The Rate-Determining Step

I am not sure if it has come up here before (probably so since I have written about all kinds of things over the years), but there was a significant portion of my life when I wanted to be a medical doctor. Life, my science grades, and my test scores took me in a different direction, and I never tried to retake the MCAT or reapply to medical school. But before all of that, I still learned quite a bit of chemistry. For some reason, I recently remembered the term "rate-determining step," which in the chemistry world refers to the slowest step of a chemical reaction. This step (often?) determines how quickly the rest of the reaction can proceed. My general chemistry professor, Dr. Dopke, explained it something like this: if we decided we wanted to go to the beach in Florida (leaving from Mercer's Macon campus in central Georgia), there would be a few steps involved. We'd need to (1) head back to our rooms/homes, (2) pack our bags, (3) load up the car (and maybe get gas), and (4) actually drive to the beach. Some people lived closer to the Willet Science Center than others, so the duration of step 1 would vary a bit. Similarly, some people pack deliberately, and others throw a few things in a bag and head out. Even with those differences, what would really impact the travel time would be step 4: getting from central Georgia to some coastal area in Florida.

Lately, I have been thinking about how much I shared as we navigated fertility treatments and how quiet I have been through pregnancy (comparatively). Medically, I have been fortunate to have an uncomplicated pregnancy, but I remained guarded because I had gotten my hopes up so many times when we were trying to make embryos and stay pregnant. I also remembered how hard it was to see what felt like the rest of the world moving forward with growing their families while no amount of hoping, praying, or throwing money at the problem seemed to work. While any updates I posted about my pregnancy were met with support and enthusiasm, I didn't want to trigger other people who were still in the infertility trenches. The days kept ticking by, though, and every week was a little better. Then when I reached 32 weeks back in March, my doctor started bringing me in for twice-weekly ultrasounds (thank you, hypothyroidism and pregnancy!) and told me we would schedule an induction for the baby. That initiated a whole new series of worries that maybe there was more wrong with me than I realized. Eventually, I grew to welcome the little visits to see how the baby was progressing--largely because everything looked good at each visit. 

Going back to the chemistry analogy, pregnancy has, in many ways, been the rate-determining step in our journey to grow our family. Cumulatively, the nearly three years we spent trying to conceive were longer in duration than this pregnancy, but there was a conclusion at the end of each month; not pregnant, try again. Each IVF cycle had its own mini-steps where I could provide updates: follicle measurements, retrieval numbers, fertilization numbers, blastocyst numbers, and testing results. Our first two embryo transfers led to short-lived pregnancies, so I always had an update about those as well. With this pregnancy, however, each appointment or update was the same: still pregnant, probably going to have a baby, but no guarantees that some unusual circumstance could strike.

We scheduled the induction for today, and I am writing this post with an IV in my arm. I am getting fluids and medication through the IV, and the contractions are starting but are mild. At my ultrasound on Thursday (May 4), Baby Davis's estimated weight was 9 pounds, 10 ounces. My doctor reported that the baby was still sitting up high, and my cervix was closed. Like for real closed. It turns out this baby is smart like their parents and figured out that life on the inside is pretty sweet. We discussed a possible C-section instead of induction, but I told him I would like to try labor and see if I could deliver vaginally. So, that's where we are at the moment. Ultimately, our goals are (1) a healthy mom and (2) a healthy baby.

After I was all hooked up this morning, our nurse told me she would be watching the baby for any changes while I rested. We have been listening to the baby's heartbeat on the monitors. Before I drifted off for a short nap, I told Richard that I was glad to be in the hospital so if anything did turn south, we would have a team ready to take the baby out and give us both the care we need so we can achieve our two goals. I am surprised at how reassured I am by the sound of this little heartbeat, and I can't wait for the end of our rate-determining step as we proceed into parenthood.

Until that happens, we continue to welcome thoughts, prayers, gender guesses, and funny labor stories. I'm going to take another nap.

Anniversaries and Pregnancy

It's been a while. I'm still here and still pregnant. These are both good things, though the holidays and today specifically have been tougher than I would like to admit.

Balancing grief due to pregnancy loss and excitement from a pregnancy that seems to be working out is challenging. The holidays hit me hard as I thought about the two babies who did not make it to see Christmas 2022 with us. Someone encouraged me not to think about the babies that didn't make it but to look forward to the sweet one on the way. Even with such early losses, I never want to forget; it does not seem fair to them or to me. 

Fortunately (at times anyway), I rarely forget something that feels important to me. As long as I can remember, I have always been good at keeping track of dates. Weirdly, I was not a superstar history student, but I can recall dates from my personal life well. This is a double-edged sword on days like today. January 10, 2022 was my first ultrasound appointment that wasn't checking for follicles or looking at the thickness of my uterine lining. (There were so many of those!) After several positive but slow-growing betas following our fresh embryo transfer in December 2021, we had an early OB appointment to check on our embryos. While I was nervous that slow-rising betas could mean an ectopic pregnancy, I was hopeful for good news.

I thought we were in the clear as long as the embryo had implanted in my uterus and not my fallopian tubes, but I learned that morning that a blighted ovum (anembryonic pregnancy) was not only a thing that could happen but a thing that was happening to me. I will never forget my doctor repeating, "I don't like what I'm seeing." Those words still haunt me; I hear them in my doctor's voice because that's how they're cemented in my memory.

A year later, I am 22 weeks and 5 days pregnant with what we hope will be the first child we get to meet in person. But also a year later, I find it difficult to be truly excited about an ultrasound. 

I haven not posted many pregnancy updates for several reasons. One is that I find baby bump shots kind of triggering, though I did totally buy into the silly trend to take a picture with Ben and Jerry's Half Baked ice cream when I hit 20 weeks pregnant (halfway). Another reason is that I have not been able to shake the feeling that the other shoe is about to drop. Pregnancy after infertility is a wild ride, even if the pregnancy itself is relatively uneventful (which mine has been so far, thankfully). It's difficult for others who have not walked this road to understand why I often feel that healthy babies happen to other people, not to me. 

I ran across my letter board in my closet today, and I have not redone it in a year. It still has the same vocabulary-themed message I wrote last January, even though I could have been using it over the past few months to share updates or write about how the baby is the size of various foods or 80's and 90's nostalgia items--I think Furby week is next week!--as reported in the pregnancy apps. Overall, though, we are doing well and hopeful that our estimated due date of May 11 (or somewhere around there because babies seem to do what they want) will be the day we have dreamed about and waited for. Please remember us over the next few months; perhaps I will update again, but I'm always happy to talk outside of the blog about the candy I am eating, how many naps I have taken lately, or what my latest maternity clothing purchase has been (lately it's running clothes!)

Special jewelry my friends have sent to help me remember the journey, our babies, and our incredible support network.

Something that made today great: I checked several tasks off of my mounting to-do list at work! 

Time I woke up: 8:55 am

Transfer #3 - Ultrasound Appointment

After three weeks and two days that somehow flew by but also seemed to take forever, Richard and I returned to our fertility clinic. (Recall that after two promising betas, they told us to go live our lives for a bit. This was definitely weird after going for frequent monitoring and bloodwork, but we managed to fill the time. I spent quite a bit of the time questioning potential symptoms--"Was that a cramp?"--and had one scare with a small amount of spotting when I finished my run one afternoon (it was fine and actually normal)). 

To cut to the chase, the news today was all good. Our ultrasound tech found the heartbeat quickly, and the measurements all looked great! Based on my treatment cycle, I hit 8 weeks pregnant today, and the baby (yes, there's a BABY!) is measuring 8 weeks + 2 days with a heart rate of 167. (I told some people 166 because I apparently forgot...but the paperwork said 167.) The baby is about the size of a gummy bear.

When we met with the nurse after the ultrasound, she told us we were kicked out of the fertility clinic and off to the regular OB/GYN (you know, the doctor where people who get pregnant in less...complicated?...ways go from the beginning). She gave us a graduation bag, which was exciting but also made me feel self-conscious because I have watched so many people carry those bags out of the clinic and felt like I was being punched in the gut. I made Richard carry the bag, and we skedaddled through the waiting room and out of the clinic as quickly but inconspicuously as possible. (It was probably neither quick nor inconspicuous, to be honest.) Then, we went to Whataburger because that's our most frequent post-fertility clinic breakfast stop.

As fate would have it, my annual visit to my OB/GYN was scheduled for 9:40 this morning, so I hand delivered our graduation papers--including a letter from my RE that began, "It is my pleasure to refer Kimberly for routine prenatal care"--to my doctor today and set up my next ultrasound and appointment. After 3.5 years of routine checkups and bloodwork, procedures, and surgery to see what the heck is going on (which remained unexplained, but we ruled out a bunch of stuff), he is ready and excited for this next adventure.

For the rest of my day, I wore the graduation cap that Maryanne and Josephine bedazzled for my LSU graduation party, and it was the perfect accessory for graduating from the fertility clinic. Since I work from home, nobody really saw it, but I did wear it to my therapy appointment. (And somehow managed to get some work done despite having three appointments!) Here's a photo of me wearing the hat and using a "clear skin" Snapchat filter because I have been picking at a spot on my chin.

And because Richard rarely gets attention on my blog (despite the fact that he's the dreamiest), here's a picture of Richard today after our appointment. He was ready to go to bed but tolerated the quick photo op. 

So, this is all pretty cool. I don't have pregnancy symptoms other than some tender breasts, mild cramping, and wanting to take 4 naps per day, but I am reminding myself that some (many?) people reach this point in pregnancy without having any symptoms or even knowing they are pregnant. We still have a ways to go--as my OB/GYN said today, we won't worry as much after 13 weeks, but we really won't stop worrying until the baby is born. Then he quickly corrected his statement and said we won't stop worrying until the baby is done with college. That's about what I had gathered independently.

Our next steps are ultrasound and bloodwork in two weeks (10/13) and a visit with the OB/GYN in about three weeks (10/21). Until then, my job is to stay hydrated, eat well, and not stress. I'm going to give it my all and hope that my best is good enough! We are excited and grateful for lots of support and prayer while we wait.

Something that made today great: It's pretty tough to top graduating from our fertility clinic.

Time I woke up: 6:40 am

Transfer #3/FET #2 - Beta #2

After the good news on Friday, I took home pregnancy tests every morning when I woke up (that's first morning urine, or FMU) to make sure I was still pregnant. While a common practice, this is not a best practice for many reasons including that the darkness of the line is indicative of the concentration of HCG...but only to a limited extent. My lines were looking good, and I got what's called a "dye stealer," which is supposedly when the test line is darker than the control line because it has stolen some of the dye that would've gone to the control line. I don't know how true all of that is. 

What I do know is that the amount of dye stealing leveled off, and I spent some time going down Google rabbit holes to compare pictures of other people's pregnancy tests and HCG levels to try to guess where mine was. I do not recommend doing this, but for full transparency, I now have a photo album on my phone called "Other People's Pregnancy Tests." I also have an album of photos of my own tests, appropriately titled "FET #3," but despite my openness about infertility and other intimate matters, I have a personal policy that prohibits posting pictures of things I peed on to my social media/blog. So, you'll just have to trust me on these.

On Friday morning, I calculated that my HCG would be around 824 if it was doubling every three days and 1308 if it was doubling every two days. In some photos, tests that looked like mine aligned with HCG around 1000. In others, tests that looked like mine were in the 500 range. Still in others, tests that looked like mine had HCG levels around 2000. So, I didn't know what to expect, but I kept hoping and praying for a healthy rising beta.

My blood result yesterday, about 99 hours after Friday's beta? 2459. Woah. This number doesn't have any 3s in it, and I have no musical recommendations based on this number, but I guess 2459 means something to me now!

I found out my result early by stalking my patient portal, and I even wondered if there was the slim possibility of a mix-up. When my RE's assistant called an hour later, she read me the same number. This time, I responded more professionally than I did when she called with our preimplantation genetic testing (PGT) results. (It probably helped that I knew what to expect.) She told me to continue all of the medications and that my RE wanted to see me around 7 weeks, so September 29 or 30. Naturally, I picked the earlier date, but it's still over three weeks away.

While I recognize that not needing to go back to the RE's office is probably a good thing, it feels a little weird to have weeks to wait after biweekly monitoring appointments for egg retrievals and IUIs. This is just one way that infertility has warped my ideas about what pregnancy is like. Pregnancy has been so difficult for us to achieve that it's hard to imagine just sitting and letting a baby grow, but that's exactly what plenty of people do. In fact, many people might not even know they are pregnant at this point (five weeks today!)

This seems to be our most promising transfer yet, so I'm remaining hopeful and dare I say allowing myself to get a little excited? I don't have any major symptoms but am definitely grazing and snacking more than usual. I'm not complaining yet, but I'm definitely going to have to find ways to stay busy for the next few weeks. There's plenty of knitting and work to do, and I'm not one to turn down a nap either. In other good news, my RE said I could run as long as I paid attention to my body and stayed hydrated. I am super hydrated, and so far run/walking is working for me.

Fingers crossed for rising betas and a growing baby!

Something that made today great: A visit to Buc-ee's!

Time I woke up: 7:45 am

Transfer #3/FET #2 - Beta #1

Today was a day I had been nervous about since January. It was the would-have-been due date for the baby we would have had if our fresh transfer from December had progressed. When I received my FET calendar and saw that my pregnancy blood test, or beta, was today, I knew the results of the test could make the day more difficult or a little sweeter. I tried to balance the grief from the past (that is sometimes still very much present) with hope for the future.

I scheduled my appointment for 7:30 am, which is when my clinic opens. They close at noon on Fridays, and they told me I would hear something before they leave. At 9:58 am, my phone rang. It seemed a little early for results (though I learned at my support group last night that the actual running of the test part only takes 18 minutes), but surprisingly, my RE was on the other end. It's always a little awkward when anyone from the clinic calls with an update because I try to play it cool and end up sounding a little like Eeyore. Especially because I know that my RE is the one who calls with bad news, I was caught a little off guard that he was calling. Fortunately, the news was good. 

Today's beta was 327, which was not a number we ever saw with our first FET and a number we did not see until more than 15 days after the transfer with our fresh transfer. Today is 10 days past transfer, so this is a good thing. Then again, I have to remember that I have seen positive pregnancy tests and had positive betas before, so I have to keep myself and my emotions in check. The next step is to see how fast the beta doubles; I'll go back Tuesday to see what's going on.

My nerdy brain decided to try to make something cool out of the number (other than, you know, that the transfer worked, at least so far) and I realized that 327 includes the number 3 and 3 cubed (27), and it was our third transfer. So, that was neat! Then, I listened to multiple versions of the Schoolhouse Rock! song "Three is a Magic Number," two of which I have linked below. Please enjoy as you enter the long weekend.

The original Schoolhouse Rock! version:

The version by Blind Melon on Schoolhouse Rock! Rocks:

"No Rain," the only other song I know by Blind Melon:

Something that made today great: Good beta news!

Time I woke up: 7:45 am

 

IVF Cycle 5 (Catching Up Installment 3 of 3)

So much time has passed since my last update that I had to go back and read my last post to know where I left off and what I said. I left off at the egg retrieval on June 21, where we retrieved four eggs. Writing this all now seems a bit anti-climatic compared to building up through blog posts with each update, but I'll try to keep it interesting.

Early on June 22, the morning after the egg retrieval, the embryologist called to let us know that all four of our retrieved eggs were mature and had fertilized. This was, of course, the best possible scenario, so we were thrilled to get the update. They reminded us that our next update would be after day 6 (June 27), so I expected an update on the morning of June 28. 

On the afternoon of June 27, the embryologist called with an update. Fortunately, I did not have time to remember that the call was coming early; otherwise, I might have started spiraling and assuming everything stopped growing. Instead, she had a very happy update: three of our embryos were graded highly and had been biopsied and frozen. The fourth embryo had arrested (stopped growing), so three was the final update. I try not to put too much weight on embryo grades, but it was nice to hear the good news.

The next stage was to wait for the genetic testing results to come back.  The wait on this part is between one and two weeks, so I was not exactly sure when we would have news. As a refresher, the rule of thumb is that less than half of embryos sent for testing come back normal. In the three cycles where we froze and tested embryos, we'd gone 0/1, 2/3, and 0/1, for an overall of 2/5.

It turns out the correct answer was July 6. My RE's assistant called to let us know that all three embryos tested normal. My response?

"Holy shit."

Then I quickly regrouped and tried to be professional.

"Well that was really unlikely, but it was definitely what we hoped for." 

In the meantime, I had started my next menstrual cycle, so I had already called my RE's office to initiate a transfer cycle. We scheduled the transfer for August 18. As with other IVF things, the first step was to take birth control pills. We later added Lupron shots, and sometime after that, Richard got COVID, and I got COVID five days after that (despite my best effort). Fortunately, the COVID situation only set us back five days instead of requiring us to cancel the cycle. I stayed on the Lupron for five extra days. Next, we added estrogen patches and tablets, stopped the Lupron, and added PIO. Thankfully, our nurse gave us a printed schedule that made it easier to track everything. 

We transferred the embryo last Tuesday (August 23). Our RE said the embryo looked great, and he was excited about the expansion. I did a bogus job preparing my bladder for the transfer. This was a rookie mistake; I should have started drinking sooner. I ended up with a full belly and mostly empty bladder, but fortunately, it wasn't so empty that they had to backfill my bladder. I do not fully understand what backfilling a bladder entails, and I don't think I want to know. What I do know is that I am glad that didn't have to happen. Here's our hopeful future child!

After the excitement of the FET, Richard took me to McDonald's, then I took the rest of the day off work to relax (read: nap) and stay cozy. Rumor has it that embryos like a cozy environment, and since this one is genetically related to me, there could be nothing better than a day of McDonald's, naps, and warm blankets. I took the next few days completely off of exercising but started power walking (30 minutes) on Friday. I'm ready to run, but I'm more ready to have a healthy pregnancy, so I'm holding off. 

Our first beta (blood draw) is Friday morning, and we are hopeful for better news than ever before. The third time is the charm, as they say (though that was wrong for our third retrieval cycle, so who truly knows?)

Something that made today great: One of my dissertation participants e-mailed me to let me know he read my dissertation and was impressed! 

Time I woke up: 8:45 am

IVF Cycle 5 (Catching Up Installment 2 of 3)

 I was surprised to check my blog and see that my last post was just over a month ago. More than ever, the weeks are flying by. I feel like I have not caught my breath in months...whew.

I left off at the end of May, which was when we heard back from the ERA that I was prereceptive and needed additional progesterone before transferring a frozen embryo. Since we used one of our euploid embryos in the October 2021 FET, we were left with one euploid embryo in the freezer, so we wanted to go for another egg retrieval first. Despite our luck thus far, we still hope for multiple children. Also, it might take more than one to achieve even one live birth. 

Since we'd been in the IVF game for a while, we had to redo a bunch of paperwork and consent forms, which felt weird and like pouring salt in the wounds, but we did not have to rewatch the videos about how IVF works. The cycle began with birth control, as all of the others have thus far. I started the stim shots on June 8, and our protocol was a little different this time. In the past, we did Lupron (10 units) and Follistim (250) in the morning and Lupron (10 units), Follistim (125), and Menopur (150) in the evening. For this cycle, we dropped Lupron entirely and did Follistim (300) and Menopur (150) in the evening for the shots. In addition, I took 100 mg of Clomid and 10 mg of Provera in pill form.

Our monitoring appointments went like this:

• June 13 (Day 6 of stims): 2 follicles - 11 mm on the left; 12 mm on the right
• June 15 (Day 8 of stims): 4 follicles - 14 mm, 10 mm, and 10mm on the left; 17 mm on the right
• June 17 (Day 10 of stims): 5 follicles - 16 mm, 17 mm, and 18 mm on the left; 12 mm and 20 mm on the right

The June 17 monitoring appointment was a tough one. My clinic closes at noon on Friday, so Friday mornings have usually been hectic when we go. A typical appointment involves bloodwork, an ultrasound, and chatting with the nurse. We waited for what felt like a while after my ultrasound, then our RE called us in. (Remember, it's usually not a good thing when the doctor talks to us instead of the nurse.) Based solely on the last year and three months, we knew our number of follicles was not stellar, but there was not much we can do about that except continue to try. 

Our RE was probably the second saddest we'd ever seen him (second only to when he saw the empty sac on the ultrasound on January 10) and said we were looking at retrieving three or four follicles. Timing the trigger shot properly would be critical to maximizing the retrieval results; he used the metaphor of threading a needle, which sounds pretty precise. I do not remember his exact words that followed in this conversation, but I'm pretty sure he said something about being stubborn and grabbing the bull by the horns...which is a pretty accurate description of my decision-making when it comes to [in]fertility. (Richard tends to use the "roll the dice" metaphor when talking about taking chances with IVF.) I think our RE also tossed out the word "recalcitrant" too, but I'm less certain about how closely I fit that one. Once he had a chance to review my bloodwork, we would decide how many more days I would continue the stims and when we would do the trigger shot.

I asked our RE if we would try again if this retrieval didn't go well, and he had a discouraged look on his face but gave me a semi-vague answer about reviewing all of the information and having a conversation about how to move forward. In my last post, I mentioned feeling like one of those inflatable clowns getting punched in the face, but this conversation left me feeling like I'd been punctured. Totally deflated.

Richard and I probably went to Whataburger on the way home from the appointment. When the nurse called later, she instructed us to continue the stim shots through the weekend and do the trigger shot on Sunday night for retrieval on Tuesday morning.

We spent the weekend in Ruston for Father's Day/my birthday (and had to come back to Baton Rouge a little early on Sunday night because I didn't bring enough Menopur...), but we finished the stims and trigger shots as planned. I went into the retrieval feeling halfway "well, hopefully this will work out" and halfway "well, this is probably going to suck." I said yes to a little extra medication to take the edge off. Then when our RE came to check on us, I even asked him if he was going to break up with us. He seemed a little surprised by the question and initially dodged the question by asking why I was asking. I told him he looked sad at our appointment on Friday, and he said he wasn't going to break up with us, but I might put him in an early grave. Fair enough; I sometimes wonder if all of this is taking years off of my life too.

Shortly after confirming that we weren't about to get doctor dumped, they rolled me back for the retrieval. We succeeded at threading the needle; our RE was able to retrieve four eggs. We were happy with that since it was the bigger end of the range our RE gave us.

Hopefully it won't take me a month to write the next update...but that will be the final installment including next steps. Ahh!

Something that made today great: I cleaned out my office at LSU!