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MONDAY, FEBRUARY 9, 2009

Today is the day. We have our big appointment with Dr. Victor Fujimoto at the UCSF Center for Reproductive Health. I have been counting down the days. Like Christmas. Remember when you were little, and it seemed like time stretched on and on and on? Then you get to the day and you wonder, what is in store for you?

I had been preparing for weeks. I wanted to know as much as I could as to speak intelligently to the doctor. I didn’t know if he would be the God Complex type or the compassionate type. Would we have much time with him? Or would this just be a quick meet and greet and then he would send us off for more testing. Having most of the preliminary testing done beforehand was a good idea, I thought. {In the end, Dr. Fujimoto was pleased with that as well.}

My husband has a completely different approach. He prefers to hear what the doctor says, then ask questions based on results. This does make me a bit nutty. I think we should have questions prepared for all the options. We STRONGLY disagree here. What a learning lesson for me. I have to remember that we don’t have to think alike, or be the same. And I can’t expect him to act and think like I do. You know, it is probably better that we are different that way…he may be more open to hearing things I don’t since I have everything written down. I tend to get stuck in what I have in my mind.

We arrived for our appointment a few minutes early. I was happy my husband was ready on time, and we were there with time to spare. My husband likes to breeze in at the last moment, rarely thinking of the details that need to be taken care of when we arrive places-is there paper work to fill out…do we need to bring a gift or wine to a dinner party…will we be checking bags at the airport? This is how we ultimately compliment each other.

The women at the front desk were so kind, and knew us both by name. This made me feel so easy, like we were not just another name in their book. The offices were very nice, and well kept. When we walked in, and I was filling out the paperwork, I noticed my husband seemed a bit distant, glassy-eyed. I think the full weight of what was happening hit him at that moment. We had talked a lot about it, but you can never really prepare until you are in a situation, I think. And, he has so much going on at work right now, I know he hasn’t really had the bandwidth to process all of this. He has told me time and again how much he has wanted a “natural baby.” He wants a family so badly, he will do what it takes. And, we will adopt if we can’t have out own. But I know that the idea of the petrie dish makes him sad. Being the romantic that he is, the clinical nature of this knocks the wind out of him.

The nurse called me in to do my initial vitals…weight, blood pressure, temp…and I wonder, why do I wear boots, jeans and a heavy sweater? My weight shows a solid 5-7lbs more than normal. What a chub. I have gained about 15lbs since our wedding. Most people like to say, oh, married life. Really, I have just felt so ill this year that I have not made it to the gym much lately. I promised myself in that moment I would do what I could to drop some weight before we began a cycle. It would be at least 8 weeks. I can do some serious damage in that time! It really just takes focus on my part, and discipline on my husband’s part. He doesn’t like to eat his ice cream alone, so I really have to get him to promise not to tempt me.

Dr. Fujimoto came out to invite us to his office. I love when the doctor comes himself to the waiting room for you. They just seem more accessible to me that way. We went directly to his office, where Dr. Fujimoto had our file, preliminary testing and initial intake form. Prior to our visit, we were required to review and complete a LENGTHY packet of information. Dr. Fujimoto had clearly reviewed our packet, studied our test results and was well-prepared to meet with us. We came prepared with a list of questions and a calendar charting my menstrual cycle, LH surge, estimated ovulation and intercourse dates.

We spent about 15 minutes discussing our previous results with Dr. Fujimoto. At this point, he suggested we move into the ultrasound room where he would perform a vaginal ultrasound. Again, my husband would be with me, with a man I did not know prowling around my coochie! My husband is actually very cool about it, I am the one who is mortified. I am hoping the more we do it, the better I will feel.

Off we went, and I undressed from the waist down. At least this time the table had some cushion, was on an incline and had stirrups. HOWEVER, there was NO MODESTY with Dr. Fujimoto. I had the paper drape over my lap, and when I lay down on the table, he essentially threw it up over my waist. ohhhkaay! This was also the first time that I had a vaginal utlrasound where I did not insert the probe myself. He was not rough or anything, I was just a bit startled…my first meeting with a male doctor I didn’t know, and he was probing me! Like I said, I think it will get easier. And I think I will HAVE to get over it by the time we go in to birth the baby. I have heard that you just CANNOT care at that moment.

During the ultrasound there was a female nurse in the room (who did not introduce herself to me, huh?). Suddenly, Dr. Fujimoto became quite serious and very professional. The casual and friendly atmosphere redirected and my husband and I became silent. I was worried. And, to be honest, I was terribly sad. Heavy news was to come. Dr. Fujimoto began dictating notes to the nurse, describing the number of antral follicles found in each ovary. He gently removed the probe, asked me to get dressed, and invited us back to his office.

When we sat down with Dr. Fujimoto for our second discussion, the air in the room felt a bit dark to me. My husband and I were holding hands, we were determined to be optimistic. This was our first fertility visit, and had the idea that we would be sent for tests and take a few steps at a time towards a diagnosis and getting pregnant. We were so wrong.

For better or worse, Dr. Fujimoto was extremely candid with us. It was hard to hear, we were stunned. BUT, to say we were appreciative is an understatement. His ability to understand complex issues and explain them to people outside the medical profession is unmistakable.

Dr. Fujimoto’s assessment was:

  • My FSH level, at 9.8 units/liter, was high, and drifting upward. This was a surprise as my ob/gyn had reported all my blood work to be in the normal range. Normal range is actually 4-7 units/liter.
  • I had a significantly low antral follicle count of 8 follicles. A normal follicle count would be 40-50.
  • My husband has a borderline low sperm count at 20million.

What did all this mean? Could we proceed with IUI? This was the recommendation from our ob/gyn. This was also the preference of my husband, it seemed the most natural option.

No. With a drifting FSH level, my ovaries and egg quantity are likely compromised. I have a low ovarian reserve, and, like most women, am shedding close to 1,000 follicles per month. IUI would provide us less than a 10% chance per month of conception. IVF would provide us a 35-40% chance per month of conception. Dr. Fujimoto strongly recommended us to move straight to IVF. Indeed, he said that if we wanted to have a family, this was our time. In fact, we had no time to waste.

We left with a handful of cards for the IVF team…the coordinator, the nurse, the billing team, the urologist…I’m sure there are more I can’t remember right now. We all agreed we would spend the weekend deciding what to do and contact Dr. Fujimoto the following week with a decision and/or any follow up questions.

My husband and I walked into the elevator holding hands in complete silence. It is not like me to not start chatting right away. I like to know what he is thinking. I usually need to pry it out of him. I was in shock, though, that we had to move to the most drastic fertility procedure from the get-go. As we walked outside, my husband ran his hands through my hair, rubbed the back of my neck, and kissed the bridge of my nose. I always know how much he loves me when he does this. I couldn’t have married a better man.

My husband went to have his semen analysis, to “give his deposit” as we like to say. I told him not to touch anything πŸ™‚ He said he wouldn’t need any magazines, he would just think about me. Sweet, but what a crock! He should take the opportunity to check it out, just make sure you sanitize!!!

His results read as follows:

Semen Volume: 5.5mL

Semen Color: White

Semen Viscocity: Liquified

Semen pH: 8.0

Sperm Motility: 64%

Sperm Normal Morph: 37%

Sperm Count / cc: 20 MIL / mL

All results here were fairly normal with the exception of sperm count. This was on the low side of normal at 20 MIL / mL. It should be 20 – 100 MIL / mL.

{sigh} We wondered if this was the issue…was my husband’s low sperm count the reason we hadn’t conceived? So far, I had fairly normal results.

During my HSG procedure, the Radiologist suggested I may have a myoma (fibroid) based on the shape of my uterus. He suggested I get an ultrasound to rule out. My test results from the HSG were written as follows:

CLINICAL HISTORY: Infertility

METHOD: Following a cleansing of the cervix catheter was advanced into the uterine cavity and water soluble contrast was injected.

FINDINGS: The fallopian tubes are normal in course and caliber and spill freely into the pelvic peritoneal space. There is a mild indication of the superior surface of the uterus. The possibility of a myoma is raised.

IMPRESSION: Normal uterine cavity and fallopian tubes.

I was able to view the image of my uterus, and it looked like a kidney, not like a pear as it should be. For some reason, I was suddenly stressed. I knew at this point we were headed down a difficult path.

I phone my ob/gyn and requested the order for the ultrasound. She was very laid back about the possibility of any complications or any myoma. She felt confident that we would be able to proceed with IUI. I didn’t feel as confident. I spoke to my husband about it. He seemed to think I was over reacting. My parents as well. I KNEW SOMETHING WAS NOT RIGHT.

I had the ultrasound six days later on January 28, 2009. It was a tough six days for me. It was all I could think about. I did too much research on the internet, and knew too much about the potential treatment / surgery to remove a myoma. It was a potential 4-5 day hospital stay and 4-6 week recovery. Everyone was telling me not to let my mind get away from me. It was a real challenge. I had a deep feeling that internally I was not functioning properly. I had been experiencing incredible pain during my periods and ovulation. I wondered if I had mistaken that pain for a myoma or a cyst.

Every time I have an ultrasound, the technician is unable to execute abdmoninally since my uterus is retroverted. I drink more water than I am supposed to drink, I wait until I think I will burst, and still, I end up having a vaginal ultrasound. This time was no different. EXCEPT…the ultrasound team was running behind and I had to wait an extra 35 minutes beyond my appointment. I nearly wet the table.

It didn’t take long for the tech to realize she couldn’t get a good view abdominally, so she released me to the restroom. I came back for the vaginal ultrasound, and found the tech to be incredibly kind and gentle. She also did something that no other tech had ever done…she gave me results as she viewed them on the screen.

She found two small fibroids and two cysts. My exam results were written as follows:

EXAMINATION: Transabdominal and endovaginal pelvic ultrasound

CLINICAL INDICATION: Fibroids

COMPARISON: 9/13/2004

TECHNIQUE: Transabdominal and endovaginal ultrasound performed.

FINDINGS: The uterus was measured 9.3 x 4.0 x 5.1 cm. A 1.3cm anterior intramural fibroid is visualized. There is a posterior fundal subserosal fibroid that measures 1.2cm. The endometrium appears smooth homogeneous and measures 6.3mm in thickness. The right ovary measures 3.6 x 3.5 x 4.5cm, while the left ovary measures 2.5 x 2.1 x 2.7cm. Two adjacent simple appearing cysts are seen within the right ovary. They measure 3.0 and 2.0cm. The left ovary is unremarkable. No free fluid is seen.

IMPRESSION: Two small uterine fibroids as described. 3.0 and 2.0cm right ovarian cysts.

Based on these findings, my ob/gyn wanted to take a “watch and wait” approach. I must say…I don’t like the idea of having any more procedures, but I don’t like “watch and wait” either. It bothers me to no end that there is something growing inside me that we will just wait to see what happens.

We had our first appointment with the UCSF Fertility Center February 9, 2009…only two weeks away. We just need to get to that appointment, I thought.

In the meantime, my husband went to get his semen analysis.

GETTING READY

January 22, 2009

We scheduled the HSG one week after my period ended, but before I ovulated. It was important to make sure I finished my period but hadn’t ovulated-if there is ANY possibility you could be pregnant you SHOULD NOT have this procedure. We also did it on a day my husband could come with me. I was a bit nervous about it, yet excited at the same time. Anytime I have the opportunity to get a look into my body I am absolutely fascinated.

My ob/gyn told me this was an easy, minimally invasive procedure that would cause mild cramping. I have a retroverted uterus and endometriosis, with a history of painful periods, and thus was concerned about my pain level. She suggested I take 800mg ibuprofin an hour prior to the procedure to relax, but that I would not need anything stronger.

The HSG is scheduled as an outpatient procedure in the surgery center of the hospital. I checked into the hospital, was given my ID bracelet, and taken into the surgery center x-ray room. My husband was able to come with meβ€”his first experience with me naked with a doctor! We entered the room and were greeted by the Nurse Assistant and the Radiologist (The procedure is performed by a radiologist, not an ob/gyn). I changed out of my clothes into a gown and laid down on the x-ray table. The Radiologist laid the lead apron over me and draped a lead gown over my husband as well. At this point, he explained the procedure to me.

  • I would scooch down to the edge of the table and bring feet up into a “frog leg” position. NO STIRRUPS! (I thought this was odd)
  • The Radiologist places a speculum in my vagina and visualizes the cervix.
  • A soft, thin catheter would be placed through the cervical opening into the uterine cavity and then a narrow metal cannula is inserted through the cervical opening.
  • Contrast dye would be slowly injected through the catheter into the uterine cavity. An x-ray picture would be taken as the uterine cavity is filling and then additional contrast is injected so that the tubes should fill and begin to spill into the abdominal cavity. (Additional x-rays are taken as this “fill and spill” occurs.)

THE PROCEDURE

I have to say, I was a bit mortified! Having the same female ob/gyn for 20 years, here I was on the table with a strange Radiologist up in my business with my husband watching. While the Radiologist was very professional, he did lack the grace and gentle nature of an ob/gyn. He did, however, talk me through every step of the procedure as he worked away. I appreciated that! He also allowed my husband to stay and hold my hand. I don’t know that my husband’s hand ended up liking that too much πŸ™‚

He placed what may have been the largest speculum I have ever seen into my vagina, cleaned my cervix with betadine and inserted the catheter. This WAS NOT mild cramping. This felt more like the most painful menstrual cramps combined with the abdominal cramps that send you running to the toilet. It was a sharp, stabbing pain that literally made me see stars and put me in a cold sweat. For a moment, I thought I would pass out. I was thankful I was already lying down. According to the assistant, I turned several shades of pale.

After a brief moment of comfort, the Radiologist injected the contrast dye, so painful. At the same time, it was one of the coolest things I have ever seen. Directly above me was a TV screen where we could see the dye filling my uterine cavity and spilling out, then flowing into my fallopian tubes. FANTASTIC NEWS! Everything was clear, and functioning as it should. It was like nothing I had seen before, and rewarding to have instant feedback from the doctor. He removed the catheter, I got up slowly, had some water, and went to get dressed.

THE RESULTS

We were over the moon that everything was flowing smoothly, it meant we were clear to proceed with IUI. In that moment of happiness, the Radiologist came in to tell us he saw an abnormality in the shape of my uterus. He saw an indentation on the top, indicating there may be a cyst or fibroid growing on top. This was something he could not see on the HSG, and recommended an ultrasound prior to any fertility procedures. Ugh. I got dressed, we left.

This is a photo of a normal HSG

normal-hsg

PERSONAL TIPS & THOUGHTS

It does hurt, sorry. The doctors will all tell you this is a relatively pain-free procedure that should cause only mild cramping. From all the women I have spoken to, and from what I have experienced and read, IT IS NOT. Be prepared for that going in. I continued to have cramps for 3-4 hours after leaving the hospital, and found that resting with a heating pad was a great help.

Rolling over. You may have to roll on to one or both sides while the speculum and catheter are inside of you. This is not comfortable. I had read prior to my HSG that this meant something was wrong. I had to roll onto both sides, but ultimately there was no blockage. Don’t worry if you have to do this, maybe they are just trying to get a thorough look.

Bring a sanitary napkin with you. After the procedure you may have blood or dye that leaks out. I was somewhat of a rare case in how much I bled (I am told), but do know that most women have some spotting or dye that isn’t absorbed.

TALK TO YOUR DOCTOR! Ask them to tell you what they are doing as they are doing it. This can be a bit scary, but if you know what is going on, you will find it really interesting. It will also distract you a bit. Also, look at what is going on the TV. It is not often you get that kind of peek into your body, so check it out!

This is not routine for you. Don’t be afraid to tell the doctor and nurse if you are in pain. This is something they do everyday, and for them is no big deal. We don’t do this everyday.

Get up slowly. Again, from personal experience, and from speaking to others, many women feel faint after this procedure. Take it easy when you are getting up. Have some water. Make sure you have had something to eat before you go. Be sensible.

During the Fall and Holiday of 2008 we received our test results.

My husband was told that his Semen Analysis was all within a normal range with one exception: He had a sperm count on the low side of normal. His count was 20 MIL/mL. Normal is 20 – 150 MIL/mL.

I was told that my FSH and Thyroid functions were within normal range (I was not told the numbers).

Based on these results, our doctor recommended we move straight to IUI. Her thought process that we simply needed help getting my husband’s sperm past my cervix (and its mucous) up to greet my egg.

To prepare for IUI I needed to have a hysterosalpingoram (HSG) to insure my fallopian tubes were clear, and there were no blockages or growths.

At this point, I had made an appointment with UCSF Medical Center. I really felt that we were going to need assistance beyond what everyone was expecting. I could feel it, even though everyone was telling me to not get ahead of myself. I was ok to do as many tests as we could with my current ob/gyn to prep, but knew we would need more.

I had my annual exam October 2008. At this time, I pressed the issue with my ob/gyn regarding next steps aiding our fertility. I was disappointed by her knowledge, or lack thereof, of both male and female fertility issues. This doctor is one of the most reputed in Northern California, and has been mine since I was 17 years old. When I asked her a few (in my opinion) basic questions, she was unable to answer them to my satisfaction. In general, I found her answers vague, uninformed and lacksidasical.

A few of the questions I asked:

  • Is there any concerns that my previous inclination toward cyst development is impeding my ability to get pregnant?
  • Has the amount of / duration of time I have taken birth control pills affected my ability to ovulate, and thus get pregnant?
  • What do you make of my cycle length(s)? (They were erratic for the first 4 months, then regulated at 24/25 days)
  • Are there dietary or environmental changes I can make to affect potential conception?

At the end of the exam, based on my short cycle length, my doctor recommended we begin a course of Clomid treatment for 3-6 months. Should this be ineffective, she recommended we see a specialist. She briefly explained to me that Clomid is the most common first-line fertility treatment used, roughly in about 25% of women with trouble conceiving. The purpose of Clomid is to establish a regular ovulation pattern. Unlike many other fertility medications which promote the production of more eggs from follicles, Clomid focuses on regular development of a single egg.

I left my appointment a bit frustrated by my doctor’s lack of knowledge, but excited to have a direction. I was off to my computer to do a little research. Google can be both a blessing and a curse in these situations.

MY ADVICE: Always proceed with caution! There is a TON of information out there, and at a certain point, you have to shut it all out and have a direct conversation with your provider to understand the best course of action for your case.

None the less…after a bit of research, my husband and I concluded that there were several tests that were supposed to be ordered prior to Clomid therapy. Additionally, I was suspect as to whether or not Clomid was the right course. After several messages to my doctor’s office, I was able to speak with her. She ordered the following tests:

  • Day 3 FSH levels
  • Day 7 LH and Thyroid

I went into the office the following day to pick up the blood work order. Attached to it was a form checklist / cover page with the title “Infertility Testing”. {I HAVE TO SAY: I actually paused, albeit the briefest of moments, when I read that walking down the hallway. It hit me that after all these years of dreaming of my perfect husband and beautiful children, all the years of loving my nephews unconditionally, all the years of gushing over my friends’ children, I was the one who was going to have trouble having a baby. All the late nights I had worked, the fantastic trips I had taken, the unbelievable experiences I had slipped away in one breath knowing I may have waited too long.}

This checklist included the description of 6 different tests the doctor may run to determine initial fertility issues. I wondered why we hadn’t discussed this previously? I read all of them, and their descriptions, noted the ones with “X” by them indicated I needed to complete, and then studied the others crossed off-as though I wouldn’t need to worry myself with those. Oddly, I did. I read them, and googled them to get an idea of the trajectory of testing ahead.

THE CHECKLIST

  1. Day 3 FSH (Follicle Stimulating Hormone) blood test
  2. Day 7-10 LH (Luteinizing Hormone) blood test
  3. Hysterosalpingogram (HSG)
  4. Hysteroscopy
  5. Exploratory Laproscopy
  6. Semen Analysis (PHEW! One that wasn’t for me!)

When I asked about the other tests, I was told that I would likely not need any of them. When I talked to my husband, mother and father about them, they told me I was being dramatic, and not to get ahead of myself. I just felt something was off.

At this time, I was VERY adamant with my husband that he get the semen analysis order from his doctor. I wanted to know on both sides what we were dealing with.

So, we were off! Testing was under way. We continued to have sex, during the right and “wrong” times πŸ™‚ We used the mucous test and the First Response Ovulation Predictor Kits to determine my ovulation. When it was time, we had sex every other day. Based on my husband’s age (42) we were told he needed a day to regenerate good sperm.

Here I am, writing my first post in my blog chronicling our experience trying to get pregnant. What a journey so far. As many women have said, you spend your whole life worrying about getting pregnant, then the rest of your life worrying about getting pregnant! Isn’t’ it the truth.

A little about me…I am a 38 year old Caucasian female of Northern European descent. I have never been pregnant, had an abortion, D/C, ectopic pregnancy or the like. In 2002 I had a pelvic laproscopy to remove a large 9cm ovarian cyst, a 7cm tubal cyst and a mass of adhesions. The biopsy from the surgery revealed endometriosis. Following the surgery, I had a series of ovarian cysts on both the right and left ovary, resulting in several ER visits. In an effort to control this issue, my ob/gyn placed me on continuous high dose (30mcg) bcp. This course of treatment quelled the cyst production to 1-2 per year.

Upon marriage in 2007, my husband (42 year old Caucasian Male of Northern European descent) and I decided to stop bcp and begin unprotected sex. After 13 months of continuous unprotected sex, and timed intercourse based on basal body temp readings, mucous changes and OTC ovulation predictor kits (for LH surge), we had not conceived. My ob/gyn recommended we continue trying, possibly with the help of Clomid, for a few more months. I felt differently, and pushed to see a fertility specialist ASAP.