Trigger Shot and Egg Retrieval

I had my trigger shots of Ovidrel and Lupron on Friday at 10:30 PM, and unlike in my first egg freezing cycle (see previous post), everything went fine. I did notice that the area around the Lupron injection started to get red and itchy over about an inch-wide area, but this was not a particularly big deal. If I were to do another egg freezing cycle, I would definitely ask for the Ovidrel again because it was much easier than the HCG.

I dragged around all day on Saturday, my ovaries felt pretty heavy and I didn’t feel much like doing anything. I was ready to get the eggs out!

On Sunday, my mom drove me to the clinic for an 8:30 arrival time. I was feeling pretty hungry and thirsty, having not had anything to eat or drink since I went to bed around 10:30 PM the night before (you are not allowed anything, even water, after midnight). During my first egg freezing cycle, I had been so nervous that I actually started getting faint during the pre-op consultation (see previous post). This time I made it through the entire consultation just fine, and the nurse asked me a bunch of questions that I didn’t remember from the first time, like if I was having any joint pain. I’m guessing those questions got cut short the first time when I started feeling faint. The nurse clarified for me that although a third-year fellow would be seeing me before the procedure and would be in the room during the procedure, Dr. Westphal would actually be doing the procedure. I appreciated the clarification because last time I found it quite strange that I never saw Dr. Westphal and only saw the fellow--it made me wonder if the fellow was actually doing the procedure.

I changed into a gown and went to the pre-op area. There was already someone there, with a curtain drawn around her bed. I learned a few minutes later when she started to wake up that she had finished her procedure already. The nurse put in an IV which hurt quite a bit, and she gave me a hot pack to help with the discomfort. Then the anaesthesiologist came in. I was a little surprised when she said, “Hi, I’m your anaesthesia doctor,” because she looked about 18 years old and was not wearing any kind of white coat or other “doctor” type clothes. I was comforted that she said she had read over the notes from my previous procedure, because everything went fine with the anaesthesia that time and I figured if she just did the same thing again, it would be fine.

Soon it was time for me to move into the procedure room. The medical assistant told me to lie at the very edge of the table so that it almost felt like I was falling off, and strapped my thighs into some large stirrups. She secured my arms with pieces of cloth while the anaesthesiologist attached a blood pressure cuff, heart rate monitor, and electrodes to monitor my vital signs. The medical assistant covered me with a warm cloth, I heard the beeping from the heart rate monitor and that’s the last thing I remember until I was back in the recovery room after the procedure.

I woke up back in the pre-op area feeling fine. The nurse asked if I was feeling any nausea from the anaesthesia, andI was not. She offered me juice which I immediately downed, and she got me a second cup of juice after remarking that I must have been really thirsty. I asked for crackers, which I knew they had from last time, as I was also quite hungry.

The nurse called the lab to check on the number of eggs retrieved, and when she told me, I couldn’t believe it: they had retrieved 32 eggs! I asked how that was possible, as there had only been 18 follicles at my last ultrasound (and the doctor had thought only 13 or 14 of them would be big enough to contain mature eggs). The nurse explained that sometimes a follicle can have more than one egg in it and that I must have had lots of follicles with more than one egg. I would find out the next day how many of the eggs had been mature. Obviously I was really happy with the result, but I still had some worries in the back of my mind: what if most of the eggs were immature? What if they had mixed up my eggs with someone else’s? It seemed so improbable that there could be so many eggs coming out of 18 follicles.

I was able to get up and leave pretty soon after I woke up, and my mom drove me home. I was still somewhat in a state of shock over the number of eggs that had been retrieved. I had some food, including a whey protein shake as suggested by the clinic to help prevent OHSS, and went to take a nap.

I woke up to use the bathroom a few hours later, and quickly ran into trouble. I made it to the bathroom just fine, but while I was in there, I started feeling dizzy and faint. I was very unsteady and crashed into the wall, overturning a mug full of tweezers, nail files, and other similar utensils on the way. I made it back to bed but was rather shaken. Why was I feeling dizzy all of a sudden? I had felt fine just after the procedure, had been walking around and had no trouble fixing myself food. I felt fine once I was lying down again, but was was afraid the dizziness would return if I got up.

A while later, I called my mom and asked her to come help me because of my dizziness. I felt fine as she walked me from my bed to the dining area and sat me down there while she fixed me a high-protein snack (I was supposed to be following a high-protein diet to help prevent OHSS). While I was sitting at the table waiting for the food, I started to feel dizzy again, and also to feel really hot and sweaty. I put my head down at first, but I continued to feel bad so I asked my mom to walk me to the living room so I could lie down on the couch. I collapsed into the couch and soon began to feel better. It seemed that I was fine as long as I was lying down. I ate my snack lying on the couch and eventually my mom helped me walk back to bed.

Thankfully, I didn’t have any more occurrences of feeling dizzy though I continued to have my mom help me for the rest of the day as a precaution.

The next morning, I got a call from the clinic with the “cryo report”: they were able to freeze 26 eggs. The lady on the phone spoke of being able to freeze “26 out of 30” which was strange because the previous day they had told me there had been 32. I regret not asking her about the discrepancy. But anyway, apparently 2 of the eggs were immature, 1 was over-developed, and one was “empty.” I don’t know what happened to the other 2 eggs. But I couldn’t believe it, 26 frozen eggs! That was really great news. My goal had been to have a total of 25-30 frozen eggs, and now I had more than that: the 26 from this cycle plus the 11 from the previous cycle, for a total of 37.

Before the retrieval, I had thought it was very likely that I would need to do a third egg freezing cycle to get to my goal number. And now all of a sudden I was there! It was a weird feeling, maybe I could now be done with egg freezing! I think that with 37 eggs, I have a really good chance of having a baby. Of course there is no guarantee about the quality of the eggs, but I have to think that with that number, the chances are good.

Update and More Waiting

As I mentioned in a previous post, I had been instructed to call the clinic with the first day of my period. So when I finally got my period I called the clinic to report this and assumed that I would soon be told to start taking birth control pills in preparation for the stimulation. (Birth control pills are often used prior to the stimulation phase in order to “rest” the ovaries and reduce the chance of ovarian cysts.) Imagine my surprise when I got the call back from the clinic that this time, I would be doing a “no pill” cycle and that I would need to start doing the stimulation injections on the second day of my period. Of course this involves now waiting for my NEXT period before starting because it was already Day 4 of my period by the time I got the call back with this information.

During my first egg retrieval cycle, I had a lot of trouble with the HCG trigger shot (see previous post) so I asked if I could have Ovidrel this time instead of generic HCG. I had trouble getting all of the HCG medication out of its vial and into the syringe. Ovidrel comes in a pre-filled syringe so it would eliminate that problem. (I learned about Ovidrel from reading other people’s egg freezing blogs.) The doctor agreed so I am relieved that it should be an easier trigger shot this time.

When I got the prescription list, I saw that my doctor is making some changes in addition to switching to the Ovidrel: Last time I was on 75 IU Follistim + 75 IU Menopur for the first 8 days of stimulation, before moving to 150 IU Follistim + 75 IU Menopur for a couple of days, and 75 IU Follistim + 150 IU Menopur on the last day of stimulation. This time, I will be on 150 IU Gonal-F and 150 IU Menopur from the start, so double the dose of what I was on for most of my first cycle. And it will be Gonal-F instead of Follistim.

I am very lucky to have insurance that covers the medications. However there is a lifetime limit on fertility coverage of $15,000 and the medications count against that limit. So I decided that it would be a good idea to find out which pharmacy had the cheapest medications so that I would not use up more of that lifetime limit than necessary. This turned out be an exercise in frustration. I called my insurance to confirm that its preferred pharmacies had not changed since last year. They are still the same--one mail-order pharmacy plus the Walgreens Specialty Pharmacy. I asked the insurance guy if I could compare the prices of the two pharmacies for certain medications, and he said I would need to call the pharmacies to do that. I called up the first pharmacy and they said that they could not tell me the prices that would be charged to my insurance plan and that I would need to call the insurance in order to get that information. Of course, when I had called the insurance, they said I would need to call the pharmacies to get pricing information. Frustrating! I did not bother calling the second pharmacy since I would be unable to do a price comparison without any information from the first pharmacy. So my attempt to be a good consumer and find out all the prices was a bust, and I ended up going with the mail-order pharmacy because that seemed more convenient. When my packages of medications arrived, I looked through all the paperwork to see if I could find out the cost of the medications, but all it told me was my copay amount, so I still have no idea how much is counted against my lifetime limit.

I have an ultrasound scheduled for around the time that my next period might start. I explained to the coordinator doing the scheduling that my periods are irregular and that I could not be certain that it would have started by the time of the appointment. She said that was ok and that basically they try to get the ultrasound within 5 days of my period, so even if it hasn’t started yet, I could still go in for the appointment. So my next step is that appointment, and to notify the clinic (again!) when I get my period. For now I’m waiting.

First Egg Freezing Cycle: The Trigger Shot

My trigger shot was to be at exactly 9:30 PM on Thursday, November 21, 2013. Earlier that day, I gave myself the last Ganirelix shot.

I had now been on hormones for well over a week. How was I feeling? As it turned out, I was feeling surprisingly normal. I had been concerned that the hormones would affect my mood and that I might experience strange crying jags or temper flares, but that did not happen. Physically I was also feeling pretty good. I was not particularly bloated, and though I thought I could feel my ovaries, I was never quite sure if it was just a figment of my imagination brought on by the suggestion that I should be feeling heaviness in the ovaries. I was however moving differently than usual, in an effort to heed the nurse’s cautions about the risk of ovarian torsion from certain movements. I was supposed to avoid anything that caused bouncing, so I walked more slowly than normal. I had also started taking the elevator up instead of the stairs up to the clinic. I tried to be careful to avoid twisting movements, though I always toss and turn a lot during my sleep so I’m sure I wasn’t able to completely eliminate twisting motions.

The nurse had suggested that I start mixing up my HCG (the trigger shot) at 9:20 PM, to be sure it was ready for 9:30 PM. When I picked up the box, I noticed it said “For intramuscular use only.” I have picked up from other egg freezing blogs and forums that some clinics have their patients do intramuscular shots for the HCG, but at Stanford we are supposed to do a subcutaneous shot. I certainly didn’t have either the training or the needle necessary for an intramuscular shot. I was concerned that I had ended up with the wrong variety of medication. I didn’t know what to do, so I paged the on-call fellow to ask.

When the fellow called back, it was apparent that she hadn’t heard of this exact problem before. I would have loved her to say, “Yes, I know it says “for intramuscular use only” on the box, but it is fine to do the subcutaneous injection.” Instead, she asked me to read her what it said regarding what kind of medicine was in the box, she told me that it sounded like the correct medication, and told me it should be fine to do a subcutaneous injection with it. An answer, but not quite as confidently reassuring as I had hoped for.

Anyway, I set about mixing up the medication and transferring it out of the vial into the injection syringe. I was able to get around two-thirds or three-quarters of the medication into the injection syringe, but I absolutely couldn’t get the last bits out. I remembered the nurse had taught me how to do it after my last ultrasound, but I couldn’t remember what exactly the secret was. I was running way behind now, between paging the on-call fellow and trying to get more medication into the syringe, it was well past 9:30. I finally decided to inject what I could before it got any later. After injecting myself with most of the medication, I set about getting out the last one-quarter to one-third of the medication which was stubbornly stuck in the vial. I held the vial and the syringe at various different angles, desperately trying to get all the medication out. I finally managed to get most of the remainder and gave myself a second injection (thank goodness the clinic had prescribed extra needles, as you need a new needle for each injection). By this time it was well past 10:00. That’s right, I had managed to screw up the timing of this most-important, absolutely-had-to-be-at-9:30 shot.

I emailed the clinic to explain what had happened and then got ready for bed--I would have to leave for my retrieval appointment around 7:00 AM the next day.

First Egg Freezing Cycle: Stimulation Phase, Part 2

I had an ultrasound on my fifth day of injections (actually I’d only done the injections 4 times because the appointment was in the morning and the injections don’t happen until night time).  The nurse asked me if I felt bloated and I said no, I wasn’t feeling anything. I began to worry that it wasn’t working properly since I wasn’t feeling anything. During the ultrasound, the doctor told the nurse (who was taking notes) about the follicles she found: “I see see an 8. Another 8. 3 smaller ones…” The “8” was referring to the size of the follicles, though I have no idea in what units. In all, it sounded like she had only found 9 follicles though I didn’t ask her about it and she didn’t offer a final count. I had been asked to bring my Ganirelix to this appointment in case it was time to start using it. Ganirelix is a drug that keeps you from ovulating during the egg freezing cycle--if you were to ovulate, you would lose all the eggs as they would be released into your body and no longer be available for retrieval. It was not yet time for the Ganirelix. I started to feel pretty discouraged. It seemed like there weren’t many follicles, certainly not the 15 I’d been hoping for, and additionally I wasn’t feeling any side effects of the medication. It wasn’t time for Ganirelix yet, did that mean the stimulation was running behind? I was afraid the stimulation wasn’t working but very well but the doctor rushed out before I had a chance to gather my thoughts and ask her about it.

One interesting thing about Stanford is that unlike most clinics, they don’t give you blood tests during your stimulation phase, only ultrasounds. While I was going through my first egg freezing cycle, I didn’t know that most places give blood tests as well, but I have since picked up that fact from reading other people’s egg freezing blogs and from the Eggsurance.com forums. It sounds like most clinics give blood tests on the same days they give ultrasounds. I guess Stanford does not consider this necessary. Maybe I will ask about the reasoning when I go in for my second egg freezing cycle because it seems sort of strange that Stanford doesn’t take the same measurements as everyone else.

Anyway, after the ultrasound, I went home and got the unused Ganirelix out of my bag to put it back in the fridge. That’s when I noticed that it said to store at room temperature on the package. All my medications had come surrounded by ice packs, so I had assumed they all had to go in the fridge. I checked the other meds and discovered that the HCG, the “trigger shot” I would take 35 hours before the egg retrieval, was also supposed to be stored at room temperature. I started to freak out. This was extremely expensive medication, if I had ruined it by accidentally storing it in the fridge, I didn’t know what I would do! I immediately emailed the clinic to tell them about my mistake and ask if the medication was ok. Thankfully they replied that the fridge would not have hurt the medications.

I  continued on with my injections routine. I did continued to do the Follistim first so that I could lie down immediately after the Menopur in case I got dizzy again. But fortunately I didn’t feel faint again after the Menopur. It was always a pain to mix up and I was always a little scared to give myself the Menopur shot, but at least I wasn’t about to black out anymore (see previous post).

I went in for another ultrasound on Day 7. The doctor again read out the sizes of the follicles. It still didn’t sound like there were very many. I told her I was worried it wasn’t working because I wasn’t experiencing the bloating or feelings of heaviness the nurses asked about. She assured me it was working fine, and that it was a good thing I wasn’t too bloated at this stage. “Don’t worry, you’ll feel it,” she said. It still was not time for Ganirelix.

At my Day 9 ultrasound,  it sounded like there were a few more follicles. Dr. Westphal said my right ovary was not stimulating as well as my left one, and she raised my dose of Follistim from 75 IU to 150 IU.  She also told me that the egg retrieval would not be on the day that was originally planned as I needed to stimulate a bit longer. It was also finally time for the Ganirelix. She told me to give myself the injection right there in the examining room. A nurse brought me a couple of alcohol swabs and then left the room. I was a little flustered. There was no instruction sheet, I couldn’t look up an injection video on the internet, and it was a tiny examining room with no sink so I couldn’t even wash my hands first. I wiped them down with the alcohol swab to try to clean them (you are always supposed to wash your hands before giving yourself an injection). Luckily Ganirelix comes in a pre-filled syringe and doesn’t involve any mixing. The needle looked a little larger than the ones I had become accustomed to. I pinched up some skin and tried to poke the needle in. It wouldn’t go in. I switched to another spot, and still the needle wouldn’t go in. I was really starting to freak out. I finally got lucky on the third or fourth spot I tried; the needle went in and I depressed the plunger on the syringe to give myself the injection. When I was done, some blood came out. I didn’t have a gauze pad or anything so I swabbed it with alcohol and hoped that it wouldn’t become irritated from my jeans. Later on, a bruise developed at that spot. I was not liking this Ganirelix at all.

Now that I was to be on a higher dose of Follistim, I was in danger of running out of medication. Follistim cartridges come in several sizes; mine were 300 IU, each good for 4 days of 75-IU doses. I had 3 cartridges in total so enough for 12 days of stimulation at the original dose, though only 10 days of stimulation had been anticipated. Now I would be moving to a higher dose. Did I need to order more medication? I remembered the nurse had mentioned during the injection training class that the manufacturer over-fills the Follistim cartridges, so we should not throw them away when we’re done in case we need an extra day. I decided to wait on ordering more meds in case the overfill was enough to keep me from buying more.

The next few days I continued with Ganirelix in the morning and Follistim and Menopur at night. I was always afraid of the Ganirelix shot in case I had a repeat of the first time, but luckily there were no more disasters. In order to give myself the Follistim dose on Day 10, I had to use the over-fill from all 3 Follistim cartridges, which involved giving myself 3 separate injections! But it was enough medication.

At my Day 11 ultrasound, it sounded like there were quite a few more follicles. I guess the higher dose was working. Dr. Westphal wanted to stimulate for an additional day, and now I was really going to be out of medication. I had a little bit of Follistim overflow left in the third cartridge, and I was completely out of Menopur. She gave me a prescription to take to the Walgreens Specialty Pharmacy in town for two 75-IU vials of Menopur, and she told me to inject the rest of the Follistim overflow, up to 75 IU. That would take care of my injections for that evening, which would be the last day of of stimulating medications. The following day would be my trigger shot, and the egg retrieval would be on the 14th day of the cycle.

The nurse took me to a little room with a table and two chairs to go over my final instructions prior to the egg retrieval.She gave me a sheet of paper that showed me exactly what time I had to take the “trigger shot” which is HCG. It makes the eggs finish maturing and gets them ready for retrieval. You will ovulate the eggs 40 hours after taking the shot, so the retrieval is set for 35 hours after taking the shot. The timing of this shot is extremely important; if you mess it up, you could basically ruin the entire egg freezing cycle. I had to sign a paper that I understood when I needed to take the shot. The nurse then showed me how to mix up the HCG using a large mixing needle and explained to me how to get all the medication out of the vial and into the syringe. And she gave me a handout about Ovarian Hyperstimulation Syndrome (OHSS). She recommended that I immediately start the suggested OHSS diet, even before the retrieval. The diet involved drinking Gatorade and Pedialyte instead of plain water, and having 3-4 whey protein shakes a day. I was a little annoyed to be told so last-minute since I would have to immediately go out and buy supplies.

I had to wait about an hour at the pharmacy to pick up my medications. And since it was a specialty pharmacy that didn’t have normal drugstore items, I had to go to another drugstore to get the Gatorade, Pedialyte and whey protein powder. That night, I gave myself the last of the stimulation shots. It was nearly over!