed to all the infertility superstitions – I ate French fries and pineapple core for days, and wore thick socks to keep my feet warm and body temperature up (even in the middle of Texas August heat). I didn’t drink or eat anything colder than room temperature (another gem passed on to me by one of my counterparts in China).
Can I pinpoint any one of these actions as “the thing” that led to our success? Not really. But you can be damn sure when it’s time to have baby #2 I will do everything exactly the same. And we were pregnant! By my birthday in August I had already tested positive at home, and that line kept getting darker and darker. Finally. Our beta HCG blood test numbers were off the charts (one great friend even told me not google HCG numbers for triplets lol) and immediately on our first ultrasound we could see both the gestational sac and the yolk sac. Life was good. Right on cue at six weeks, we saw and heard his heartbeat for the first time. Each week we were exactly on the expected marker, and at ten weeks pregnant, we graduated to our normal OB! It was also at this time that we stopped all medications since the placenta would start to take over around that time to supply nutrients to baby.
The thing about infertility is that it never really leaves you. We finally had success, but we were too nervous to share the news. I was terrified when we stopped the injections that something bad would happen. I bought an at-home baby doppler so I could listen to his heartbeat whenever I felt nervous. Even though I felt pregnant and had all the typical first trimester symptoms, it wasn’t a reassurance given our previous history. And I didn’t yet look pregnant. Fast forward – to my dismay, I didn’t really acknowledge my baby bump until about 23 weeks. Even now at 28 weeks, I am not “obviously pregnant” to strangers that look at me. No one moves out of the way for me at the grocery store or gives up their seat for me on a bench ha. But I am slowly moving past this every time I feel our baby boy kick.
We did finally share the news with friends and family and the warmth and love we have received has been overwhelming. While it hurts to recall all we went through, I am so happy to share our story with you all. I love receiving messages from others who have experienced similar troubles and/or losses. I want to share that you are not alone. It may feel that way sometimes, as this is a topic that many don’t like to talk about, but that’s ok. Everyone deals with struggle in their own way, and I can assure you that infertility is much more common than you think.
Was this process daunting? Yes. Were there times I wanted to give up? Of course. But is it worth it? In the words of the now canceled Mr. Big… abso-fuckin’-lutely. You are stronger than you know. If you had told me a year ago that I would have gone through all this and come out the other end stronger, I would have been blown away. In fact, I am blown away, and beyond proud of myself and of Burjis, and our ability to meet all of life’s challenges as a couple. We can do hard things.