In which I apply to FSP's graduate program

Application to University of ABC
Jyde Hekyll

Some people know that they want to go to graduate school from a very young age. My route has been more circuitous. For the past several years, I have been planning to join the high rollers of the financial industry. I was driven by great curiosity about the mechanisms of complex finance, as well as about the salaries.

But after a series of disheartening rejections on the finance job market, I decided to reconsider my plans. I spent a while thinking about my life until I came across a newspaper article about a recent Nobel Prize winner. His work was so thrilling that I knew immediately that I wanted to be a scientist myself, and have the opportunity to make exciting discoveries like that one every day. And as my roommate so wisely pointed out, with the economy in the shape it's in, there has never been a better time to try graduate school.

Although I have no lab experience, I am confident that I will be a significant asset to my chosen graduate laboratory. I enjoy nothing better than sitting and thinking for hours, often without budging a muscle (except when I get a text). As a scientist, I will have the chance to do this all the time, which will be perfect for my focused personality. And I look forward to the security of science and tenure after the rollercoaster of the financial industry!

The other part of the application asked about my specific research interests. If you read my college transcript, it should be clear that I consider myself a scientist of broad pursuits. I majored in economics, but I made sure to find time for my deep and abiding interest in science, whether it is about the wonders of motion (Physics for Poets), the miracle of the universe (Introductory Astronomy for Non-Majors) or the fascinations of the cell (Remedial Biology I). In this respect I strive to model myself after Sir Isaac Newton, who as I'm sure you know contributed to numerous branches of science, and also ran the Mint. This is my goal as well.

In summary, DEF University will be a perfect match for me. The bucolic urban areas, the vibrant night-life, and the wide selection of Thai restaurants are just what I'm looking for. I look forward to your response.

Ghosts in the lab

Whether because the holidays remind me of A Christmas Carol, or because the economy is threatening Dickensian-level poverty and wealth stratification, my thoughts turn to the Ghosts of Labs Past, Present, and Future.

What does the hovering specter of Lab Past say? "Dr Jekyll, you need to polish up one manuscript, collect a bit more data for another, and perhaps write a review, all for Grad Lab."

Ghost of Lab Present: "Data! You need data! More of it! You are planning on talking about this project at a conference in a few months--get on it."

Lab Future: "Dr J, you need to start working on this grant/fellowship proposal. It will set you up for a great project in your second postdoc lab. But it cannot happen unless you actually get cracking."

To some extent, the pressure of projects past, present, and future are recognizable to anyone. But I think postdocs--especially those of us with lingering graduate work, and that means a lot of us--are particularly likely to feel torn by our ghosts. We know we need the grad publications to be out of our hair so we can apply ourselves to our current work. We need the postdoctoral research to be humming so that we can start making a splash at conferences. And we need to have a foot out the door with small independent grants or other efforts at defining our intellectual futures.

Scrooge's manic freak-out following his ghostly visitations bears uncanny resemblance to the OMG-so-much-work-to-do waves of anxiety that periodically beset me.

I dearly wish that I could vanquish my ghosts by sending a neighborhood boy to buy the largest goose in the butcher shop.

IVF 16: Isolation

Although (because?) I am feeling surrounded by support right now, I'd like to discuss the ways in which infertility is an isolating diagnosis. The sentiments may be applicable to more situations than just infertility, but this is the one I know about. This post is in part for the commenter who said that she was reeling from an "IVF or adopt" diagnosis.

First, the emotional sense of isolation. While 10% of the American population may struggle with conception, your own diagnosis of infertility almost inevitably arrives when everyone else in your cohort is pregnant, or about to become so.

What's more, not only does hardly a week seem to go by without yet another friend telling you that they have "news," nobody in your life is likely to announce that they've been trying for two years and it isn't working. We all know that you don't tell anyone when you're "trying." Well, you also don't usually tell people when you're failing. For the first two years or so of this struggle, the only people who knew that there was trouble were two of my friends, one of Dr Hyde's friends, and my immediate family.

My friend X who is also struggling with fertility problems put it thus: "I feel as though my husband and I are just this sad couple."

"What do you mean?" I asked. "You're the life of every party."

"Yes," she said, "but that only reinforces the fact that we go back home to failure."

And it's true. There's a sense that you are shouldering this burden alone, perhaps more so than if you had a more popular medical problem.

One solution, of course, is for people to be more open about their struggles with conception. It's a little tricky, though, to know what to say. You are potentially airing not only your own medical problems but your partner's. You are inviting discussion about some areas of your body that you used to think of as private. Announcing infertility is (literally) a Debbie Downer.

What's more, you're not always guaranteed sympathy. There are people who will tell you that pregnancy's not all it's cracked up to be, or that they know people who have very cute adopted kids from Country Z. These things are true, but you wouldn't think of telling someone who just lost a leg that at least she would never have problems finding matching socks.

I've been lucky in that the response, when I've told people about our problems, has been universally supportive--but I'm still always nervous that someone will tell us to suck it up and adopt, or quit adding to the world population, or whatever.

Another emotion that arises is jealousy, and attendant self-loathing. I would like to think that, despite our own struggles, I was the sort of person who could be happy when other people got pregnant. Nope. I say nice things on the phone and then I go cry with rage and jealousy and helplessness, and with shame that I am not in fact a nice enough person to be happy for others. Nice.

I had always felt close to Friend X and her husband, but still I felt inhibited from mentioning our problems to them. Since they were also married and stable, I was dreading the day that they would come to me with "news." When instead X mentioned what they were going through, I couldn't believe my ears. They'd been in our lives all this time, but both they and we had kept quiet about our continued failure to have kids.

From that point on, I've been more willing to tell friends about our situation. Our isolation was self-imposed--not that anyone else has confessed to sharing these problems, but at least I've stopped feeling like we carry a big sad secret. This is not to say that everyone going through this ought to stand up and announce it in lab meeting, but to note that if all of us stay quiet, we won't find each other. And while the internet is a great place to locate a sympathetic community, real life friends have a lot to recommend themselves, too.

Second, the physical sense of isolation. Some women, when they hear about struggles with conception, say something along the lines of, "Well, pregnancy and childbirth isn't exactly a walk in the park." And of course they're right about that. Even "easy" pregnancies cause discomfort and pain and restricted activity.

For anyone who wonders why people would go to such lengths just to put themselves through the difficulties of pregnancy and birth, I would say this. Imagine that you were born female but that you never had menses. "Lucky you," your friends would say. "It's awful, and inconvenient." Meanwhile, every women's magazine you read has an article about menstruation--readers' stories of when they got their first periods, debates about maxipads with wings, the Eight Signs That You Should Visit the Gynecologist. When groups of women are together, they talk about PMS, or about sex during their periods, pro or con.

You would feel jealous. Not because having a period was such a desirable thing, but because it was such a fundamental part of every other woman's life that to lack it was to be excluded. And wouldn't you sort of hate your friends for telling you not to want what they all had?

Take that sensation and convolve it with the knowledge that most women enjoy aspects of pregnancy and birth, and say that it was a life experience they wouldn't miss--it was defining. The fear that you will never have that experience is real.

Once, before I had told my GradAdvisor that Dr Hyde and I were struggling, she launched into a speech about how childbirth made women stronger (I think it was prompted by the pregnancy of yet another lab member). "Knowing that you can go through that and come out the other side makes you realize how much strength you have inside, and how much stronger we are than men really. It's such a transformative experience and you learn so much from it."

She had no intention of hurting me, but it took every ounce of self-control not to run away crying. Infertility's pretty fucking transformative too, I wanted to say, and I've grown a lot stronger from learning to control myself in situations like this.

It's important to realize that adoption is not a solution to infertility, per se. It's a solution to the ultimate goal--having children. But it's not a cure for being able to share in the experience of conception and pregnancy and birth and newborns. If this cycle and whatever comes after it doesn't work, then I will give up on having that experience. The defining moment of my personal life won't be childbirth, but perhaps--what? Accepting that I won't give birth? Signing adoption papers? Seeing our adopted kid for the first time? I don't know. We don't have a narrative constructed around that path.

I think there would be more forgiving attitudes towards IVF and related procedures if more of us were speaking up about them. Cancer used to be a stigma, a shame, a secret. Patients stripped those attitudes away by organizing support groups and societies, by asking for help in fighting cancer, by going public. We're never going to get past the "you're buying a baby/you ought to adopt" response until we do the same for infertility. Reasonable people may always disagree on whether we high-consumption Americans should be having kids at all (or having more than the replacement rate, or whatever), but that argument needs to be separated from the fact that some people go to greater lengths than others to have those kids.

IVF 15: One egg in Dr Jekyll's basket

There's no reason for the hiatus in updates except the obvious one, that during my mandatory 48-hour bed rest I went on a Colin Firth marathon, and have only just finished the second DVD of the BBC miniseries version of Pride & Prejudice. (Because some people who know me read this blog, I categorically deny the rumor that other Firth-related rentals included "Bridget Jones 2.")

The embryo transfer on Monday was not traumatic. If anything it tended towards the unintentionally silly. The two assistants who prepped me were new to me (a pity, because I've grown comfortable with all the staff I've met). The older one looked about 21, and the other--a trainee--had such a baby face that I wondered if it was legal for her to see the sort of adult entertainment I was going to provide.

I'm not sure why no one told these young ladies that they should probably do a dry run-through of the procedure before bringing the patient into it, but it was rather comic. First of all, the embryo transfer is treated as a sacred ritual in this fertility clinic, with advice like, "You may bring a copy of your favorite CD if you like," (who in hell would want their go-to album to turn into a IVF soundtrack? And what if I brought in death metal?)

In the event, we decided that there was no music we wanted forever associated with the special, special moment of us, our potential baby, and five other strangers in one room together, which was just as well because I doubt we could have replaced the soft New Age tunes that were already playing. And in any case, given the relative importance of my role (don't twitch), Dr Hyde's role (don't talk), and the doctor's role (everything else), we preferred for him to have the music that he wanted.

Anyhow, the assistants brought me in and laid me on the bed and took a preliminary ultrasound to make sure my bladder was full enough to push the uterus into better alignment with the cervix (in most women, it's tipped forward above the cervix like an empty upside-down hot water bottle). Check. Then the "older" assistant had me put my legs up. She showed the other one how to wrap my legs with a towel and then a warm sheet (yay!) so that I didn't get cold.

The younger assistant proceeded to completely biff it. There was some unwrapping and some re-wrapping, followed by, "It looked so easy when you did it!" Similar antics followed the height adjustment of the leg supports ("Which mark were you lining it up with again?") and then the removal of the lower half of the bed, where my legs had previously rested ("Wow, your knee must be stronger than mine because when I push in there it just doesn't unlatch!")

The doctor's office, wisely, had already given me a tab of Valium.

Finally, they turned off all the room lights except for the ultrasound monitor and one surgery lamp, which I thought of as the Twat Spot. "The doctor should be in any minute." Oh good, because this isn't weird.

More music, more waiting, and finally the doctor, the embryologist, the two assistants, and Dr Earnest Resident appear. "Hello!" I chirped, oblivious that this was Quiet Time. "Good morning," Dr Big Shot whispered in my ear reprovingly.

And then the big moment. Dr Hyde, who had a seat near my head, was invited to look through the microscope at the lone blastocyst that had been selected. I almost unwrapped my legs to go join him, I was so jealous. But he returned and said that it looked terrific, just like tissue he would want to see under his own microscope ("Patchable!"), and furthermore that it took after him.

After that, Dr Earnest Resident took over the ultrasound, my nether regions were unveiled and the Twat Spot reangled, and the whole procedure began. The doctor swabbed out my cervix, which didn't hurt--it wasn't the sort of scrub brush they use for Pap smears--and then did a trial run with the catheter, trying to get the measurements and angles just right.

It turns out that Dr Big Shot has written a recent review on embryo transfer optimization, so I can tell you quite a lot about what he was trying to do. First, multiple studies show that if there is any trace of cervical mucus, blood, or other drippy bits on the catheter tip, the pregnancy rate is decreased significantly. It's not clear precisely why this is, but keeping things clean is a priority.

Second, proper placement of the catheter is critical. Ideally the embryo will be ejected into the middle third of the uterus. It must not be ejected into the uterine lining itself, which sounds trivial until you see your uterus under an ultrasound: at this phase in the cycle, for obvious reasons, it's pretty much all lining. (In women who have given birth previously there may be more space, but in us nulliparous types the uterus is a deflated balloon.) So the doctor has to thread the catheter through the cervix and into the uterus, taking care to touch neither mucus, blood, nor endometrium along the way.

Who knew that Operation was really training up little doctors?

So we watched while the thin white line of the catheter snaked up through my cervix into the uterus, shooting straight down the middle of the space defined by the uterine lining. After the trial run, it was time for the real thing. They load the catheter with 20 uL of culture medium, with the embryo about one-third of the way in from the tip.

We watched again as it snaked up my lady parts. The culture medium must have a different density than water or for some other reason is distinctly visible on ultrasound. Dr Big Shot pushed it out and we saw a white streak shaped like a comet exit the catheter and take up residence. After a pause the catheter was out, the doctor was cleaning up, and everything was over. But they took an ultrasound picture of our little comet, and it is now at home, right next to his report card.

"How do you feel?" murmured Dr Earnest Resident. "That was much better than sex," I replied loyally.

Then I was wrapped in more warm blankets, kept supine for a half-hour, and eventually allowed to dress and be wheeled out to the car. The "older" assistant said, "It's so nice when they go so smoothly like that." I immediately revised my opinion of her upwards.

I doubt I need to tell you that my thought process for the last five days has gone something like this: "Hey, did I feel something? Was that a little cramp? Is that a sign? If so, is it a good sign or a bad one? Wait, has it stopped? Is that good? Is it next Friday yet?" Repeat this, with small variations, every ten seconds or so and you will have a good representation of my state of mind.

IVF 14: Game, SET, match

Last night we became preoccupied with the choice of whether to have one or two blastocysts transferred. All along we'd assumed two was the right number, because we felt up to handling twins and wanted the extra safety margin that came along with a "spare."

However, there turn out to be a host of reasons for considering single embryo transfer (SET):
--Multiple pregnancies, even twins, increase the risk factor for all types of prenatal problems: gestational diabetes, pre-eclampsia, etc.

--On average, twins are born at 35 weeks (5 weeks preterm) and weigh 5.5 pounds (2.5 kilos), rather than the 7+ lbs (3.5 k) of singleton babies. Preterm labor and low birthweights place them at greater risk for all types of neonatal problems: cerebral palsy, developmental disorders, digestive problems, etc. (Not to say it always does! Plenty of preemies are just awesome. But the odds are longer.)

--It could even get worse. For unknown reasons, blastocyst transfer during IVF is associated with a higher-than-average rate of identical twins: ~3% of births following single embryo transfer are identical twins. Thus it is not unimaginable that two blastocysts could produce triplets. You don't want to know what the risk factors are for triplets.

--Even in relatively uneventful twin pregnancies, women are often ordered to bed rest for weeks or months to reduce the chance of pre-term labor. I am selfish enough about my career and sanity to want to minimize that possibility.

--A surprising number of studies have now shown that in women under 35, the chance of pregnancy following SET is indistinguishably lower than the chance after two-blast transfer (depending on the study, the numbers are usually something like 59% vs 61%, respectively). Meanwhile, the risk of twins is ~3% and 45%, respectively.

--Due to the sky-high cost of intensive neonatal care for preterm babies, reports suggest that if all good candidates for SET were to select it over two-blastocyst transfer, the increased cost for a second frozen-embryo transfer (if the first one didn't take) would run an extra $100 million--but the savings on neonatal intensive care, due to the reduced number of preemies, would be around $1 billion. And on average, there would be no change in the number of live births.

--For these reasons, the American Society of Reproductive Medicine now officially recommends SET for women who meet the following guidelines: Under age 35; first IVF attempt (or second attempt after successful first); plenty of high quality blastocysts for freezing. Check, check, check.

Europe is way ahead of us on this. Why? Well, patients here usually pay out of pocket for IVF, meaning the cost of an additional frozen embryo transfer (~$3K) is not negligible. Most insurance plans, though, will cover a reasonable portion of neonatal care costs. So patients think with their pocketbooks: why take the risk of having to do this again, if Kaiser will pick up the tab on the other end? In contrast, because IVF is covered in most of Western Europe, couples are more willing to take the chance of needing a second cycle, and so doctors in fact refuse to transfer two blastocysts to women in my category. Europe has noticeably lower rates of multiple births, and accompanying lower rates of neonatal problems. (Learning this has possibly shifted my stance on mandatory insurance coverage for IVF, but I'll talk about that in more detail in another post.)

Meanwhile, the emotional recoil at reducing one's pregnancy chances, however minimally, by transferring one rather than two is hard to understate. We've been working on child production for three years, during none of which have we gotten younger. The holidays are coming up. I want to spend Christmas beaming at Dr Hyde, not crying under a comforter.

Even less nobly, I must admit that I have been so jealous of my fertile friends in the last few years. The thought of twins brings out my competitive streak. Two at once! Top that, all you "on our very first try!" folks. It's embarrassing to write, but it's how I feel.

So we spent last night wavering, angsting, talking, Googling, and thinking. What would be worse: failing to get pregnant on this cycle and blaming ourselves for only transferring one? Or getting pregnant with twins, perhaps forcing me to bed rest, perhaps putting them at greater than average risk for complications, pre-term birth? And what were the relative likelihoods of these events? Impossible to calculate. We went to bed undecided, though Dr H leaned a bit towards SET.

In the morning we met with the embryologist. She had great news for us: we have a total of ten viable blastocysts, with five of them achieving the highest grade they give (4AA).

As straight-A students ourselves, we took this as a given (and thought that perhaps our 3AA and 4BB blasts were not living up to expecations) until she explained that she grades strictly: she rarely sees a 4AA, let alone 5 of them; that 3BB is still above average; and that the majority of embryos they transfer are 4BB or 3BB quality, and the clinic has awesome success rates with those.

I don't mind saying that we preened like peacocks. "Er, could we have a copy of that report card?" Dr Hyde asked.

So we took the plunge and just transferred one 4AA beaut. Will post later about the details of the procedure (no amnesia this time, and Dr Hyde got to watch too), but the gist is that all went smoothly and we are having a restful day at home.

Next Friday is the final exam.

IVF 13: Quantum of baby

As many of you know, the start of pregnancy is back-dated to the woman's last period, not the actual moment of conception.

Thus as I sit at home, with Dr Hyde's and my genetic material cavorting in someone else's incubator, I may or may not be pregnant, depending on the results of a test in two weeks.

It feels uncannily like a version of Schrodinger's cat, where a cat boxed with poison under control of a particle's behavior has to be considered both alive and dead until the particle's behavior is measured.

Of course, Schrodinger invented this scenario as a reductio ad absurdum of the quantum hypothesis (Copenhagen interpretation, if Wikipedia serves correctly) that a particle exists in all different states until it is measured.

This IVF cycle feels a bit like a reductio ad absurdum, too.

Tomorrow we transfer the blastocysts. We have planned all along to have two transferred, but I am suddenly getting cold feet about the risk of twins and wondering whether to have only one. Last minute decision making under the sway of hormones--not a great idea.

IVF 12: Nineteenty!

The embryologist said that she got a total of 24 eggs that were mature enough to inject with sperm (how this is possible I don't know, but it sounds as though all of the 10 "intermediate" eggs ripened up in the incubator, plus the 13 mature, plus one other?).

Of those, 21 fertilized, which they can visualize by (as I understand it) the fusion of the two pronuclei. 2 look abnormal, leaving us with nineteen extremely small Hydes! We are obviously happy about this. Statistically ~40% will not make it to blastocyst stage, but if we do even that well, there should be two blastocysts to transfer and around 8 to freeze.

This is good because I am quite confident I don't want to go through this process a second time. It hasn't been awful; in fact it's been easier than I expected, although also more time off work. However, as it has progressed I have grown more reconciled to the idea of adoption. Perhaps all the injected hormones are piping up to chorus "Any baby, any baby..."?

And of course, it is easy to say this from the smug position of knowing we should (hope, hope, hope) have enough blastocysts to grow our own baseball team. I might feel paradoxically more attached to IVF if this were going badly. As we all know, it's easier to take the long view when you're feeling good.

It's nice to feel optimism, for a change. The process of diagnosing, trying to treat, and coming to terms with IVF has been wearing--pessimism is the natural result from bad news at every turn. So I'm grateful for both our progress thus far and for my newfound (however temporary) sense of calm about the alternatives.

IVF 11: They're in my uterus, stealing my eggs.

In one of my favorite children's books, Tal, an itinerant storyteller named Noom-Zor-Noom is trying to win a king's contest for best children's story. He asks the child Tal to accompany him as he travels to the kingdom, while Noom-Zor-Noom reads Tal his stories so that Tal can select the best.

The book is a delightful mixture of their journey, Noom-Zor-Noom's stories, and a talking donkey. I highly recommend it for children in the age 6-11ish range.

Anyhow, Tal's favorite story (spoiler!) involves a giant who overtakes a carefree tropical village. The giant demands that the villagers feed him all their best fruit, with only the unripe or damaged fruit left over for the villagers, who begin to grow weak and despairing. Finally they hatch a bold plot: they open a number of fruits, scoop out the flesh, and replace it with stones. Then they sew the fruit back up again and feed it to the greedy giant.

The giant is incapacitated by a terrible stomachache from the rocks in his belly and never bothers the villagers again.

For the last few days, I have felt increasing sympathy for the giant.

I am a thin woman; I do not have "fat" days; if my jeans are too tight it is because they have just emerged from the dryer, not because I have put on weight.

But for the last three days, I have exclusively worn a pair of corduroys that used to gap dreadfully at the waist. The 32 follicles reached 15-20 mm in diameter, and my abdomen was swollen and tender. It was sometimes painful to walk, and I stood and sat like a 7-months-preggo lady: using my arms for leverage.

Today they fished the little girls out. The anesthesia consisted of a sedative for the surgery prep, followed by the intravenous anesthetic propofol. Here's what I remember:
--changing into one of those awful hospital gowns + hair net (just like in the mouse colony!)
--Golden oldies radio station.
--The nurse-anesthetist taking three tries to find a vein.
--Demanding an extra blanket.
--"The sedative should take effect shortly, but you'll still be conscious up until the moment that they go in for the retrieval."
--"Put your legs up on these padded bars."
--Waking up in the recovery room.

Here's the funny part. I was apparently quite a chatty patient. Both nurses say that I was peppy and asking questions ("Really good questions," marveled the anesthetist) up until they gave me the actual propofol dose. I looked with interest at the ultrasound. They sterile scrubbed me inside and out. I have absolutely no memory of any of this.

Nor do I have any memory of my first hour or so of recovery, during which I apparently asked yet another barrage of questions ("So Dr Earnest Resident and Dr Big Shot each did one ovary? Who did which one?") Dr Hyde says that I was also making witty comments (Dr Hyde: "They're still counting all your eggs--they probably don't have enough capacity to count them all because you had so many!" Dr Jekyll, nuttily: "They had to add an extra bit to the computer--16's not enough.") WTF, Dr J, WTF.

Zero recall. It's like having been through an alcohol blackout, sans hangover, when you wonder what incriminating secrets or irritating propensities you might have shared.

Anyhow, they retrieved 27 eggs, of which 13 were mature (yes!!), 10 were "intermediate," meaning they'll slosh them in the incubator in hopes of ripening them up enough for insemination, 3 were too immature, and 1 was too old.

The whole procedure took longer than anticipated, in part because of my Ovarian Bounty, and in part because they dropped something into the sterile field, so they had to take off all the drapes, resterilize, rescrub, and replace everything. Again, no memory of this.

While it's great news that there are so many potential eggs, because there's a drop-off at the fertilization step (only ~60% are likely to become fertilized, even after they inject a sperm), it also suggests that I am at risk for ovarian hyperstimulation syndrome. Mild OHSS (bloating, cramping-- check, check) is not a big deal, but if it progresses, the ovaries swell up and fluid accumulates in places it shouldn't, possibly requiring hospitalization.

I am supposed to pay close attention to whether I gain more than two pounds in a single day (fluid alert). We don't even own a scale.

Perhaps I will just drape my still-tumescent belly over the balance in lab. This will cause all my labmates to think I am crazy and to stay the hell away from me, so that would be awesome really unfortunate.

Thanks for all your good wishes. We hear tomorrow how the fertilization went.

IVF 10: See the pain.

On Monday I had my third ultrasound in four days. Dr Earnest Resident and Dr Big Shot became concerned about the thickness of my uterine lining. They have been measuring it regularly, and it looked thinner than it had on Sunday. Ruh roh.

Then Dr Big Shot leans in closer to the ultrasound screen.

"Oh, you see this indentation in the uterus?"

Err, yes (uh oh uh oh uh oh).

"That's a cramp! Your uterus is cramping and we can see the muscle contraction causing an indentation! It's also distorting the lining to look thinner."

That certainly explains the sensation.

On the bright side, how many women can claim to have seen their own uterus cramp? (Don't all raise your hands if this is something you get to watch during late pregnancy too; I'd like to focus on feeling special for a little while.)

If anyone cares, although uterine cramping feels unlocalized achey, on the ultrasound it looked more as though a rubber band was being tightened around one section of the uterus. Who knew?

Due to my strong reaction to the medications, the doctors have cut way back and I hardly had to inject anything at all this week, for fear of overstimulating the girls. Yesterday Dr Hyde gave me the "trigger" shot of human chorionic gonadotropin, which will drive the follicles to ripen. The shot is timed 35 hours prior to egg retrieval, because at 36 hours after the shot, the eggs will start being released from their little fluid prisons.

In other words, the nice thing about this doctor's appointment is that there is literally no way they'll keep me waiting.

One disappointing piece of news--I had hoped Dr Hyde could blog the retrieval, as I will be under general anesthesia. But it turns out that they won't let him in the room. Perhaps he will just blog about the waiting room magazines (which, bizarrely, include Parenting) instead.

IVF 9: Standards

In the grocery store, I gaze at the selection of milk, and as usual, self-righteously select the one stamped "From cows not treated with rBGH." Who would want all those nasty synthetic hormones driving milk production?

Then I go home, eat dinner, and inject the day's dose of Follistim.

IVF 8: Emotions

As several of you have commented on, I've been holding up well emotionally thus far. What helps:

--Dr Hyde is 100% supportive ("No, you go relax, and I'll do the vacuuming!")
--The doctors and nurses are friendly, happy to talk, and act as though they're delighted when I have an ultrasound on the Friday after Thanksgiving--really, where else would they rather be than at work, helping us try to conceive? Their positive attitude is reassuring.
--Talking with friends and blogging both provide a chance to let off steam, and to focus on the narrative and analysis, as opposed to the deep lurking worry.
--The drugs I've been injecting have been happily unable to mess with my head (aside from some kick-off headaches), to my relief. They're not making me all nutty the way that hormones can (although I anticipate the progesterone will be a different story).

Today, though, I'm starting to feel more anxious. In part this is because we spent yesterday hanging out with my cousins, one of whom is visibly pregnant. It's hard for me to see pregnant bellies anywhere, and a whole day of seeing my (younger) cousin was just dispiriting. The worst was when we went to the mall and inadvertently pulled into a parking space that read "Reserved for expectant mothers." The other people in the car cheered. "We've got one! We can actually park here!"

That side of the family is not known for its tact.

Another reason I'm getting antsy is that I am constantly reminded what we're doing, because my follicles have now swelled to outrageous size. Friday's recount (when I managed to stay solemn-faced) revealed 19 follicles on one side, 13 on the other. Today's ultrasound showed that the largest follicles are 16-18 mm in diameter. A little math gives us an approximate volume of 2 cubic cm for each one.

Did I mention there are 32 of them, all inside my abdomen? 64 cc of extra stuff in there? I feel bloated, full, and fat, and sudden movements provoke uncomfortable twinges. It's not awful, but I can't entirely forget about it, either.

Finally, today the doctor announced that the follicles were looking plump enough that we would probably do the egg retrieval on Wednesday. Although at some level I knew it would happen this week, the fact that there is now an actual date is giving me pause.

On the plus side, this makes me feel much better that the folks in the animal colony screwed up and killed my mice for this week's experiments. I was annoyed at them, but now I think--well, if you had to do that, good timing.

InADWriMo final update: OK

Nothing much happened on the paper this week. GradAdvisor had hoped to give me more comments before the T-day break, but she didn't. I'm not too annoyed; I know it's been a busy couple of weeks in lab. I just hope we can dig into the manuscript soon. It's my dream to send this off before 2009, though I doubt that will happen.

Still, I'm happy with the overall progress we made: a draft within the word limits, most references (that I could think of) in place, and the figures are finished or very nearly so. Yay InADWriMo and thanks for the nudge!

IVF 7: Ethics

I wasn't planning on getting into the ethical implications of IVF, but after reading some of the angry online comments to Alex Kuczynski's piece in the Times Magazine this week on gestational surrogacy, it felt pressing.

The arguments against IVF fall into three main categories:
1) If you can't have kids, there's probably a reason, and IVF only circumvents Nature by letting you pass that problem on to the next generation.
2) Why not adopt a child in need, rather than spend time and money pursuing "biological" children?
3) It's a giant waste of money and medical training for a problem that is not directly related to health.

In addition, there is a widespread perception (as reflected in the comments to the Times article) that couples who choose IVF are narcissists, people who cannot imagine loving a child that did not spring from their own loins.

Dr Hyde and I discussed all of these issues before deciding to try IVF. Some of these arguments have validity and still worry me; others don't. Let's take them in turn.

1) IVF circumvents natural selection.
First off, there are many reasons for infertility, and not all of them are heritable. Age, especially of the female partner, is the most obvious one, but there are others, including certain types of injury. Often, the cause of infertility is not known, making it impossible to say with any confidence whether it is heritable.

In our particular situation, we know the cause (or think we do), and doctors simply don't know if it's heritable. After all, it's only recently that couples with our problem have been able to have children. In this respect, we think of ourselves as being on the forefront of a giant experiment. Yay, experiments!

Would we still have tried IVF if we knew that any affected children would also be unable to conceive? I don't know. Of course, if we can conceive through unnatural means, then they would be able to, as well. Still, it's a heavy burden to put on them. There are no known health problems associated with our particular situation; if there were, we would have spent longer on this issue.

In any case, the point is that people who do have genuine, heritable health problems are not usually looked down upon for having children. Bad backs run in your family? Nobody says, "How dare you have children and put them at risk? Lower back pain is a sign that you are not genetically fit to continue the line!" So if you think IVF is immoral because it passes on bad genes, all I can say is: good luck defending your decision to propagate your family's hypertension, heart disease, bad teeth, and fallen arches.

2) Why not adopt?
Well, we still may. If a couple of rounds of IVF don't take, or if we want to add to the family later on but don't want to go through the medical hassle, we will adopt.

Adoption is not hassle-free, though. One friend who is working on her second international adoption listed all of the countries that have recently cut back on allowing babies to be adopted by foreigners. The list ran roughly, "All of them." Waiting lists are long, and if the rules change mid-process, you may not get a child at all.

I don't know anyone who has recently adopted domestically, but I do have one friend in her sixties who adopted her children in what she described as "the halcyon years for adoption--after the war but before Roe v Wade." I'm a firm supporter of all types of abortion rights, but there is no denying that legalizing abortion reduces the number of babies available for adoption. I have heard both good and awful adoption stories; like any method of acquiring a child, it's fraught with uncertainty.

Again, though, the proponents of adoption (in online commentaries, that is) usually seem to believe that infertile couples have a special responsibility to take care of the world's neglected babies. You just don't hear them saying, "Due to the population explosion and the number of needy children out there, everybody, including me, should adopt." No, somehow it's always the infertile folks who have to lead the charge of moral rectitude.

3) Should we really be using medical training for such a frivolous pursuit?
Three words: elective plastic surgery.

Now, I'm not of the belief that just because we can do it, someone else should pay for it. I don't think IVF should normally be covered under basic health insurance, because it's both expensive and medically unnecessary. However, Dr Hyde's health insurance is willing to cover one round of IVF, and we may be hypocrites, but we're not fools: we're taking the money.

4) You're all narcissists.
Interestingly, people often say this in the same breath that they claim that the only reason anyone wants kids is because society "brainwashes" women into thinking that they're not whole without children.

As a biologist, I find these statements make me laugh like a hyena. Wanting kids? Is normal, and biological, and without that drive the species would die out. Wanting kids that are genetically related to you? Again, totally normal. Adoption is, biologically speaking, somewhat perplexing.

Of course, we use our giant brains to make decisions that run contrary to our biology all the time, and thank goodness, because otherwise there might be more fighting, more rape, and fewer scientific conferences. But I don't think that someone can be labeled a narcissist for wanting biological children.

I'd also point out that the very fact that so many people are willing to spend $10,000 or so per cycle of IVF, even to go into debt for this purpose, says something important about our urge to have children. (It also says something important about the American willingness to go into debt, but that is more Ben Bernanke's problem than mine.)

I do think that some people have trouble knowing when to stop. When you are running out of money or ruining your quality of life by endless cycles at the infertility clinic, it is time to let go. But I can say that with sympathy, rather than with rancor or judgment. I can see all too well how difficult it would be to turn away from a particular vision you'd held of how the future looked.

It looked like an embodiment of the love between you and another person.

That's not easy to give up.

IVF 6: Pharmacopeia

A look at what's going into my body this month.


1 - Birth control pills. Two weeks of them to set my cycle.
2 - Prenatal vitamins. Duh.
3 - Baby aspirin. Voodoo. Daily voodoo.
4 - Lupron. Prevents ovulation. Started injecting it a couple of weeks ago.
5 - Follistim. Drives the follicle growth. Comes with a nifty pen-like injection device.
6 - Menopur. Ditto, but no pen-like device. More on it below.
7 - Novarel. One blast to ripen the follicles, right before egg retrieval.
8 - Vivelle. Estrogen. Fantastically, comes as a patch, like Nicoderm.
9 - Medrol. Somehow this helps.
10 - Progesterone. The dreaded intramuscular injection, for two weeks after embryo transfer.
Background - Sharps container and assorted syringes and needles, and alcohol swabs and gauze pads. More needles are hidden in various containers in this figure, too.

It's way more fun than any amount of sex.

Sunday was the first day of Menopur and Follistim injections (plus Lupron continues: three needle pricks, every day. But who's counting?) I had to laugh when I read the Menopur information. It turns out it's made from the urine of menopausal women.

I told Advisor this (as he has been both supportive and interested in the whole process of IVF), and he laughed out loud. "You mean, like witchcraft?" he said.

Anyhow, I had an awful reaction to the first Menopur injection. The subcutaneous injection itself stung a bit, as the Menopur is resuspended in 0.9% NaCl, and I have to inject 1 mL. The bad part, though, came immediately afterwards. I started feeling faint, and then nauseous. My skin was prickling and I broke out into a sweat. Sounds seemed to be coming from far away, as though I were underwater and Dr Hyde was trying to call to me from shore. In short, it was exactly the same reaction I once had to a shot of epinephrine (in an unrelated doctor's office procedure, to minimize some bleeding.) It didn't last long, but every minute felt prolonged, even dreamily timeless.

I can think of three primary possibilities:
1) Panic attack. This is the superficially most plausible explanation. However, I've never had a panic attack before, and I wasn't even feeling particularly apprehensive about the Menopur. As I say, the only other time I've felt this way is after an actual epinephrine shot. Of course, this whole procedure entails some stress.

2) Actual traces of epinephrine in the meds? Seems unlikely, but then again this is an extract, not a synthesized enzyme. Anything is possible, I suppose.

3) The follicle stimulating hormone and/or luteinizing hormone in the Menopur triggered a reaction. Again, doesn't seem likely but I just don't want to believe that this was panic. Given that I'm injecting in the abdomen, could a small amount have been taken up quickly and triggered a hypothalamic-pituitary-adrenal response? Dr Hyde, this time remembering his rightful job as my husband, said afterwards, "You know, you really don't have a lot of fat in the abdomen, so maybe it was taken up too quickly."

I don't think we'll ever find out, because I haven't had that response again. On the one hand, am obvs. happy about that; but the scientist in me sort of wants to see it occur again. N=1 is fun but not informative.

Today I also began the first of about ten days of daily blood draws at the doctor's office. (I am so, so grateful that the dr's office is within biking distance of my lab.) These are to monitor blood estrogen levels, and adjust medication dosage accordingly. While I was there, I ran into Dr Earnest Resident. "Good morning!" she said, and started laughing.

At least I am memorable, even if they do have "TROUBLE" written in all my charts now.

InADWriMo update: Rockstar!

Although I gave GradAdvisor the manuscript last week, she didn't end up having time to read it. But! she sent me an email explaining that she wouldn't have time to read it as promised, and what the reasons were (lab craziness).

So I spent this past week revising the manuscript, which had been a bit sloppy when I first sent it to her (lots of "(ref)" and half a figure missing). I photoshopped up some data (not in the illegal way), rounded out the last figure, and cut the manuscript down within the word count limits!

I sent it off to her yesterday, and she has already sent me preliminary comments, with promise of more insight before Thanksgiving. So far, this paper is the most swimmingly pleasant of any paper we've written (this is our third). Of course, I thought that also about paper #2 before it degenerated into a stony-faced stand-off, so we'll see.