Hiring humanities-style

My college roommate recently finished her Ph.D. in Renaissance studies. She and I met up today and, as we often do, ended up comparing and contrasting the academic life in the sciences versus the humanities.

In particular we discussed the new faculty hiring process. As many of you probably know, the annual Modern Language Association convention is a hotspot of hiring committees. Here's how it works.

1) Nearly-finished graduate students and postdocs send applications to programs that have announced interest in hiring junior faculty.

2) The faculty hiring committee selects perhaps 10-20 of these applicants for a first-round interview. "Meet us at the MLA. We'll be in Hotel X Suite Y!" they say.

3) First-round interviews give the committee a chance to weed out anyone who is less impressive in person than they were on paper. Perhaps 3 of the candidates survive this cut.

4) Those 3 candidates are then invited to the university on the standard expenses-paid two-day interview with a talk, faculty meetings, and perhaps a demonstration teaching opportunity.

5) Someone is hired (or not).

Compare to my department's setup, where the hiring committee labors long and hard to cut all of the applications down to 5-6 people, each of whom will be invited for a two day on-campus interview.

The advantages to the two-step hiring system are obvious.

a) The department only ends up flying 2-3 serious candidates out, as opposed to the 5-6 for our bio department positions. Costs cut in half.

b) Along with that, fewer schedules need to be coordinated for serious candidates--the usual "is all the hiring committee in town on a date that the candidate can visit?" bit is cut in half. The committee needs to be available for 2-3 days at the MLA, which they might well have attended anyhow, and then just a few on-campus dates.

c) The committee can also afford more risk-taking on the first round. Because people pay their own way to the MLA, there is no added cost (besides an hour or two for the interview) to interviewing a controversial or apparently borderline candidate.

d) In fact, the committee can also invite Europeans or Australians etc with no added cost, in marked contrast to the hiring process in my department. Again, this increases the opportunity to find a gem of a candidate who isn't from a Big Name lab, and whose application just looked a bit "risky."

Of course, I'm just a postdoc and I've only watched hiring committees in action, not served on one. What do you think? The two-step process offers many advantages and I can't think of any disadvantages, as long as your field holds an annual convention with significant attendance (as mine does). The initial costs of interviewing are borne by the candidate who flies to the conference, and the committee has a much better idea what they're getting before they invite people out to campus.

My roommate, incidentally, was one of two people invited to an on-campus interview at her target school, and she proceeded to knock the faculty's collective socks off. They voted unanimously to hire her. They said that even if she declined, they would not hire the other guy at all. (She found this all out after the department chair accidentally cc'ed her on an email to the Dean about the salary range they could offer this new hire. My friend, having seen the max they were willing to offer and the interest they had in hiring her, successfully negotiated the maximum salary. She is awesome.)

Anyhow, I am curious what the advantages are to our more expensive and arguably more conservative, "only Nature paper and BigShot recs need apply" approach.

Coloring outside the lines

The more prestigious the journal, the more likely it is to have draconian word and even reference limits. (Just kidding, PLoS! You're totally prestigious too.) This is especially true of brief-format style articles, like the one GradAdvisor and I are currently writing.

I am by nature a follow-the-rules sort of person, but GradAdvisor had this to say as I proposed hacking our current manuscript down to the bone to meet the journal's requirements: Put in everything you want in the first version. Otherwise, you run the risk of pissing off reviewers by not including enough information for them to evaluate the paper properly. Also, if you cut the reference list to meet some arbitrary standard, and your reviewers' publications are the ones that get cut, you could be in trouble. If the manuscript is accepted, you can always trim later.

I find this advice both hilarious and frightening. Hilarious, because it's absurd to conjure a situation where critical information is included for the reviewers--but not for the final (hopefully larger?) audience. Frightening, because, same reason.

Is this how you also approach tight length limit manuscripts? Obviously try not to be egregiously beyond limits, but otherwise figure that you'll cut it down if necessary? And if so, do you think this is a bad sign of how publishing operates--pleasing the reviewers if not the world? (Not you, PLoS! I know you already thought about how terrible this is.)

Of course, besides better reviewer mojo and sheer laziness, there is another reason not to cut the manuscript to size quite yet: if it gets rejected, the next journal down the pipe has longer word limits.

We're in Detroit, stealing your money

Andrew Sullivan found a good one. Click to get the text at the bottom, which is genius.

I don't know enough about the auto bailout to know if it was a critical stop-gap or a giant money squander, but either way this is hysterical.

IVF 17: One bun in Dr Jekyll's oven

Well, we cheated. We've been doing some home pregnancy tests this week. You have to be cautious about interpreting them because the hormone being tested for, human chorionic gonadotropin (hCG) is also part of the IVF regimen as a shot to trigger ovulation. hCG is estimated to clear out of the system with a half-life of about 28 hrs, meaning that if you had a trigger shot of 5000 units (as we did), it will take at least 10 days for the exogenous hCG to drop below testable levels on the home pregnancy tests.

So we waited until 14 days after the trigger shot for our first home pregnancy test, which was Monday. Two lines! One faint, but clear. We had a three-pack, and on Tuesday morning the line was stronger, and on Wednesday morning even stronger. hCG levels rise dramatically during early pregnancy, so this was reassuring. Still, we waited to celebrate until today's blood test, which is quantitative rather than qualitative.

And the good news--we are way past the "dubious" hCG level and are officially 4 weeks and 2 days pregnant! Huzzah!

This means that back when I was posting angsty perorations about IVF, I was technically knocked up. Creepy.

It is a bit bizarre to have so many people know that you are just barely pregnant. The whole family knows, of course, as do a number of our friends and most of my work colleagues, just because this process was too complicated and emotional to hide. As my mother said, "Yeah, at 6 weeks pregnant I was just thinking my period was running a bit behind."

In any case, although it is still many weeks before the nerve-wracking first trimester is over, we are grateful and happy to have come this far.

I don't plan on blogging much about the pregnancy itself, in part because I want to get back to science blogging, and in part because pregnancy is just not that novel a topic. Of course, I'll let you know if there are any crazy developments. Thanks everyone for your encouraging comments.

Author, author!

We are readying another paper from GradLab for publication, and dealing with that age-old problem, authorship.

This paper began when a tech in the lab made an experimental observation. Advisor and I thought this observation was remarkable, and encouraged/drove him to follow up this observation with more experiments. He performed admirably, shoring up the original data and adding some new pieces to it.

What would turn this observation into a paper? Advisor and I debated a few different ways that it could become a paper. I did a set of different experiments myself to help flesh out the manuscript. In all, I contributed about 1/4 of the experimental data of this paper. The tech's data represents about 2/3, and remaining technical help from others in the lab rounds out the story.

At about this point, both Tech and I left GradLab. I wrote up this paper for publication, and GradAdvisor and I have been tweaking it for several months.

When I sent the close-to-finished manuscript out to all authors, I listed me and Tech as co first authors, in that order. I thought this seemed like the best solution given that
1) He had contributed much more than I had experimentally
2) He had made the original interesting observation that launched the whole paper
3) I had provided the writing and intellectual drive, plus ~1/4 of the experiments.

GradAdvisor disagreed. "You conceived of this paper, and you should be sole first author, with Tech second."

I was surprised and not a little concerned by this. Should I be first author on a paper whose experimental data is 3/4 someone else's? (It's not as though I'm a theorist!) Yes, the intellectual drive was primarily mine, but it would never have mattered if Tech hadn't made the first key experimental observation--which forms the "cool" factor of this paper; my experimental contributions are nice but not the main point.

A friend of mine familiar with the situation gave me the same advice--that the intellectual contribution was what mattered most, and therefore I deserved first authorship.

Because both Advisor and my friend agree, even over my objections, that I am selling myself short on authorship, I am changing myself to be sole first author. But I still feel a bit as though I cheated Tech out of a joint-first authorship. Will this fade over time as I come to recognize the primacy of intellectual over experimental contributions? Or will I keep feeling guilty that I got a "free" paper?

In the end, I wrote one of those "author contribution" sections that you see occasionally nowadays, and this left me feeling better. It is now public record who contributed what to this paper (although of course the intangibles remain just that). This decision has helped reconcile me to the authorship order, because I no longer feel as though I'm pretending to have done more than I have.

Now I just have to break the news to Tech...

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.