Day 7 Ultrasound

I had another ultrasound yesterday, and things are looking a little better--this time the doctor said she thinks there are 13 or 14 follicles that are big enough. So that is an improvement over the last ultrasound, even though it’s not quite the number I was hoping for.

The egg retrieval is coming up on Sunday. Tonight is my last night of stimulation injections, tomorrow morning is my last Ganirelix, and tomorrow night I do the trigger shot at exactly 10:30 PM. That means that in all, I will have done 8 days of stimulation injections, which feels much shorter than the 11 days I did last time. I am on double the dose of medication this time so I guess it makes sense that it would take less time in total. But I can't believe that this egg freezing cycle is almost done!

I also learned that in addition to the Ovidrel trigger shot, I will also be doing a shot of Lupron at the same time. I am not sure why this is necessary but I will do as the doctor says! I have to pick up the Lupron shot from Walgreens Specialty Pharmacy tomorrow. They mix it up specially and it has a limited shelf life.

In other news, I am definitely feeling my ovaries! Last cycle I thought I felt some heaviness, but I wasn’t entirely sure that it wasn’t my imagination. This time I am positive--I especially feel the one on the left, it is sort of an achy feeling that I especially notice when I am lying down. I hope this means there are a lot of good eggs in there!

Injections Day 2

I started feeling unusually bloated after dinner. Could this be due to my growing ovaries already? It seems too soon to be feeling the effects of the stimulation drugs already but I didn’t eat a particularly big dinner or anything. Not sure what’s going on.

I did my second day of injections. This time a spot of blood appeared when I pulled out the Gonal-F needle. I didn’t have gauze handy so I dabbed at it with an alcohol swab. The Menopur stung again going in, but was otherwise uneventful.

I am speeding up with the injections--last night it took me almost 30 minutes, tonight less than 15.

Starting the Stimulation

My period came yesterday, so that means that I started my stimulation injections tonight. This time there were 33 days between periods, which is kind of a long time, but better than last time when there were 39 days between periods!

I went in for some blood tests today for various hormones, including some that need to be tested on day 2 or day 3 of the period. I got tested for FSH, estradiol, AMH, and prolactin. The hope is that these tests will give some insight into why I have such a long time between periods. I did not actually have these tests because of the current egg freezing cycle though I have learned from reading other egg freezing blogs and sites that most clinics test for estradiol (and maybe other hormones too) at the beginning of each cycle; however Stanford does not routinely do that. In this case I was having the tests to try to find out why my menstrual cycle is so long. But I am kind of glad I got these tests done at the beginning of the cycle anyway, even though Stanford doesn’t use them.

My injections went well tonight. I was doing Gonal-F for the first time(since I used Follistim during the previous egg freezing cycle) and I am happy to report that the Gonal-F did not hurt going in. I even had a pretty easy time with the Menopur injection, my old nemesis from the first egg freezing cycle--though that one did hurt going in.

Now I will have to wait and see if there are different side effects compared with last time.  I am on double the dose of medication, 150 IU Gonal-F + 150 IU Menopur compared with 75 IU Follistim + 75 IU Menopur last cycle. Therefore I am a bit concerned that I may experience more side effects.

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!

First Egg Freezing Cycle: Stimulation Phase, Part 1

During the stimulation phase, you inject yourself with hormones to make multiple follicles grow at the same time. I was nervous about this for several reasons: 1) I don’t like shots, let alone giving them to myself! 2) I was nervous about mixing up the medications wrong; it had all seemed very complicated during the injections class and I was not confident at all that I would avoid mistakes 3) I was concerned the hormones would turn me into a crazy, emotional mess. Overall, I was not looking forward to this part.

I was instructed to work on a clean surface, so I swabbed down a kitchen tray with rubbing alcohol, placed it on my desk, and started setting out the supplies I would need. I had two injections to do: Menopur and Follistim. Menopur is the more complicated one; I scarcely remembered anything from injection training class so I pulled out the step-by-step handout on how to administer Menopur. It turns out there are 18 steps. I also watched the injection training videos provided by Freedom Fertility Pharmacy but I had trouble remembering the steps even right after watching the video, so the handout was my best friend.

I mixed up the Menopur according to the instructions on the handout and loaded it into the syringe. I pulled up my shirt, pinched a chunk of flesh, and paused with the needle close to my belly. This was the moment of truth--would I actually be able to push in needle? It took me a minute to work up the courage, but eventually I poked the needle into my skin and depressed the plunger. It was no picnic, but it wasn’t that bad.

Now on to the Follistim. The Follistim does not require mixing; it comes in a vial which you put into a special Follistim Pen. I followed the instructions on the Follistim handout, attached the needle, and selected a new patch of skin to inject. This injection turned out to be easier than the first one. I thought the Pen seemed silly and gimmicky at first, but it really did make things easier. The only hitch was at the end, you are supposed to take off the needle and throw it in the sharps disposal container. There are instructions on how to do this on the instruction sheet. But despite following the instructions, I just could not get the needle off. I tried and tried and it just wouldn't become detached from the Pen. I was starting to panic when finally I managed to get it off.

It took me about 40 minutes to do that first set of injections, but I was sure I would speed up once I stopped having to watch the injection videos and read every word of the instructional handouts.

I expected my second day of injections to go more easily, but much to my surprise, it did not. I again started with the Menopur. This time when I injected the Menopur, I started to feel faint. I became sweaty all over. I walked my hands along the walls to support me as I moved from my desk to my bed to lie down. I lay curled up in the fetal position for about 20 minutes before finally getting up the courage to do my Follistim injection, which I brought into bed with me in case I started feeling faint again. Luckily the Follistim injection was much easier. I felt pretty discouraged--it was going to be a long 10 days of stimulation if this happened every night!

Fortunately the third day of injections went more smoothly. I decided to do the Follistim first, since it was easier and that way if I felt bad after the Menopur injection again, I wouldn't have to pull myself together for the second injection. Follistim went fine, though I still had trouble getting the needle off to dispose of it. I was of course terrified of the Menopur and had to really get up my courage to do that one. But it actually went ok. Immediately after giving myself the Menopur injection, I lay down as a precaution. But luckily I didn't feel dizzy. Things were looking up.

First Egg Freezing Cycle: Preparing for the Stimulation Phase

I called up the Stanford clinic and let them know that I wanted to go ahead with the egg freezing. After some phone tag, the nurse and I finally connected and she set me up for several appointments including a baseline ultrasound, a class to learn about the medications, and a day 5 ultrasound. I drove to the clinic to pick up a schedule showing me when I should start taking birth control pills (which are used prior to the stimulation phase to rest the ovaries), when I should start the stimulation meds, and the tentative date for my egg retrieval.

My first task was to start birth control. I also had to order the medications necessary for the stimulation phase. I learned that getting fertility drugs is not the same as getting most prescriptions. I had assumed I would just be able to use my normal pharmacy, but in fact you have to use a specialty pharmacy that has the special fertility drugs. First I had to call my insurance to learn which specialty pharmacies I could use under my plan. I ended up using Accredo mail order pharmacy though I also had the option of going to a Walgreens Specialty Pharmacy in town.

My meds arrived via overnight fedex, in 3 boxes each filled with a foam ice chest and numerous cold packs. I put all the meds in the fridge and set out the sharps container, syringes, alcohol pads, and needles on a side table. Wow it was a lot of stuff! The clinic had given me a list of all the meds and supplies they had ordered, and advised me to double-check that everything had arrived. I had a hard time doing the inventory because it was all so unfamiliar to me--how was I supposed to know what a 27 gauge needle looked like? I fumbled my way through the inventory as best I could and discovered that the Menopur was missing. I called up the pharmacy and they had no good explanation for why the Menopur hadn’t been shipped, but they shipped it overnight so luckily it arrived in time for the start of my stimulation protocol.

I had my baseline ultrasound after being on birth control for 9 days. I know Dr. Westphal was checking to make sure there were no ovarian cysts; not sure if she was looking for anything else as well. Anyway it went fine. I had my IVF orientation class the same day.

Most of the people in the class were going through regular IVF as opposed to egg freezing. Many women were there with their partners, and one couple even brought a (noisy) child with them. I guess they are struggling with “secondary infertility” which is the term for when a woman already has a child but is having trouble conceiving another one. There was one other girl just doing egg freezing, but I think she was doing it for medical as opposed to elective purposes. She was very young (probably high school age) and had her mom with her, and she only had one ovary. So I suspect that I was the only one there for “elective egg freezing.” I was surprised by how young the women going through IVF looked. Most appeared to be in their thirties, not even necessarily their late thirties.

The class covered a lot of information very quickly: showing the names of all the clinic staff, talking about the different kinds of stimulation protocols, going over what would happen at egg retrieval, talking about semen sample retrieval (since most women were going through regular IVF), what happens post-retrieval for the women going through regular IVF (embryos grown in lab, transferred back into uterus), the wait for pregnancy test after the transfer.

The real meat of the class was the injection training. All the stimulation drugs are injections, so we had to learn how to give ourselves shots! And how to mix up the medications. There are a lot of steps to mixing up Menopur, which comes as a powder and must be mixed with a liquid and put into a syringe. I had trouble keeping up and had to keep looking over at my neighbor to copy what she was doing. We struck up a bit of a conversation. She asked me if I had done any IUIs first. I didn’t know at the time what an IUI was, or that it was something that was frequently tried before moving to IVF. I just said no. I didn’t let on that I was only there for egg freezing because I thought it would be insensitive to mention that to a woman who was clearly there because she was having trouble conceiving.

We practiced giving the shots on oranges. I knew there was no way I would remember all the steps, but luckily we were given a step-by-step instruction sheet to help us. I left the class feeling excited, like I was taking on a new big project.