Have you ever loaded your kids into a cryogenic tank and taken them for a ride? I have. Just last week we drove our frozen embryos from our old fertility clinic to a brand new San Francisco clinic. If you’re lucky, you will never have to do this. But depending on a woman’s age, about one in six couples will be dealing with infertility at some point. Here is a little overview of what to expect when you are not expecting.
If a friend shared their infertility story with you, you have probably heard them say that it’s a “process.” I hate to agree, but be prepared to work on this project for many months, even years. And there is no guarantee you will succeed. We had tried for four years before we were blessed with our baby girl. In the meantime, my older sister tried for exactly one month. In fact, everyone around you will be getting pregnant left and right, or so it will seem. Your girlfriends will be coming back from vacations knocked up, your coworker will have a fourth baby “by accident” and your ancient looking facelifted neighbor will show up with brand new twins in tow. Oh, and she will tell you in an elevator how lucky you are that you don’t have kids because you can sleep through the night. You will be painfully aware of your otherness, thanks in part to people’s insensitive comments reminding you that you are not meeting society’s expectations.
What NOT to tell people who are trying to conceive:
Stress and depression are two things most people do not associate with infertility until they go through “The Process”. According to new research, infertile couples are three times more likely to divorce. The mental state of a person suffering with infertility is often compared to having terminal illness. Even though people do not die from the infertility itself, there is something terminal about it. When my partner and I struggled, I often wondered whether I would ever know what it was like to carry life inside me, or whether I would ever look into the face of my child. In the end, our marriage survived. But not without scars.
You have been trying for over a year. You pee on ovulation test sticks and nag your partner to “make a deposit” on specific days, regardless of how tired, sick or horny any of you feel. Your concern keeps growing with every monthly visit from aunt Flo. You decide to talk to a fertility specialist. You show up at the clinic naively hoping for an opening in their schedule, and that you’ll have a baby by Christmas. At least that’s what I thought. And boy was I wrong! Before you are even considered a good candidate for in vitro fertilization (IVF), you need to undergo a number of tests, some of which are quite painful (I’m talking about you, hysterosalpingogram!). These tests try to identify the cause of your infertility and inform the doctors how to proceed. Before being able to undergo IVF, some women need to have fibroids removed, others need to start taking thyroid hormones, adjust their lifestyle, and everyone needs to adjust their expectations. Most women try a few months on Clomid medication along with intrauterine insemination (a.k.a. the “turkey baster” method) before the big guns come out.
Photo by Spring Fertility San Francisco
In about 40 percent of infertile couples, the male partner is either the sole cause or a contributing cause of infertility. If reproductive urologist recommends a treatment for your partner, it might delay the start date of your IVF cycle by at least three more months.
After about a month or two of testing, you might be deemed eligible for IVF and ready to be put “on the schedule.” Yay, how exciting! You are going to be pregnant next month, right? Wrong again! Depending on how patient-centric your clinic is, the IVF cycle starts with two weeks to two months on birth control. Yes, you will be taking birth control in your attempts to conceive. The birth control allows your ovaries to rest before going full throttle on IVF drugs. You then get a period and start injecting yourself with at least two different hormones every day, for about 12 days. One tells your ovaries to mature more than one egg, and the other prevents ovulation. When I took these drugs, I felt like a hybrid of a pincushion and a force fed duck at a foie gras farm. My ovaries were blowing up with growing follicles, each holding one maturing egg. After two weeks of these injections, along with daily or bi-daily early morning blood draws followed by vaginal ultrasounds, you will be told that the follicles are mature and it’s time for the harvest, ehm, ovulatation. To trigger the ovulation, you will be asked to give yourself another shot, the largest of them all, followed by a minor surgery, during which the surgeon harvests the eggs at their perfect ripeness just hours before your body would have shot them down the fallopian tubes.
To retrieve eggs from ovaries, the surgeon uses an ultrasound-guided needle. The ultrasound probe goes into the vagina and points sideways towards one of the ovaries. When a ripe follicle is in clear sight, a telescopic needle comes out, travels through the vaginal wall (not the cervix), through soft tissues between abdominal organs, and enters the ovary. It then slurps out the “juice” from every follicle in sight. After all follicles are emptied, the same is done to the other ovary. While you are undergoing the procedure, your partner is asked to provide a sperm sample. In some cases, frozen sample is used. If everything goes well, by the time you wake up from light general anaesthesia, the embryologist already knows how many mature eggs were harvested. Remember, this is an invasive pelvic procedure so you will need to take it easy for about a week before being able to walk straight.
Time starts ticking the moment your precious eggs are out of your body. Eggs and sperm are prepped and the mating dance begins. Egg is surrounded by thousands of free floating sperm in the hope that the best swimmer wins. But more often than not, an embryologist manually selects and injects a sperm directly into an egg (intracytoplasmic sperm injection, ICSI). And you can bet you pay extra for the ICSI!
Photo by Spring Fertility San Francisco
The day after the procedure you get a call from the embryologist giving you the fertilization report. Hopefully, most of your eggs accepted the sperm and have officially turned into embryos. These few embryos are now fighting for their lives. A number of things can go wrong in the next 3 to 5 days. Many of the embryos will arrest (stop growing) due to genetic issues or the stress of the lab environment. Just as baby formula is far from being a perfect replacement for breast milk, an embryology lab isn’t nearly as perfectly tailored for the embryos as your own uterus.
On day 3 after fertilization, your embryos have 6-8 cells. On day 5 they have 100-150 cells and are called a blastocysts. Doctors love to see embryos grow into blasts because a blast has already proven that it can grow into 100-150 cells;to have survived the harsh lab environment for a whopping five days shows strength! Another great thing about blasts is that, if tested by preimplantation genetic screening (PGS), they result in fewer miscarriages and genetic abnormalities than day 3 embryos.
But here is the catch 22: Blasts are better (think “quality”), but there are always more of the day 3 embryos (think “quantity”). And what sucks the most is that, if you don’t have enough on day 3, it is possible that all of them might arrest by day 5 and you end up with nothing. That’s why some clinics only transfer day 3 embryos. However, clinics with better embryology labs are more likely to grow blasts and transfer them on day 5.
After your embryos have grown to day 3 or day 5, a decision has to be made whether to freeze them or transfer them into your uterus on that day. If you have many good embryos, you can transfer some and freeze the rest. Transferring fresh embryos used to be the preferred way because not all embryos survive freezing (vitrifying) and thawing. However, if they do survive it, you are more likely to get pregnant from previously frozen embryos because your body had at least a month to rest since the egg retrieval procedure—and it also didn’t just go through a storm of IVF hormones. Luckily, vitrification technology has advanced significantly in recent years, making 99% of embryos able to survive the thaw. Many doctors now recommend frozen embryo transfers (FETs) instead of fresh transfers. FET is a lot less involved than a fresh cycle, but it does take at least a month, sometimes requires taking hormones and definitely requires frequent blood draws and vaginal ultrasounds.
After the precious embryos are transferred into your uterus, you will be anxiously waiting for a positive blood pregnancy test. So much is at stake: you have just spent a fortune on an invasive treatment and getting a period will feel devastating. If you don’t get pregnant, you will be deciding whether to transfer more frozen embryos, do another fresh cycle, consider egg donor, sperm donor, gestational carrier, or a combination of these things. Some couples come to a decision to give up on creating their human from scratch and opt for adoption.
If you do not have insurance, expect to pay $15,000-$35,000 for a single IVF cycle and $2500-$3500 for one FET. The pricier ones include genetic testing, which itself costs up to $8,000. Depending on your insurance, your coverage might range from nothing, 50% off a single IVF cycle, $20,000 lifetime coverage, or you might end up on one of the new generous plans with Progyny, a new fertility science and insurance startup. When checking your coverage, make sure to also inquire about the coverage of medications, which cost $3000-$5000 per IVF cycle and are often not covered at all.
There are very good reasons they make you sign so many liability waiver forms. You can die from complications that result from infertility treatments. One such complication is ovarian hyperstimulation syndrome. I personally experienced an urologic emergency after an egg retrieval procedure during which my bladder was pierced. A huge blood clot blocking my urethra caused acute urinary retention and my bladder expanded 2.5 times. Had I not been catheterized in time, I would have died. Next time you undergo an egg retrieval, please fully empty your bladder right before the procedure and make sure you are able to pee before getting discharged.
How to choose an IVF clinic
Now that you know what to expect, let me tell you how to pick the clinic that gives you the best results. First, understand the stats. There are two types of stats: embryology lab stats published on clinic’s individual websites, and fertility success rates published on Center for Disease Control (CDC) website www.cdc.gov/art/artdata. These two sets of stats look like they have nothing in common!
No matter how good your eggs are, they aren’t going to produce great embryos if the embryology lab isn’t good. Lab stats tell you how well the lab can grow your embryos. The most important numbers are fertilization rate and blastocyst conversion rate. Some clinics perform 25-30% better than national average; that’s why it is so worth checking these numbers. Also inquire about genetic testing. Clinics that perform genetic testing on biopsied embryos not only have lower miscarriage rates, they also guarantee that babies will not be born with certain genetic disorders. This is reassuring, especially for older mothers who have higher chromosomal abnormalities than younger women.
Fertility success rates published on CDC website aren’t as easy to understand as lab stats. They are broken down into sections based on whether the eggs are your own or from a donor, and whether the cycle was a fresh cycle or FET. The most important statistic is not the “percentage of pregnancies” but the “percentage of transfers resulting in singleton live births.” Pick the clinic with the highest percentage for your age cohort. But don’t do just that. Look for red flags. Unless you want to be the next Octomom, steer clear of clinics that report high “average number of embryos transferred”. More embryos do result in higher percentage of total live births but also increase chances of multiples which are higher risk for both women and babies. And lastly, to calculate the rate of miscarriages, deduct singleton and twin live births percentage from pregnancies percentage.
Remember, clinics are competing for your patronage and might offer benefits that will take off some of the stress:
But don’t take my word for it. Go ahead and tour a few clinics to see for yourself. Do take your time, it can make the difference between never having your own child and having one.
As my own treatment approaches, I worry about finding someone to watch my girl while I undergo a baseline ultrasound. Fertility clinics don’t allow children in waiting rooms because not everyone in the waiting room is as lucky as I am. I know what it’s like to carry life inside me and what my child’s face looks like. And even if I never succeed creating a second child, I consider myself lucky.
Learn more about HEYMAMA member Petra Cross here. Want to read more about mamas’ fertility journeys? Check out this interview with Allison Kasirer, author of Conceivability: What I Learned Exploring the Frontiers of Fertility.