Not to be left out …

While the Intended Mom (or Egg Donor) is going through the process of shots and meds and blood draws and ultrasounds to reach the point of egg retrieval, the hopeful-surrogate-to-be, not to be left out, is also being put through her medical paces.

Let me preface this post by saying: Every reproductive fertility clinic does things differently; they each have their own protocols and tests and procedures, and sometimes even do things differently from doctor to doctor and patient to patient. Although I’ve done months and months (and years and years) of my own fertility treatment, and IVF twice for myself, and surro-IVF three times already (seven times if you count the transfers that didn’t work) --- well, I have a memory like Swiss cheese and can’t be certain of all the exact details. So as I’m telling you the story, please keep in mind that it’s how I remember the story as it relates to ME, and different fertility patients might have had different experiences. Heck, I might even have some of my own details wrong. But I promise to do the best I can … what with this swiss cheese brain and all.

Like I mentioned previously, the surrogate and the IM have to get their cycles in synch with birth control pills. The overall calendar-schedule of an IVF cycle is centered around when the doctor predicts the IM will be ready for her egg retrieval. The goal for the surrogate is to get as close to “ready” to receive the embryos as she would be in a “normal” cycle as if she was getting pregnant on her own. (Clear as mud? Did I explain that well at all?)

About three or four weeks before the tentative egg retrieval date, the surrogate will begin giving herself injections of a drug called Lupron. (Please bear in mind that EVERY SINGLE SOLITARY step of an IVF cycle is “tentative” … that’s one of the things about IVF that can be so maddening; you just don’t know for sure when you’re gong to do things until a day or two before you do them, making it difficult to make plans, especially if long-distance travel is involved.) Lupron is a drug that suppresses the production of testosterone and estrogen, to “quiet” the ovaries, and often comes with a wicked headache side effect. The first few times I used it I got the headaches, but the last few times I didn’t … who knows??? Lupron is normally given as a little sub-q shot in either the thigh or tummy, and the once-a-day shots last a few weeks. Sometimes, one giant dose of the drug is given as an intra-muscular shot; I’ve only done that once and am not sure of the difference …. Again, it just depends on your clinic’s protocol.

A week or so later the surrogate will discontinue the birth control and get her period. Then, in the weeks between getting her period and going for the embryo transfer, the surrogate will be started on estrogen, which regulates the hormones, and fluffs up the uterine lining, to trick her body into getting ready to be pregnant. The estrogen can be given by pill, patch, or suppository (at least that is the only three ways I’ve ever gotten it …. I think. Oh, swiss cheese brain, why must you fail me???)

Throughout these few weeks of hormone therapy, the surrogate will need to be monitored with blood tests to make sure her hormones levels are where they need to be, and ultrasounds, to make sure her own ovaries are not producing eggs, and to make sure the lining of the uterus is thick enough to sustain a pregnancy. If the Intended Mom’s clinic is long-distance (which mine have always been) you have the added bonus of having orders and test results faxed back and forth between the “ordering” clinic and the “monitoring” clinic. In Georgia, my monitoring clinic was almost 45 minutes away from my house, which made for a lot of driving near the end of each cycle, when I was having blood draws and ultrasounds every other day.

The surrogate's shots, pills, suppositories, blood draws, and ultrasounds will continue until the IM has her egg retrieval and the clinic decides whether the embryos will be transferred at two days old, or five days old. Theoretically, five-day embryos, called blastocyst embryos (or “blasts”) are stronger, healthier, and often are quoted a higher success rate for pregnancy--- the risk is that the embryos could quit dividing at day three or four. Some clinics don’t want to play the waiting and guessing game --- how many eggs fertilized, and how many died off? If we wait until day 5, are we risking the cycle, and what if there are not any left???? So, some clinics will do automatic 2-day transfers, but most try to wait until day 5 as long as it looks hopeful that enough embryos will make it that long. (This part of the process is stressful to me, and is why I would never make a good gambler. Well, that and the fact I'm too cheap to part with my money.)

This un-certain stage of the process can also be frustrating because plane tickets need to be purchased, hotel reservations need to be made, childcare arrangements must be made, etc. I’m not really a “fly by the seat of my pants” kind of gal, so about this time in every cycle I tend to get a bit overwhelmed with the what-ifs. Then I realize stressing out about things isn’t going to help, and hey, I’ve only got a few days left where I can drink, so I normally fix myself a big ole’ margarita and just relax about it all. (Kidding. I can’t stand tequila. I drink scotch.) (Kidding again. You guys KNOW my drink of choice is Amaretto!!) (Well, honestly, my drink of choice is Diet Dr. Pepper, which is probably I would never make a very good alcoholic.)

A few days before the transfer, the surrogate is normally started on a seven-day course of antibiotics (better safe than sorry, as there will be lots of people and instruments down there in the next few days!) and a seven-day course of baby aspirin, to increase blood flow to the uterus and help promote implantation. Some clinics also prescribe a seven-day course of steroids (oh, yeah, because with all the other drugs we’re not hormonal enough already???) to keep the body from rejecting the embryo as “foreign”, since our own bodies “know” they did not produce it.

It’s the most bizarre thing, really, having a conception as artificial as this one, yet trying to trick the body into thinking it is totally natural. Suffice it to say, lots and lots and lots of drugs.

Also a few days before the transfer, the surrogate starts giving herself once or twice-daily injections of progesterone, to help the body sustain the pregnancy. Again, since she didn’t get pregnant “naturally”, her body is not producing the right hormones in the right amount, so supplementation is needed. These are the “big” shots that go in our rear ends; some girls give them to themselves (me) and other girls prefer to have someone else give them (I’ve done that, too.) These shots are thick; progesterone suspended in oil, and you're usually giving yourself at least 1CC. They will continue for at least two weeks, or if pregnancy is attained, for up to twelve weeks. Even an ass as big as mine runs out of available spots after a few weeks, and most surrogates wind up with big, lumpy hips that are bruised and sore. Oooh, Pretty!!

At the point where the RE determines it is time for the transfer, the surrogate will travel to the clinic. The transfer itself, considering all the time and work and cost and effort that led up to it, is probably one of the simpler parts.

The surrogate (and almost always the IPs) will arrive at the clinic at an appointed time, and the fertility doctor or the embryologist will discuss with them how the embryos are looking, how they are (hopefully) dividing and growing as they should. They’ll talk about how many to transfer -- usually this decision has already been made, and even written in the contract, but occasionally, if the embryos look stronger than they anticipated, a doctor might recommend putting in only one. If the embryos look weaker than expected, or if perhaps only three have survived to this point, a doctor might recommend putting in all three. The actual decision, however, is up to the surrogate and the IPs and ALL should be in agreement. This could be the difference between carrying (and ultimately RAISING) one, twins, or triplets, and EVERYONE’S feelings should be considered. Just because a couple is anxious for kids doesn't mean they should throw eight or ten or a dozen embryos in there .... and just because a surrogate thinks it might be a neat experience to carry twins or triplets, the very real risks of a multiple pregnancy must be considered, and the very real consideration must be given to what the IP's ultimately want. Although I'll admit to almost always getting desperate right at the last minute and hoping the doctor throws in a dozen to increase our odds of it working. {/sheepish}

The transfer is done concurrent with an abdominal ultrasound, and it’s important that the surrogate have an extremely full bladder, (have I emphasized "extremely" enough???) to ensure better vision for the doctor. This is the part of the process I like to call “This Sucks”. They advise you to drink six to eight cups of water, and then put you in a room or cubicle, on a table or in a bed, in a paper gown for an hour, waiting for your bladder to fill. If your bladder is a teeny-tiny pixie-fairy acorn-sized thing like mine, it will fill rapidly, then you’ll spend 45 minutes cursing the doctor who is making you wait, and worrying that you’re going to pee all over the table. Seriously. I’ve almost peed on the table before. Then, when they put that ultrasound wand on top of your bladder and press down as hard as they can, you can't even think of the miracle that is hopefully taking place .... it takes every ounce of self control you have not to wet the table right there.

At long last, it’s time. The transfer takes a little longer than a pap smear, and involves the same basic positions and instruments. The difference, of course, is the incredibly fragile, precious cargo being transferred from the lab to the doctor to the, uh, “place of deposit”. The catheter containing the embryos is threaded up through the cervix into the uterus, and then you can sometimes see on the ultrasound screen a little "poof!" of white light as the fluid, containing the 100-celled beings that will grow up to be doctors or lawyers or surrogates themselves someday, (Hey, who knows? It could happen) is syringed out of the catheter and into the uterus, hopefully attaching themselves to that uterine lining that is now thick and fluffy.

Embryologists inspect the catheters under high-powered microscopes to be certain the embryos don’t get stuck in the catheters …. And the entire process can be viewed on the ultrasound screen by the surrogate and the parents. Once they determine the transfer is complete, the surrogate typically lies on her back about half an hour after, then is free to get up and leave. Or, get up and go straight to the bathroom, do not pass go, or I swear to high heavens you will wet yourself.

Some clinics require no bedrest afterwards; some require “light” or “modified” bedrest for a day or two. Then, no heavy lifting, no saunas, no hot tubs, no tampons, no douching, and no jumping on trampolines for two weeks. Oh, and sex. Absolutely no sex, the doctor will be very clear about that. But of course, that’s been the case for a few weeks already if you're paranoid like me and don't want to do anything to "disturb the area" …. Remember when I said the husbands have to be on board for anyone wishing to be a surrogate? Yeah, well, that’s yet another reason why. (Blaine will be so happy that I talked about our sex life to the entire Internet, don't you think?)

Then, you begin what is traditionally called “The Two-Week Wait” – the most agonizing time of an IVF cycle, waiting to see if it worked. The two weeks when you convince yourself you’re not going to hyper-analyze each and every twinge, and you’re not going to spend every spare second wondering if it worked, and you’re not going to continuously mash on your own boobs to see if they’re sore yet ----- but you totally will anyway, all those things.

Many surrogates take home pregnancy tests, and some get positive results as early as four or five days after the transfer. Sometimes a surrogate won’t get a positive until a few days later … and sometimes, a surrogate won’t get a positive home test at all, but the blood test that is ordered for two weeks later will show a happy, surprise positive.

And sometimes, the blood tests are negative, and the whole process just blows.