Today was the sombre meeting with Dr W, a meeting I had requested as I was suddenly struck by fear and indecision about ploughing back into an IVF cycle with the exact same hormones, protocols and probable results.
I had a difficult time setting up the meeting, with the nurses answering my calls and pleading queries with some delay. I really think that IVF doctors and nurses are completely understaffed in Singapore, particularly at the public hospitals and especially since the start of the higher government co-payments. In particular, I think it is ridiculous to have doctors treating both IVF and regular cases. I understand that they need the practice and the repeat business but, personally, women in their latter stages of pregnancy, by definition, are no longer infertile. There are infertility queues out the door at public hospitals and it would make much more sense to have a few doctors concentrate on those cases.
In the meantime, I request to have my bloodwork tested again, and this time, after our glorious break in the US, my FSH, which had remained high through April–July, plummeted to 11.4. What was going on here? Either my hormones were out of whack — a very likely explanation, really — or else the break in the US had this effect. And if it was the break, was it the break from work and work stress or the break from the social stress of always being reminded of children and having a homogenous and, to be honest, stiflingly undiversified circle in Singapore? Was it a freedom break from the preoccupations of women in Asia, circling between seasons to marry, work and have children?
I wanted to believe, or think, that it was a response to both, to somehow feel validated that, as much as I liked to believe my work wasn't stressful, my bloodwork said otherwise. Neither the input nor the outcomes were replicable, of course. But in fact, all my theorizing, too, was put to pasture by Dr W. today. He explained that it simply meant my hormones and ovarian reserve were not getting worse, but they were certainly poor, and that corroborated with the dismal result of getting just 1 egg in the past cycle. FSH measures were not the best (did he say this to discourage my independent seeking of the re-test?) and fluctuated with cycles, and 11.4 or 15.6 were all purely indicative, but of the same thing.
Also, he said that the protocol they used in NUH was what I had followed the previous time; therefore, that would be the same protocol used going forward. While I have often said that public sector clinics are really good at what they do, one area of deviation, I feel, between my previous private-sector doctor and our doctor now, is that the private-sector doctors are more willing to work with individual patient needs. So, if you are an older woman, or a poor responder, or have low ovarian reserve (or all of the above), then you might actually get better results (may, not saying you will) with a different protocol. Firstly, what Dr W. seemed to be saying is that the protocol worked for most patients, so that's what we all were given, which didn't sound particularly good to me, given my poor results on it; and, secondly, in terms of using any additional therapies, he said he had so far only had three patients on growth hormones (injectibles for three months prior to IVF cycle), so, in essence, although he is renowned as a very good doctor, it seemed that at least his IVF cases weren't very difficult. And, in a way, they couldn't have been if he had prescribed them all the standard protocol. That was troubling.
All in all, he told us that while each cycle was independent and there were definitely instances of drastically different results, I would most likely get similar results and the probability of succeeding in an IVF round — wait for it — was as similar to that of women in the 40–45 age group, who had similar test scores to myself, and that probability was south of 10% (whereas it should be 30% at 32).
Well. There it was, as always, matter over mind. As it always is in such circumstances. And so put to rest all the silly theories about letting yourself get fat, or exercising more because it made you feel good, eating hot food and just banking on your physiological age. None of it really matters if your eggs are few, old and of poor quality.
Being an investing person, I can only conclude that 10% is a terrible risk-reward. I would never bet on it and it felt like I would just be hurling myself off a cliff of medication and drugs, to try to get a hope that was laughably unfavourable. If I knew something had a 10% chance of a successful outcome, I would say thank you very much and walk away; to do otherwise is irrational.
IVF is a lot like chemotherapy. There are no guarantees that it will eventually lead to a completed deal, but without it, there's no chance for success. Each cycle is a necessary step in an evil, painful process. At the end of each session, you pray that soon, the process will draw to a close. And maybe one day it does.
Also, like chemotherapy, infertility seems full of false promises, phoney cures and hope, rather than failure. It always seems to be somebody's friend, somebody always seems to have succeeded, somebody had twins, somebody got pregnant at 42 (you don't think those celebrities freeze their eggs earlier or use donor eggs?), somebody's friend, every knows somebody who suddenly got cured and is so blissfully well — it's torturous. Somewhere in a Thailand clinic, or while taking Peruvian superfood supplements, or using growth hormones, there is an infertility-free town, with an infertility-free circus and an infertility-free clown, who dances for infertility-free kids. The audacity of hope makes it so hard to move on while it's still Possible.
One thing that I do often think is that I didn't get married particularly late. I didn't start in any of this process particularly late. There are so many women who fall into the 50% of woman fall pregnant within 6 months of actively trying (yes, that is the actual statistic, if you're wondering, the remaining 25% within 1 year and 15% within 1.5 years), but when I look around the clinic at the many women who have not and will not, I often think they should test all the women before they start on higher and tertiary education. How many of us would push on to an MBA or a PhD, if we knew we had a 10% chance of success at IVF? How many of us would have married the first suitable guy that came along? We might have been happy, the same way arranged marriages are often happy. Would I have? I don't know — maybe. I'll never know because you can't miss what you never had. I moved past it.
More broadly, I just feel that much of this mismatch between biological and chronological age for women is inefficient. Whether it's because you made different choices, or whether you met the right person late, the truth remains that a very small percentage of women get married at 24 and have children at 27. The process of meeting and being with a partner, or even knowing yourself, isn't efficient; it doesn't rest on whether you are thoughtful, beautiful, dynamic or intelligent; it's path dependant. Yet, we don't, globally, encourage fertility testing, allowing women a completely unplanned decade of their twenties, followed by a stressfully planned decade of their thirties.
I don't know if it was his stern outlook or just a weakening of my own resolve, but, after a few tears rolled away after the meeting, it didn't hurt as much as I thought it would. It felt terrible, don't get me wrong, but it corroborated with our lousy result from before. Maybe because my own dad is a gynaecologist, I inherently had always understood the quality implications of the poor response to even the most aggressive dosage, or that there had never been fertilization, after all this time.
Over the course of this process, even though it has reduced me to a whingy, depressed, "shattered" — as one insensitive clout described my tired appearance this morning — shell, one thing I have noticed is that it has reduced the importance of most other things as well. I have become less inclined to jump to conclusions, react to inequity or try to build relationships when I no longer see the point of the effort. I don't care about many things anymore, nor care, as I used to, about what some people say or think. I think this experience has hardened me, humbled me and strengthened me. Maybe it's just the process of so much senseless hurt that it has been an unfairness so unforgivable, so basic, so hard to let go of, that it makes other slights easily forgivable and exposes the triviality of most acquaintances, assumptions and exchanges.
It mattered little that I could have achieved a result before and more that once we were done with this process, we truly would have just each other, and how we were to each other and what we planned to do with our lives going forward. The truth is, I was living in fear that one by one, I'd see all my friends disappear into their families and I'd see younger, or even older women, easily being able to get pregnant again and again, and it would never stop hurting and reminding me of what we did not have. The truth also is, though, that the husband and I could easily have had children, had we tried when we were dating, or had we met and decided to be parents at 22 (which we didn't and could not have). That we don't have them now, or even if we don't ever have them in the future, is not so much a tragedy as it is a circumstance, even a coincidence, of context. And while it is not a good thing, it is also not a bad thing to have really considered parenthood, in the way that only adoptive parents have really and necessarily considered it.
Maybe it was time to work on that and put aside these fruitless attempts at fertilization and just get on with finding our little boy and girl, and someday our dream of having a family, a family that would love, irritate, support and travel with each other. It hurts because I know I love them, even though I've never met them. It hurts less because I know I can love them. How much more should I really make myself unhealthy if I want to be around for our family later on? I know I'm doing what I am now because it matters, but one day, it won't matter and they will.
Second cycle, I still don't know what to do.Thank you to all the readers, unknown and otherwise, for your kind comments. It really has made my day each time, I am so grateful and humbled by your concern.
I've been feeling really moody. For the last few days, I've been going through the ups and downs of feeling angry and frustrated. I can feel myself yo-yo-ing and there are moments where I just don't want to talk to anyone, and then moments where I feel emotional and sad. I'm not stressed, but sometimes I wonder if I'm slightly depressed. (Or, alternatively, if this is a normal feeling, all things considered). I'm also out of sorts because of the Noreistherone and who knows what else; I haven't been sleeping well, I feel tired and lethargic all the time, and I'm piling on weight, which I can feel from my pants and top getting tighter, heavier and more uncomfortable. The Noreistherone is the pre-cycle medication given by our Dr W; it doesn't help the cycle itself, it's a mild contraceptive to enable him to better time the cycle and hence encourage the follicles to grow in lock-step size (this has never been an issue for me, but sometimes follicles can be of dramatically different sizes).
At work, as much as I appreciate the distraction, the lack of change irritates and disillusions me. I suppose you could say I'm in no mood to work (that is, if you believe there actually exists some holy grail of a mood to work). There are many days when I don't want to be still here because it reminds me of how much time has passed and how nothing has changed. After clocking in all this time at work, literally over the last decade, I want to move on and progress, I want to have my free time with my family and kids and explore the world with them, not sit at a desk watching the world metaphorically go by on a screen. (None of this, by the way, has to do with the actual content of my work, and, I admit, is not a feeling constrained to the office, merely that I spend most of my day there).
I'm not eager or naive about the work and sacrifices if you actually did have a kid. There are many times when I think I don't really want my house destroyed and I rather like having enough money for spontaneous clothes and holidays. I'm just tired of being where we have been in the run-around for the last two years. I'm pragmatic that in the interim, we're not getting anywhere with trying naturally. We are set for a second cycle in Sept. As I've mentioned before, I have reservations about not changing protocol at NUH but I'm not sure there's much that can be done about it, nor if changing the protocol would even produce any results. Mostly, I dread the injections and the frequent visits. I dread that it will all add up to another big zero. I dread that after it does, we will have been trying for two years with zero results. It's human to be frustrated by that, no? Or else, inhuman if that doesn't upset you.
Most days are alright, and then there are those few emotional days that seem to be a regular feature every month. I wonder if it the hormones from the past IVF? I don't think so because I'm not sure they remain in your system, but I never used to have these emotional fallouts before this started. I used to measure the times between when I cried as years; now it seems to be every month. Today was one; I got out just in time and was in my car (it's always in the car, maybe it's a mark of how much time I spend commuting). I had just gone to pick up DHEA capsules, which I hate taking, the same way I hate all large capsules and tablets from Dr N's clinic (NUH does not stock these but private clinics do, over-the-counter, now that they are approved for use in Singapore). It always starts the same way — you get some sad but otherwise completely innocuous reminder, like you see how old some child has grown or girls posting pictures of their newborn families a year after they put up wedding pictures, to say nothing of the multiple sets of twins or shotgun pregnancies, or the insensitive women who keep posting their sonograms on Facebook and it's just too hard to hold on to the strength to be cheerful and hopeful. The emotion just wobbles over and you can't hold back the wretched sobbing and incapability to rationalise that it's not meant to be fair or possible. When you really don't know what you are doing.
Be resilient, I scolded and tried to tell myself. It will happen! It will happen, if you just have faith and keep going. Stop being all hiccupy and puddly, you are stronger than this! But part of myself also said maybe it's better to be happy. Maybe praying isn't going to change God's plan for you and this feeling bad just means you haven't let it go.
Today was another bad day: I went for my 5-day scan after 400iu of Gonal-F and, guess what, the 3 antral follicles on the right and 2 on the left had progressed to 2 on the left and zero on the right. Yes, zero. I'm not sure I've ever had zero follicles on one side before. For a moment, I entertained the deliciously depressing thought that my right ovary had perhaps just entirely run out of eggs and shrivelled up. This sounds like a ridiculous idea, but the acupuncturist told me that all females aren't actually born with that many eggs; each person has about 400 eggs to last you about 33 years of periods. So, if you start puberty at 13, that's until you are 46 years old, or younger, since some may atrophy naturally along the way. Or, if I'm like my mum and am menopausal at 37, an entire decade earlier than usual, then you have to assume you have a lot of dud eggs, or that they perhaps get released two at a time? Whoever knows. (I suppose that's how natural in fraternal twins are made, so it's clearly possible).
The funny thing is, doctors are human too. I had, of course, hoped for a large number of follicles, or at least as many as there were at this stage previously (6 on the right, 2 on the left). I felt that the last few days have gone really well and I have rested amply, slept and tried to go easy on myself in all possible ways. I've had relatively little cramping, although I've been tired. When Dr W did the scan, I could sort of tell that the result wasn't good. He paused a few seconds longer than usual and jabbed around, as if in trying to ascertain the result, and his face didn't change, almost as if he was naturally trying to hold in his disappointment and revulsion.
He continued with our treatment, moving on to prescribe Pergoveris (meant to improve egg quality and number) and Centrotide (to prevent premature ovulation) even though I wanted to question: should we cancel our cycle? What's the point of taking Centrotide to prevent ovulation when there is hardly anything to prevent? How can this be (he said that antral follicles are merely potential follicles and for some reason they haven't yet developed). More follicles might show up in the coming days, but while I definitely hope that is true, I also know that these will trail 8mm below the first two and thus likely be too small and far behind to be significant. Given follicles mature at 20mm, it is not mathematically unsound to say that unless the smaller new ones play crazy catch-up, the difference may be too far to overcome, or it suggests few more may be produced. Basically, what we are experiencing are these [classic low responder symptoms].
My two dominant feelings were how absolutely rubbish it was that I had taken all this medication (yet again) to produce just two follicles. It clearly does show that I am not just resistant to the meds but increasingly so. When I looked back at the IUI charts, I note that, at even 75–112.5iu of Gonal-F, which is a really mild dosage, or sometimes even just 5mg Letrozole (Clomid tablets), I was producing 3 to 7 follicles on a 5th-day scan of 8–11mm size (again, I was producing fewer and smaller follicles with each try, which I now think the doctors should have picked up on). And, secondly, that it was not worth putting us through the emotional and physical tax of more medication and retrieval if the number, to begin with, is so low.
The vectors of IVF are quality and quantity, and, at each stage, both are culled. For example, the first two weeks, but particularly the first week of stimulation medications are to increase the number of follicles produced. If you are normal, then you will get 15–20 follicles; if you are a poor responder like me, then anywhere under double digits (hence 10 the last time wasn't actually a good score, but it was a good score for me). Not all these follicles will yield eggs, although the statistical probability is 70% and it is generally correlated to egg quality. Some doctors also believe that these results have to do with medical protocol, or the kind of medication used and your response to them. Most people thus might get 10 eggs from 14 follicles, while we got 1 egg from 10 follicles. Not all the eggs will get fertilized — again, this has to do with egg quality — so, out of 10, you might get 8 fertilized, or you might get 6. Not all the fertilized eggs will make it to blastocyst; again, you might get 4 blasts, or be down to 2 blasts by Day 3 or Day 5.
So, if you hear big numbers upfront, like 8 eggs or 6 fertilized, you can pretty much imagine that you are home-free, particularly if you don't have problems with implantation. These are the people who are most likely to succeed or when you know that your chances are good. It's also why a Day 5 scan of 2 follicles is really pretty depressing. Our old doctor called me up when he heard I'd be around to his clinic for DHEA (this is why you pay for private care, I suppose) and gave me a supportive talk — he told me that given our condition, we would just have to be strong and steel ourselves to fight on, that we would need to see it as a process and not as a one-time fix solution. It was possible, he suggested, that we should just use low dosages and retrieve a few eggs at each time, but because we'd never had high numbers, we would have to continue to be aggressive and patient. I wasn't as emotional this time, I suppose time and recurrence has built up both my resistance and detachment somewhat, but I was still really disappointed. I guess I was hoping in vain hope that our follicle count would be better, but I'd expected it to be at least similar to the previous time. I wish we could just get lucky.
