Healthy Eggs

I've been thinking about whether I should adjust my diet at all in order to encourage "quality egg production".  One way to measure a successful egg retrieval outcome is the number of eggs (though not too many or else you risk OHSS), but perhaps more important is the egg quality.  What good is retrieving 20 eggs if very few of them are of sufficient quality to progress to the next stage?

Quick flashback to high school biology: the human cell is a diploid cell and has 46 chromosomes (which hold your DNA).  However, ovum (what I've been calling my "eggs") and sperm are reproductive haploid cells (aka gametes), and each only has 23 chromosomes (half of what we need to create a full cell).  When the sperm fertilizes the egg, the 23 chromosomes from each haploid cell fuse to form a single diploid cell containing 46 chromosomes.  This cell now has a unique set of genes, and it subdivides by mitosis to grow and become an embryo.  One of the factors in embryos not progressing beyond a certain stage may have to do with chromosomal abnormalities (Mother Nature's way of saying that that particular fertilized egg is just not meant to be).

The "egg spindle" organizes the 23 chromosomes in the ovum ("egg").  It's normal for a certain number of eggs to have abnormalities, but the occurrence of these abnormalities increase with age.  I found a summary explaining potential spindle abnormalities accompanied by images of what a healthy egg spindle looks like compared to an abnormal one.  I guess if an egg's spindle doesn't exist or looks highly fragmented, they won't freeze the egg.

When they retrieve my eggs, they will look for eggs that are "spindle positive" (good-lookin' spindles).  Here is video that shows you how technicians detect spindles.   At this stage, I don't think they will do a screen for chromosomal abnormalities-- they probably do this as an extra step (and cost) when I thaw and fertilized my eggs, before embryo implantation.  (I will ask my doctor to confirm this.)  The fact is that the cryopreservation process can result in additional spindle and chromosomal damage, which is why you end up with fewer usable eggs than you freeze.  Recent advances in egg freezing have helped improve the post-thaw yield rate, which is one of the reasons why I am choosing to undergo egg freezing now.  I am also hoping that technology in thawing and fertilization continues to improve, and that we're even further along by the time I'm ready to use these eggs.

What am I eating?

So-- back to the matter at hand.  What do I eat (or avoid)?  Many post-ers on IVF forums seem to promote a high fat, high protein, low carb diet, the reasoning being that such a diet encourages cellular development.  Some also say to cut out dairy (not sure why).  Some say pineapple is good for IVF transfer (less relevant to me).  There is the soy controversy.  Plenty of hydration is essential.  Some say B vitamins (which are said to help reproductive organs).  Chinese medicine says that women should only take in warm foods (no ice cream!), and meanwhile, my yoga instructor warned me not to overheat my body (ice cream, hooray).

OK, so no one really knows for sure.  What makes sense to me is to eat a well balanced diet rich in fruits and vegetables, heavy on protein and "good fats", and if eating carbs, choosing whole grains.  This works better for my body type, so this is what I'm going to pursue.  I am also taking a B vitamin complex supplement (which includes folic acid) and one Viactiv calcium chew a day (which is part of my regular diet).  I will not give up my ice cream; it is my foil to the Menopur.

This morning, I took advantage of the fact that it is Sunday and made myself a nice brunch of eggs, avocado, bacon, and multi-grain toast with raspberry jam:

I know I can't eat like this every day, but I've got to feed my growing eggs.

Smoking, Alcohol, and Caffeine

Smoking-- I mean, that just seems dumb.  I mean, whether you're undergoing egg freezing or not, just-- no.  Moving on.

I've read a lot about the negative effects of alcohol on egg retrieval success.  The Guardian article says that in a Harvard study, women who drank one or more alcoholic beverages a week had an 18% less likelihood of success at producing an IVF baby as compared with women who did not drink at all.  White wine for women and beer for men seemed especially detrimental.  Another UK article from the Daily Mail says that eliminating alcohol, caffeine, and smoking can help women conceive "naturally" instead of resorting to IVF, providing further evidence that these substances just aren't helping women conceive.

Now, women undergoing IVF have more factors to be concerned with than women going through egg freezing-- namely, IVF patients need to prepare their body for egg retrieval and embryo implantation (whereas I can worry about embryo implantation later).  It is possible that alcohol and caffeine interfere with implantation, and maybe it has little effect on healthy egg production itself.  And to be fair, you're born with all the eggs you've got-- you've already subjected your poor ova to years of college drinking and whatever other substances you may have abused in your less responsible years (or even now).

As someone who likes to drink at least two glasses of iced tea a day and enjoys wine with dinner several nights a week, I would like to believe that this is the case, that I don't need to worry about alcohol and caffeine consumption, but since no one can assure me that it's OK (my nurse said, "the occasional glass of wine is fine; one small cup of coffee a day is acceptable"), I've chosen to avoid both.  I figure that since I'm spending over $15K of my hard-earned money to undergo this procedure, it seems foolish to run this risk.  It is also makes sense-- your body doesn't actually require alcohol or caffeine to function, and both are known to have some negative effects on your body; why marinate your eggs in a toxic brew while you're going through this expensive and sensitive procedure?  And what if these substances interfere directly or indirectly with the hormones I'm taking?  I want to provide as regulated an environment as possible so that the hormones work optimally and my body is appropriately reactive to  any adjustments my doctor may make to my course of treatment.

I began drastically reducing my caffeine and alcohol intake about one month ago.  In the last month, I've only had four glasses of iced tea (heavy on the ice, very little tea), and none in the last 10 days.  In terms of alcohol, I've reduced my intake to "a few glasses of wine per week" in the last month (all red wine, no white), and in the last ten days, I've only had one glass of rose (I was desperate, on a terrible blind date, what was I to do?).  I have vowed to eliminate alcohol and caffeine entirely during my cycle, and I've been sticking to it.

Cutting down alcohol to a few glasses a week has had a few immediate positive outcomes-- my skin looks great, and I think I even lost a little weight since I've stopped drinking hundreds of wine calories a week!  Plus I don't spend as much money when I go out, which is good, because I'm spending $15K on this procedure and every little bit helps.  I think I may make the reduced alcohol consumption a regular part of my life, though I can't wait to have my first glass of rose post-retrieval.

Cycle Day 3: PM Shot

Now for the dreaded Menopur again.

I took the Menopur and diluent out of the fridge a half hour before the appointed hour to bring them up to room temperature.

I iced the injection site for about five minutes as I prepared the shot.  Mixing the medication was a little easier this time; I felt like I knew what I was doing...  sort of.  Still, the Q-Cap didn't go on the syringe easily (as if the threading on the two pieces didn't match), and I wasn't sure if I was supposed to try with a new syringe or what.  I plowed ahead with the Q-cap and syringe I was working with.

Once I was ready to inject, I sat for about thirty seconds with the needle hovering over the injection site, and finally, I just stabbed myself.

It hurt a little bit less going in than yesterday, so maybe the icing helped.  The Menopur still burned as I injected it into my body, though maybe not as bad as yesterday, so maybe bringing the medication to room temp also helps a little.

The most unpleasant part of all this is that I swear I feel the medicine going into my body, and it burns, and I feel twinges around the area reacting to the medication.  There was even a little blood this time when I withdrew the needle, which means I hit a capillary (not a big deal, the nurse said).  And the injection site smarted a bit afterwards but is fine now, fifteen minutes later.  I think that icing the area helps temper the surface sting and skin reaction a bit, and bringing the medicine up to room temp doesn't make things worse, so I think I will make these two steps part of my Menopur routine.

I don't think I will ever get used to giving myself Menopur.  It will still be a dreaded moment of my day. But then there is always ice cream.  (Blue Marble's famous Strawberry, this time.)

Exercising on Hormones

So one of the first things the nurse told me during my "training session" with her is that when I start my hormone cycle, I will need to take it easy with exercise.  Why?  Because the hormones are stimulating the ovaries, and they will enlarge as they grow more follicles than usually do.  If I were to do bouncy exercise or do inversions in yoga, I run the risk of ovarian torsion, which is when ovaries do a somersault and the fallopian tubes holding my ovaries in place get all twisted up.  If this were to happen, I'm told that I will feel severe pain in my abdomen, and that I should go to the ER.  They should be able to untwist the ovaries, but there is a chance that I'd lose an ovary (if blood restriction were severe) and/or do permanent damage to my reproductive organs.

Right, so no exercise during stims.  I'm not a gym rat to begin with, but I do enjoy doing yoga a couple of times a week, and I was hoping to continue this during my cycle.  However, I spoke with my (amazing) yoga instructor, Stephanie, who said that during hormone injections (and also when women are pregnant), their connective tissue grows elastic and is therefore susceptible to tearing and stretching.  And ligaments don't "stretch back".  Stephanie suggested that I not attend class during my cycle and for a week or two afterwards until the hormones have left my body, and instead, she helped me shape a home practice that is suitable for my condition.

Some general "Do's":

• most standing poses will be OK, but I may want to work with my feet wider than usual
• symmetrical poses are ideal; try to avoid asymmetrical poses
• side bends are great because they elongate the iliopsoas muscles in the abdomen, which help create "space" for whatever is going on in my belly
• go easy on the ligaments; my body is different under the influence of hormones, so I have to be more gentle

Some "Don'ts":

• No twisting, deep forward bending, or core exercises in general (compresses the ab area)
• No inversions
• No sun salutations, especially with jumping (in addition to risk of torsion, she thinks there's too much risk for ligament damage in my hormone-filled state)
• Only do what feels good

Here are some examples of poses, she said are great:

• Downward-facing dog, or the modified versions of "Wall dog"or "Chair dog" (doing a "down dog with your hands against the wall or back of chair)
• Warrior 2 (up to seven breaths on each side)
• Triangle (up to seven breaths on each side)
• Ardha Chandrasana or "Half Moon" (one of my favorite standing poses!  apparently very good for fertility in general)
• Supported Bridge Pose with a block under my low back for support
• Supported Fish Pose with a rolled up blanket under my shoulder blades, knees, and head for support
• Side Bends from either supported Virasana (sitting on a block) or sitting on the floor with your feet out in a V
• Supta Baddha Konasana or "supported reclining bound ankle pose"- I must modify this pose by setting up a bolster on a block so it's almost like a leanback.  Then I sit with my back against the bolster (my butt should be hanging off) so that I'm sitting up more than the guy in this picture.  I must also support the knees with blocks or blankets so that I don't overstretch my hip or knee ligaments.  I can sit in this position for 15 minutes or as long as I like.  Stephanie said that if I do one pose, this should be it for its therapeutic and calming benefits.

In terms of other exercise, my nurse said that leisurely walks are fine, and that I shouldn't be concerned about running up or down the stairs to catch the subway.  I also plan to go for gentle bicycle rides-- hope that isn't considered too "bouncy".   I will ask my nurse before I do that though.  It's too hot this weekend anyway!

Cycle Day 3: AM shot

Today it's another 100+ day in New York City, a fun day to be undergoing hormone stimulation.  I have visions of myself drenched on the subway today, after a hot flash attack.

I couldn't bring myself to stab myself quickly with the Gonal-F needle again.  I watched with horrible fascination as the needle entered my skin slowly...  and I definitely felt the Gonal-F needle go in this time-- I think I may have been pinching the injection site too hard.  Next time, I might try just injecting the needle without pinching at all.  And the thought I had to help alleviate the sting from the Menopur shot is to, 1) bring the diluent-- the solution I use to mix up the Menopur powder-- to room temp before using it tonight, 2) ice the injection site before inserting the needle.

In terms of side effects, none noticeable yet, except I feel like my face looks really bloated-- but that may be my imagination.

I've written my doctor this morning asking him to contextualize my course of treatment.  I do not expect tons of attention from my doctor, but I do expect someone to let me know why I'm taking the amount of medicine I'm taking, and what exactly the follicle count pronouncement means ("six on each side").

Cycle Day 2: My First Shot

I arrived at the doctor's office this morning to a room overflowing with women waiting to have their blood tested (testing hours are 7am to 8:30am).  It just hit me how many women need reproductive help these days (including myself), and what a business reproductive medicine is.  It was hard for me to think about the situations some of these women were in, potentially at the end of their options...  I hoped for most, that they were just starting an uncomplicated journey towards a happy reproductive outcome.  I spotted a woman I'd met before, the wife of an acquaintance of mine, but thankfully she did not recognize me.  That would have been an awkward conversation.

While I waited for a half hour, I settled up my bill.  You know, the took a casual swipe of my new credit card with the 0% APR to charge $9000, and I handed over a check for $750 made out to the anesthesiologist.  I was relieved that the credit card went through on its maiden swipe with no hitch-- thank you, Chase Slate Visa, for the no interest loan and for arriving just in time (yesterday) so that I could use you to pay for my oocyte cryopreservation cycle.

Then I got called for my blood test which was quick and painless.  After waiting some more for an exam room, I was seen by a doctor (not my usual doctor) for a quick pelvic ultrasound to see how my ovaries are doing.  She said that she saw about "six follicles on each side", that I'd likely start my meds tonight, and that I should expect a call from a nurse later today after my blood results come in.

At first I was a bit upset to hear that I only have about 12 follicles because, to recap, each follicle holds only one egg, so I thought that this would be the maximum number of chances I'd have at egg retrieval.  Also, sometimes a follicle holds no egg, or the egg it holds will be immature at the time of retrieval and therefore unusable.  It is highly unlikely that 12 follicles will result in 12 mature, retrievable eggs, which is why we want to see a higher follicle count.

But reading up on various IVF forums, it seems like part of the reason I'm taking the follicle stimulating hormones is to encourage follicles to grow, including small ones that may not have been visible on the ultrasound.  It seems like many women produce more visible follicles as the cycle progresses, so I just have to hope that the hormones do their magic, and that the next time I go in, there will be more follicles.

So I got the call around 2:30pm, and I am to start on 150 IU of Gonal-F and 150 IU of Menopur tonight.  Starting tomorrow, I just take the Gonal-F in the morning and Menopur at night, and then I go in three days later (Monday morning) for another round of blood tests and ultrasound.

I attended what will be my last yoga class for a little while this evening, because I can't do "bouncy" things while I'm on stims (for risk of "torsion", when the enlarged ovaries get all twisted up).  I thought it was an appropriate sendoff to my cycle.  Goodbye, headstands, I will miss you...

I'm relieved that I'm starting my cycle over a weekend so that I can process what is happening to my body in relative peace quiet.  I can let my body adapt to the medication, and I will have the time and head space to be good to myself, do restorative yoga poses (at home), etc.  

I braced myself for the administering of the medication.

I decided to start with the Gonal-F first because seemed more manageable, because it comes in re-usable "pen" form.  Each time I use it, I add a new (small) needle, adjust the dose, inject, and discard the needle.  To change the dose, I just twist the arrow to the amount I need.

I wanted to stab myself quickly as the nurse instructed me to and the woman in the injection training video did so efficiently, but after staring back and forth at the needle and my intended injection site for about 50 seconds, I realized that the two were not going to come together unless I did something, so I resorted to slowly pressing the needle into my skin.  It didn't even hurt, just a tiny pinch.  Pretty simple!  This is the one I'll do in the morning, so it's good to know that it's no fuss and pretty painless.

And now, time for Menopur.  I watched the video at the Freedom Pharmacy Teaching site about three times and re-read my notes from my injections class with the nurse to make sure I understood what I needed to do, and I was still nervous.  The tricky thing about Menopur is that it comes in powder form, so you have to mix the powder with a liquid solution called "diluent" before you can inject yourself with it.  My dose is "two vials" (each vial is 75 ml so it was a 150 ml dose), so I had to go through the mixing procedure twice.  I kept seeing air bubbles in the syringe that I couldn't get out, so I was a bit concerned.

Finally, I injected myself.  This time, the needle hurt going in, and the entire time I was pressing down on the plunger, I felt that unpleasant sting that certain shots have where you really feel the medicine going into your body.  I wonder if it's because the Menopur was cold-- I'm going to try to bring it to room temperature the next time I use it.  (I don't need to store Menopur in the fridge like I have to with the Gonal-F and Ganirelix, but it was 101 degrees in NYC today, and the nurse told me that it never hurts to keep everything in the fridge.)  The Menopur was a really unsettling experience.  I highly encourage the makers of Menopur, Ferring Pharmaceuticals, to work on a "pen" solution like the Gonal-F people have.

I reiterate that I can't believe that they let just anyone administer this kind of medication to themselves because it's a little complicated.  The most anxiety-producing aspect is how sterile everything has to be, and I'm scared that I'm not disinfecting correctly and introducing germs.

The injection sites were sensitive immediately after the shots, but no blood.  About an hour later, all redness went away, and my skin felt normal again.

After the mildly traumatic Menopur incident, I administered myself a scoop of pistachio almond ice cream from Blue Marble which I had ready to go in the freezer (bought as a post-injection reward earlier today).  I might need ice cream after every Menopur shot.  Thank goodness I don't have to do Menopur for another 24 hours.

Meds Today, Shots Tomorrow?

My hormones arrived today at the office!  It wasn't as fun as receiving a shipment of shoes from Nordstrom's, but almost.  

It was 97 degrees in NYC today, and I was a bit concerned because the Ganirelix and Gonal-F need to be refrigerated (or at least at room temperature), but fortunately, the chilled pouch it came in was still cool, though the ice packs were very melty.  I brought frozen gel packs into work from home, and I kept the packs and the meds in the office fridge during the day, and then repackaged everything (surrounding the Ganirelix and Gonal-F with icepaks) so that they'd stay cool on the sweltering commute home.

Today is Cycle Day 1.  Tomorrow morning, Cycle Day 2, I head into the doctor's office to have my blood test to check hormone levels and ultrasound to check how my ovaries are looking, and that afternoon they will call me and let me know if I should begin my hormones that night, and what the appropriate dosage is.  I continue to go in about every other day so that they can monitor follicle progress and adjust meds until I'm ready to take my final shot, the Ovidrel, which triggers ovulation.  I should be on meds for eight to ten days, but it might be slightly longer.

All of my injections are subcutaneous (i.e., fleshy part of the skin) instead of intramuscular (inside the muscle), which is good because it should hurt less.  Subcutaneous shots are generally administered in the abdomen or thigh area-- I'm aiming for the abs because I'm plenty fleshy there!  No injections in the butt like in the movies-- those would be subcutaneous.  I think where you administer the shot and how deep depends on the type of medication.

Why am I taking hormones in the first place?  Usually your body produces one mature egg a month during ovulation.  For my purposes (and for IVF patients who go through this same hormone stimulation process), they want to produce many more eggs to scoop them out all up at once.  During my cycle, they want to suppress all of my natural fertility-related hormones during this time and use synthetic hormones instead in order to grow my eggs (which grow inside of egg "follicles"), as many as possible (within reason), at the same time, so that as many mature eggs can be retrieved when the time is right.  The more responsive you are to hormone stimulation, the better your chances are of a successful outcome, primarily because then the doctor has more in his control over your fertility environment.  

My doctor hopes for "ten to 12 eggs" from me.  I'm hoping for more, because ten eggs doesn't give me a lot of chances.  I read somewhere that 15 eggs seems to be the ideal number (though I'm not sure the basis of that study-- IVF -- correlates with what I'm trying to achieve here), and many more eggs than that can mean that the patient was overstimulated (learn about ovarian hyperstimulation) and doesn't necessarily result in good quality eggs.  According to the article, in this study, during 2006-2007, if they retrieved 15 eggs for an IVF cycle, a woman age 18-34 had a 40% chance of a live birth, which was considered.  That number is quite low, so I'm hoping that technology has improved a lot since 2007 (I think it has) and that fertility rates are better at private clinics than UK public ones...

So here's what I'm going to take:

• Gonal-F -FSH, taken in the morning throughout my entire cycle, used to stimulate follicular development
• Menopur - FSH and LH, taken at night throughout my entire cycle, used to stimulate follicular development
  
• Ganirelix - taken at night starting around Day 7, prevents the pituitary gland from secreting large levels of LH which would trigger ovulation
• Ovidrel - Just a single shot that I administer timed 36 hours before egg retrieval for final egg maturation and release

Here are the amounts I've been prescribed, but I may take more or less depending on how my follicles are progressing:

• GonalF:
• 2 x 300 IU pen (2 refills)
• 1 x 900 IU pen (1 refills)

•  Menopur:
• 25 x 75 IU vials (1 refill) 
• plus syringes and needles because I have to mix these myself

• Ganirelix:
• 4 x prefilled syringes, 250UG/0.5ml each (1 refill)

• Ovidrel:
• 1 x prefilled syringe, 250 mcg (no refills)

You can see videos here of how the medications are administered.  The Ganirelix and Ovidrel are prefilled syringes so that's straight forward.  The Gonal-F is a prefilled pen and you can adjust the dose by twisting the pen to the appropriate dose.  That seems easy enough.  But it's the Menopur that's the most complicated.  I have to put together syringes and needles, mix multiple vials of medication, change needles, and then inject myself.  I can't believe that they actually allow just anyone to administer this medication to themselves-- there are a lot of careless people out there, and I could see them making a mistake in the dosage.

My biggest fear was the dreaded air bubble-- I mean, haven't many characters in books and movies died tragically from the unseen but deadly air bubble in their shot?  I asked my nurse this, and apparently air bubbles are only deadly when introduced into bloodstreams, not flesh, so I am at low risk of inadvertently offing myself.  Small comfort when I think of all the shots I have to give myself.

Cramps, Crankiness, and Countermeasures

I've been on the Pill for about 18 days now, and today I started getting really bad cramps, as if I were about to get my period.  I'm certain that my body is rebelling against the hormones, which makes me a little bit nervous because I am more likely to produce more/better eggs if I respond well to the hormone medication (rather than fighting it).  I'm already feeling so bloated and I'm wiped out by 10pm every night, plus I'm definitely a bit cranky and hypersensitive.  I have to be careful about acting as normal as possible at work.  I'm seriously wondering what's in these pills-- and what will happen when I switch to hormone injections!

So I end my Pill popping on July 18.  On July 22, I will go in for a blood test, and assuming all goes well, I will begin my twice daily hormone injections.  I am going to be on Menopur, Gonal-F, and Ganirelix (which starts a few days in).  I'm told that I should be consistent with my injections.  Given that I need to go in for bloods every other morning by ~8:00am, I will probably be getting up at 6:30am to give myself injections.  Ouch.

I am nervous about pumping my body full of hormones and not being able to regulate my mood through regular exercise.  I turn to yoga in these trying times, especially headstands, and unfortunately, due to the hyperstimulation of the ovaries, I'm at risk for "torsion", i.e., when your ovaries get twisted up from too much movement.  "Bouncy, repetitive motion" is forbidden during hormone stimulation, and nevermind inversions like headstands.

So I took a private yoga lesson with one of my yoga instructors who taught me a number of cool poses I could do in my delicate state (I sound like I'm preggers).  She says that the hormones will make my ligaments stretchier so I have to be careful about protecting them more.  The one pose she said is absolutely the best for relaxation and quieting the body is supta boddhakanasana aka "reclined bound angle pose" or "Goddess Pose", as my instructor calls it.  Here's an example of it.  For me, my instructor said that I should lay on a propped up bolster for more support (so instead of flat on the ground, so like I'm sitting up more).  See the blocks under the knees-- these are to support the hip joints lest my hip ligaments overstretch in my hormonal state.  She said that doing this pose for ten minutes a day is all the yoga I need.

I'm also considering going to acupuncture for treatment, if only it will help me to relax.  I once sought acupuncture treatment for lingering pain from a minor hernia surgery several years ago, and I will never forget how the acupuncturist was able to help "melt away" some of the tightness and pain in the surgery area in a way that no doctor, medication, or massage would.  I've heard that acupuncture can help with "fertility", so I figure it can't hurt.

I may also treat myself to a full body massage to help with relaxation as well as improve circulation in my body.  I'm assuming that this can only help, not hurt, fertility.

In the last few weeks, I have avoided caffeine and greatly reduced my alcohol intake after reading this Guardian article, and I think this is making me cranky.  I have few vices, but I miss my chilled wines and iced teas in this hot weather. 

So tired, need to go to bed now.