Countdown

One day left until pregnancy test.

I hate to say it, but I don't think this one worked. :( I'm not trying to be pessimistic--I understand how important optimism is through this whole process. I also remember last time I didn't think it worked... Right away....  But a day before the test, I had spotting. In fact, I've had spotting every single time I've been pregnant--ectopic, miscarriages, and the last time I did IVF.

I have not had any spotting this time.

I do have slightly sore boobs, which I would take as a good sign, but they've been sore since the transfer. So I can't do much with that. Actually, I had very different side effects this time. No real lupron headaches, and no acne until recently. I had horrible cramps after retrieval. Last time (especially because of OHSS) I took it easy. This time I was working really hard, getting our house ready to sell, packing, and chasing a toddler. I doubt all the activity helped.

I'm preparing myself that it's not going to work. If it doesn't, we'll try again. We do have a bunch of B3s on ice....

Get out your calculator--it's time for fun with numbers!

I asked my fertility clinic for their implantation data, just to get a sense of what we would do if this time doesn’t work and we end up trying again with one of our B3s…  It was really interesting.  (Ask your clinic for their stats!)

As expected, for a single egg transfer, B1 has the highest implantation success rate—about 70%.  B2s are less successful—around 50%.  B3s really drop off—less than 20%.  They also rate the morulas.  For a single embryo transfer, M2s have about a 30% chance, and M3s have about a 20% chance.  (They don’t rate M1s—probably if you’re perfect, you make it to a blastocyst!) 

They also rate success of two-embryo transfer, depending on the exact quality of the two embryos.  For example, the rates of implantation for TWO B1s is also about 70% (actually a hair lower than the implantation rate for a single B1).  BUT the chance is 50% that the resulting implantation is twins.  In other words, if you implant two B1s, you have about a 1/3 chance of no implantation, 1/3 chance of 1 embryo implanting, and 1/3 chance of two embryos implanting.  BUT, if you just implant a single B1, you have the same chance of implantation (about 2/3) but no risk of fraternal twins. 

The stats are similar when “lesser quality” embryos are implanted along with a B1.  The chance of implantation does not increase significantly if you move from one B1 to a B1+B2/B3/M2/M3, but the chance of twins rises dramatically.  So if you’re lucky enough to have a B1, it seems like you should just implant the B1.  Implanting a second embryo does not appear to make pregnancy more likely, but it dramatically increases the incidence of twins.

Things do get a little dicier for people (most of us!) who don’t have a B1 to choose from.  For people with two B2s (still a good result!), if both are implanted the implantation rate rises from 50% to almost 70%.  BUT the chance of twins also rises dramatically—from almost zero (only identical twins) to about 1/3.  In other words, if you implant two B2s, just like the B1s you have about a 1/3 chance of no implantation, 1/3 chance of 1 embryo implanting, and 1/3 chance of two embryos implanting.  Not that we had two B2s to choose from, but if we did we still would have only implanted one—the risk of success with a single B2 is good enough (50%) and the risk of twins implanting from two (30%) is too high considering the implantation rate only rises from 50% to 70%.

Where I think the decision gets really hard is if you don’t have a B1 or B2, or even a blastocyst at all.  Like I said, with a single B3 your odds are only around 20%.  (And some of these are very small sample sizes—so take these numbers with a grain of salt.)  But if you implant two B3s, your chance of implantation rises to 50%, and of that 50% the risk of twins is about 1/3.  In other words, if you implant two B2s, you have a ½ chance of no implantation, a 1/3 chance of implantation of 1 embryo, and about a 15% chance of twins.  Those numbers start to look like odds I would take—that is, the risk of twins with a double implant (15%) does not outweigh the risk of not getting pregnant with a single implant (20% success rate).  The rates of success with a B3+morula are similar to the rates of success for B3+B3.  So again, if I had a B3 and anything, I’d seriously consider adding the other one as well.

Another thing I found interesting—my lab did not break this data out, but I was able to calculate it—the percent of each kind (B1, B2, B3, M2, M3) they use in their transfers.  About 10% of the embryos transferred are B1, about 50% are B2, and the remaining are split pretty evenly between B3, M2, and M3 (about 15% each).  Obviously the ones they use are, on average, better than what they retrieve.  I.e. I got a B2, which I used, and three B3s, which I may or may not use.  So on average women are not obtaining 10% B1s, they’re just picking their best ones.  Like I mentioned, the lab told me about 5% of what they retrieve is a B1, so it’s still pretty rare.  But because people tend to USE the best embryo they have, 10% of the embryos transferred are B1s, and because people often transfer more than 1 embryo, about 15% of transfers involve at least a B1.

These are just averages observed based on a relatively small group, and not all factors can or have been taken into consideration.  (Also, I don’t know if these include frozen transfers or if they are just fresh transfers.)  As an example, I am sure very few women would choose to only implant a B3 if they had another B3 or morula to choose from.  So it’s likely that many of the women implanting a single B3 were doing it because that’s all they had, not because it was choice.  And if you do IVF and end up with only a single B3, that might suggest there are other issues (less quality egg/sperm) making that B3 less likely to survive.  Compare the woman who has only a B3 to choose from to the woman who has several B3s.  You’d think even if they both implanted a single B3, the woman who had more B3s might have a better chance of success.  But in the real world, the multiple B3 lady probably implanted two B3s, so the multiple B3 numbers look even better when compared to the single B3 numbers….  Does any of this make sense??

Also keep in mind that these are just implantation rates—not pregnancy rates.  There’s still about a 10-15% risk of miscarriage even after implantation, similar to the rate of miscarriage after a normal pregnancy.

Wow, this is a lot of math!  Does anyone else’s head hurt??  I know this is a lot of math to follow without actually seeing the numbers.  But if you’re thinking about how many embryos you might want to transfer, take a look at your clinic’s numbers and figure out what makes sense for you.

Ice Ice Baby

The day after our transfer (day 6) we got a call that three more of our embryos reached the blastocyst stage. (So two more pooped out.) They were all B3, which means not great quality.

Oh well. 

We decided to freeze all 3. When I asked, I was told a majority (2 out of 3) would probably survive the thaw, should we need to use them. When I asked if the success rates were lower with frozen than fresh, the tech told me actually they are higher--probably because the ones that thaw are so much hardier. 

Good to know. 

Transfer day!

The most exciting day has to be transfer day. How many--if any--made it to blastocyst? What are their ratings? Oh the suspense!!

We had 6 still growing on day 5. (So either the 5 cell from day 2 didn't make it, or he rallied and someone else pooped out. I didn't ask.)

One made it to blastocyst, and he was a B2 (blastocyst, level 2). Yea! One was a late stage morula, level 3. And the rest were morulas, one level 2 and the rest level 3s.

We decided to use B2 (like last time!) and continue to cultivate the rest in the hopes we have something to freeze on day 6 or 7.

Good luck B2!

The age-old question: to implant two embryos or one?

Last time we decided to do a single embryo transfer. A majority of people in the US going thru IVF opt for two embryos to be used, but as the technology improves and people start weighing the risks of having twins versus the risks of having no kids at all (at least in a single round), more and more people are deciding that for them, it makes more sense to use one embryo at a time. This is especially true if you have a good chance of success with one embryo.

Here are a couple interesting medical articles on the subject:

http://cdn.intechopen.com/pdfs-wm/32061.pdf
http://home.smh.com/sections/services-procedures/medlib/docs_articles/OBGYN/ABOG_2013_Jan/acog_kresowik_010913.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700678/#!po=12.5000

Based on what we read, and our experience last time, we decided to transfer a single embryo if we had a B1 or B2 on day 5. We are young (I'm only 35, hubby 37), we have not had a failed IVF attempt, and if we had a good quality embryo we felt like our chances were good enough. While there would be some increase in success if we used two, there would be an astronomical increase in the chance we'd have twins. (Nothing against twins, but twin pregnancies are much harder on mom and the babies. Not to mention the idea of twin newborns... and toddlers... makes my head hurt!) Also, we have the resources to pay for another round of IVF if needed. So--assuming we had a B1 or B2, the decision was easy for us--one little blasty.

Scrambled eggs

The day of my retrieval, we had 17 eggs. (1 more than last time!) And I was not at risk for OHSS. Score!

Of those 17, 14 were mature. Of those 14, 11 fertilized. (79% fertilization rate.**) Of those 11, 3 fertilized abnormally and 1 stopped dividing. 7 fertilized and were dividing normally.

When they checked the 7 remaining on day 2, all looked good and were rated "level 2."*  6 of them were doing well--6-8 cells. The last one was "only" a 5 cell and, as the tech told me, "probably won't make it." (Poor guy!) So we decided to let them keep growing and go with a day 5 transfer--like last time. (If we only had a couple and they were not doing well, we might've done a day 3 transfer.) About 50% of the day 3 embryos make it to day 5, not all of those will make it to blastocyst, and their ratings can change. So we just had to wait to see who made it--and what they looked like--the day of the transfer. (If none make it to blastocyst for day 5, they'll push the transfer to day 6 to give them more time to grow. They will freeze the remaining blastocysts--if any--up to day 7.)

*At my clinic, they have 3 levels for rating the embryos. Level 1 is no issues spotted, i.e. they are perfect. I have been told those are very rare (less than 5%). Most have some nominal issues (60%) and are level 2. The ones with more significant issues are level 3. I was also told that the level 1s and level 2s have similar success rates (although the level 1s are higher), but the level 3s see significantly less success.

**Last time, we had a 93% fertilization rate. Unsurprising that it went down, considering we're 3 years older. I've read that fertilization rate can be a predictor of implantation rate--that is the better your fertilization rate the better your chances of implantation:

http://rinaudolab.ucsf.edu/rinaudolab/pdf/rinaudo.pf4.pdf 

Our doctor suggested that might be true for a low fertilization rate (less than 50%), but did not think our small sample size (93% to 79%) meant much because they were both still pretty good.

The times they are a changing

The last time we did IVF was just about 3 years ago.  (As long as it took us to get pregnant the first time!) Because my protocol was successful, I was not surprised that we followed a similar one this time around. But a few things have changed in the IVF world, at least at our clinic:

1. No more progesterone shots. 

For the fresh cycles, they now use suppositories as the standard. Remember how stressed I was for the shots last time? So happy that we don't have to deal with those.

2. Only one day of bed rest after transfer.

Last time it was two days. Not that I'm going out to run a 10k anytime soon, but it's nice that I can shower the day after transfer!

Not really a change in protocol, but a change for me--because of my risk for hyper ovarian stimulation syndrome last time, and based on some of my early estradiol measurements after we started stimming (117 on day 3), the doc cut back on my folistim from 225 units to 150 units.

Background

How did we get here? Well, after our son was born at the beginning of 2012, we immersed ourselves into parenting. It was exhausting (6 weeks in I got shingles!), and stressful, and wonderful. After I (reluctantly) stopped breastfeeding at the beginning of 2013 (his choice, not mine), we waited a couple of months for my period to return. Once that happened, we started trying to get pregnant again. No ovulation predictor kits, no fertility monitors, no body temperature measurements--just low-key. I allowed myself to hope that I would be one of those people whose bodies "just figure it out" after being pregnant once before.

Nope.

We tried for about 9 mos. Nothing. Now, admittedly, there were months when due to our travel schedules etc. we probably missed the window, but we felt like we'd given it enough time--especially with our significant history of infertility and our now advancing ages. (I was 29 when we first started to get pregnant and I am now--gulp!--35.) Plus, if we are lucky enough to have a second kid, we'd love for them to be about 3 years apart, which meant we didn't have a ton of time.

So we made the easy decision to take another stab (jab? poke?) at IVF.

Two week wait reboot

Hello friends. It's been a while. We've been immersed in post-baby bliss/craziness for the last couple of years, but are excited to take the plunge once again. And so begins our second pass at the two week wait. Wish us luck!