The surgery schedule is super tight, with fifteen-minute intervals. If either you or your surgeon is just a little bit late, the follicles will release the eggs, they’ll float down the fallopian tubes and your cycle is wasted. You have to time it to the minute.
It’s funny now to think that non-IVF women are oblivious to the fact that their natural hormones have just triggered an egg to be released. There’s no indicator at all. At best, a woman may have a vague idea that this is her fertile window. An IVF patient is aware of every stage of conception because she needs intervention at every step.
This is where Mario played his part. Although frozen sperm could be used, it was preferable that Mario provided a fresh sperm sample when Roshan collected the eggs. The problem was that he had to come down from Queensland to do it. Even though we had thirty-six hours’ notice from the moment I took the trigger injection, it was impossible to predict exactly when the trigger would occur because it all depended on how the follicles were developing. Follicle size was paramount!
Mario and I would spend time on the phone trying to plan ahead for when he’d have to fly down. Roshan was finessing the size of the follicles, with slight alterations to the medication that I was injecting to either stimulate or slow down growth. The aim was for the eggs to reach the right size in good time; day to day it was in the hands of the experts, so we couldn’t book plane tickets.
It was incredibly stressful not knowing the timing. I worried that Mario wouldn’t make it to Melbourne for the egg pick-up and the cycle would be wasted. This is a time when I could totally relate to couples who decide to put their lives on hold during IVF; it dictates your lives very precisely.
I dreaded making that phone call.
‘Babe, the pick-up’s been moved to Wednesday. You’ve got to come down tomorrow.’
‘I thought you said it was going to be on Friday!’
‘Yeah, I thought it was, but the eggs grew faster than we thought.’
‘I’ve got that big meeting with the board tomorrow. I don’t think they can move it.’
‘Ah no, I’m so sorry. The eggs just went ahead and fired up overnight. There’s nothing we can do …’
It wasn’t easy. There was so much uncertainty about outcomes and schedules, but Mario didn’t want to whinge to his colleagues about what we were going through. Luckily, he always made it on time.
For the first cycle, my pick-up was at eight o’clock in the morning. I got to the hospital in plenty of time and waited anxiously for my slot to come up. At 7.55 a.m., I was lying on the operating table, still not anaesthetised and no sign of Roshan! My adrenaline soared and I was muttering like a madwoman: ‘Where is he? What’s he doing? These eggs are going to release on their own and float down the fallopian tubes.’ I couldn’t afford to lose a single one. Minutes later, Roshan waltzed in, they put me under and it was all over very quickly.
While you’re under, the specialist performs an ultrasound (vaginal) guided retrieval. A fine needle with a tube attached is introduced via the vaginal wall. It punctures the ovary and then extracts the eggs and fluid from inside the follicle, which are collected in a test tube and passed to the embryologist. He or she then examines the contents to ascertain if each egg contains the material required for fertilisation. They are then carefully placed into a portable incubator and taken to City Fertility Centre while you are moved to recovery.
I’ve heard that surgeons may write a number on your hand to let you know how many viable eggs were retrieved, but Roshan prefers to tell the patient in person once she wakes up. Mario had dropped me at the hospital and had then gone straight to the clinic to give his sample. By the time I woke up in the recovery room, he was back by my side. I was feeling crampy and bloated and a bit sore. After all, my body had been accommodating seventeen follicles and suddenly they were gone.
I was in a room with patients who had all come out of different operating theatres. You don’t know if you’re lying next to someone who is an IVF patient or having their wisdom teeth out. That first time, I woke up next to a woman who had just been told that her fertility specialist had not retrieved a single viable egg. I could hear her crying softly. I was desperate for Roshan to come and tell me my result. I knew that I had seventeen follicles but they could all have been duds – just empty follicles or bad eggs. You only know that they are viable when they have been extracted and viewed by the embryologist.
Finally Roshan arrived and told me that he had retrieved ten eggs. I thought, ‘Why only ten? What happened to the other seven?’ He went on to assure me he chose the ones that looked like they had the best chance of survival and he was pleased. It was a good result.
When it comes to eggs, Roshan’s mantra is ‘Quality, not quantity’.
With IVF there are so many small triumphs and failures along the way. This time I was lucky, while the woman next to me was devastated. I felt so sorry for her; I wanted to give her some of mine. As discreetly as possible, Mario pulled the curtain across to give the woman some privacy – but also so that I wouldn’t have to witness her sadness. This was one of those moments when I needed to tune out and not get pulled into someone else’s emotions.
Mario flew back to Queensland and I went home to rest. I felt so helpless. Now, more than ever, the process was out of my control and all the action was elsewhere.
Meanwhile, at City Fertility, the eggs were being put together with the sperm. There were two ways of doing it: either drop the sperm on top of the eggs and let nature take its course, or opt for a process, as we did, called intracytoplasmic sperm injection (ICSI). This is an incredibly delicate procedure, performed by the embryologist, where each egg is directly injected with a single sperm. It costs a little more and some of the eggs may break, but it gives the sperm its best chance to get where it’s supposed to be and do what it’s supposed to do. Then they place the sperm–egg combos in an incubator that is divided into four sections, for four different and very hopeful patients.
Twenty-four hours later, the embryologist rang to tell me how many of the eggs had successfully fertilised. I had been warned that there was always a chance that none of them would succeed, and when the call came, my hands were shaking. Of the ten eggs retrieved, six had successfully fertilised. This was good news, though I was still disappointed with the drop-off.
The next few days were torture. I was under the false impression that we’d lost all the ones we were going to lose and I was not prepared for the fact that from Day 1 to Day 5 it was expected that we would continue to lose embryos. I must have been told at some point, but I simply hadn’t registered the reality. I felt helpless. The things I could control, I did. I continued my yoga and my new diet, and I visited my TCM doctor and allowed my body to recover from the egg pick-up procedure.
At the clinic, a steady stream of embryologists will stay by the incubators, keeping an eye on things 24/7. Every day, the embryologist on duty would ring with an update on what was happening with my embryos. It was like the contents of those Petri dishes were already my children! The embryologist would say something like, ‘Embyro number one is steady at four cells; embryo number two is a slowcoach, not doing much but may catch up; and embryo number three is a bit like Cathy Freeman going for gold at ten cells.’ Then a day later, I’d get, ‘Slowcoach number two has dropped off altogether and Cathy Freeman had a false start, I’m afraid.’
I would have phoned every hour if I could have. It would have achieved nothing other than driving the staff completely nuts. There was zero that anyone could do at this stage of the game; it was all about time passing and whether each embryo would develop normally or not. I lay awake at night fretting about what was happening down at City Fertility. What if it burnt down with my future children inside? What if there was a power outage and the incubators switched off?
I was so invested in those little guys. Every time one gave up it felt like a tiny death.
By the end of five days, we had only two left.
I was gutted. I’d had
no idea how fragile they were. I combed the internet for clues. What was the usual drop-off rate? What was the typical result for a woman my age? I tried to distract myself while I waited for the next call. I remember watching hours and hours of MasterChef, but I continued to obsess over the state of my embryos. This was when another destructive thought pattern set in: we’ve spent a lot of money and there are only two embryos left … When you start putting a dollar value on the embryos you produce, it seriously messes with your mind.
This period of time gave me a tiny taste of what it must be like for people who need to constantly weigh up the cost and the results during the process. For many, IVF is a serious financial hardship. Cost was a factor for us but it was not prohibitive, and I was lucky to be able to afford to use IVF as I needed it. For others, every cycle represents a sacrifice that has a direct impact on their daily lives. I won’t pretend to imagine how difficult that must be and the painful dilemma it poses. Every so often, a proposal comes up for IVF to be fully covered by government subsidies so that every woman of childbearing age can have access to IVF if she chooses, but these rumblings never seem to go anywhere. In the meantime, IVF is an unaffordable luxury for many people on low incomes – a situation that doesn’t sit right with me.
9
The First Two-week Wait
I’d be sitting up in bed with my laptop at 3 o’clock in the morning, clicking on page after page of discussion threads about the 2WW and all the signs I should watch out for to confirm I was pregnant. The incredibly frustrating thing was that the women who were sharing their stories online would suddenly stop and I’d be left hanging. I’d never find out if they got pregnant or not. It was excruciating.
AN EMBRYO THAT HAS REACHED the five-day mark in an incubator and is still growing strong is considered the gold standard. In some circumstances, a clinic will recommend that the transfer occur on the third day, giving the embryo its best chance to grow inside the mother. This will usually happen when there is only one viable embryo left. With no other embryos to choose from, all hopes for a successful cycle rest on the single survivor and it is thought the uterus is the best place for it.
It’s good to get to Day 5 though. Day 4 is often when an embryo drops off, so if it’s still going a day later it may be a serious contender for pregnancy. Roshan prefers to do transfers on Day 5 when the embryo has (hopefully) progressed to blastocyst stage. A blastocyst is made up of multiple cells that will one day be the placenta, and a cluster of cells that will be the foetus. A 5-day blastocyst sitting in an incubator in a fertility lab looks exactly the same as a 5-day blastocyst inside a uterus in a non-assisted pregnancy.
At City Fertility, when a 5-day embryo has reached blastocyst stage and is ready to be either placed back into the mother or frozen, the embryos are graded according to their quality:
A: Perfect. The highest quality for transferring or freezing
AB, BA and BB: Okay for transferring or freezing
BC: May be worth transferring or freezing
C, D: Not worth transferring or freezing
Most clinics use a scoring system but, confusingly, they’re all a bit different (for example, ABC versus 12345) so it’s tricky to share information about embryo quality.
Embryo quality comes down to three main factors:
1.the number of cells (the more cells, the better)
2.the uniformity of the size of the cells (the more regular, the better)
3.the degree of fragmentation (the less fragmentation, the better).
There’s a whole lot more technical information you could read up on, but this is an instance when you’re very much relying on the expertise of the embryologist. The embryologist will advise your specialist on the number and quality of embryos that you have to work with.
During those first five days of angst, as you wait for phone calls from the clinic, you are advised to rest up and drink lots of water. The aim is to focus on readying your uterus to host an embryo. I went to my acupuncturist a few times to help warm up what we called my ‘oven’; it was good to have something to pass the time!
At Day 5, with two embryos at blastocyst stage, it begged the question: do we transfer one or two embryos? A double embryo is not automatic, in fact the IVF industry within Australia has strict policies and guidelines regarding the number of embryos transferred. As a rule (with a few exceptions), couples undergoing IVF in Australia are not permitted to transfer more than one embryo per cycle; that was also the policy and perspective of City Fertility Centre.
The fertility specialists at City Fertility Centre are allowed on occasion to make exceptions for certain patients based on many medical conditions, and consent to transfer two embryos instead of the ‘permitted’ one. Roshan thought long and hard about our fertility, and thought he should at least discuss the idea of transferring two embryos based on my fertility issues and advanced age.
Mario and I had a long discussion with Roshan about the risks involved in a multiple pregnancy. It was sobering to contemplate the fact that the rate of premature births is much higher for twins. Health issues for mum and babies during a twin pregnancy also significantly increase. In addition, there was a strong argument to use only one embryo this round, so that we would have another one for later. I always like to have something in reserve, although I wasn’t afraid of a twin pregnancy either.
As first-timers, Mario and I felt we didn’t have enough knowledge or experience so we put the question to Roshan. He (and City Fertility Centre) always preferred the safe side and he recommended one embryo, but he wasn’t opposed to the idea of two either. Then, somewhere in there, we all agreed to transfer two.
On the evening of Day 4, the embryologist rang to say it was looking good and I should prepare to come in the next day. She rang again in the morning to confirm that the embryos were at a blastocyst stage and were going strong. I headed to the clinic.
I was advised to have a full bladder because it’s easier to manipulate the uterus when there’s something to push against. My bladder was so full that I had to go to the toilet to let a little bit of wee out in case I embarrassed myself in the waiting room! Having to stop mid-stream before I emptied the lot was quite a feat.
Normally, an embryo transfer is a pretty simple and straightforward procedure. At City Fertility, it takes place in a small space just off the room where the incubators are located so that the distance between incubator and uterus is as short as possible.
The procedure is a bit like an elaborate pap smear. You sit in what looks like a dentist chair, but your legs are splayed out to the sides. The seat is adjustable so the doctor can tilt your hips to the ideal angle, and the whole seat reclines. An ultrasound is set up on the lower abdomen so that the doctor has an overview of the uterus, which will help with guiding the catheter and embryo to the right spot. There is a very strong light beaming directly onto what is the focus of everyone’s attention – your vagina.
Confronting? Just a little. But it’s all very matter-of-fact and you have to remember that these doctors have worked with thousands of vaginas. It’s just another part of the IVF scenery.
Once you’re settled in the right position, the doctor uses a speculum (just as for a pap smear, but this one has a light on the end) to open up the vagina and view the cervix, which is the narrow passage leading from the vagina to the uterus. Under normal circumstances, the doctor places an ‘outer’ catheter through the cervix and into the opening of the uterus. He or she will then rest the end of the catheter at the location in the uterus where it looks like the embryo will have the best chance to implant and then inform the embryologist that everything’s ready At that point, Roshan shouts ‘load’.
The embryologist extracts the selected embryos from the incubator with an ‘inner’ catheter (or syringe) and brings it over to the waiting patient. This is carefully inserted into the ‘outer’ catheter and the fertility specialist gently squeezes out the contents. That’s how it’s supposed to happen.
In my case, it
was a real battle for Roshan to open up my cervix. A tight cervix is not uncommon for a woman who haven’t given birth, but mine was also at a difficult angle so Roshan had to use a special clamp called a tenaculum to straighten it and hold it in place so that he could get the catheter through. It was a struggle for him and surprisingly painful for me.
Of course, we didn’t anticipate any of this. Roshan already knew that my uterus was tilted on a strange angle as the result of one my many sporting injuries. The adjustable seat got a major workout as Roshan found the right way to tilt my hips. The tightly closed and bent cervix was a new challenge to deal with. Despite the fact I have a high pain threshold, after a while those clamps began to ache and it was all a little distressing and difficult. Roshan assured me that once I had given birth there would no longer be a problem; he said that the cervix opens during the birthing process and from that point it would always be slightly open, just enough to insert a catheter into. Roshan was absolutely right, but it was no help to me at that point! I have heard that some women are so intimidated by the thought of the catheter that they opt to have the transfer procedure under general anaesthetic. After that first transfer experience, I can totally understand why.
A long forty-five minutes later, the two embryos were safely deposited and I was left alone to recover, tired, sore and a bit emotional. Because it was supposed to be a quick and relatively painless experience, I hadn’t considered bringing someone along. Mario was in Brisbane. I’d spoken to my sisters and Mum on the phone when I was about to head in, and Mario’s mum, Laura, had given me a little religious statue of the Madonna to tuck into my handbag for good luck. The unexpected difficulty of that first transfer made me wish I had a support person with me. I was also surprised to feel an intense longing to share this moment with someone. My future child or children had just arrived in my body. This was monumental!
Frozen Hope Page 9