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!

Alcohol and Caffeine

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 was a little worried the other night because I read online that "research into alcohol consumption among couples being treated at a fertility clinic found fewer successful pregnancies when the women drank several glasses of wine a week, or the man had a daily beer" (The Guardian, 2009). Another article said that "drinking as little as three small glasses of wine a week could reduce a woman's chances of conceiving by two thirds over a 3-year period," and 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" (RSCBA, 2013).

This freaked me out. I had been drinking the occasional glass of wine up until the night before stims, and I know David has had the occasional beer as usual. The doctor and nurse never told us to cut out alcohol prior to treatment. I sent my nurse a panicked email, and she responded the next day with "Not to worry. An occasional glass of wine or beers here and there will not make a significant impact on your IVF cycle or on the sperm." Phew!

I also posted to an IVF message board, and received some encouraging responses that brought me some relief:

• "My nurse told me that I was allowed one glass of wine each night during stims, but I did not partake. I only stopped drinking the day before my first stim shot. I have also been told that 1 drink with caffeine per day is ok...I am still in my two week wait, so I don't know if my cycle worked or not yet, but I wouldn't stress too much about it. Nothing you can do to change it now unless you want to wait 3 more months before you start."
• "I drank on a regular basis leading up to stims (I'm a one drink per day kinda gal, plus several drinks per day on weekends). I did absolutely abstain during stims though."
• "We did IVF beginning of January so lots of holiday parties, New Years, both our birthdays in January etc. I got 9 blasts out of 14 eggs and am 19 weeks with a healthy little boy. You know what is worse than the beer and wine you've had... Stress. Don't worry what is done is done and many of us have had a glass or more to get thru this difficult time. You absolutely have not ruined anything!!! I would have him stop drinking by the trigger shot for the fresh sample however. Best of luck! Enjoy that glass now cause you may end up not having one for a long time if you're lucky :)"
• "I drank up until the day before starting my IVF cycle. I now have a 4 month old. Don't stress about it :)"
• "This is because it takes eggs and sperm about 3 months to develop. In the 3 months prior to IVF you are both producing the eggs and sperm that will ultimately be used to create your embryos. Technically, anything you do during this time period can have an impact on your eggs and sperm. There are lots of recommendations involving diet, alcohol, supplements and even the avoidance of BPA or other environmental toxins. It's impossible to do everything perfectly and it sounds like you've only had a moderate amount of alcohol anyway! I didn't prepare at all for my first IVF cycle. I had 1 or 2 drinks a day up until 3 weeks before retrieval. It worked for me and many people are successful with IVF without having to prepare at all. I'll be 2 years older (35) for my next IVF cycle and that scares me so I am preparing this time, including drastically reducing alcohol."

I think that it wouldn't hurt to reduce or eliminate alcohol and caffeine in the 3 months prior to IVF (for both you and your husband), but that ultimately, it is not going to drastically compromise your chances. I think that had I known this information prior to starting, I would have cut out alcohol and reduced my caffeine intake starting in March...but since I didn't know this, I'm not going to stress about it. As Plautus said, "Factum est illud; fieri infectum non potest." Done is done; it cannot be made undone.

Day 7 of Stims

Top: Gonal-f
Bottom: Cetrotide in its "Lunchables" pack

Update
I started stims on Friday (5/20/16), had a check up on Monday (5/23/16), and again yesterday (5/25/16). On Monday, during the u/s, the sonographer found 9 follicles in my right ovary and 10 in my left, and was able to measure a number of them that were 10+ mm. That afternoon, my nurse called and told me that they were surprised to see how quickly I was progressing (she assured me this was "a good problem to have") and that the doctor wanted to dial back on my Gonal-f (from 175 IU to 150 IU), to increase my Menopur (from 75 IU to 150 IU) and to add in a morning injection of Cetrotide (0.25 mg). My estrogen (estradiol) level was at 109 pg/ml. Yesterday, the u/s showed that more follicles were enlarging, and when my nurse called she said that my estrogen level was now at 781 pg/ml. My next appointment is tomorrow (Friday, 5/27/16).

Stims: Day 6 - 2nd morning of Cetrotide (25 mg),
5 nights of Gonal-f (175-150 IU) & Menopur (75-150 IU)

Starting Cetrotide
I was a little nervous to inject the Cetrotide, as I've heard it also burns and can cause an itchy rash at the injection site, but I found it to be pretty unremarkable. It is refrigerated, and comes in its own little "Lunchables" style pack, with syringe pre-filled with sterile water, powder vial, and alcohol swabs--I like how convenient this is. My only problem with it is getting all of the powdered medicine to dissolve completely. The injection itself didn't burn for me and only itched a tiny bit the first day, but nothing like a mosquito bite or anything. I did bruise at the first injection site. This morning when I did the injection, I accidentally stabbed my middle finger as the needle bent and went through the cap. I'm not sure if it was the throbbing pain in my finger or the medicine, but I got super nauseated and dizzy, and it was all I could do to rifle through my parents' bathroom drawers to find some Neosporin before I passed out. Luckily, I just barely made it to my bed before falling over. It was a rough morning.

The trigger
I got some good news from my nurse. I have been a little anxious about my upcoming trigger injection, as most of what I've read has stated that they need to be injected intramuscularly (i.e., in the butt muscle). We were prepared to hire a nurse who would be on call for 3 consecutive evenings (cost ~$125-$175) to come give me the injection, which could very well be in the middle of the night. My nurse told me that all my medications including the trigger injection will be given subcutaneously in my abdomen. She explained that there are 2 types of trigger injections: Lupron and HCG. "The reason why some physicians use one over the other is the mechanism of the trigger. For those patients who have a lot of follicles or are at risk for developing ovarian hyperstimulation syndrome (OHSS), you would use the Lupron, as this medication is in your system for a short amount of time. The HCG trigger is for the patient who will have an average response to the stimulation medication as the HCG medication is in the system longer." So I don't need to hire a nurse, and I can do the trigger injection myself!

Exercise
I was told I could continue my normal cardio and strength training during the early stages of injections (days 1-5), but by day 6, I would want to decrease the intensity and focus on non-impact exercises (yoga, light elliptical, swimming, etc.). Yesterday was day 6, so I took Noah for a 2 mile walk. Today I am going to do the same, but also hit the gym for a light elliptical workout (decreased intensity/time). I did an entire week's worth of cardio/strength from Saturday-Tuesday, so I was at least able to get that in...but it's going to kill me a little to not be able to do strength training as usual. Oh well...I'll live.

Mickey Collector's Series Band-Aids

Little treats
I've decided to reward myself after my nightly injections with a little treat: popsicles. I am loving these little Outshine Fruit Bars. They're only 35-45 calories a pop (ha!). I also got some Mickey Band-Aids, because who doesn't love Mickey? Little things like that, walking the dog, and working out, have helped keep me sane. I've been getting daily headaches which I am able to treat (for the most part) with Extra Strength Tylenol, lots of water, and naps...I've been taking lots and lots of naps!

1st and 2nd night of Stims

I did it. I gave myself 2 injections last night.

Last night I went to see my friend, Vince, play a show in WV, and then left early to get home before 10:00pm to give myself my first injections. My mom was by my side, but I insisted on doing everything myself.

Currently, I am taking 175 IU of Gonal-f and 75 IU of Menopur. Gonal-f is refrigerated, and can come in the Redi-ject pen, which is a disposable, pre-filled, and ready-to-use. You just dial your dosage, screw on the needle, and inject. Gonal-f (Gonadotropin FSH) is a follicle stimulating hormone that basically makes multiple follicles (cysts containing eggs), and causes multiple eggs to grow to a mature size. The Menopur needs to be reconstituted with sodium chloride solution (sterile water). Then you draw it up in a syringe from the vial and inject it. Menopur has 2 kinds of hormonal activity: FSH (which helps increase egg production, like Gonal-f) and LH activity (which assists with ovulation).

I did the Gonal-f first, because I knew the Menopur was going to sting. I will say that both needles were small and did not really hurt that much going in. The Gonal-f does not sting, but the pen trigger bothers me because I'm not able to watch as the medicine goes in, the way you can with a regular syringe. Mixing the Menopur is an art form, and I had to watch the instructional videos several times. It's really hard to get every drop of medicine out of those vials into the syringe. The Menopur does sting, and it seems to sting more toward the end. It's not unbearable, it's just uncomfortable. 

Left: Look how cute this little Sharps container is!
Right: The Menopur comes with vials of sodium chloride solution you use for reconstitution.

Last night, I felt good after my injections and I was really proud of myself. Today I am feeling a little depressed realizing I'll be doing this everyday (and eventually twice a day) for a couple weeks. I really cannot imagine doing multiple rounds of IVF. There is so much involved!

I think the hardest part, for me, is the isolation. This is a very lonely process, especially with my husband and friends nearly 2,200 miles away. Since we haven't told many people, I can't really post about anything on social media, which is hard. I am one of those people that really thrives on the support and encouragement received from others on social media...and since I can't really talk about my experience, I am relying on the support and encouragement of the few people that know about it...and of course, most everyone is super busy and preoccupied with their own lives, so I don't want to trouble them with my woes.

Right now I really just want to lie on my couch under my favorite blanket, snuggle my Golden Retriever, watch a cheesy Lifetime movie, and cry. Part of me wants to tell everyone, "Hey, this is what I'm doing. Look how brave I am giving myself injections every night. I'm doing this so that maybe we can have a baby. This. Really. Sucks." But I can't. 

So instead, I am trying my best to stay sane...I'm working out as much as I can within the restrictions I've been given. Under doctor's orders, I've eliminated alcohol and caffeine from my diet, and the only painkillers I can take are Extra Strength Tylenol (meaning my normal go-to for headaches, Advil, is out.) 

This is going to be a long couple of weeks...