Dear Y,
I miss you! I hope you are doing well and that you are enjoying the Spring. I'm sorry I haven't updated much, work had gotten crazy with the end and beginning of another year. The bosses and everyone else really, playing the game and dancing behind coconut trees to see who had been promoted or rewarded. Also, you know the truth is that I started this blog so it would feel like I was talking to friends like you, whom I can't always update personally, friends where I truly feel mutually invested in what goes on in their lives and how they are feeling. But I can't shake the growing feeling, that I don't want to write anymore.
The first part of this is, of course, how long this wretched search for a kid has been going on and my partial denial of how long it really has been. Part of me wants to stop writing, for the same reason that I want to stop thinking about the topic, which is to be able to move on. I don't want to keep re-hashing the same old because then it doesn't fade away. And the second and ironic reason is that although I don't really care about strangers (the world isn't That small), I am discomforted by the feeling like the blog is also read by people whom I may know and who aren't as much supportive as judgemental. I haven't stopped writing yet, because, well, I guess I haven't reached the tipping point.
We did get the call back from the clinic. The embryos were better quality this time around, but compared to the perfect spherical, transparent Grade A cells that you see in the IVF textbooks, ours are always rather scrambled and granular. To be honest, looking at them, via microscope pictures, scares me, because they look so imperfect. Being me, I've googled "pictures of ugly embryos successful IVF" more times than I choose to remember.
Grading is done on several scales, the first is mitochondrial strength and that just determines how many days they can push on and keep dividing. In theory, to be 'great', they need to be 8 celled on Day 3 and a blastocyst on Day 5. 'Good' is anything above a 6 cell on Day 3 and a blastocyst on Day 6 morning. This is only the most obvious scale, the others are things like even size of each divided cell, little fragmentation (pieces of protein that somehow fall off or get ejected from the nucleus), low granularity particularly in the center of the nucleus and the last of course, is the chromosomal normality and the presence of ICM (inner cell matter) and a fetal pole, which becomes the heartbeat.
Out of the 10 matured and fertilized eggs we got, 3 were too fragmented to use, 3 were slow growing (2-4 cells on Day 3) and 4 were nice 6-8 cells with decent grades, so they were frozen. That was the initial report. I felt very ambivalent after this because firstly, I was disappointed that the drop-off rate was so fast, that the embryologist was freezing on Day 3 because he might be concerned there would be nothing left on Day 5. Inherently, there isn't a quality difference between Day 3 and Day 5, it's the same cells on Day 5 as Day 3. But the success rates for a Day 5 blastocyst are 50%, versus a Day 3 which are 25-30%, because it is more developed, 80-100 cells at Day 5, versus 8 at Day 3, hence by sheer attrition of numbers, it is a clear predictor of quality.
The odd thing, though, is that many Day 3 embryos actually take when replaced, leading other doctors to think it's better to put them back. There are a lot of cases of women who put back Day 3 embryos and had them take, while the rest of their embryos which they cultured to Day 5, simply expired in the petri dish. So all the doctors do agree that if it would have been fine at Day 3, it would also have been fine at Day 5 and vice versa, they just don't know what gives any single embryo the spark to kick it into life.
They all say that they've put back Grade A Day 5 blastocysts and had them all not take, and they've put in Hail Mary Grade D Day 3 embryos where they themselves felt the probability was lousy and the kids are completely healthy and cute. In public hospitals in Singapore, they do mostly Day 3 because they need to get through as many patients as possible and because they need to get as many babies as possible. In private clinics, they like to push to Day 5 to prevent unnecessary miscarriages, or making a mockery of the unbearable two-week wait when it might have been inherently, a chromosomally abnormal embryo to begin with.
The doctors don't know why my egg quality is so poor, as to cause the high attrition rate and degree of fragmentation. The embryologist said he suspects I have a defective meiotic spindle (the spindle is the apparatus within each egg that divides the cells) but again, this is only within some eggs, so it's not conclusive and it's really just a scientific way of saying the same thing, which is that you have old or crap eggs.
The extension of this is that if this cliff in quality happened when I was 31 and 32, I will probably be menopausal in 10 years from now, at 43, and I was fertile probably much earlier than most women. I don't blame myself at all for not having children in my teens and twenties, which is when apparently it would have been best for me (how third-world!), but it kills me particularly, that the couple of years after we got married in my late twenties and when we held off trying because he had new jobs, may have produced a vastly superior quality.
The other extension is that more of your eggs may be chromosomally abnormal, which typically happens to women after 35. In every crop of eggs, there are good and bad, that's the nature and purpose of IVF, but the percentages of each can differ hugely from person to person and batch to batch. In both natural and IVF pregnancies, 75% of the miscarriages occur because of chromosomal abnormalities. In the last round, we had 8 eggs; by Day 3, only 3 were left. Of these 3, 2 made it to Day 5 but one was struggling along as a morula (technical term for Day 4) and never made it to blastocyst, and the last was a blastocyst but had little ICM and no fetal pole. Therefore, it most likely had a chromosomal abnormality. Such a blastocyst, if implanted, would have miscarried after no heartbeat could be found at 6-9 weeks.
In other countries, on the Day 5, you can also do what is known as a PGD (Pre-Genetic Diagnosis), which confirms up to 90% that it is chromosomally normal. This is similar to the Harmony test that pregnant women take after 5 weeks. In Singapore, you can't do a PGD unless you have an infectious hereditary blood disorder, because it also tells you things like gender. But after our previous experience, you can imagine why I was terrified that without a 5-day blastocyst, there was no even semi-conclusive, visible way to know that they might not be normal.
As it turned out, we had a somewhat reassuring surprise after a few mopey days, which was that of the three unfrozen, slow-growing 2-4 celled embryos that were left to culture, because the embryologist didn't think they really made the grade to freeze, one did become a blastocyst and although it was an ugly poor-quality one (since it had been a poor quality Day 3 embryo to start with), it appeared normal, with ICM and a fetal pole. So he froze it on Day 6.
As one doctor put it, bad embryos don't make bad babies. Bad embryos make no babies, because they don't implant or they miscarry. Embryos only have a potential for life and the ugly embryos don't have any less potential, because it's all probabilities. The only real test of the viability of an embryo is whether the womb will accept it and nurture it. So by extension, I guess I have to tell myself that if it doesn't work, it is only because the embryos weren't good enough.
That's my long way of telling you that we aren't anywhere different. And also, that it all sounds like a logical process, but the emotional process and the infinite wastage of time googling things like "meiotic spindle" and mentally calculating the percentage of women with "day 3 success stories", "poor quality eggs" again and again, is exhausting and unproductive but you do it because these years of waiting and hoping drive you out of your mind and there is nothing else to do. Plus, I get bored easily, which you already know.
There is no guarantee, nor even likelihood, that this will work. People keep telling me things like be positive and send positive thoughts to your embies (I think I do, but anyway, it feels disingenuously infantile and insensible). But we may have spent a ton of money, effort and pain, in getting to the same starting point we were at, now two years ago.
In the meantime, we just wait. We are waiting for either a month with great uterine lining thickness, so they can begin the FET (frozen embryo transfer) process, or possibly, for a month with good antral follicle count, to do a repeat stimulation cycle and bank the embryos, with the hope to build up the number we have and a better mix of Day 3 and Day 5. This waiting is punctuated by many false starts, a lot of envy and gnashing of teeth.
I really want to travel and visit, but my plans are all curtailed. Basically we wait from month to month. And the waits for the doctor, are excruciating because their time is elastic and your need isn't really urgent. Although the kind nurse just calls me 15 minutes before I'm due in, so I can have a normal day, that normal is defined by watching the hours tick by after my 'originally scheduled' time, while I try to work in intermittent shifts. I shouldn't complain, just being able to get help or afford it whilst still being able to be intellectually engaged, is, I know, a luxury.
By the time you know that nothing is going to be done that month, it's too late and too expensive to plan anything or go anywhere. I've had plans fall through so often, or gotten stressed at having to make last minute changes, or wait on tenterhooks to 'see if we were still going', which of course, made things like doctor visits and scans far more anticipatory than they really had to be — that I've just given up planning much!
I'd like to make it back to reunion at university in October and road trip across the South. I'd like to go to Turkey or Prague, or Italy or Brazil for the World Cup, and Tokyo for my old roommate's wedding in late May. But, note the word 'would like'. I have no idea what I'm doing, no change there. The only constant, really, is uncertainty.
I'm getting better at dealing with uncertainty and closer to the point where I can make parallel decisions. I think there are three fronts where I'm doing this... okay, trying to do it. The first is using the time to work on the life angst and work issues, like what do I want to do next in my career? Do I want to consider a posting (and seriously considering means changing a lot of our stable, Singaporean life right now, as you well know) or do I want to change what I'm doing totally? Am I unhappy because I'm impatient, or because I'm also bored?
If a posting, would I consider going to London, or do I really want to go back only to the US? If I change what I do, what company would hire me and where would I be able to contribute? Can I really contribute? And what kind of pay cut would I take? Is the pay cut such that I should try to sell our investments (yes, it is)? Do I really want to work harder and start again? Do I want to just take a break, or not work at all, or do a Fulbright?
These are kind of scary questions and for me, there isn't any consideration of being a stay-at-home mom. To actually pull the trigger, I imagine, would be even scarier still, but at this stage of inertia, I'd be happy to get some kind of resolution or just progress...
The second area is trying to giddy-up on the adoption forms, which are still languishing in our drawers and learning about egg donors. I can't keep doing stimulations, even if I do have reserves of eggs. We might conceive naturally someday, but who knows when that might be, in three years, in six years, or never. I need to know what we are going to do next. So I have been doing serious thinking about whether I am more comfortable with egg donation or adoption, and there are split reasons for each.
One thing that I've been doing is trying to touch base with old friends, in part because I realize that if I'm going to change, then maybe few of my young, occupied mummy friends are going to change with me. It would be wrong to expect them to be able to. I finally met up with our old friend J. It was so good to talk after so long, I almost cried. I've missed her hard-nosed sensibility and sharp sense of humour, it is lovely to get updates on what and it makes me wonder why we had left off before. I think it was because for a while, we were at different places in our lives. But it made me think I've let an awful lot go over the last few years, without even realizing it.
True to her forthright practicality, she introduced and arranged for me to meet her medical friend, who herself did the egg donor route at 30, after having complete ovarian failure in her twenties. Her story was entirely gripping, but the end result now is that her two girls are 4 and 1, and she's really, very happy. I looked at this example of a woman that I felt I could identify with, who had wanted and felt the same things as me, and her beautiful, well-adjusted children ("Mama had no eggs, no eggs at all! So Tata gave her an egg and I grew in her belly and she has me, now she's fine!") and I was seduced by how little trauma was involved, especially for the child, which may not be the case in adoption.
As you can tell, since the adoption forms are still in the drawer, I'm wondering whether we have a sort of mental hurdle with really having this child. (Isn't it terrible to admit to ambivalence when you've already done so much and been so crazy — but it is there!)
The thing is, since I can't have a child easily, do I want to force the issue right now — after all, you can adopt anytime and you can go get an egg donor most anytime also. But it would affect whether we could take a posting somewhere else (not many spare Asian children outside Asia!), whether I could restart my career trajectory, and how much help we would need or need to live with.
If the last two years have already felt limiting, I ask myself, if I simply plunge onward into getting a child by any means, am I confident that it will take away all my dissatisfactions, will it right all the wrongs that I've been restless about? Or won't it make me more frustrated, while juggling even more balls in the air?
The third thing I've been working on is, with a mutual friend WT, I'm co-founding an NGO and applying for grant money. She created a support group for women dealing with infertility in Singapore (for now) and the NGO is to do more: first, to be a repository of comprehensive and updated medical resources and treatments that are available in Singapore, and where and how to seek these out (this was really lacking when I did research, and the resources that exist are uncoordinated); and second, to lobby the government to be involved in policy decisions around financial, legal and medical processes to do with fertility. Right now, Singapore is hopelessly behind most Asian countries on topics like egg freezing, surrogacy, egg donorship, chromosomal testing and even the regulation of adoption agencies, all of which are privately run with little oversight.
This is partly because of the sensitive nature of these topics — which we will have to overcome, given the diminishing fertility statistics, later marriage age and lower percentage of marriage that are emerging in Singapore and globally — but also partly because the nature of the government's official stance toward women is to conjoin women, reproduction and work, in a tripartite that leaves any alternative situation, like infertility, homosexuality, single or unmarried women/mothers, or even stay-at-home mothers, falling between the cracks in terms of financial support or policy equality.
Our hope is, firstly, to help others to make informed decisions, but secondly, to be involved as educated, reasonable and experienced women who can perhaps help to even out policy discussions and point out the targets and returns as to where and what support is needed. We're neither uptight science-is-sinful, give-me-free-childcare paleo mothers, nor are we bra-burning-liberal-turkey-baster feminists, so hopefully that stands us in good stead to be taken seriously by old, male technocrats!
Part of doing this was to go through what has become my own scarily thick folder of medical bills and reports. You know I really like lists and files, right, but this file just had everything chucked in it willy-nilly. I have procrastinated organizing this file over the last two years! And when I finally had to, for tax computations (damn 15th April — do you know I pay three times as much tax as my colleague who earns the same amount but has three children and thus almost maximum working mother relief!? I swear I've spent as much as her just trying to get there.) and to substantiate our examples of medical protocol and expenditure differentials in public and private hospitals to the Health minister, I realized why I'd left it so deliberately piled up and it's because going through the file was a store of bad, depressing memories.
Superstitiously, closing the books on them seemed like a way of finalizing that these opportunities and tries were, indeed, over, and that itself felt incredibly demoralizing. What do you do with the phone numbers and cards of gynaecologists and embryologists who just seem like ghosts of Christmas past? Or the memories of younger and older women who have gone on to multiple children both naturally and on IVF, then paralleled with your own lousy experiences?
I don't know, but I'm just carrying on as best I can and, hopefully, letting go wherever I can. Love you and want to hear more about what you've been up to and how you are coping.
