3 Years

Today is our fourth wedding anniversary.  It marks the 3-year point of our TTC journey.

Something that I find even more shocking, is that I just realized that this day also marks over 5 1/2 years of suffering from infertility... even if we didn't realize it until we were a couple years into it. But it's the number our doctors really care about.

You see, we went off of birth control due to other health-related issues for me in September 2008.  That was nine months before our June 2009 wedding.  We tried to be careful *most* months, using condoms or abstaining when we thought I might be ovulating, but back then I didn't keep a calendar or chart temps or anything.  And some months we honestly didn't care and went for it anyway.  Back then we thought we were lucky that we didn't have any oopsies before our wedding.

Beginning on our honeymoon, we decided we wouldn't start "trying" yet, but we also wouldn't try to prevent.  So we just did whatever we wanted and let whatever happened happen.  A year went by as I finished up grad school and again, we figured we must have just been lucky, since we still had not gotten pregnant before we were completely ready.

Where the three-year-mark begins:

By our first wedding anniversary, in June 2010, I had graduated from grad school, was interviewing for my first real professional job, and we knew the time was finally right.  We'd been together for seven years, been through a lot of milestones together, and everything had finally fallen into place for us.  We were officially ready for the next step, we were going to start our family!  Although even then, I distinctly remember B voicing a faint concern that was beginning to creep into his mind.... why hadn't we gotten pregnant by "accident" yet?  We hoped nothing was actually wrong and we really were "just lucky."

I remember being so excited, I started buying all kinds of books about what to expect before you're expecting, I downloaded an app for my smartphone to track my cycle, I even bought ovulation kits and pregnancy test kits.  I think I also bought my first basal body temperature thermometer at this time, having heard you were supposed to chart your temp but at the time not fully understanding why.

Nearly six months passed, and we were still not pregnant.  I needed to have my yearly exam anyway, so I figured I'd ask what steps should be taken to get us checked out just in case, since several of my friends and acquaintances had been suffering from various forms of infertility.

My OBGYN recommended we start with B getting tested first.    In January of 2011 he did and we got our first analysis with low numbers.  We tested again in April, same.  I started getting all my tests done, everything checked out until the HSG... those results came back with a blockage.

We got a second opinion with a urologist specializing in male infertility.  He did a special test on B's sample to check for sperm defragmentation.  Like all his other counts, they came back on the low-end of the normal range.  That cost us $400 out of pocket.

The new doc wanted me to get a second HSG, I did in July and they were able to break through the block this time.  He suggested we give it a couple months.  Nothing.  In October we did our first IUI.  It didn't work.  We wasted $1300 this time.

Our doctor recommended another IUI, I read on my health insurance website that we could get IVF for $5000 down in Illinois, and a friend's sister was able to gather free meds for me.  We thought we'd go for it, rather than doing a few rounds of IUI which would add up to the same amount quickly anyway.  You can read about what happened with that here.

When we decided not to do IVF in January 2012, we decided to do one more IUI in case B's counts improved at all post-wash this time.  In February we did an IUI cycle, but B's post-wash count came back so low this time, they couldn't even in good faith recommend we proceed with the procedure.  $900 wasted.

The urologist suggested varicocele repair surgery to see if it improved B's counts.  He agreed to the procedure and went under the knife in April 2012.  His counts did not significantly improve by the three or nine month marks post-surgery.  At least our health insurance covered this one.

Here we are, over a year past his surgery, and exactly three years past our official TTC date, and well over five & a half years of unprotected sex and still no baby.  Still no hope for improving our situation naturally.  Just waiting.  Planning for IVF next year.  Sitting alone together in the empty house we bought last year with plenty of room to grow our family.

But at least we are together.  And this is our four-year wedding anniversary.  We do have a lot to celebrate today, and we will.  But I just wanted to take these few minutes first to pay respect to everything we have been through together the last 3-5 years.  The strength it has taken for us to face these difficulties is something to be honored and celebrated too.  So today, we really do have a lot to celebrate.  And hopefully next year at this time, we will have even more to celebrate and plan for, especially if the IVF early in 2014 works and we have the baby of our dreams on the way :)

Maybe things haven't changed so much afterall

OK, so back in March, I wrote a post claiming that a "change" had occurred.  You can read the original post here: http://inconceivablestory.blogspot.com/2012/03/change-has-taken-place.html, but the point of it was that I was trying to say that I wasn't so sad all the time about my & B's struggle with infertility anymore.  I was even trying to come up with justifications for the idea that it might be better to live "child-free."

So, the truth is, I don't think anything was changing inside of me, and I don't think I'm ready to accept the idea of a child-free future at all.  You see, five days after I wrote that post, one of my best friends emailed me to tell me that she is pregnant again - with her second child.  So she'll have two kids, ages two and under, before B and I are able to conceive our first.

I wept. 

I couldn't help it.  I wasn't upset with her of course, I was just sad for myself.  You see, when this friend announced she was pregnant with her first child, B and I had not been preventing pregnancy for a while, but we had not yet decided to "try" for a baby yet either.  

A couple months after she announced her first pregnancy, B's and my one-year wedding anniversary rolled around and I graduated from grad school with my second master's degree.  It was finally time for my life long dream to come true.  We started trying for a baby.

By the time my friend's first child was born that Fall, she asked if I had "the itch" yet.  I told her I've had the itch since I was about twelve, and that B and I had been trying and were just waiting for that special month to arrive when we'd have the good news we'd been waiting for!  

Of course, in the back of our minds, B and I were already wondering if something was not quite right.  We'd only been "trying" for three or four months at that point, but before that we'd not been preventing for a year, ever since the wedding.  And I'd been off of birth control for medical reasons for about eight months prior to that... with many months of not being careful.  So really, we wondered, why hadn't we gotten pregnant yet?  Just lucky we hoped...

For months after my friend's baby was born I'd spend several days a week visiting her and her baby.  It was great timing because I was finally done with grad school, in my first real job, and finally had free time like a normal person!  Plus, I was able to get the baby fix I needed on a regular basis.  Her child was the most beautiful being.  She was such a good baby, and to this day lights up my world every time I see her.  The best way to describe her is as a perfect little blessing.  And now, as she is getting older, it is such a delight to see her growing and learning.  

So anyway, I spent a great deal of time with this friend right before and ever since the birth of her first baby.  She was such a considerate and thoughtful friend and always asked me how things were going with our own baby making efforts every single month.  Somehow she'd always ironically call on the the day I'd gotten my period.  Oh well, I'd joke, another month of drinking and banking sick time at work for my eventual maternity leave!

By midwinter that year, B & I still were not pregnant and we really started to wonder if there was something bigger going on that we should know about.  For young healthy couples they usually say to wait for a year of unprotected sex before testing for infertility.  But since we'd already been having unprotected sex for over two years (though we'd only been actively trying to time things out for about 6 months), B started getting tested... just in case.

It's best to get the male tested first because it's much less invasive than the female infertility workup.  It's best to rule out male factor infertility first, before you begin poking and prodding the female partner.  In January of 2011, we got our first analysis results back showing that B could potentially have low counts.  But it was January, and we are in the upper-midwest, and he'd done it at home, taken it outside to drive to the clinic, and delivered it to them about half an hour later.  We decided that there were too many variables and we'd get a second opinion.

In April that year we went to the only urologist in the area that specializes in male factor infertility - Dr. J.  B's sample came back slightly better this time, but still just on the cusp of the border between the range of what's "normal" and what's a problem.  We had another sample sent away to a lab out west somewhere... the only one in the country that tests for DNA fragmentation to see if that was our problem.  Again, he was right on the border between normal and the problem zone.

All this meant that B's swimmers could be the reason we hadn't conceived yet, but the evidence wasn't conclusive.  Dr. J did notice that B had varicoceles which could be causing his lower counts, but even that wasn't conclusive as many men get them who don't suffer from infertility.  He suggested we keep trying for 4-6 months and if we had no luck, try an IUI, which should give this counts the little extra boost they needed.  So we started up all the female infertility tests on me in the meantime (just to be sure there wasn't anything additional on my end to worry about while we were trying naturally), which continued throughout the summer.

We were still hopeful that there was nothing wrong, but as each month went by with one negative pregnancy test result after another, eventually my friend stopped asking if this was finally the month.  Instead she started asking how the testing was going and if we knew anything new that could help us.

That summer we did learn that I had a blocked fallopian tube, which sent me into a panic at first, until my OBGYN reminded me that I should still have a 50% chance of getting pregnant because most women ovulate from each side every other month.  Anyway, they were able to go back in and open it up and it's been open now for 10 months and guess what? Still no pregnancies.

Anyway, I've blogged before about all the testing and IUI's and it all ended with B having varicocele repair surgery last month.  Since it takes a man 90 days to produce new sperm, we are now in a waiting period.  We can't test to find out if the surgery improved B's counts until July, so no thoughts of trying for a baby until then.

Apparently, a good percentage of men who undergo this surgery see improvement after those 3 months!  Of those that don't, many of them will see improvement within about 6 months.  Of those that are left, some will have improvement within a year, and a few within two years after the surgery.  

So, we're hopeful about July, but shouldn't get our hopes up too high.  Or, maybe a better way to think about it is that we shouldn't lose all hope if the counts don't improve because there may still be a chance for things to get better down the road with a little more time.

So that's where we are at with the whole TTC thing, and that's the update (for now) on what we know about how B's surgery went.

But what does any of this have to do with my friend telling me she's pregnant and/or me saying things haven't changed so much after all?

Well, my point is that this friend telling me she was pregnant again kind of burst my bubble.  It brought back all the happy hopeful memories of when B and I first started out on our journey toward parenthood.  It reminded me of times when friends having babies was just exciting, not bittersweet.  But it also reminded me how long we've been TTC.  It reminded me of where we started out and all that has happened along the way to bring us to where we are today.

It made me think about the fact that she'll be done having kids before I even start.  Any of our hopes to be pregnant together were thrown out the window.  It made me wonder what it will be like to be going through the baby phase once all my friends are done with it and reclaiming their bodies, sleep, and free-time.  It made me think that once again I was behind all my peers in "life" (committing to a serious boyfriend, getting engaged, finishing school, buying a house), but this time not by my own choosing, and it made me feel sorry for myself.

I know I had written that wonderfully optimistic post about how something had "changed" inside of me and that somehow now other people's pregnancies weren't bothering me as much.  I do think that is still true, but not because something inside me changed.  And to be honest, my friend's being pregnant didn't "bother" me.  The reason it made me cry is not because she is pregnant again (because of course I'm very happy for her, and told her that immediately...and honestly truly meant it), but because it triggered emotions about myself that I hadn't been feeling for a couple months.  But again, not because anything had profoundly changed inside me to make me feel differently.  Rather, I think I was just distracted.

Distracted by B's impending surgery.  Distracted by work.  Distracted by the warmer weather and exercising the dogs.  Distracted by the biggest financial decision that B and I have ever made together....

Distracted by the process of buying our first house!

Stay tuned for more to come on that soon :)

Varicocele Surgery: What are the success rates?

Varicoceles are identified in 35% to 40% of men with primary infertility and 81% of men with secondary infertility.  The majority of available evidence favors the surgical treatment of clinical varicoceles in men with infertility, which is thought to halt their duration-dependent effects.

Varicocele repair surgery can result in a significant improvement in semen parameters in 60% to 70% of men, with natural pregnancy rates up to 50%.  Men with larger varicoceles tend to have poorer semen quality than those with smaller varicoceles, and tend to have greater improvement with repair surgery.

Overall, a significant percentage of couples who undergo varicocele repair surgery will go on to achieve pregnancy without ART, and those who do need ART will have optimized their sperm quality.

It takes 90 days (3 months) for the male body to generate new sperm, so no improvements will be seen for 3 months following the surgery, with best results occurring in the first year, and some even into the second year following the surgery.

How this relates to us:

Since B and I have scheduled the surgery for the first week of April, that put our TTC routine on hold until around the week of the 4th of July.  Some things I've read online claim that better results are seen after 6 months, so that will put us at October before we'd really have our hopes up.  If it doesn't happen by the end of the year (trying naturally), then I think we'd be ready to allocate some money into our flex spending account for 2013 to try a few more rounds of IUI next year.

If trying naturally and with IUI's through 2013 doesn't work for us, then the next step would hopefully be saving up for IVF in 2014 or beyond.  I'll be 32, turning 33 by then, so our odds of successful IVF will still be high, but we'd only have a couple of years to get it done before my fertility starts falling.  

But seriously, IVF? The idea of saving up $13,000 for one round of fresh IVF cycle seems plausible by then... but what if that doesn't work what would we do?  With the plan described above, IVF is obviously our last resort.  

We could try to save up for the "shared risk" programs out there, where you pay $20,000 to $26,000 for 3 rounds of fresh and 3 rounds of frozen, and if it doesn't work, you get some or most of your money back.  But where would we come up with that kind of cash?  It would take longer, and then again my fertility will just decline further the longer we wait.

I wish I had a crystal ball.  I'd love to know that I'm just "catastrophe" thinking right now and we'll be pregnant naturally this summer.  Or that one round of IVF will get us twins and we'll be done.  Or that nothing will work but a 3rd frozen IVF cycle and so I should not bother getting my hopes up with anything else along the way.

Also, I wish we'd win the lottery.  That would solve a lot of our problems.

What the heck are varicoceles?

A varicocele (VAR-ih-koe-seel) is a dilation of the veins that drain the testis, known as the pampiniform plexus. A varicocele is similar to a varicose vein that can occur in your leg.

As it turns out, varicoceles are present in approximately 15% of the general male population. They account for up to 40% of male factor infertility, yet nearly two-thirds of men with varicoceles are fertile... so could varicoceles be causing mine & B's infertility?

The answer I've been able to come with so far is "maybe."

Causes

Varicoceles are typically not noticed until after puberty because testicular blood flow remains low prior to that and so these veins do not become apparent until adolescence when blood flow increases.  However many are not detected until a man is evaluated for fertility problems later in life. 

It's not certain what causes varicoceles, but many experts believe a varicocele forms when the valves inside the veins in the spermatic cord prevent your blood from flowing properly. The resulting backup causes the veins to widen (dilate). 

Varicoceles usually occur on the left side, most likely because of the position of the left testicular vein. However, a varicocele in one testicle can affect sperm production in both testicles. 

Our doctor, Dr. Jay Sandlow (I like to refer to him as "Dr. J"), published an article called, "Do varicoceles really affect male fertility?" in Sexuality, Reproduction & Menopause, arguing that it is not the valve that is the issue, so much as the anatomy of the entire drainage system that plays a major role in the the development of varicoceles.

"Because the left side drains into a system with higher resistance (the renal vein), small venules may persist or open during embryogenesis." - Jay Sandlow

Don't ask me what that means... after looking up definitions for venules and embryogenesis, I think it means the way a man's anatomy is formed while still a fetus determines whether he'll have varicoceles, though they aren't detected until after puberty when things really start flowing down there.  Maybe I should ask Dr. J if I understand that correctly though :)

How can they affect fertility?

In cases of where men who have varicoceles happen to be experiencing infertility, varicoceles are thought to cause spermatogenic defects by raising the intratesticular temperature in both the affected and the adjacent testes. However, not all varicoceles affect sperm production, which explains why not all men with varicoceles (in fact, most of them), are fertile.

Diagnosis


When varicoceles are suspected of causing infertility, abnormalities in all of the seminal parameters are usually present.  However, they can also cause isolated defects in sperm count, motility, morphology, or function.  Therefore, according to the article written by Dr. J mentioned above, the results of semen analysis are not a good predictor of the presence or absence of varicoceles.  And so, they are typically diagnosed by physical examination.  Most experts agree that the only varicoceles to worry about are the ones that can be detected by physical examination, though ultrasound can be used to identify them as well.


In our case...


B's were visible right away upon physical examination, and he has them on both sides.  We discovered this back in April 2011, but because the results of his seminal parameters testing were all coming back within the range of normal fairly consistently, Dr. J instructed us to first continue trying naturally for 4-6 months, with timed intercourse (only every other day during the fertile period of my cycle).  


That brought us to September, when we did our first IUI, which failed.  That's also when we learned how low B's "good sperm" counts were post-washing.  It was at that time that Dr. J recommended doing one more IUI, and if the numbers came back that low again post-wash, then he would recommend varicocele repair surgery as our next course of action.


We attempted an IUI earlier this month (February 2012) and his count came back lower than last time, so in effort to save money, we didn't even go through with it.  I was on clomid that cycle for the IUI, so there could have been a chance of increased fertility for us naturally... but I got my period Wednesday night so [sigh] that's disappointing.


So we scheduled the surgery for early April.  I'll post more soon about what that entails and what the success rates are.

Surgery Scheduled

B's varicocele surgery has been scheduled for April 5th.  He'll need 5 days after the surgery to recover so we won't be going home for Easter this year.  This was the best time for us to schedule the surgery though because he only will have 3 days of sick time built up by then and his work gives him Good Friday off.  So between the weekend, the holiday, and his sick time, he'll have just enough time off.


I still plan to post more about what varicocele's are, how they can effect infertility, and what the surgery is all about soon.  In the meantime, we are just mentally preparing for this big next step.

Why Even Bother Washing Sperm?

The title of this post, "Why even bother washing sperm?" is what we asked our medical professionals after getting the results of B's post-wash counts this morning.  Before the wash, he had 11 million of the little guys, they say 20 million is normal, but this wasn't a bad number to start with.  Post wash though, we only had 3 million good ones left.  So we wondered, why even bother washing them when you lose so much, why not just put it all up in there and let the good ones fend for themselves.


Turns out their are two reasons according to our urologist's assistant:


1.) We really don't want the dead, slow, or "just jiggling" sperm up in there anyway.  They may have DNA fragmentation or chromosomal abnormalities.  If we'd had intercourse, they wouldn't have made it up into my cervix, that close to the about-to-be released egg(s).  We only want the best of the best to make it in there.


2.) If they put unwashed semen directly in my cervix, it would cause MAJOR pain and cramping. A woman's body creates all kinds of defenses for us. Outside the cervix, special chemicals dissolve the semen around the sperm so that only the sperm gets inside the cervix.  Semen isn't meant to be inside the cervix.  We do want the sperm put directly in there though, because that's what improves our chances of them meeting my egg(s).


So here's how it went down this morning: we had 11 million sperm total.  Of those, 3 million were dead, slow, or "just jiggling," but 8 million appeared to be moving around pretty fast.  Not a bad number.  After the wash, only 3 million made it through the obstacles of washing.  Only 3 million were actually good enough to make through an IUI procedure.  They want a minimum of 5 million good sperm post wash.


Last time we had 4.3 million and felt we were close enough to their minimum to go ahead with the procedure... and it didn't work.  This time we were even less than last time.


If we decided not to do the IUI with such a low count, we'd lose this month.  We had already done the u/s this morning, so we'd have to pay $400 for that, but we'd get $900 back of the $1300 back that we'd paid for the entire package if we cancel the IUI.


We cancelled it.


In the back of our minds, we always knew that the reason we were doing this IUI was to see if B's counts come out as low as they did last time.  If that was just a fluke, then trying more conservative methods such as IUI's would be a better choice for us then jumping to IVF (which we had been all set to do last month... see the navigation bar above for details on what happened).


But if his counts came out low again, then B's Urologist, Dr. Jay (as I like to call him), recommended varicocele repair surgery for us.


I'll post another day about what varicocele's are and what the surgery will all entail.  Right now I'm still just kind of absorbing the fact that we aren't doing the IUI today.  I know we were mostly doing it to see if his counts would be low again, but I had to go into it thinking we were going to have a chance at getting pregnant because otherwise, without optimism, there would be no chance whatsoever of conceiving.  Not to mention how awful the stress of going through all of this for no reason/without hope would be.


The other thing I'm trying to process is that we may now have just transitioned from the category of unexplained infertility to male factor infertility.  


I always wondered if it would feel worse to have a diagnosis, or if I was correct in feeling that unexplained is worse.  So far, I think I was right. At least if you have a diagnosis, there might be some action you can take to try and fix the problem, which for us, may be this surgery.  Even if you had a problem that couldn't be fixed, at least you'd know that and not torture yourself every month trying all kinds of things in vain, or suffering through the two week wait (2ww) month after month. No, you could move on.  You could move on to more extreme ART treatments such as IVF, or move on toward acceptance of adoption or a childless life.  But not knowing always keeps you stuck in limbo!


So it's only been a few hours since I received all this new information, but so far it feels a little disappointing, very surprising, and a little bit motivating.  As my RE pointed out as I walked out of his office this morning, we have a plan of action again now.  And having some sense of control in all this is one of the biggest thing that infertiles struggle with.  So I'm excited to have a little bit of that again.  For now anyway ;-)