Blood Sugar Checks

It’s been an interesting experience checking my blood sugars.  For one, it turned out that I was initially checking at the incorrect time.  I had always been taught that the sugar checks are one hour after meals, but didn’t realize the timing was one hour after the first bite.  Even as a physician, it was one of those details I didn’t learn until I had to do it myself.

I have to acknowledge that unlike a true gestational diabetic, I don’t have to check my sugars regularly.  After checking the fasting sugars in the morning and seeing that they were generally normal, I stopped bothering to do that regularly.  I don’t check my sugars one hour after every meal, but rather when I know I’ve eaten food that’s questionable.  And honestly, there are times that I ate what I felt like eating, and didn’t want to feel more depressed by seeing the elevated number after.

Initially, I experimented to see what raised my sugars.  Even though I was told that in pregnant women, fruit and dairy tend to elevate sugars in the morning, it turned out that my morning fruit smoothies were fine.  It turns out that I don’t have to be super strict with what I eat, but I do need to be careful.  If I go too crazy with bread, pizza or the like, my sugars will be high if I don’t go for a walk right after.

We wanted to travel before Ayfee arrives, so we took a trip to New York City a couple of weeks ago.  It turned out that it worked well with my glucose intolerance, because we walked a ton, which allowed me to eat more freely.  It wasn’t practical for me to check my sugars too often while out and about, but when I did check, they were generally ok.  It was exciting to see on the activity tracker on my phone that I’d walked 5 or 6 miles each day.

Here’s WZW in Central Park:

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More recently at home, I’ve been hiking a trail that’s about 5 miles with a lot of uphill areas (25 floors according to the tracker).  It’s a pretty tough workout for me at 32 weeks, and takes me about an hour and 40 minutes.  Even afterwards, I can eat freely and my sugars will be fine.  Like I had a fatty ice cream treat after my  last hike, and my sugars weren’t even close to being high.  Besides the fitness aspect, it’s a huge motivation for me to do the hikes so that I can reward myself with carbs and sugar after.  I can pretty much eat whatever I want right before and right after the big hike.

Even later in the day, it seems like I can eat more carbs, and my sugars will remain normal.  I doubt I could eat something really sugary, though, many hours after the hike.  Definitely by the next day, the effect wears off.  If I’m sitting all day in the office, I have to be careful even eating a sandwich for lunch.

Unfortunately after my last hike, I noticed more pubic symphysis (pubic bone) pain and low back pain.  It’s probably due to the separation of my pelvic bones in preparation for childbirth.  I never had that with WZW’s pregnancy, but I’m not surprised.  It seems like my patients having their second or more baby seem to have more pain symptoms on average.  One of the physical therapists I work with recommended a support belt for pelvic instability that I’ve been recommending to my patients.  Now that I’m having symptoms, I decided to order one for myself.  Will let you know if that helps.

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Glucose Intolerance

Hitting the 24+ week mark means doing the glucose test to check for gestational diabetes.  Different institutions test differently.  At mine, we start with a 1 hour test involving drinking a 50 gram glucose load, then checking a blood draw for glucose an hour later.  If the value is elevated, then you have to go in fasting, get your first blood draw, then drink a 100 gram glucose load and check your blood sugar every hour for 3 hours (four total blood draws).

The rationale for doing the testing this way is that the 1 hour test catches more women than actually have gestational diabetes (it’s a more sensitive test), without requiring everyone to do the full 3 hour test, which would be painful.

With WZW, I had an elevated 1 hour test, so I had to do the 3 hr confirmatory test, and it was normal:

https://paleoob.wordpress.com/2015/06/09/the-3-hour-gtt/

I was hoping that last time, I had an elevated 1 hour value because I was following more of a Paleo diet, and my body wasn’t used to handling such a large glucose load.  This pregnancy, I’ve been much more lax with the carbs and sugar.  Alas, I was wrong.  This time around, I had to do the 3 hour glucose test again.  And one of the values after the glucose load was high, meaning I was diagnosed with glucose intolerance.

Glucose intolerance is basically a step below gestational diabetes.  I was certainly relieved not to have overt gestational diabetes, which would have meant being on a strict diet and checking my blood sugars 4 times per day (fasting in the morning, and an hour after each meal).

With that said, I was told that I essentially still need to eat like a gestational diabetic.  I found that frustrating- they tell you things like not to fast over 10 hours, and to avoid fruit and dairy in the mornings since pregnant women tend to have higher sugars in the mornings.  I’d been making smoothies for breakfast because it was a convenient way to add fiber and hydration in the mornings.

I found it difficult not knowing how strict I really needed to be, and not knowing what my blood sugars were actually doing.  I would love to go back to being Paleo, but it’s not that easy.  During pregnancy, it’s like something takes over you- you can’t eat the same, certain things smell terrible, etc.  For many of us, the draw of carbs and sugar are really hard to resist.  At 27 weeks, I am just now approaching my pre-pregnancy weight, and I still feel nauseous after I eat.  So it’s been an annoying existence of not being able to eat normally, and I’ve been tending to snack on starchy crackers and the like.

The not knowing, and inevitably still eating some carbs left me feeling guilty.  So I decided to get a glucose meter to be able to see for sure what was going on.  Normally, a glucometer is not given to women with glucose intolerance, but if a doctor thinks it’s appropriate, it can be ordered.  Lucky for me, I can just ask my doctor/colleague.

The glucometer comes with a bunch of test strips and little needles (lancets).  For each blood sugar check you have to insert a new lancet into the part of the device that detaches to prick your finger.  You also insert a new test strip into the meter itself.  You prick the side of your finger, squeeze to get a droplet of blood, then touch the test strip to the droplet to get your reading.

It’s been interesting to see the results.  For the most part, my fasting values have been fine, though I’ve had some mildly elevated values here and there.  My fruit smoothies with no added sugar have not raised my blood sugars.  But some other things, like a gluten-free bagel (made of mostly tapioca, eggs, and cheese) for breakfast have raised my blood sugars.  But then I also once had a regular full-carb bagel and was ok.

The results are a little inconsistent, but overall it’s a relief that I don’t have to be super strict like a true gestational diabetic.  I still can’t be totally cavalier and eat a ton of carbs, and certainly need to be careful with the overt sugar.  I’ve stopped downing mountains of crackers as snacks switched to nuts, chia seed pudding, cheese, and the like.  It also helps if I walk after eating some carbs, so that my sugar doesn’t end up as high after the meal.

I feel for all of the ladies who have gestational diabetes, because it is a huge daily challenge.  I know my pregnancy hasn’t been terrible, but it’s still been difficult dealing with the daily nausea and the constant battle of wanting to eat certain things even though I know it’s better not to.

This all does go to show that sticking to a more Paleo lifestyle long-term is the best for me, since I do apparently have a propensity towards diabetes.

Ayfee

So far so good- in addition to the genetic testing, the anatomy ultrasound was also normal.  All of the available testing for the baby has come back normal, so we are relieved.  We’d been dropping some major hints, but we finally told WZW after the ultrasound result came back.  He was really excited to hear that he’s going to have a baby sister.  We had been asking him if he wants a baby brother or a baby sister, and he’d said sister.  I suspect it’s because he thinks it’s less likely that he’ll have to share his precious toys, particularly his trucks.  He’s probably noticed from his preschool classmates that the girls are less interested that stuff.

We told him that we’d name her once she’s born, but that he can choose what we call her while she is in Mama’s uterus.  He chose Ayfee, and we have no idea where that came from.  It makes my heart feel warm and fuzzy as he often asks to kiss “my baby,” ie Mama’s belly, and will say that he’s going to take good care of her.

It was really interesting to read the comments after my last post.  One reader essentially has the opposite opinion of me- she preferred having two girls, and will be totally fine with having a girl for baby #3, whose gender is a surprise until delivery.

Now that I know it’s a girl, there is a lot to be excited about.  First of all, I’m happy for my mother-in-law, who has four sons (my husband has a half sister through his father).  I sincerely hope that our daughter can have a special relationship with her grandmother, who never had a daughter of her own.

There are also various girly interests to experience together.  I myself wasn’t super girly as a child, and my mom wasn’t all that knowledgeable about things like makeup, hair, and fashion.  While I’m no expert in those areas, either, I do love Sephora and my favorite color is pink.  So I think it will be fun to do stuff like paint each other’s nails and other girly endeavors.  I would do my best to offer makeup advice, and even my husband will tell her no cakeface as he calls it (the ladies who have an obviously thick layer of foundation on).  My mom didn’t have Google to help her when I was a girl, but I do.  So it will certainly make it easier to find ideas for hairstyles even if Ayfee ends up with a different hair type than mine.

As a girl, I kept diaries, and my parents have kept them all.  I think they’re still stashed in my old room.  Hopefully at some point if I can get it together and get them all organized by date, it might be nice to share them with Ayfee.  I’m sure the contents of them at this point will be silly or embarrassing to me now.  I envision letting her read my diaries as she gets to the age I was when I wrote the entries, so that hopefully she can relate to them.  I guess it will be a little weird to hear the voice of your mother as a child.  I even kept a journal of when I started my period, and kept track of when each of them came.

I also think that being an OB/GYN, there is a lot for me to share as she gets older, such as what’s normal with periods, and what is normal with our bodies.  A lot of my patients aren’t all that knowledgeable about what goes on “down there,” and hopefully I can raise her to be more comfortable with her body and to know what’s normal.

Having one boy and one girl will be different than having two of one gender, so we are very lucky to get one of each.  It’ll be an interesting experience to see how our two kids differ, not just due to inherent personality but also based on gender differences.  Since I grew up with a brother, I think it’ll be good for WZW and Ayfee to have each other, as they can learn more about the other gender.  I have no doubt that there will be plenty of fighting as they get older, but what I look forward to is the joy of seeing their positive and loving interactions as they grow up.

 

It’s a Girl!

Since we didn’t have the embryos tested for genetic disorders, we did the blood tests to check for chromosomal and other disorders.  My particular healthcare system offers the NIPT (non-invasive prenatal testing) to women 35 and older.  This test is a blood test drawn around 11 weeks, and checks for trisomies 13, 18, and 21.  Trisomy 21 is the same thing as Down syndrome.  The test also checks the sex chromosomes for disorders, so the fun part is that you get to learn the gender early.

For women who are not yet 35 years old, they are offered the California state screening that everyone in the state is offered.  The first blood draw is around 12 weeks, and there is an optional nuchal translucency ultrasound (NTU) that is also performed around that time.  The ultrasound mainly measures the nuchal translucency, which if thicker than normal indicates a higher risk of Down syndrome.  But younger women are also at risk for structural deformities (whereas those of us over 35 are at higher risk for chromosomal abnormalities), so sometimes the early ultrasound can pick up some major malformations.  The NTU is not performed for those who have the NIPT done.

The women who have the NTU done get a preliminary result regarding risk for Down syndrome, but have to wait for the 2nd trimester results to come back to get the final results.  One benefit of the NIPT is that you receive the chromosomal testing results earlier, which can be helpful in case there is an abnormal result.  From there, patients can opt to do additional testing like an amniocentesis, which involves taking a sample from the amniotic fluid and testing for chromosomal disorders.

Since the blood tests are screening tools, the results can rarely be incorrect.  While the amniocentesis is not 100% accurate, it provides a much more definitive diagnosis.  Some people (especially those with significant risk factors) can consider skipping the blood tests and going straight to amniocentesis, but a lot of people hesitate because of the slight risk of pregnancy loss associated with the procedure.

Women who have the NIPT done also have the same 2nd trimester blood draw that is done with the California state screening test.  That’s because it checks for things like neural tube defects that are not assessed in the NIPT blood draw.

I’m 18 weeks now, and I’m still waiting for the results of the 2nd trimester blood draw.  But thus far, the NIPT results were normal and showed that we’re most likely having a girl.  I also have my anatomy ultrasound coming up.  This ultrasound is performed on all patients, even those who decline the state screen and NIPT.  It will check for major organ malformations of the brain, heart, kidneys, etc.  In our offices, those who don’t do the NIPT typically find out the gender with this anatomy ultrasound.

My husband and I would have been happy with another boy- we just want a healthy baby, and I’m hoping all of the tests and ultrasound results come back ok.  So far, until the results come back normal and we feel comfortable sharing the news of the pregnancy with the masses, we’ve held off on clearly telling WZW that I’m pregnant as well.  He definitely wouldn’t know how to keep it a secret.

To be honest, I’m a little scared to raise a girl.  Not that my fears are necessarily based on any real facts.  Since we have a boy, it seems like a known, as in we generally know what to expect, although of course every child can have very different personalities.

It’s probably more of a reflection of my own issues growing up.  I have this impression that it’s so much more complicated to raise a girl.  I would be concerned about cliques and Mean Girls-type situations.  I’d also be concerned about raising her with self-confidence and to have a good body image.  I would want to avoid stereotypes of what are boy interests vs girl interests.  We’ve certainly come a long way from the days my mother grew up in.  She was told that since she was a girl, she didn’t need to go to college like her brother, and all that really mattered was for her to get married and have children.

I think about two of my good friends that I’ve known since elementary school.  One comes from a family of 4 girls, and the other a family of 3 girls.  Growing up, and even into young adulthood, it seemed like they had more complicated relationships with their sisters.  I only had one brother growing up, and yes we fought a lot as kids, but it wasn’t the same as what I saw with the families of all girls.

One of my colleagues’ wife is a life coach.  They have two adult sons, and she once said how much respect she has for mothers of daughters.  Based on her experience as a life coach, she thinks it’s more challenging raising daughters.

So I’m not crazy to feel this way.  But I also realize that you can have challenges with children regardless of gender.  I once read an interesting quote from actress Kerry Washington in Marie Claire magazine,  “We think children come into the world and it’s our job to mold them and create them and teach them who to be so that they can be the best version of themselves, but it’s actually completely upside down. We get sent by God the kids we need so we can grow in order to be the parents they need us to be.”

As an aside, my husband played football at Cal with Kerry Washington’s husband, Nnamdi Asomugha.  Nnamdi also played for our local 49ers.  So it was funny when the news came out and I told my husband, “Nnamdi married Kerry Washington.”  My husband responded in all seriousness, “Who’s Kerry Washington?”

Going along with Kerry Washington’s quote, I suppose we’re having a girl because it will be a learning experience for us.  I had a feeling it would be a girl, partly because of our fear of having one.  We are happy either way, and I am excited to be able to buy some baby girl clothes.  Actually, since it’s been a few years, I’d be happy to buy baby clothes for either gender.  But I have a thing for (tastefully done) rainbows, and it’s much easier to find girl clothes with rainbows.

It’s funny how it worked out that my parents had a boy and a girl, my brother has a boy and a girl (twins), and now I will, too.  What’s also spectacular is that we can get all of my niece’s hand-me-downs.  She was born in July and our daughter is due in August, so that should hopefully work out well with clothing sizes and seasons.  But I will still want to buy a few things for her myself.

Still Nauseous

So far so good, I’ve gotten to 12 weeks now.  When I hit 11 weeks, I was able to stop the progesterone injections, so that was a nice milestone.

The nausea has gradually improved, so I can eat a 1/2 sandwich or more at a time.  But I still feel gross if I eat too much, which is frustrating.  I’m constantly thinking about food.  I always make sure I have a snack on hand so I don’t get overly hungry.  And because of the limitations in how much I can eat, I fantasize about what I want to eat next.  While I’m eating, I feel great, so it’s often hard to stop.  But then after eating, I usually feel sick to my stomach.

While I still like soup, especially with the cold weather, I’ve gravitated towards sandwiches as well.  I think it’s because of the bread- I’ve been frequenting a bakery near work that uses freshly baked bread to make their sandwiches.  In general, I tend to snack on starchy foods, which I know aren’t the healthiest but seem to be better tolerated.  Overly heavy and greasy foods are a no go.

So far I’ve plateaued at about 15 lbs of weight loss.  It’s kind of perverse, since the daily nausea is so frustrating, yet I have to say it’s nice to finally lose some weight and fit into clothes that I didn’t think I’d ever fit back into again.  My face looks less chubby than it did before, too.

Given the improving nausea, I will probably start to gain some weight back soon.  Based on WZW’s pregnancy, it improved but I never felt 100% back to normal until I delivered.  So I probably won’t be able to eat large meals like I did prior to pregnancy.  I guess that’s good, to prevent myself from gaining too much weight during my pregnancy, which a lot of my patients have trouble with.

Thankfully, I’m able to tolerate fruits and vegetables better now, so I’ve started making more smoothies.  The heavy carbs have wreaked havoc on my digestive system, causing constipation.  So I’ve started taking docusate stool softeners regularly, and sometimes milk of magnesia to help with that.

I have a love-hate relationship with ginger tea.  I love the fact that it helps my nausea and is natural.  But I hate the taste of it.  After my pregnancy with WZW, I couldn’t stand ginger anymore.  That gradually faded, and now out of necessity, I’m back to the ginger tea.  But it’s definitely not something I enjoy drinking.  The Yogi brand of ginger tea seems to be easily available at various grocery stores like Trader Joe’s and Whole Foods.  I find that brand to be strong, and therefore less palatable, but ultimately works the best to make my stomach feel better.  My husband recently bought the lemon ginger version for me, and it’s a little more palatable.  We’ll see how it works to ease my nausea.

For the first time, I decided to try the prescription medication Zofran (ondansetron).  We had used it for many years for nausea/vomiting in pregnancy, but more recently there was a study that associated its use with increased risks of cardiac defects in babies.  One study is not definitive that this is truly the case, but to be safe, we’ve been waiting until 9-10 weeks of gestation before using it.  At that point, the main cardiac structures have developed already, so if any defects occurred, they wouldn’t be attributed to Zofran use.

I decided to try it since this daily nausea is pretty miserable.  My patients generally seem to find the Zofran more helpful than the other prescription anti-nausea medications.  I got the form that dissolves in your mouth, as opposed to needing to swallow it like a regular tablet.  I find that it helps briefly, but then the nausea comes back.  For me, the ginger tea works better.  But sometimes I just can’t take the thought of drinking more of that tea, so I’ll take the Zofran for temporary relief.

I’m thankful that so far things are going ok in the pregnancy, but I’m hoping the nausea gets better and better soon.

Prenatal Vitamins

We had another ultrasound today, and it was more good news!  I’m 9 weeks now, and the fetus is still viable.

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I feel a little more relief now, since most miscarriages happen before this time.  What I wasn’t expecting is that my nausea improved a little last week.  Meaning I went from eating only bites at a time and feeling ill pretty much all the time, to now being able to eat maybe a 1/4 sandwich at a time.  It’s not great, but I’ll take it.

It freaked me out, since last time shortly before the miscarriage was diagnosed, I started to feel improvement of my nausea.  So last week I did a vaginal ultrasound on myself (quite awkward), and was relieved to still see a viable fetus in there.

At the height of the worst nausea, there was one Sunday that I stayed in my pajamas the whole day, and only left the house to go to the mailbox.  Now, I’m still tired all the time, but a little more motivated to do my normal activities.  It’s definitely frustrating to only be able to eat small amounts of food at a time.  I’m still having a lot of soup- I’m all about the chicken bone broth, which at least provides a decent amount of protein.  And I’m also snacking on simple starches.  Unfortunately, I’m not getting a lot of fruits and vegetables at the moment.  I can’t wait until I can eat more normally.  I’ve lost 10 lbs. thus far.

When it comes to prenatal vitamins, patients often ask if there is a particular brand that I recommend.  I tell them that the brand doesn’t matter- they all contain the necessary folic acid.  And it’s usually cheaper to just take 1000 mg of fish oil daily separately, as opposed to buying the fancy vitamins that have the DHA included.  For those of us who are very nauseous, the gummy/chewable vitamins are fine temporarily.

My husband recently came across a prenatal vitamin from Ritual that I decided to try:

https://ritual.com/products/essential-prenatal-multivitamin

I was aware that the folic acid that is normally found in prenatal vitamins is not always that well-absorbed.  These Ritual vitamins have the methylated folate version, which is more ideal.  The folate is most important in the first month or so after conception, so I started them a little late to really help prevent neural tube defects.

The capsule design is also supposed to be slow-release and not cause nausea.  I usually take them in the morning when I’m drinking my bone broth, so it’s hard to say if that really is the case.  They also have a little tablet in the bottle that is lemon-scented.  Sometimes it’s nice just to open the bottle to sniff the lemon scent to help with my nausea.  They also contain vegan DHA from microalgae.  Based on all of that, I figured they were worth a try.

The vitamins of course are pricey, at $35/month to subscribe, and they mail a bottle to you monthly.  You take 2 capsules daily.  Given the price tag, I’d say it’s most worth it right after you conceive, and to continue while you’re really nauseous.  After that, as I tell my patients, no vitamin is a replacement for a healthy diet.

I was curious to try them for a month.  If you try to cancel your subscription after that, they offer you 20% off for the next 3 months.  Also, if you refer others, you’ll each get $5 off.  Here is my referral link in case any of you are so inclined: https://share.ritual.com/x/mdhOWN

For most people, $35/month is a lot to shell out on vitamins, so it’s not realistic to take them for the entire pregnancy.  But given the methylated folate and capsule design, I think it’s worth it for the first month or two.

The Parasite Diet

We got great news with the first ultrasound!

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There is a viable, 7 week fetus in there.  And thankfully, just one.  We’ll still have another ultrasound or two in the coming weeks to confirm that things are still progressing normally.  But it’s definitely a relief that things are going ok so far.

The downside is that the nausea this time around has been really bad.  It got bad quickly, and it’s the worst I’ve ever had in my 3 pregnancies.  Each time, I’ve had to limit the amount that I can eat, because I’ll feel sick to my stomach if I eat too much.  With WZW, 9 weeks was when I could only eat bites of food at a time and lost 5 lbs in a week.  With the miscarriage, the nausea started earlier and I lost some weight, but I was able to keep snacking and eat small meals.

This time, I’m already at the point of eating only bites at a time.  I think I’ve dropped 7-8 lbs in the past week.  I’ve never vomited, but my caloric intake is well below my usual.  I am eating far less than WZW is.  I stocked up on starchy snacks, but haven’t gone through them as quickly as I thought I would.  Even with the snacks, I can’t eat much at one time.

I seem to do better with soup and cooked food in general, which is contrary to some of my patients who have meat aversions and prefer fruit.  So I got some chicken bone broth and other soups.  At least they contain protein, so that will help with my nutrition to some degree.  And with the colder winter weather, the hot soups are comforting to eat.

In the past, I was all about the sparkling water because I couldn’t drink regular water.  The flavored sparkling water is still preferred over still, but I find that it doesn’t seem to help my stomach as much this time around.  Ginger tea, which I don’t love the taste of, seems to help my stomach the best.  Even then, it doesn’t take away the almost constant state of nausea that I’m in.

I’m trying to be happy that things are going well so far in the pregnancy, and keep telling myself that it could be worse (as is with my poor patients with hyperemesis gravidarum).  But it’s a pretty miserable state.  In addition to the constant nausea, I’m feeling really tired as well.  It definitely makes getting through my work days more challenging.  Today is a Sunday, and I stayed in my pajamas all day.  I only left the house to go check the mail.

I’ve been telling WZW that Mama’s stomach doesn’t feel well because I have a parasite.  Shortly after the embryo transfer, we’d explained a little of it to him.  Well, next thing we know, one of his preschool teachers said that he said something about Mama having a baby, but it’s too small to see.  We tried to play it off, but I’m sure they suspect something.  We decided that in order to prevent him from spreading the news too early, we’ll call the baby a parasite.  Hopefully that is not as clear to others what he’s talking about.

And So It Begins…

With WZW, the nausea started at 7 weeks and peaked from 9 to 12 weeks.  When I got 9 weeks with him, I lost 5 lbs in a week because I could barely eat anything- just bites at a time.  With the pregnancy that ended in miscarriage, the nausea started at 5 1/2 weeks, and continued until I miscarried, granted it improved a little in the week before I found out the pregnancy wasn’t viable.

This time, I thought I’d try taking vitamin B6 prophylactically.  Vitamin B6 (pyridoxine) is commonly used to treat nausea/vomiting in pregnancy, and I’d read that women who take prenatal vitamins prior to conception tend to have lower rates of nausea/vomiting, thought perhaps to be due to the vitamin B6.  So I tried taking 50 mg daily with my prenatal vitamins.

Alas, this time at about 6 weeks, it started.  At first I could eat normally, but would just feel gross after.  It quickly progressed to feeling nauseous constantly.  So the vitamin B6 definitely didn’t help prevent the nausea.  So far, all I know is that the initial hCG levels were going up appropriately.  I am still waiting for the first ultrasound to find out if this pregnancy is even viable.

I know it’s a good sign that the nausea is developing and worsening.  But it’s hard to feel very happy when you feel terrible all of the time.  This time, it seems worse and constant, as opposed to before when I’d mostly feel it after eating and therefore have to eat small amounts frequently.  Once again, I made a trip to Trader Joe’s to pick up a bunch of starchy snacks and flavored sparkling water.  Definitely not Paleo snacks- at this point, I’m just doing what I can to get by.  Since I’m so early in the pregnancy, I’m dreading it getting worse and worse.

I feel so bad for my patients who have really bad symptoms of nausea and vomiting, aka hyperemesis gravidarum.  I recently saw a patient who is having her third child, and she had already started getting IV hydration before her formal prenatal intake appointment at 8 weeks.  She also said that instead of it getting better after the first trimester, it lasted 5 months with her other pregnancies.  She wants to work, but can’t due to the debilitating symptoms.  How terrible that must be for her.  I really hope my symptoms don’t get worse than they did with my previous pregnancies.  It was very uncomfortable, but I was able to handle them and still work.

Embryo Testing

So far so good, the first pregnancy test was positive!  They had me check a blood pregnancy test 2 weeks after the egg retrieval.  This makes sense, since normally I tell patients to check a pregnancy test two weeks after ovulation/conception potentially occurred.  This usually ends up being around the time of the missed period in women who have regular cycles.

Since the embryo transfer occurred at Day 5, the wait was only 9 days, so it didn’t feel like eternity to me.  Since I’ve spent most months of the past two years waiting two weeks from ovulation to the pregnancy test/period, 9 days wasn’t so bad.

Next, I will check the hCG level again to make sure it’s rising appropriately.  From there, I’ll have to wait another couple of weeks for my first ultrasound to see if a fetus is present.  And even then, we’ll want to check a little later to make sure it’s still viable.  So there’s still a lot of waiting to do.

I’m aware of all of the possibilities.  There is a possibility that the pregnancy will end in miscarriage again.  With IVF pregnancies, the risks of ectopic pregnancy are much higher.  An ectopic pregnancy means that the embryo implants somewhere outside of the uterus, usually in the fallopian tube.  If not detected early enough, and it keeps growing, the tube could rupture and cause hemorrhage, which would be an emergency, requiring surgery.

In many cases such as this when we know someone is pregnant from early on, we can often detect an ectopic pregnancy early based on the hCG levels rising more slowly than normal.  If detected early, a medication called methotrexate is often used to treat it medically.

Another possibility is twins.  We only transferred one embryo in the hopes of reducing the chances of twins, but sometimes the one embryo decides to split and becomes twins, or rarely more.  I hope this doesn’t occur, since twins are at high risk for complications like preterm delivery.  Also, when twins share the placenta (called monochorionic twins), there’s a higher risk for them to have an unequal distribution of blood supply.  It’s called twin-twin transfusion syndrome, and in some cases could be severe.

For twins that come from two separate eggs and sperm, such as if two embryos were transferred or a woman naturally ovulated two eggs, you’d end up with fraternal twins and wouldn’t have to worry about the twin-twin transfusion syndrome.  You’d still have to worry about risks like preterm delivery, though.  Not to mention the craziness of having two babies instead of one.

We decided not to test the embryos for genetic (chromosomal) disorders, which is why we did what’s called a fresh embryo transfer.  Many people choose to do the testing, which requires freezing the embryo to allow for the testing, and then transferring it into the uterus a little later.  That would have been a frozen embryo transfer.

The testing I’m referring to is called preimplantation genetic screening (PGS).  The test is designed to screen for chromosomal disorders in general, as opposed to looking for a specific disorder.  For people who have a known disorder, it definitely makes sense to test the embryos for that specific disease, and to only implant the unaffected embryos.  This targeted testing is called preimplantation genetic diagnosis (PGD).

Based on my limited knowledge, I don’t think there’s a right or wrong answer when it comes to the decision to test the embryos.  I’m 37 yo, will be 38 soon, so statistically the chances of chromosomal disorders are less than say, for a woman who is 40 yo.  But since I’m over 35, there is still a higher chance than in a younger woman.  One of my friends who had to do countless cycles of IVF before finally having her baby said that they didn’t do the testing of the embryos.  Her doctor mentioned the possibility of false positive results- meaning the results can occasionally show that there is an abnormality when none is present.  Also, she was concerned about the theoretic risks of disrupting an embryo at its early stages to perform the genetic testing.

I think what my friend’s doctor was referring to is the embryo testing that is most commonly performed now, called the blastocyst biopsy.  When the embryo reaches the blastocyst stage at about Day 5, it’s made up of more than 100 cells.  The biopsy takes cells from the outer cell mass which eventually becomes the placenta, as opposed to taking a biopsy from the inner cell mass which will become the baby.  Sometimes the biopsied cells don’t reflect the actual cells of the baby, and therefore you could end up with erroneous results.

My impression is that the errors don’t happen too frequently, which is why many people are commonly having the testing performed.  I have friends and colleagues who have had the testing performed, and their babies turned out just fine.  Not to mention celebrities like Chrissy Teigen have been open about doing IVF.  She mentioned knowing the genders of the embryos before implantation, so they clearly had the testing performed.

The benefit of having the testing done is to greatly reduce the risks of a chromosomally abnormal baby.  Because many chromosomally abnormal embryos/fetuses do not develop beyond a certain stage, this would theoretically reduce the risks of miscarriage.  Also, it would be terrible to later do the genetic screening during the pregnancy, only to find out there is an abnormality.  That would result in the difficult decision for many couples as to whether to terminate the pregnancy.

Our thought was that if there is a chromosomal abnormality, then there’s a decent likelihood that either the embryo wouldn’t develop well enough for transfer, or that there would be a miscarriage.  Our doctor said that in the many years he’s been doing IVF, there have only been a few times that there ends up being an abnormality like Down Syndrome that is detected later in the pregnancy.  When it comes to gender, that doesn’t matter at all to us.

Of course, I’m a little nervous about the prospects of having a miscarriage, or later doing the blood test in the pregnancy and finding out there’s an abnormality.  In case this embryo doesn’t take, we thankfully have a frozen one as backup.  Apparently it is possible to thaw it to test, and then refreeze it.  There would be more of a chance with that scenario to damage the embryo during the process (compared to if we’d decided to do the testing in the first place).  So it may not be worth it.  But if neither embryos take and we have to go through the egg retrieval process again, then it would make sense to consider the PGS from the get go.

 

 

My first cycle of IVF

It’s quite the experience going through one’s first cycle of IVF.  For about a week and a half, I had to inject myself twice per day.  There are all kinds of different protocols used depending on the patient, and I’m not familiar with how the fertility doctors choose which protocol.  For mine, I took Follistim in the morning and Menopur in the evening.  The Follistim comes with a pen device.  You change the cartridge and use the pen to dial up the dose you need.

Follistim

On the surface, it’s more attractive than the usual vials and syringes, but in reality you are trying to maximize use of each cartridge since these medications are so expensive.  So on many days, I’d have to finish one cartridge, then change it out, and give myself a second injection to complete the dose I needed.

The injections I needed to take were all subcutaneous, meaning given in the fatty tissue of the lower abdomen, upper thighs, or back of the arms.  I personally didn’t have a problem giving them to myself, so I used the lower abdomen, changing locations with each injection.

The week before the egg retrieval was scheduled, I went in for ultrasounds every other day.  Prior to each of those ultrasounds, I went to the lab to have my progesterone and estradiol levels checked.  These help determine if the dosing of my medications is appropriate.  With the ultrasounds, my doctor checked to see how many follicles appeared to be developing, and measured their sizes.  As they started to get close, he had me start Ganirelix injections along with my evening Menopur.  The Ganirelix prevented me from ovulating spontaneously.

Once the follicles were just about ready, I injected the hCG two nights before the scheduled egg retrieval.  The hCG is called the trigger injection, as it is timed to trigger ovulation.  So I injected it Tuesday night in preparation for a Thursday morning egg retrieval.  And that was my last injection.

While I’m thankfully not afraid of needles, it is a drag having to inject yourself multiple times daily and go to the lab every other day for blood draws.  I feel bad for the women who have a really hard time with needles.

The day of the retrieval, I went into the area of their office that’s like a mini operating room suite.  Just like if I were going to have surgery, I changed into a gown and they placed an IV.  They gave me antibiotics through the IV prior to the procedure, and then for the procedure itself the IV was used for my sedation.

I have to say, I felt a little nervous being on the patient side, once I got into the procedure room.  They have you lay on the procedure table with your legs in the rests to get you in the position for the procedure.  Then they put a strap over you to keep your arms down by your sides, so you don’t accidentally move them during the procedure.  Looking up at the machines and lights from that position is enough to make anyone feel a little nervous, even though I’ve been in many similar operating rooms before.

Once the sedation got going, I don’t remember anything.  They described it as me being in “twilight,” meaning lighter sedation than general anesthesia.  Nonetheless, I don’t remember anything after that.  From watching the procedure a few times in med school/residency, it entails taking an ultrasound, similar to the vaginal ones used in the office to check the follicles.  The difference is that once the ovary is visualized, there is a needle attached that goes through the vagina, and then sucks out the liquid from each follicle.  Ideally, there should be a single egg in each follicle.

This device is attached to tubing that connects to the microscope, so the eggs go directly there.  An embryologist is right in the next room, looking through that microscope, counting how many eggs are retrieved.

I woke up in the recovery area, and felt really sleepy, like I wanted to take a nap.  They did say some people don’t remember this part, which is why they brought my husband in to review post-procedure instructions with me.  But I do remember things after that.

They made sure I could walk around and use the restroom, and then I was able to leave shortly after that.  Even if I felt better, they advised that my husband drive me around the rest of the day.

I remember in residency, I once worked with an attending physician who told patients about the similarities between the ovaries and the testicles.  There is a condition called ovarian torsion, which sometimes occurs when women have cysts in the ovaries.  The weight from the cysts can cause the ovary to twist, which then causes extreme pain.  If left untreated, the twisting can block the blood supply to the ovary and women can lose that ovary.  If caught soon enough, surgery can be performed to untwist the ovary and save it.

The ovaries and testicles have the same origins embryologically.  They develop into one or the other depending on the gender of the fetus.  I remember the attending saying that this twisting of the ovaries is similar to if you twisted a testicle on a man.  That definitely helped get the point across to the male partners of the patients regarding the severity of the pain the ovarian torsion was causing.

So understandably, sedation is needed for a procedure like this where a needle is poking the ovaries multiple times.  Afterwards, I had the expected cramping of the lower abdomen.  It wasn’t super painful, but definitely uncomfortable.  I considered taking something for the pain, but in the end I didn’t bother.  Heat packs helped.  I’m glad I took the day off after the procedure as well, since it would have been tough getting through a full work day not feeling my best.

Even though I didn’t feel nauseous or vomit after the procedure, which they warned can happen, my stomach felt a little off, even a few days after.  Not sure what that’s from.

The day after the procedure, referred to as Day 1, they told me that 3 eggs fertilized out of the 10 that were retrieved.  The embryo transfers (implanting the embryo into the uterus) are usually performed on Day 5.  However, if the embryo quality isn’t looking that great, they’ll implant on Day 3 to try to give them a better chance.  I guess the thought is that the uterine environment might be a little better than the petri dish.

Since 3 eggs fertilizing out of 10 wasn’t a lot, on Day 1 they told me that I might have to do the transfer early on Day 3.  That was pretty disappointing, after going through all of this.  I was hoping that even if this first embryo doesn’t take, I’d at least have another to freeze and try implanting again later.  If there are frozen embryos, then the transfer alone is a less cumbersome process.  I’m not sure exactly what it entails, but certainly not all of the injections to stimulate my ovaries like with the egg retrieval process.  I imagine it would be much less costly as well.

Thankfully, they called the morning of Day 3 to say that the 3 embryos are looking good so far.  One has 10 cells and the others have 8 cells, so they are dividing appropriately.  So I’m on for Day 5 transfer.  Phew!

In the meantime, now that the egg retrieval is complete, I have to take an estradiol tablet and place a vaginal progesterone suppository 3 times a day.  While this is better than injecting myself, it is still a lot to have to remember medications so often.  Thank goodness for the reminders on my phone.

At the IVF center, they gave us some fun toys- a sperm stress ball and an egg that shakes like a rattle.  Of course WZW is having a ball with them.  I asked him what he thought the sperm was supposed to be used for.  He said, “Um, to take stuff out of my nose?”

IMG_7901

So now, I’m waiting for the embryo transfer on Day 5.  From there, they warned us that it will feel like eternity to wait the 2 weeks until the pregnancy test.  Even if it’s positive, I’ll have to keep checking and making sure the levels are rising normally.  And it will also be a number of weeks before confirming the viability of the fetus.  For now, it’s going to be a lot of waiting and hoping for the best.