Remember that song from elementary school? You got married and then you had kids! That's what we expect out of life. That's what I expected anyway, and I always figured making a baby was easy. A guy and a girl get together, the egg comes out of the ovary, hooks up with sperm, and viola! You've made a person!
I grew up thinking things were that simple, and I'm guessing a lot of people think that too. I have plenty of friends who have gotten pregnant while trying NOT to get pregnant! When it's so natural and commonplace like that, I doubt many people stop and wonder about all the different processes that have to happen in order to make a baby. Well, not much beyond egg meets sperm anyway.
I wanted to bring you along on my infertility journey and part of that is understanding the miraculous things that have to happen in order to make a baby. When you learn about this stuff, you start looking at everyone as their own miracle. We are the ones that made it! We are literally one in a million!
That's because a woman starts out with one to two million eggs at birth and she will never make more than that. She will eventually run out. Supply is limited, especially when there are thousands of eggs that are growing and maturing and trying to become a viable egg on a daily basis! Yes, every day you have so many eggs at one stage or another. But they will all fall by the wayside. All but one! One lucky egg each month out of thousands that tried! And YOU are the one that made it. You, me, and everyone else on this planet. We are all miracles.
We could dig deep into just how miraculous all of this is. We could talk about DNA and cellular changes and get down into the nitty gritty of all the hormones involved. Yes, I would love to do that and open your world to just how fascinating and complex and miraculous all of this is. You could learn something new and probably come to appreciate just how amazing you are.
But I really don't want you to feel like you're reading a biology textbook.
So, I'm going to pare everything way down for your sake. But I do need to share a few important points so that you can get excited about the process and understand the terms I'll be using in future posts. Trust me, I'll be trying to make this as interesting as I can!
Follicle is a really important word. Eggs are not just floating around independently, but are actually encased in what's called a follicle. The follicle is like a housing unit for the egg, like an incubator, and it helps the egg to grow and mature. In the picture below, you can see the dark spot as the egg, and the yellow part as the follicle surrounding it.
The egg and its follicle will need to grow much larger and more complex before the egg is ready to be released and that whole process of maturation takes about three to five months. So they start out simple and small, as primordial follicles, and then become bigger and more complex, becoming primary and secondary follicles, and then eventually they become antral follicles, which are big enough to see on an ultrasound!
An antral follicle is different from younger follicles because it now has a fluid filled sac inside of it, next to the egg, and that sac will grow and grow until the egg is released. You can actually measure it on an ultrasound and when it gets to a certain size, you know it's about ready to release its egg!
If you're like me, maybe you thought there was just one egg growing and developing each month, the egg that eventually ovulates. But the ovaries are a very busy place, with thousands of eggs at all stages of this process at any given time, some growing, some dying, and only one winner in the end.
Here's a more involved diagram that you really don't need to study unless you want to. You can follow the follicle all through its growth process, a process called folliculogenesis, which is a really cool word to say. It is pretty amazing to see how big that fluid filled sac gets! By the time it releases an egg, it's about the size of a penny.
This process doesn't happen all on its own, by the way. The follicles do seem to wake up and start growing all on their own, which is pretty amazing. Somehow they just know that it's time to come out of their deep sleep, and no one knows how or why. So they start growing without any outside help. But once they become antral follicles then they are finally responsive to hormones in the body. And they need those hormones to keep going!
On the antral follicles, there are these little receptors reaching out for motivation. They need some encouragement to keep growing and get that egg ready for its big debut. What they need is called follicle-stimulating hormone, what we call FSH.
Every month, your average woman will have about 15 antral follicles that are competing for that FSH. They grab hold of it and start growing. You can actually watch this process happen on an ultrasound. The follicles appear as black dots in the ovaries. They will all be about the same size at the beginning of a menstrual cycle. But as the body releases more FSH, you will see those follicles grow over the next few weeks, sucking up that hormone. Eventually, one follicle will take the lead and become the dominant follicle. This is the one that will release its egg, that special one that made it all the way to the end.
Here's a picture of my ovary and a dominant follicle from a few years back. You can see a few other follicles there as well, the smaller black dots that got left behind. Can you see the sad face next to the dominant follicle? My poor dying follicles made a sad face! They didn't make it and got left behind. :(
This is what in vitro fertilization is all about. Instead of looking for a dominant follicle, we are going to clap like crazy for all of the follicles that are in there. We don't want one egg to win the race. We want as many of them as we can snatch! Everyone's a winner!
So we give extra amounts of that FSH, doing injections every day for about 10 days, and we keep a close eye on the progress, watching everything on ultrasound every two or three days. You can see a video here of the latter stages of that process, where my ovaries had grown lots and lots of follicles! See how big they are, and there are so many! Gavin is in one of those follicles!!
In vitro fertilization has always felt a lot like gambling to me. We drop a whole lot of money and hope we get lucky, hope that all the money and doctor visits and drugs and procedures give us a baby in the end. Every penny spent is well worth it when you get a baby, but it sure cuts deep when you spent that money on failure and heartache.
When you're gambling with that kind of money, you try to evaluate your chances of winning and decide whether the risk is worth it. Unfortunately, it's impossible to put an actual figure on your chances of success, especially since there's still so much we don't know about the reproductive process, why some things work and some things don't.
But there are a few things we can do to help us guess at our chances and that's how this whole in vitro process starts. We are trying to get an idea of how successful I will be and also trying to do whatever we can to increase those chances!
That's where those follicles and FSH and other hormones come into play!
What we're going to do is measure my hormones and take a look at my ovaries and see where we're at. What do we have to work with? Here's a little video of me heading to my first appointment, ready to get my blood work done.
I used to be pretty terrified of blood work and shots and all that. But when you do what I do, it becomes routine. I still don't look when they are doing the needle stuff. Yuck. But I don't dread it anymore.
So what are they looking for in my blood? It's pretty neat, actually. In their earlier stages of development, follicles actually have a detectable little substance they give off, called anti-mullerian hormone (AMH). Depending on that number, we can get a good idea of my egg supply. Remember that a woman has a limited egg supply and that supply starts to deplete more rapidly once you reach your mid-30s. I'm not there yet but it's coming up quick! My biological clock is ticking very loudly!
We want a good egg supply. The better the egg supply, the more likely we are to have success with in vitro fertilization. It gets much harder as you get older and you're literally running low on eggs.
Well, I got my results back and my AMH levels (my egg supply) is in the 34th percentile for women my age. That's still in the average range but it's slightly lower than I was hoping. I'm a little disappointed by that but it certainly could be worse!
But we have another way of detecting egg supply too, one that is a little more obvious. Remember those antral follicles we can see on an ultrasound? If we look at how many we have at the start, then we should have a good idea of how many we will end up with after doing the FSH injections. With those injections, we know we can stimulate those follicles, cheer them on and get them all to grow. So we can usually assume we will get about as many eggs as we have follicles.
As I mentioned, an average woman my age may have about 15 antral follicles altogether at the start of each cycle. When I went in for an ultrasound on day one, we found 33 follicles! Here is a video of my ultrasound, taken June 15th.
33 sounds like a fantastic number, right? Especially after my slightly low AMH levels, now I have a great follicle count to balance that out. This is very normal for PCOS women. They tend to have great egg quantity, with lots of eggs to choose from.
But we also tend to have poor egg quality, and quality matters a lot! In fact, even though the sperm contributes half the equation, they've found that the egg quality is a much bigger deal than the sperm quality. The eggs are the superstars of the show!
I am proof of poor egg quality. I got 27 eggs out and only ended up with one baby. That means only five percent of my eggs were really any good and that kind of stinks. Of course, Gavin ended up being such an awesome kid, we are thinking he must have hogged all that awesomeness for himself and left none for the others!
Egg and embryo quality can be broken down into three categories:
(1) Physical structure - How does the embryo look in comparison to the norm? Is it breaking apart and fragmented or is it well put together? They actually grade embryos by looking at their physical structure but that isn't always dependable. I talked to an embryologist once who told me that the perfect looking embryos - the perfect looking A+ embryos - never seem to make a baby. And guess what? Gavin was a "fair grade" embryo, the least attractive of the bunch. And look at him now! Still, we do know that physical structure can give some idea of quality.
(2) Energy - Eggs come out of the ovary with their own energy supply. Think of it like a tank full of gas. They need that fuel to keep them alive and functioning until they can embed into the uterus and start getting energy from the mom instead. But until that time, they're on their own and some eggs just don't have enough energy to get them from point A to point B. They may fertilize, but then they tucker out before they can implant. They've found this to be more of an issue in older women, who's eggs tend to have a little less fuel than younger women. Unfortunately, there's isn't a way to detect energy reserves in an embryo, as far as I know anyway.
(3) DNA - Really, this is the most important part of the whole equation. If there is an issue with the DNA, then we have an embryo that will not develop or it will likely abort at some point during the pregnancy. There is a test they can do where they take one cell from the developing embryo, very early on in its development, and look at the DNA to see whether everything is in order. That really is the best way to determine egg quality and your likelihood of success, but it is very expensive to do and can be harmful to the embryo.
All we do know is that my track record suggests poor egg quality. It is common for women with PCOS to have poor quality eggs and since only five percent of my eggs turned into a baby last time, we can expect a similar result this time around too. Also, since I miscarried three times but we found no evidence of any issue with my body or my uterus in aborting the pregnancies, then we assume the DNA was no good and the pregnancy aborted.
Thing is, I know a lot more about egg quality than I did before and I have it on my mind this time. So does my doctor. We are both hoping for quality over quantity this time. There's still a lot we don't know about egg quality and what we can do to improve it, but we do have some ideas and we are implementing those ideas now. Will it make any difference? Who knows! But we're going to do whatever we can to give me a better chance of success.
So here are the things we are trying, some of which I've already been doing!
(1) Increase circulation - Egg quality can improve when there is good blood flow into the ovaries. The best way to improve blood flow is to exercise and to drink lots of water. Luckily, I've been exercising a lot this year already, so that should help. But I do need to do better about drinking water! Massage is also supposed to help so I guess I need to recruit my husband for a few sessions a week. Hey, sacrifices need to be made!
(2) Diet - It's been difficult to identify exactly which foods are helpful and which are detrimental but we do know that increased insulin seems to decrease egg quality. That means sugar should be avoided in order to keep insulin down. In general, I've been eating better this year already but the goodies are still an issue and I need to change that. I'm also taking metformin, which helps regulate insulin levels and has been shown to improve egg quality.
(3) Hormones and supplements - Prenatal viatmins are a given and I've been taking those for months and months. Antioxidants seem to help improve egg qualityas well so I'm currently taking CoQ10 to help with that. I am also taking DHEA which can help regulate metabolism and other hormones in the body.
They've also found that stress hormones can decrease quality so I need to help regulate those on my own. One way is for me to go to bed earlier, which is hard for me to do! I love my nighttime! But it may help, not only to decrease stress hormones but to increase melatonin, which has been shown to increase success rates. At least I feel my life is generally much less stressful than it was before!
(4) Different regimen - With my last in vitro cycle, we blasted those eggs with a lot of FSH. We went hard and fast! This time, the doctor wants to try going slow and steady. I will be taking a little bit lower of a dose of the hormone and may be on it for a little longer than last time. But they've found that slow and steady can be better at increasing quality.
This is where we stand now. We know that my quantity is pretty good. We also know there's a good chance that my egg quality is not so great. There isn't much we can do about quantity but we are doing everything we can to improve quality.
What are my chances? I'm still not sure. It's still a gamble. But I do have some hope that our efforts to improve quality will help my outcome be a little better this time around. Frankly, I'm happy to even have the same outcome. My expectations are more realistic now and I know that one baby out of four tries is not too unreasonable.
So let's keep our fingers crossed!
I hope you learned something and I hope you appreciate a little bit more how much of a miracle you are! Especially if all of this happens so perfectly inside of you, if you are able to conceive easily on your own. And remember, we just scratched the surface here! There's so much more to know!
Maybe I'll do a whole other post about hormones. Maybe.
2 comments:
Wow it is exciting to hear the details about you trying again. I learned a lot by reading through this - you know A TON. You are awesome Andrea. GO TEAM TAYLOR!!!!
Melissa
You need to print this blog. It's amazing!
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