Monday, April 21, 2008

The Nuts and Bolts of It

(and please, no lame puns about how I used the word “nuts” in a post about reproductive organs.)

(Oh, wait. Maybe I’m the only one who would have noticed.)

So, I know a few people in life (not that I’m naming any names :cough: my sister :cough: ) who simply need look at their husbands across a crowded room and they can get pregnant. My sister (again, not that I’m naming names) has four boys and every one of them was conceived on the first try. Oh, the irony, considering she and I have the same DNA and even after six years of trying, numerous specialists, injectable drugs, and using every instrument known to mankind but a steamroller or a frying pan, I still wasn’t pregnant. But I digress, with my whining about myself. I also have a high-school friend who after having three kids in three years with her first husband, decided with her second husband that they would like to have a baby as well --- he needed a vasectomy reversal, and still, BAM! First month out of the gate after the reversal, she was pregnant. Or the friends I’ve known (three, thank you very much) who managed to get pregnant even AFTER their husband’s vasectomies .. and one who managed to get pregnant …. TWICE … after her tubes were tied.

For the people in the worlds of infertility and surrogacy, however, it’s a whole different story. By the time you really sit down and try to understand the process of conception, from ovulation to fertilization to implantation, you realize just how many, many, many things must go exactly right in order for someone to get pregnant. On the female side of the issue, you’ve got egg quality, ovulatory issues, that pesky cervical mucous, tubal concerns, lining issues, and hormones, to name just a few. And while the men aren’t quite as complicated, they have their worries as well with sperm count and motility. Wear briefs, not boxers, so the little swimmers can move around; correct any varicoceles, don’t use lubricants with your condoms --- (wait, you’re still using condoms? Maybe THAT is why you can’t get pregnant!!) get plenty of vitamin C, no hot tubs, no saunas, just say no to pot, and don’t ride bikes. (Although actually, I think the jury is still out on those last two … but still, just say no to pot. Even Nancy Reagan will tell you that.)

Anyway, my point is, there are actually so many things that need to go RIGHT in order for someone to get pregnant that at times it seems like a miracle anyone ever does, let alone those thousands of teenagers who manage to do it without trying in the back seats of cars. Once you enter the world of surrogate-reproduction, you truly, if you haven’t already, come to appreciate the exactness (and also the sheer dumb luck) of reproductive medicine.

Becoming pregnant as a traditional surrogate is not that complicated, though no less of a blessing. Because she is using her own eggs, the surrogate simply (if the word “simple” can EVER be used when talking about fertility!) monitors her ovulation, and then is inseminated, either at home or in the doctor’s office, with the Intended Father’s sperm. Hopefully, ten to fourteen days later, give or take a few days, she’ll get a positive result on a pregnancy test. If not, she can try again the next month. It’s about as close to a “normal” conception as you’re going to get in the world of surrogacy. Again, “normal” being a relative term in this process.

For a gestational surrogacy, however, the process is quite a bit more convoluted, for both the surrogate and the Intended Parents.

First of all, the cycles of the surrogate and the Intended Mom (or Egg Donor, if that is what they are using) must be synched up; normally that is accomplished with birth control pills. Often, the Intended Mom (IM) is using a surrogate because she has had a partial hysterectomy, meaning she has her ovaries, but no uterus. In that case, she has to have numerous blood tests to determine *where* she is in her cycle (no pesky periods to let you know for sure) before the bcp’s can even start.

Once they cycles are lined up, the Intended Mom undergoes a series of shots to increase ovulation, continued blood tests to check her hormone levels, and ultrasounds as well, to monitor the process. Women are born with a finite number of eggs, and traditionally, only one is released by the ovaries, to be sucked up by the fallopian tubes, to be transported down for fertilization each month. (Yes, ladies and gentleman, Biology 101, right here, no extra charge.)

For women undergoing IVF, however, the doctors want to optimize their chances for success by forcing the ovaries to produce many more eggs than that. The women are monitored to make sure they are producing enough eggs, but not too many. That the follicles containing the eggs are big enough, but not too big. Hyper-stimulation is a real concern, as that could lead to ovarian rupture, so the women are monitored very, very closely. At the point *right before* they are ready, they receive a shot of hcg (human chorionic gonadotropin) and then eighteen (approx) hours later an egg retrieval is done.

Egg retrievals (also called aspirations) are normally done via an outpatient surgery. Typically, powerful anesthesia medications are given through an IV so that the woman is "out" during the egg retrieval procedure. Back when I did IVF for myself, my doctor called it "Milk of Amnesia" meaning it wasn't a general anesthetic, but I remembered nothing of the procedure.

A needle is passed through the top of the vagina under ultrasound guidance to get to the ovary and follicles. The fluid in the follicles is aspirated through the needle and the eggs detach from the follicle wall and are sucked out of the ovary.

The fluid with the eggs is passed to the IVF lab where the eggs are identified, rinsed in culture media, and placed in small culture drops in plastic dishes. The dishes with the eggs are then kept in specialized IVF incubators under carefully controlled environmental conditions. When all of the follicles have been aspirated, the woman is monitored closely for about 1 hour - after which she is discharged home.

Sperm from the Intended Father (or even more rarely, a sperm donor) is mixed with the eggs about 4 hours after the egg aspiration, or sperm is injected individually into eggs – a process called ICSI which is sometimes used when sperm count or motility is poor. The following morning the eggs are checked for evidence of fertilization. In a perfect world, every egg would have fertilized, but I would say a more honest estimate is about 75 percent. Sometimes more, sometimes less, and occasionally, the dismal news is received that none of the eggs have fertilized and the entire cycle is a bust.

The eggs that did fertilize are now called embryos, and they are cultured in the IVF lab for 2-5 more days (again, thanks to attrition, only a percentage normally continue growing as they should) before the selected number are put into the woman's uterus with the embryo transfer procedure.

And that’s where I come in.

PS. Ding, Ding, Ding! We have a winner! Actually, we have several. All of you who guessed I hate "D", the dentist --- you are correct. I don't mind testing, even though it can be boring .... I tolerated the Pilates class, even if my core muscles didn't .... and maybe I'm some kind of pervert, but the gynecologist doesn't bother me in the least.

But the dentist??? With the guilt that comes from not flossing at all enough? With the whirring and buzzing of the instruments, and the drooling, and the little sucky thing that slurps the saliva out of your mouth? And the scraping on my teeth with those sharp, pointy, SCRAPEY instruments??? Ugh, I'm getting all skeevy just thinking about it.

But thanks to the person who suggested taking an iPod -- awesome idea. I have to go back next week to have a cavity filled (my first in I don't know how many years, and they said it is UNDER a previous filling, how on earth does that even happen, so they're taking out the old filling to fill the newer, bigger cavity, and like that's not bad enough, my new dentist {who I actually like very much} took one look at my x-rays and his only comment was, "Hang on to your dental insurance, you're going to need it in the years to come" ... I mean come on, was that supposed to be HELPFUL!?!?!?!) so yes, I will definitely have my iPod on my "Soothing Melodies" playlist for the appointment next week.

Maybe if I could get my hands on some valium as well ....


Mamasita said...

The more I read about your surrogacy and infertility journey - the more amazed I am by you and all you have done. You're just amazing!

Sherri said...

My dentist just built a fancy new office. Massage chairs and a TV over your head, and they just hand you the remote and let you watch what you please. I have to admit, it does help make it a better experience. Anything to distract you from the sounds of the equipment is a good thing.

And you're giving us quite an eduction on the nuts (ha ha ) and bolts of surrogacy. I never thought about the two women having to be at the same place in their cycle. It makes sense when you explain it though. Thanks for sharing all this with us

Sherri in NC

Anonymous said...

I was not lucky enough to be knocked out for my own egg retrieval. I had a useless shot in the butt, and felt every bit of it. I sucked it up, but decided I would NEVER do that again if it didn't work. It didn't. We adopted our first daughter less than 2 months later. :) The pain of that retrieval is something I can still remember very clearly, 15 years later, and more so than my emergency c-section that came 2 years later.

As for your test, I didn't comment, but my guess was the pilates class. That would have been it for me, hands down!!

Anonymous said...

Oh and don't forget the best part of IVF....the sheer chaos of it all!

Hurry up and wait and then everything goes fast-fast-fast! No one explains much to you, they expect you to know, and it seems a miracle they even know what day it is let alone are able to get people pregnant!

Anonymous said...

Actually grandaughter's pediatric dentist does give us a prescription for valium for her to take before she comes in so why dont you get some too? Sure helped her and the laughing gas too. She doesnt actually need it anymore as she looks forward to her dental visits now and goes in happily! She is 11and has now been to the periodontist and will have to have a tooth removed by an oral surgeron soon plus now has braces on. She goes without the valium now and I have no problems taking her now for these procedures. I thank the pediatric dentist for that. She is get some valium from your dentist too. You can do it Kristie!

Diana893 said...

So I love how I'm checking blogs as my study break before I get ready to start on the ins and outs of the reproductive systems (complete with quite graphic pictures) and you make it all so much simpler! Really, you should teach sex ed 101! :)

So I totally would have laughed at the "nuts" comment even if you hadn't mentioned it, and I thought you'd appreciate this... here's the mnemonic we're taught in nursing school for benign prostatic hypertrophy... it's literally NUTS: Nocturia, Urine dribbles, Tries to urinate, Small stream. Gosh your blog + these mnemonics = one quality education! hehe.

In all seriousness I think it's amazing all that you've done to help others make a family. Major kudos to you!

katy said...

I too am one of those people who get pregnant very easily. Phone sex will do it for me. When my youngest was about 5 I started having trouble with vision and headaches and the first question the neurologist asked me was "did you get pregnant without even having to try?" Come to find out that is one of the symptoms of a condition I have...that and gaining large amounts of weight easily and trouble taking it off.

Anonymous said...

"Skeevy" Definition please? LOL I have never heard that particular one. Amusing!
I HATE scraping, hate it, hate it, hate it. Valium=good idea, but will likely do the Tylenol thing like I usually do, no good drugs on hand :-)