Pre- and Post-Egg Retrieval - What Worked for Us

I've been thinking about writing about the lifestyle/diet changes we made pre- and post-egg retrieval as well as pre- and post-transfer. There are some things I wish I had known about before we got started (like cutting out alcohol and caffeine several months beforehand), so I thought it might be helpful to share these with anybody who is getting ready for an egg retrieval!

Now that I have 2 egg retrievals under my belt, I thought I'd share what worked for us. I will preface this by saying that I am not a doctor, and that not everything I am sharing was specifically recommended by my doctor. A lot of what I ended up doing came recommended by other people going through IVF, research studies/articles, other fertility clinics, etc. I will try to link to resources where I can. Please don't feel like you have to do any of these things, or that you messed things up by not doing these things. My thought process is this: Since we are investing so much into this--financially, emotionally, physically--I want to do whatever I can (reasonably) do to improve things, whether that is egg/sperm quality, number of eggs retrieved, quality of embryos, implantation rate, etc. I figure, even if there isn't scientific proof behind things, if it's not going to hurt, why not give it a shot so that I don't regret things later? I'd rather know I tried my best than live with the "what if?" later on. 

Scroll down to the bottom for Conclusions, or a recap of what I discuss in this post.

Exercise: 3 Months and Prior
This is absolutely something you should talk to your doctor about. They will let you know if you're at a healthy BMI, and what you can do to help achieve one. Doctors generally recommend achieving a normal BMI, as "obesity has been found to alter mitochondrial function and increase oxidative stress, leading to reduced fertility and egg quality. It can also alter hormonal balance, disrupting ovulation." If you have some time before starting Stims--maybe you're saving up money, or waiting for a good time--this is a great time to start exercising and improving your overall health.

Exercise: During/After Stims
You should definitely consult your doctor about exercise during/after Stims, and during/after the 2WW. My nurse said I could continue my normal cardio/strength training during the early stages of injections (days 1-5), but by day 6, I would want to decrease intensity and focus on non-impact exercises (yoga, light elliptical, swimming, etc.). The main concern with strenuous exercise during Stims is that the medications will cause your ovaries to enlarge as the follicles start growing. According to the Southern California Reproductive Center, "You need to protect your ovaries during this sensitive time and avoid strenuous training. Your IVF cycle is not a time to push any limitations...Your body is already working extremely hard during your IVF cycle, so take the time to acknowledge yourself for that." One thing to think about after egg retrieval is the risks of ovarian torsion or ovarian hyperstimulation syndrome (OHSS), so following your doctor's orders and avoiding strenuous exercise are very important here.

Diet: 3 Months and Prior
Alcohol/Caffeine
I read an article that said that "given that egg and sperm maturation takes up to 3 months, it is ideal to stop/reduce alcohol consumption for at least three months before attempting pregnancy." I didn't know this prior to my first egg retrieval, so I had a minor freak out and wrote all about it here. I came to the conclusion that it wouldn't hurt to reduce/eliminate alcohol/caffeine in the 3 months prior to IVF (for both you and your partner), but that ultimately, it is not going to drastically compromise your chances. Knowing this information, we eliminated caffeine/alcohol from our diets 3 months before our 2nd egg retrieval, and I think it did make some improvements for us!

Vitamins/Supplements
My nurse did encourage me to take a prenatal vitamin before we started Stims. Memphis fertility specialist, Dr. Amelia Bailey, recommends that "a woman planning pregnancy should start taking a prenatal vitamin with DHA 6 months before conceiving." She (and other other specialists) also recommend Coenzyme Q10 (CoQ10), DHEA, DHA, folic acid (as needed), and Vitamin D (as needed). CoQ10 is helpful for overall sperm and egg health. Vitamin D insufficiency and deficiency in women attempting to get pregnant has also become an increasing concern. (This article is really helpful if you're thinking of taking any of these mentioned vitamins/supplements.) I personally just took a prenatal vitamin, fish oil, and Vitamin D supplements before and during Stims.

According to Dalene Barton-Schuster, Certified Herbalist and Birth Doula, "The life cycle of sperm, from production to maturation for ejaculation, ranges from 42 to 76 days...to make a plan for increasing fertility and boosting sperm health, you should start at least 2-3 months prior to giving sperm for IVF." CoQ10 is said to improve men's sperm motility and count. There are also many articles claiming that selenium, Vitamin C, zinc, and other vitamins/supplements can help improve male reproductive health. Three months prior to our 2nd egg retrieval, David cut out caffeine/alcohol. He also took a multivitamin, 200mg of Ubiquinol (CoQ10), and the Daily Wellness Company's Fertility Blend for Men daily. The Fertility Blend for Men is something I stumbled upon a few weeks prior to our first egg retrieval. It has great reviews online, and contains many of the recommended supplements to boost male fertility, such as L-carnitine, Vitamins B/C/E, zinc, and selenium.

Here's a helpful article on pre-conception vitamins written by Sarah Yang for the Bump. Here is an article on nutritional guidelines for your fertility treatment published on the Southern California Reproductive Center's blog.

Diet: During/After Stims
My nurse told me that during Stims, "the recommendation for caffeine intake is less than 600 mg" per day and that restricting "all caffeine intake is preferred." She also said that "no alcohol intake is preferred/recommended." I checked and she said that it would be okay to drink caffeine-free Diet Coke and decaf coffee. I had eliminated diet sodas and artificial sugar from my diet once I became pregnant, so it was easy for me to continue avoiding it during my 2nd egg retrieval, though I've added in the occasional Diet Coke or Splenda now that I'm done breastfeeding. (We don't plan to do our next embryo transfer for awhile.)

I think that eating healthy is something that is great to do now for yourself and for your future baby! There are a lot of diet changes you need to make when you become pregnant, so it doesn't hurt to start getting used to those changes now.

Acupuncture
I had never given much thought to holistic medicine (except for chiropractic) prior to IVF, but my fertility clinic actually has an acupuncture facility right in their building, so it was something I looked into. Some studies have shown that "when used in conduction with Western fertility treatments, acupuncture increases conception rates by 26%." Others say that "acupuncture is not harmful and most of those so treated swear by it. For the nay-sayers, what can be said with certainty is that at the very least acupuncture has a 'feel good' aspect to it and in most, evokes a psychological benefit that should not be discounted." My thoughts are that it's not going to hurt anything, so why not give it a shot? I didn't do acupuncture prior to my first egg retrieval, but I did do it for about a month prior to my 2nd one, and I think it did make some improvements for us the second time around.

Conclusions
My main suggestions for Before Stims (preferably 3 months or prior):

• Exercise and get to a healthy BMI
• Eat healthy--limit/eliminate caffeine/alcohol, fake sugars, trans fats, processed foods, etc.
• Take prenatal/multivitamins, CoQ10, and other recommended vitamins/supplements
• Acupuncture (talk to your acupuncturist, but you can start 3 months prior, or even 3-4 weeks prior to Stims)

My main suggestions for During/After Stims:

• Limited non-strenuous exercise (as discussed with your doctor!)
• Continue to eat healthy--eliminate caffeine/alcohol, fake sugars, trans fats, processed foods, etc.
• Continue taking prenatal/multivitamins, and other recommended vitamins/supplements as needed (and recommended by your doctor)
• Acupuncture (talk to your acupuncturist about what they recommend for during Stims and leading up to the embryo transfer...)

Day 7

Yesterday was Day 7. In the morning, I received an email from my nurse stating that the remaining embryos did not make any changes overnight and the culture was terminated. :( The total number of embryos that we biopsied and froze for PGS was 4. I am disappointed with the number we ended up with. I had planned for attrition, but did not expect it to be so quick! I was hoping for at least 5 or 6 blasts, but given that we only had 2 on Day 5, I am thankful for the 2 more we got on Day 6. My nurse also told me that she has moved to a different position within the clinic and I will be working with a new nurse.

I am supposed to start birth control again tomorrow, Friday, 6.10.16, and will take it for 18 days. The PGS biopsies are supposed to go out by tomorrow and the results should come back within 2 weeks. At that time we will discuss the date for the embryo transfer. 

The 4 frozen embryos are graded AA, which is great. Although clinics often grade their embryos differently, an AA grade generally means that the inner cell mass quality is good (many cells, tightly packed) and that the trophectoderm quality is also good (many cells, forming a cohesive layer). They didn't give me a grade for the expansion (usually a number from 1-6).

Everyone always talks about the 2 week wait (2ww) for after implantation, but for me, the 2ww starts with waiting for PGS results!

Day 6 after ER

I received phone calls from the nurse on Days 1-2, and today, Day 5. The ER counts as Day 0, and we left knowing they had retrieved a total of 19 eggs. On Day 1, the nurse called to tell me that of the 19 eggs retrieved, 17 were mature, and 11 had fertilized successfully. On Day 2, we found out that of the 11 embryos, we had 2 x 2-cells, 3 x 3-cells, 4 x 4-cells, and 2 x 5-cells. Days 3-4 fell on the weekend, and the lab likes to allow the embryos to develop undisturbed during those 2 days. Monday was Day 5, which is the day most embryos become blastocysts. Traditionally, embryos were transferred to the uterus on the 2nd or 3rd day of development after IVF because they were only able to sustain growth for 2-3 days in a lab setting. Advances in medicine have allowed them to survive longer than this, after 5 days of growth, in which the cells should have divided many times, with those surviving to this stage likely being stronger and healthier. Basically, a blastocyst is an embryo that has developed for 5-7 days after fertilization, and has 2 distinct cell types and a central cavity filled with fluid (Advanced Fertility, 2016).

On Day 5 (Monday), the nurse called to tell me that 2 of the embryos had reached blastocyst and were biopsied and frozen. (We are doing PGS, so the biopsy will be sent to the lab and the embryos will be frozen until we are ready to transfer.) She told me that there were 3 embryos at the early blastocyst stage, and that the remaining embryos were as follows: 1 x 3-cells, 4 x 6-cells, and 1 x 7-cells. She said that they were going to check again tomorrow to see if any of the early blasts had reached full blast stage and also to check on the progress of the remaining 6. To be honest, this news hit me pretty hard. I was expecting the numbers to go down every day, but I hadn't expected to go from 11 to 2. I immediately started worrying and bracing myself for a failed cycle. What's worse is that David had to leave yesterday so I got the news right as we were eating lunch together, before heading to the airport. :(

Today was Day 6, and I was incredibly nervous when I answered the phone. The nurse told me that 2 more had made it to blastocyst and they were able to biopsy and freeze them. I immediately felt better, knowing we now have 4 embryos that made it. We still have 3 more compacted morula, that are not quite blastocysts yet. When they are compacted, the cells and cell borders are becoming fuzzy as the embryo "compacts" or melts together. This is basically the stage right before blastocyst. So I am praying hard for those compacted embryos to grow tonight and make it to the blastocyst stage tomorrow. Tomorrow is Day 7, the last day they will be allowed to grow to. After this, the embryos that haven't reached blastocyst will be discarded. The remaining 4 embryos are as follows: 1 x 3-cells, 2 x 6-cells, and 1 x 7-cells. Most likely these will not make it to blastocyst by tomorrow (Day 7), but I am praying for a miracle.

As silly as it sounds, throughout these 6 days, I have gotten attached to these 11 embryos. The night of Day 2, after the nurse told us 11 had fertilized successfully, I started praying hard for each of those 11 embryos. It was amazing to me to know that conception had occurred, that this had actually happened, and these could be our future babies. Knowing that some of the embryos won't make it makes me a little sad. I have been rooting for them and praying for them and and thinking about them, and it's upsetting to think about them being discarded. I know that this happens naturally in our bodies, and that the reason they are discarded is because they would not survive beyond this, but part of me can't help but be a little sad and grieve for them.

On a happier note, I weighed myself this morning and I am back down to my original weight (before starting stims), so at least the bloating is going down.

The Day After

The day after my ER (Thursday, 6.2.16), my pain was low/moderate, but I was not feeling 100%. One of my friends had a really hard time after her recovery (bed rest for a week), and I've read many accounts from women who suffered from OHSS, so I was pretty blessed to feel as well as I did. 

I gained 3.2 lb. within 24 hours (3.6 lb. total within 48 hours), so I called my nurse who told me that weight gain is common after ER, especially with the fluid you receive while you're under anesthesia. I also read that your follicles will fill up with fluid after the ER. The nurse recommended a high protein diet (chicken, Greek yogurt, etc.) and to continue drinking electrolyte drinks over the course of the next 2 weeks. I read on a forum that the sodium (from electrolyte drinks) encourages the cells to retain fluid instead of spilling out into the abdominal cavity. I usually prefer diet sodas, so the idea of drinking tons of sugary sweet Gatorade did not appeal to me, and though I like Smartwater, the electrolyte content is low, so I found Powerade Zero, which has 0 calories and <1 g carbs, and the Fruit Punch is pretty good.

After drinking at least 32 fl. oz. of Powerade a day, I have been steadily dropping the water weight and today (6 days after ER), I am back to my normal weight (before starting stims). I also felt well enough to go back to the gym on Sunday (4 days after ER), though I've been taking it easy on the elliptical and doing low weight/low rep weights. I did have to take Colace for a couple days to get my system back on track. :)

I know I am lucky to have had a pretty easy recovery after ER, as I know that is not always the case. Here are some of my suggestions taken from my own personal experience:

• Rest. Rest as much as you need to. I recommend staying in bed after you get home from the ER, and possibly the day after if needed.
• Drink electrolyte drinks. I started out drinking plain water, but found that drinking Powerade (or Gatorade or Propel) helped flush out my system and drop the water weight.
• Eat protein. Eat lots of protein: eggs, chicken, nuts, Greek yogurt, etc.
• Go to the bathroom. After drinking all that Gatorade, you're going to be making many trips to the bathroom, but that's ok. Your body is flushing out excess fluids. You also may feel some abdominal cramping which can worsen when you haven't had a bowel movement. After anesthesia, it can take your body awhile to become regular again. My nurse said it was ok to take something gentle like (non-stimulant) Colace (if you are having trouble in that department. 
• Trust your body. Your body will let you know what you can/can't handle. If you don't feel well, call your nurse. Keep track of your weight, body temperature, etc. so you have a reference. Take pain medication if needed, and stop when it's not needed anymore. If you are up to it, and the doctor says it's ok, start going back to the gym or walking your dog...just don't do too much too quickly.

I realized today that I am feeling pretty good; dare I say, back to normal? I'm glad I'm giving my body a chance to recover a bit before having to start more injections to prep for the FET!

Egg Retrieval

Yesterday (Tuesday), the nurse called me with my bw results: Progesterone level at 5.3 (they look for 3+); Luteinizing Hormone (LH) level at 49.2 (they look for 15+). Everything was all set to go for my egg retrieval (ER)!

The ER was scheduled for this morning at 9:45. David and I arrived at 8:15am and I was taken to the hospital area and given a gown, booties, and hair cap. I signed all my forms, discussed my discharge instructions, got changed, and then the anesthesiologist (Dr. Steve) came in with more paperwork and started my saline IV. He joked that I was a human pin cushion after seeing my arms, and despite the local lidocaine he gave me before inserting the catheter, I hated having that thing in my arm. I have probably had a handful of saline IVs (emergency room visit, wisdom teeth removal, etc.) but there's something about having that thing my arm that I can't stand. Dr. Steve was so nice, but as soon as he left, I started getting nervous and a little teary-eyed. It was so great having David there to comfort me; he showed me my favorite sloth video and I was laughing again in no time. Soon David was taken away for his sample, and I was alone in the room for a little bit.

All dressed up and no place to go. :)

Throughout the process, I could see and hear a little bit of what was going on in the next room on the other side of the curtain...this was great because I could mentally prepare myself as far as which nurse/doctor/tech I'd see next, and what the time frame was. When the woman next door was taken away to the OR, I knew I'd probably be in there in the next 30-40 minutes. David came back right before the nurse came for me to make sure I relieved my bladder before going to the OR. Then we walked David to the exit (to the waiting room), and she brought me into the OR. In the OR I saw Dr. Steve again, as well as 3 nurses. The embryologist came in to confirm my personal information, and then Dr. Steve started my anesthesia. Before I knew it, I woke up in my room with Nurse Sabrina. She asked me if I was in pain, and gave me IV pain medication when I told her I was, which helped, and then told me to go back to sleep. 

The next time I woke up, David was sitting next to my bed in the chair. The nurse returned and gave me some saltines and water, had David give me some oral Norco for the pain, and had me drink some Sprite to increase my sugar levels. She went over discharge instructions with me again, and relayed dietary instructions to David, and then told me that my doctor would come in to speak to me before we could leave. I could hear another woman that was crying from the anesthesia wearing off (it was heartbreaking!). I asked Nurse Sabrina if I had done that, and she said no, but that I was extremely funny. I asked her why, and she said I kept asking questions about how I got to my bed and who brought me there. She said she loved my voice (which was a little scratchy), that it reminded her of a character from Gravity Falls, and that I should do voiceovers. :)

My doctor came to see how I was, and told me he had retrieved 19 eggs. I was hoping to hit an even 20, but he said he was happy with anything over 15. We discussed the protocol for the next few days, and the PGS and tentative FET schedules. Then I was able to get dressed and leave. After stopping at Arby's and KFC, we got home just before noon.

Nurse Sabrina had instructed David to make sure I focus on consuming Gatorade, protein (meat, nuts, cheese), and broth, all of which David kindly got for me from the store after I woke up from a nap. I've had some spotting throughout the day, but nothing excessive. The pain is uncomfortable (similar to really bad menstrual cramps). It gets worse when the Norco wears off, but it's not unbearable. I took it easy the rest of the day, napping and resting on the couch. Tomorrow the doctor will call me to tell me how many eggs were mature and fertilized with ICSI.

David's parents are coming tomorrow for a quick visit; I'm hoping I am feeling up for the company. Unfortunately it didn't work out in their schedule for them to come a little later, and David will also be leaving after the weekend, so we are making do!

Bloating, Weight Gain, and Ultrasounds

Progression of abdominal swelling:
Left - Stims: Day 6; Center - Stims: Day 10; Right - Morning of ER

I read that ovaries are normally the size of walnuts, but with IVF can swell up to the size of plums or even small grapefruits! So prior to starting stims, I was preparing myself for the swelling and possible weight gain. (I've read varying accounts on weight gain--some women gained nothing, some gained only 5 lb., others gained closer to 15+ lb.) Today, (the morning of my ER, which I will write about in the next post), I weighed myself and I was up 1.8 lb. I will say that I had a lot less swelling than I was expecting, and my discomfort was pretty manageable (with only a few days of bad headaches at the beginning and a little bit of abdominal "heaviness" towards days 8-10 of stims). I thought I'd post a comparison of my abdomen: Day 6 vs. Day 10 vs. Day 12/ER. I actually looked and felt more bloated on some of the days in the middle of stimming compared to the morning of my ER.

Top: Uterine lining; Bottom: Follicles in my ovary

I also wanted to share some photos from my ultrasound on Day 10 (5.29.16). This entire process has been so interesting and I've learned a lot about my body and what it's capable of doing. 

I've also really surprised myself at how strong I am when I need to be. This first cycle (up to ER) was scary and difficult at times, but it was nothing I couldn't handle and make it through. I've endured endless blood draws and needle pricks, had a ton of invasive ultrasounds; I've gotten over any kind of embarrassment with doctors; I've learned to give myself subcutaneous injections! I've also spent time getting myself healthy--both mentally and physically. I'm surprised that eliminating alcohol and caffeine was as easy as it has been (though I have definitely craved a glass of Malbec here and there!). 

If you are reading this and you are interested in IVF, but are scared of the needles, doctors, and protocol involved--be brave! If I can do this, so can you. In the end, those needle pricks, blood draws, and doctors appointments will (hopefully) be totally worth it. I'm keeping my eye on the prize!

Pulling the Trigger Tonight!

Today is Memorial Day, day 11 of stims, and I went in for an early u/s and bw appointment and was told I'd be triggering this evening! Last night I decreased my Gonal-f from 125 IU to 100 IU and kept the Menopur the same; Cetrotide was the same this morning, and I will be triggering tonight with 0.8 cc of Lupron (Leuprolide Acetate).

My estrogen (estradiol) levels were 3606 (Saturday, 5/28/16); 4835 (Sunday, 5/29/16); and 5604 (today, 5/30/16). They are seeing approximately 16-18 large follicles. I'm hoping this will be 18-20 by Wednesday, which is Egg Retrieval (ER) day!

My trigger is scheduled for 9:46pm tonight, and the ER will be exactly 36 hours after this, so 9:45am on Wednesday, 6/1/16. Tomorrow night I will take 2 Azithromycin (500 mg) tablets, and then no food or water after midnight. I am excited about the upcoming ER, and not super nervous or scared yet. I'm sure it will start settling in tomorrow night!

Day 8 of Stims

Stims: Day 8 - 4th morning of Cetrotide (25 mg)
7 nights of Gonal-f (175-150 IU) & Menopur (75-150 IU)

Today is my 8th day of injections. The veins in my arms are a little bruised so blood draws are a bit harder for the phlebotomists. During the u/s, the sonographer found 10 follicles in my left ovary and 14 in my right. She said that I could expect to make appointments for every day this weekend. I keep forgetting that the fertility clinic is open 24/7, because the doctors, nurses, sonographers, etc. need to be ready at any point in time to retrieve eggs and implant embryos! Reminds me of when I worked at an emergency vet hospital all during grad. school. Memorial Day is Monday, and they don't get the day off.

I didn't get a call from my nurse this afternoon so I called the after-hours number and the nurse on-call called me back to tell me that the doctor wants me to decrease the Gonal-f dosage from 150 IU to 125 IU, and to keep the Menopur and Cetrotide doses as is. I have another appointment scheduled for tomorrow morning (Saturday).

David comes tomorrow night, so I am excited. It's been lonely and difficult not having him here, and I know he's been bored at home by himself so hopefully this will make things a little easier. David coming means that the egg retrieval is right around the corner! We don't have the date set yet, but it should be some time next week!