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Sae’s IVF Timeline

By Personal No Comments

It’s such a crazy thing, infertility. I felt like there was this epic sense of urgency and boy, was the learning curve steep. A lot of the posts here are information based – it’s all the research I’ve done for myself and my journey. With that in mind, I thought it might be helpful to share the raw emotional stuff as well as the informational. 


IVF Round #1 – Jan 2015. Ovulated early.
IVF Round #2 – Feb 2015. 2 Frozen embryos.
IVF Round #3 – Aug 2015. 3 Frozen embryos.
IVF Round #4 – Oct 2015. 1 Frozen embryos.


Infertility Discovery
– Oct 2014. When fertility punches you in the face. 
– Nov 2014. Shock and making decisions.
– Jan 2015. Have an IVF Plan. Yet to execute.
– Tagged IVF Discovery

IVF Round #1
– Jan 2015. A green light. IVF straight on.
– Jan 2015. The screening tests.
– Jan 2015. Today I tried to stab myself with a syringe.
– Jan 2015. What IVF looks like.
– Feb 2015. I ovulated early.
– Feb 2015. The aftermath.
– Feb 2015. How to be kind to yourself.
– Tagged IVF#1
 

IVF Round #2
– Feb 2015. Being hopeful, while still giving IVF the side eye.
– Feb 2015. Round Two.
– Feb 2015. Egg Collection.
– Feb 2015. Fertilisation! Through the gate! 
– Mar 2015. Waiting and wishing.
– Mar 2015. The end of Round Two (An anticlimax).
– Tagged IVF #2

IVF Round #3
– Jun 2015. Back at the Clinic.
– Jun 2015. We’re not doing IVF this month. My FSH is too high
– July 2015. FSH Levels – 8.1!
– July 2015. Getting through the shots.
– Aug 2015. Egg Collection.
– Aug 2015. I’m scared to hope.
– Aug 2015. Please survive, little embryos!
– Aug 2015. Two of Twelve, a Sad 16%
– Aug 2015. Bonus Blastocyst
– Tagged IVF#3

IVF Round #4
– Oct 2015. Round 4 – CD1
– Oct 2015. Bloods, chaos and practicing patience.
– Oct 2015. Kick off and IVF Costs.
– Oct 2015. Counting Down – Four Days to go! 
– Oct 2015. Egg Collection.
– Nov 2015. OHSS + Watching our Embryos Grow/Die
– Tagged IVF #4

After IVF
– Nov 2015. Sharing is Caring
– Jan 2016. Happy New Year
– Jan 2016. On taking a break from IVF
– July 2017. Turns out 2016 *was* our Year.

2016 – Turns it out it *was* our year

By Personal No Comments

It’s weird to write this on the other side…

In 2016 I did get pregnant. I found out in January. Ironically not long after I posted that last post. And just so it’s clear – it was a spontaneous pregnancy. Not an IVF one. We still have those six, beautiful frozen little blastocysts, and after all four hard, expensive rounds, we conceived *naturally*.  What. The. Hell.

I found it really really difficult to settle in the pregnancy. I was convinced that my infertility had caused some chromosomal issues. So, we did an amnio, and we had to wait till I was 16 weeks, and another three weeks for the results. We found at 19 weeks that our little baby was chromosomally perfect – and that he was going to be a little boy! 

We were over the moon and felt finally okay to tell people at 20w.

Here’s the kicker though – despite being chromosomally perfect our little guy inherited an incredibly rare metabolic disorder called Nonketotic Hyperglycinemia. Unbeknown to us, Zee and I are both carriers.

We spent the first two weeks of our baby’s life in NICU praying he would live. We spent the next two weeks praying he’d breathe by himself and we’d be able to take him home.

 And sure, we were able to take him home. For about three weeks before the seizures kicked in. After that, it was three weeks at the hospital, three weeks in intensive care and two months in hospice on end of life care.  End Of LIFE care.

Oh, my beautiful baby. 

It’s been a heartbreaking, horrid time. We were, eventually, able to come home. And while things aren’t rosy (oh hey seizures, and profound developmental delay and constant trips to the hospital) every day that our gorgeous little guy is with us is a good one. 

I blog more openly about our journey over at www.teammikaere.com.  We’re fundraising for a cure at justgiving.com/team-mikaere, so if you could spare $10, that would be amazing. 

I probably won’t be blogging here as frequently, but I wish you luck, hey. And hope. Got my fingers crossed for your BFP. Maybe this year will be your year too! 

Love,

Sae x

PS – Awkwardly, my name isn’t really Sae. It’s Elly. And Zee’s name isn’t Zee, it’s Sam. Sae is an acronym we use sometimes – Sam and Elly. I guess this is it – we’re out! x

What you should know about Thin Endometrial Uterine Lining

By Research 21 Comments

When I was in the midst of an IVF cycle I was having ultrasounds every second day or so. You get pretty comfortable with your doctor putting a wand up your vajayjay and looking at your lady parts. My doctor without fail would always say ‘Oooh, you’ve got a beautiful lining, a beautiful beautiful lining.’

We never planned to transfer on a treatment cycle so my lining thickness was irrelevant. My doctor said it to soften the blow before we got to my disappointing ovaries.

I got an email the other day from a lovely lady who wanted to know about thin linings and it really got me curious. So I did what I always do and started digging.

WHAT IS THE UTERINE LINING?

You uterus has three layers and the innermost layer is called the endometrium – it’s the layer that thickens in anticipation of an embryo implantation.

During your period, the top functional layer of your endometrium fragments and sheds. Afterwards, during the first half of your cycle (before ovulation) your ovaries produce estrogen which helps the underlying basal layer of your endometrium reconstruct the functional layer. After ovulation, your body produces progesterone which thickens the endometrium further. This also helps increase the number of blood vessels in the lining, in anticipation of implantation.

If fertilisation doesn’t occur, your progesterone levels drop which causes your endometrium to fragment and shed, and you get your period.

WHAT DOES ‘THIN LINING’ MEAN?

A typical cycle is about 28 days. During this time your endometrial lining should increase, starting at 3mm at the end of your period and, once your oestrogen levels are in full swing, it should thicken by around 1mm a day till it’s at optimum levels. Ideally, the optimal lining thickness is between 10 – 13mm at around day 21 of your cycle, the day implantation is most likely to happen.

Typically, ‘thick’ is considered anything more than 8mm. When the endometrium is thiner than this, the embryo will have problems implanting. If the embryo does implant, a thin endometrium may not be able to supply the necessary nutrients to maintain the pregnancy.

This study (Source) suggests that a thin layer may lead to an abnormally high concentration of oxygen in the epithelial cells, causing a rise in free radicals which can be toxic to cells (and an implanting embryo!)

It’s been shown (Source, Source) that implantation rates are higher when the endometrial thickness is greater than 9mm.  This study (Source) showed that a positive beta, ongoing pregnancy and live-birth rates increase significantly with increasing endometrial thickness, independent of the effects of patient age and embryo quality.

In saying that, live delivered pregnancies are possible despite thin endometrial lining (5mm or less) but the pregnancy rate is poor (only 5.7%. Source).


As a personal (and very non-scientific, so take it with a grain of salt) example, in my last round of IVF my lining was measured every few days. Here’s my thickness during the first half of my cycle:

CD 04 – 3.7mm
CD 09 – 9.0mm
CD 11 – 9.8mm
CD 13 – 10.7mm


WHAT CAUSES THIN ENDOMETRIAL LINING?

Low oestrogen/low progesterone

Your cycle is run by oestrogen and progesterone, so if you’re having issues with your lining it could be cause by a lack of oestrogen (pre ovulation) or by low progesterone (after ovulation) (Source).

If you get regular scans and bloods your RE can explain what is happening with your lining. If it’s clear you have a thin lining, your RE might prime your uterus with oestrogen medications during a cycle to see if the endometrium thickens. If it doesn’t, it’s an indication that hormones my not be your problem.


Inadequate blood flow

If there isn’t enough blood flow to your uterus, your lining is unlikely to thicken. This study (Source) found a correlation between issues with blood flow in the uterine radial artery and a thin lining, in comparison with normal lining.

This was also associated with poor growth of the epithelial tissues (they line the cavities and surfaces of blood vessels and organs), poor vascular (blood vessel) development and a decrease in vascular endothelial growth factor (a signal protein produced by cells to create new blood vessels).


Overuse of Clomid

Clomid (Clomiphene citrate) is a drug that helps ovulation, and is often a first line treatment for infertility. It works by attaching to your estrogen receptors which trick your body into thinking your estrogen levels are low. This triggers the production of GnRH (gonadotropin releasing hormone) within the hypothalamus. This, in turn, stimulates the pituitary gland to increase production of follicle stimulating hormone (FSH) which triggers activity in your ovaries to stimulate follicles and induce ovulation. (SourceSource)

Since Clomid is an antiestrogen, using it can cause a blockage in the stimulation of estrogen in your lining. Clomid has two parts. Once you stop taking Clomid, one part leaves the body within a week while the other one remains, acting as an anti-estrogen for up to six weeks.

When Clomid is used for more than three months in a row, the anti-estrogen isomer build-up causes thinning of the uterine lining.  Several studies have found endometrial lining thickness is significantly thinner in women taking Clomid than women not taking Clomid. (SourceSourceSourceSource)

It’s strongly suggested that a thin endometrium caused by Clomid is due to impaired lining growth thanks to the lack of estrogen. This is a major cause of poor pregnancy rates in women who showed a thin endometrium by Clomid treatment. (Source)


Fibroids

Fibroids are growths that can develop in the uterus. They form from muscle cells that grow abnormally. As they grow, they develop into non-cancerous tumours.

It’s not clear what cause fibroids to grow. It appears they’re (at least in part) genetic, so if your mother had fibroids it’s likely you might also (Source). If you’re obese (Source), black (Source) or eat a lot of red meat (Source) you are more likely to get fibroids.

There are several different kinds of uterine fibroids:

  • Submucosal fibroids are found inside the uterus.
  • Intramural fibroids are found inside the wall of the uterus, typically just underneath the endometrium.
  • Subserosal fibroids are outside the uterus.

This study (Source) compared 163 patients with fibroids (in any location) to patients without fibroids, and found no statistically significant differences between endometrial thickness.

However, they did find that some fibroids had an effective on the the pattern of the lining. Typically your endometrium is made up of glands that grow through out your cycle. These glands grow in a kind of pattern as your cycle processes.

They found that patients with fibroids of any size or in any location had glands that grew with a non-proliferative pattern when compared to patients without fibroids. This in turn was associated with less live births.

Intramural fibroids had a 4% nonproliferative rate and a 31.4% live birth rate. Intramural fibroids that was on the edge of the uterus was even more likely to have a nonproliferative endometrial pattern (5.3%) and a significantly reduced live birth rate (19.1%).

Subserosal fibroids appeared to have no effect on endometrial pattern or thickness, as might be predicted. This was also supported by this study (Source) which suggested subserosal fibroids do not appear to have an impact on fertility.

Returning to lining, the current treatment plan for fibroids is to suppress estrogren/progesterone production. It’s thought fibroid growth is associated with estrogen/progesterone, so by suppressing the hormones you suppress fibroid growth. This is shown when a woman enters menopause and her hormones decrease, fibroids tend to shrink in size on their own (Source). However, this will interfere with endometrial development (and the thickness of your lining).

There was also this case study (Source) where a patient had a uterine artery embolization for her fibroids. An artery embolization is where the arteries that supply blood to the fibroids are blocked, causing the fibroids to shrink. However, by blocking these arteries you are blocking the blood supply to the uterus and the endometrium, which could permanently stop your periods and any lining growth.


Oral Contraceptives with Progestin

Progestin is a synthetic progestogen similar to progesterone. It’s the active ingredient in the injected contraceptive Depo Provera (medroxyprogesterone) and the intrauterine device (IUD) Mirena.

It’s also used in oral contraceptive pills.  Typically oral contraceptives are pills that contain both estrogen and progestin – they block ovulation and your body is less receptive to a fertalised egg during ovulation. Some oral contraceptives contain only progestin. These pills make the cervical mucus thick, preventing sperm entry to your uterus.

Long term use of progestin, especially at higher doses thins your lining by decreasing the size and number of glands in the endometrium and reducing the spaces inside cells (known as the cytoplasm of a cell). (SourceSource, Pages 40-53).

This study (Source) found that using a oral contraceptive consistently provided a thin endometrium, helpful before a hysteroscopy. Not helpful if you’d like an embryo to implant.


After a dilation and curettage (D&C)

Dilation and curettage (D&C) is a procedure to remove tissue from inside your uterus. It’s performed to diagnose and treat certain uterine conditions — such as heavy bleeding — or to clear the uterine lining after a miscarriage or abortion.

This study (Source) followed 444 women, and measured their lining one day before ovulation, and a 5-7 days after. They split the women into groups, depending on the number of D&C’s they had.

Mean lining measurements 1 day before ovulation:

0 D&Cs – 10.00mm ± 0.58
1 D&Cs –  9.83mm ± 0.47
2 D&Cs – 8.90mm ± 0.92
3 D&Cs – 7.42mm ± 0.18
4 D&Cs – 7.40mm ± 0.07

Mean lining measurements 5-7 days after ovulation:

0 D&Cs – 10.62mm ± 0.68
1 D&Cs –  9.64mm ± 0.49
2 D&Cs – 8.48mm ± 0.96
3 D&Cs – 6.32mm ± 0.15
4 D&Cs – 6.90mm ± 0.04

You can see that the more D&Cs that were had, the smaller the lining thickness. They measured the estrogen and progesterone levels and found no significant correlation in these ladies (indicating it was likely to be the D&C, and not a hormone problem). They also looked at age and found no significant correlation there either.

This study (Source) followed 1400 women through their IVF cycles. 13 women had persistently thin endometrium linings of 7mm or less. They found that when a persistently thin endometrium was because of D&Cs, even if the thickening of the lining eventually occurred, the pregnancies that resulted in a live birth were few.

This could be because of resulting scar tissue, leading to Ashermans Syndrome.


Ashermans syndrome/Intrauterine adhesions

Also known as: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, endometrial sclerosis, and intrauterine synechiae.

Asherman’s syndrome is characterised by adhesions or scar tissue in the endometrium. Adhesions are bands of tissue that can form between organs (like your uterus, fallopian tubes or ovaries) or between your organs and the wall of the abdomen

This typically is caused by a D&C (dilation and curettage) on a recently pregnant uterus where the uterine wall was scraped with too much force damaging both the functional layer and the underlying basal layers of the endometrium. (88% of cases, Source)

Asherman’s syndrome can also be caused after the removal of polyps and fibroids from the uterus, or even a cesarean (Source) or a uterine bacterial/inflammation infection.

If your endometrium is scarred and blocked with adhesions, your lining is unlikely to respond to the estrogen, which means your lining is unlikely to thicken. You may find your periods are shorter and less heavy (Source). If the adhesions are not removed, it’s likely they’ll block the flow of blood from your period and could cause endometriosis (Source).

One study (Source) discovered a correlation between Müllerian/Paramesonephric duct anomalies and uterine adhesions. Like other organs, your reproductive organs take shape when you’re a fetus. Your uterus and fallopian tubes develop from two ducts known as the Müllerian/Paramesonephric ducts.

During normal development, these ducts fuse together forming a single uterus with an open cavity and two fallopian tubes. Sometimes these don’t form like they should, and these are called Müllerian/Paramesonephric duct anomalies.

It’s thought that because women with Müllerian/Paramesonephric duct anomalies are predisposed to miscarriages, they are likely to have a higher rate of D&Cs performed which leads to a higher incidence of Asherman’s syndrome.


In-Utero exposure to diethylstilbestrol (DES)

Diethylstilbestrol is a synthetic, non-steroidal estrogen that was created in 1938 (Source).

From about 1940 to 1971, DES was given to pregnant women in the mistaken belief it would reduce the risk of pregnancy complications and losses. In 1971, DES was shown to cause clear cell carcinoma, a rare vaginal tumor in girls and women who had been exposed to this drug in utero. Follow-up studies have indicated that DES also has the potential to cause a variety of significant adverse medical complications during the lifetimes of those exposed, like that of a decreased endometrial thickness (Source).

Note: I’ve included this, as the book does explicitly confirm the link, but it doesn’t provide sources and I couldn’t find any explicit studies. In saying that, there is a close structural similarity between DES and clomid, which has been shown to cause thin linings could explain why the administration of clomiphene to DES daughters is more likely to result in a thin lining.


SK3 – Calcium activated potassium channel 3

This may be a bit of a stretch, but in the interest of providing as much information I can I’m including it. It’s quite scientific, and took me a while to understand. Inside the structure of a cell, there are potassium channels. These channels are membrane proteins that control the flow of ions across the membrane to control electrical signals, and they’re found in virtually all living organisms.

Calcium activated potassium channels are potassium channels gated by calcium. Calcium ions are important for cell signalling, as once they enter cytoplasm (thick solution that fills each cell) they regulate some of the enzymes and proteins.

SK3 is a calcium activated potassium channel that belongs to a family of small conductance channels. We know these channels exist in the endometrium lining. This study (Source) found that a reduced number of SK3 was associated a thin endometrium and unsuccessful pregnancies.

The idea is that with less SK3 in the endometrium meant a rise a cytosolic calcium – the amount of calcium in the cytoplasm – and an increase in membrane hyperpolarization. This is where the membrane potential is negative, and inhibits cell events. The membrane requires a larger stimulus to get it moving again. In chemical speak: membrane hyperpolarization is induced by thapsigargin, a Ca(2+)-ATPase inhibitor, cell migration, and F-actin assembly.

Essentially – the less SK3 channels found in the endometrium, the more likely you are to have a thin endometrium. The same study found similar results in SK3 channels in mice.


Other Causation Notes:

I looked into a link between pelvic inflammatory disease/chronic bacterial infections and lining. Essentially, it’s a bacterial infection in the uterus, fallopian tubes and ovaries that could cause scarring in the fallopian tubes (most likely) but in extreme cases can cause scarring of the endometrium, which may prevent the lining from growing. At that point, it’s essentially Ashermans Syndrome.

I also looked into a link between a retroverted (tilted) uterus and thin lining, but I couldn’t find any research to indicate a correlation between the two.

I also couldn’t find any research that linked a sedentary lifestyle with a thin endometrium. While I understand the theory (being active increases blood pumping around your body, which should increase the blood moving to the uterus) I couldn’t find any scientific research linking the two.

While there is some research that covers studies where the patient had both premature ovarian failure and a thin lining, there isn’t any research indicating that premature ovarian failure causes thin lining.


WHAT HELPS THICKEN ENDOMETRIAL LINING?

Estrogen/hCG

hCG stands for Human Chorionic Gonadotropin. It’s a hormone produced by an embryo after implantation. It’s hCG that is detected in pregnancy tests. LH stands for Luteinizing Hormone. When your eggs are mature you’ll get a spike of LH in your cycle, which triggers ovulation and helps your follicles/ovaries produce oestrogen/progesterone.

It’s thought that in your endometrium lining there are LH/hCG receptors. This small study (Source) was a proof of concept study, and hypothesised that if hCG was given early in your cycle, when your eggs and follicles are growing and maturing it might help your endometrium.

They gave 17 patients with previous implantation failures and resisting thin endometrium oestrogen, and part way through, 7 days of hCG. This was used to prime the lining before progesterone was started. They found the endometrial thickness increased from 5.2mm to 6mm. A third of the patients had a 20% thickness increase after HCG priming. Unfortunately, 29% had no change. Surprisingly, seven of the women became pregnant after, which suggests that receptivity of the uterine lining may have normalised.


Estrogen/hMG

hMG stands for  human menopausal gonadotropin – it’s a synethetic medication extracted from the urine of post menopausal women. It’s used because it reflects the state of menopause, with high levels of FSH  and LH.  FSH stands for Follicle Stimulating Hormone, it helps control your menstrual cycle and the production of eggs by the ovaries. LH is Luteinizing Hormone – when your eggs are mature you’ll get a spike of LH in your cycle, which triggers ovulation and helps your follicles/ovaries produce oestrogen/progesterone.

This study (Source) had women with a lining thickness of less than 6mm on the cycle days 6-10 split into two groups. One took hMG daily, and the other oestrogen (known as micronized 17beta-estradiol). They did ultrasounds every few days to measure the lining. They also measured the number of follicles and how many eggs were mature at the time of retrieval.

In both groups the lining thickened. However, low-dose hMG resulted in larger follicles and a significantly higher number of mature eggs (15.1% vs. 10.5%).


Estrogen/Progynova

Progynova patches contain estrdiol (a version of estrogen). They’re applied to the skin release around 100 micrograms of estradiol every 24 hours. This is called ‘transdermal therapy’ as the medication is absorbed via the skin. This case study (Source) had a patient that improved her endometrial thickness to 7.6mm, and was able to carry twins.  This particular case should be taken as  grain of salt though, as it’s a single patient and may not work for everyone.


Increasing uterine radial artery blood flow.
(via
Vitamin E, L-arginine and Viagra)

The radial aterty are the secondary veins that supply blood into the endometrium. By increasing the blood flow through the radial arteries, the theory is that it will improve the endometrial lining.

This study (Source) measured 61 patients who had a lining thickness of less than 8mm, and a high radial artery resistance.

This a measure of blood flow. Essentially, blood flow through a vessel (like a vein, or the uterine radial artery) has a particular pattern that can be seen with an ultrasound. This pattern is caused by two different pressures – one from the heart as it beats blood through your body and the other pulled by the organ it supplies blood too. Most of the peripheral resistance is offered by arterioles (smaller blood vessel that branches out from an artery and leads to capillaries, like the radial artery) because of changes in the vessels wall muscles (Source).

A high radial artery resistance indicates a low rate of blood through through the vessel, to the endometrium.

These patients were given several supplements to help widen the radial artery. They were split into three groups:  Vitamin E (which can act as an anticoagulant, which thins the blood and prevents it from clotting (Source), L-arginine (is an amino acid, which is converted into nitric oxide inside the body. This causes blood vessels to open wider for improved blood flow) and Viagra (which enhances signalling through the nitric oxide pathway, improving blood flow when taken vaginally).

Please be aware before I share the numbers, that the sample sizes were small (approximately 12 patients per group).

Vitamin E improved the lining (for 52% of patients) and the radial artery resistance (72%). This group also had samples of their endometrium examined in a few patients (5) and they found Vitamin E improved the glandular epithelial growth, the development of blood vessels, and vascular endothelial growth factor protein expression in the endometrium.

L-arginine improved the lining (for 67% of patients) and the radial artery resistance (89%).

Viagra improved the lining (for 92% of patients) and the radial artery resistance (92%).

The control group, only one person (10%) improved in either the lining or the radial artery resistance.


Improving Blood Flow with Pentoxyfylline + Vitamin E

This retrospective (Source) looked at how blood flow to the endometrium could be improved with Pentoxyfylline and Tocopherol (otherwise known as Vitamin E).

Pentoxyfylline is tablet typically used to improve circulation. It’s a hemorrheologic agent that helps blood flow through narrowed arteries. Tocopherol is a family of Vitamin E compounds. Naturally sourced vitamin E is called d-alpha-tocopherol.

20 women who hadn’t responded to conventional hormonal stimulation and linings 6mm or less were prescribed both Pentoxyfylline and Tocopherol.  As it was a retrospective study, all the women took the medication from anywhere between 1-18 months. However, 73.7% of women showed an improve in endometrial thickness, moving from a mean thickness of 4.37 mm (+/-1.5 mm) to 6.05 mm (+/-1.83 mm) after the treatment. 40% went on to become pregnant.


Acupuncture to improve blood flow

There are a small number of acupuncture studies with variable quality, so it’s not clear how effective acupuncture is, exactly. There have been some basic research studies which suggest that acupuncture can help regulate the blood flow of different organs, like the heart (Source, Source) the skin, and muscles (Source, Source) in both animals and humans.

This study (Source) measured the spread of blood flow before and after acupuncture. They found that acupuncture increased blood flow.

There was only one study I could find that mentioned endometrial thickness explicitly. The study (Source) looked at how acupuncture effected the endometrium and hormone levels of rats who were taking clomid (a drug that stimulates your ovaries to release eggs). They found no significant differences in endometrial thickness between the acupuncture and no acupuncture groups.

Other studies looked at uterine blood flow. We know that if there isn’t enough blood flow to your uterus, your lining is unlikely to thicken. This study (Source) found a correlation between issues with blood flow in the uterine radial artery and a thin lining, in comparison with normal lining.

It’s thought that the positive effect of acupuncture is because it changes the uterine blood flow and momentarily calms down your central nervous system’s tendency for flight or fight by sending endorphins (caused by the stress/slight pain of acupuncture). Relaxation and stress reduction is also thought to help (Source).

This clinical trial (Source) looked the pregnancy rate and uterine artery blood flow in 44 patients. They were split into two groups – acupuncture or no acupuncture. They measured the  pulsatility index of both the left and right arteries in the patients uterus before and after acupuncture.

Pulsatility index is a measurement of the blood pressure in your arteries. When your heart beats it contracts and pushes blood through your body, which creates pressure on the arteries. This is called systolic blood pressure. Your diastolic blood pressure is the pressure in your arteries when your heart rests between beats. By taking your peak systolic and minimum diastolic measurements and dividing them by the velocity of a full heartbeat cycle you get the pulsatility index.

This study (Source) showed that Uterine Artery resistance (shown with a Pulsatility Index measurement) goes down during the middle a cycle to prepare for implantation, regardless of age or parity.

Returning to the clinical trial, they found that while there was no difference in pregnancy rate between the two groups (had acupuncture group 30%;  no acupuncture group, 28.6%). The mean pulsability index of both uterine arteries was significantly reduced after acupuncture (left uterine artery, 2.3 to 2.0; right uterine artery, 2.4 to 2.2). There was no significant change in PI in the group with no acupuncture (left uterine artery, 2.5 to 2.3; right uterine artery, 2.4 to 2.3). So, acupuncture is helpful for improving blood flow to the uterus but looking forward, did not increase the pregnancy rate.

This study (Source) ran a similar 10 women study, but they down-regulated their patients to exclude any hormonal effects. Their patients had acupuncture sessions twice a week for four weeks. A baseline pulsability index was measured before the first treatment and subsequent measurements after the eighth treatment, and then again 10-14 days after.

They found that the mean pulsability index was significantly reduced after the eighth treatment and lingered 10 – 14 days after treatment.

This study (Source) found that electrical stimulation of acupuncture helped improve pulsatility index in uterine ateries to normal levels. It also helped induce ovulation.


GM-CSF

GM-CSF stands for Granulocyte Macrophage Colony-stimulating factor. Granulocyte macrophage is a protein that contains a type of white blood cell that protects your body by eating any foreign cells. Colony-stimulating factor is a protein is important in cell signalling – it’s released by cells and affects the behaviour of other cells.

Typically it’s secreted into the fallopian tubes and the uterus a few days after ovulation – when fertilisation is due to take place. The level of GM-CSF will fluctuate throughout your cycle, but is typically at it’s highest in the mid-luteal phase (a few days after ovulation).

GM-CSF  is key in early pregnancy, particularly in embryo development and implantation. It’s thought that GM-CSF inhibits the stress response of the embryo cells, stopping cells from dying due to stress (Source).

This study (Source) is a small but positive one. They flooded the uterine with G-CSF of 4 women who couldn’t increase their thickness. These women had already tried estrogeon and medication to widen their blood vessels. Within 48 hours of the infusion all four women had their thickness increase to 7mm, and all four conceived.

This study (Source) was an extension of the previous GM-CSF study. Still small, and uncontrolled but worth a look. It was a pilot of 18 months that followed 21 women with thin lining (anything under 7mm) on the day of their IVF trigger. They’d all tried other treatments which were unsuccessful.

During the next cycle, the day before the trigger GM-CSF was flooded into the uterus with a catheter by slow infusion. If their lining had not reached at least a 7-mm within 48 hours, they got a second infusion after egg retrieval.  The mean lining thickness increased from approximately 6.4mm to 9.3mm. The ongoing pregnancy rate was 19.1%.


Hysteroscopic Adhesiolysis

Hysteroscopic adhesiolysis is the where uterine adhesions (like that caused by Ashermans Syndrome) are broken down, using either microscissors or extreme heat/cold.

This study (Source) followed 187 patients whose uterus was blocked by adhesions. The type of adhesions were varied in severity: mild/filmy adhesions, moderate/fibromuscular adhesions and severe connective tissue adhesions. After treatment, normal mensturation was restored in 88.2% of patients who had menstrual abnormalities (like amenorrhea, hypomenorrhea and dysmenorrhea). Of the 187 patients, 143 women achieved pregnancy, and of those 114 (79%) achieved a live birth.

They found the outcome correlated with the type of adhesions and the extent of the blockages. Patients who had a mild adhesions had a pregnancy rate of 81.3%, while those with severe adhesions had a 31.9% pregnancy rate.


Stem Cells

This is a bit a of a reach, but in the interest of sharing everything I’m including it. Generally speaking, stem cells are like a base cell that can grow into any other kind of cell. Some might differentiate and become specific to their task, and some return to the stem cell population to be used again.

An embryo is made up of stem cells, and you’ll often find stem cells in bone marrow. As stem cells have specific markers so they can be identified. It’s thought that the  endometrium has a layer of these cells that allow for the lining to regenerate after your period.

This study (Source) followed a women with severe Asherman’s Syndrome, whose lining was perpetually at 3.2mm. When conventional methods failed, they isolated stem cells from her bone marrow and placed them in her endometrium. She was given high rounds of estrogen (pre ovulation) and progesterone (post ovulation) to stimulate the growth of her lining. Her endometrium grew to 7.1mm with good vascularity on transfer day. The embryo implanted and the study followed her pregnancy to week 8.

I’d be wary, as this is a single report with a single patient. I’d want to to see several fleshed out, rigorous scientific studies to understand that the results are repeatable and due to the stem cells.


Other Treatment Notes:

There was no research to indicate that low-dose asprin of baby asprin improved lining thickness. This study (Source) found that there was no demonstrable increase in endometrial thickness in the group that had aspirin. However, there was a statistically significant increase in implantation rates in the aspirin-treated group (24% versus 9%) and also an increase in clinical pregnancy rates in the aspirin-treated group when the final endometrial thickness reading was greater than 8 mm. This study (Source) found similar results.

This study (Source) found no change in endometrial thickness when taking clomiphene citrate or the aromatase inhibitor letrozole.


As always, I’m not a doctor, or a scientist or an expert in anyway. I’m someone who has looked at the research available on the internet (from published scientific journals) and presented what I’ve found. If you have any questions or doubts please please talk to your doctor. 


Can Vitex help you with low progesterone?

By Research No Comments

A friend emailed me the other day – had I heard of Vitex? The information out there is mixed and she wasn’t sure whether to take it or not. I flicked back a quick email with what I knew (which was mostly to avoid it), but after some thought I decided to look into it proper.

What is Vitex?

Vitex Agnus Castus is the berry from a chaste tree, native to the mediterranean. It’s berries are used in herbal medicine, often used for fertility.

What does it do, really?

Taking Vitex can stimulate your hypothalamus to produce more dopamine. High dopamine levels suppress prolactin (Source) which will go on to increase progesterone production.

This is helpful because progesterone is key to your fertility cycle. After ovulation, your LH levels trigger a change in the corpus luteum (the now empty follicle in your ovary) which starts progesterone production to supports the developing embryo.

If the embryo implants successfully, at week 7 the corpus luteum will tag team progesterone production out with the placenta. If pregnancy did not occur, the corpus luteum disintegrates which causes the progesterone production to fall,  triggering the endometrial tissue to break down and your period will start.

In short, progesterone supports the embryo and maintains your uterus lining so the embryo can implant.

Why is low progesterone a problem?

Short Luteal Phases

Your luteal phase is the time post ovulation before your period begins. It should last 11-14 days, which is the lifespan of the corpus luteum. If your luteal phase is shorter than 11 days, it’s likely your corpus luteum did not form as it was supposed to. This is called a luteal phase defect and is associated with low progesterone. (Source)

Early Miscarriages

Up to 35% of women with repeated or habitual miscarriages have a luteal phase defect. This is thought to be a result of an inadequate maturation and development of the endometrium, or the tissue lining your uterus that the embryo implants into. This in part is due to inadequate progesterone levels. (Source)

Low progesterone values are associated with miscarriages and ectopic pregnancies (both considered non-viable pregnancies) and high progesterone concentrations with viable pregnancies. (Source)

How does Vitex help?

By improving progesterone levels, Vitex can help woman with established luteal phase defect (shortened second half of the menstrual cycle) and high levels of the hormone prolactin.

If you have irregular periods, it may normalise your menstruation cycle and encourage regular ovulation (or it may mess it up completely. The research is mixed).

Is Vitex right for me?

Yes, if you have:

  • Low levels of progesterone post ovulation
  • Luteal phase defect
  • High prolactin levels
  • Irregular periods

If you do not suffer from any of these, it’s unlikely Vitex will help you.

Does it Work?

This double-blind, placebo-controlled pilot study (Source) had a small sample of women (30) who had difficulty conceiving take a nutritional supplement containing vitex (chasteberry) and green tea extracts, L-arginine, vitamins (including folate) and minerals.

The monitored their changes in progesterone level, basal body temperature, menstrual cycle, pregnancy rate and any side effects.

After thee months, the supplement group had increased their progesterone levels and increased the number of days with high basal temperatures (indicating ovulation), while the control showed no change. After five months, 33% of the supplement group were pregnant, while the control group had no pregnancies.

This double blind, placebo-controlled study (Source) had a larger sample (93) of women who had difficult conceiving take Fertility Blend, a supplement containing vitex (chasteberry), green tea, L-arginine, vitamins (including folate) and minerals.

The monitored their changes in progesterone level, basal body temperature, menstrual cycle, pregnancy rate and any side effects.

They monitored the same effects: progesterone level, basal body temperature, menstrual cycle length, pregnancy rate and any side-effects.

After three months, the supplement group had increased their progesterone levels and had significantly increased basal temperatures. Women in the supplement group who had either a short (less than 27 days) or long (>32 days) cycles normalized. The control group (N = 40) did not show any significant changes in progesterone levels, basal temps or menstrual cycle length.

After three months, 26% of the supplement group were pregnant (26%) compared to 10% in the control group (10%; p = 0.01).

In short, taking nutritional supplementation may complement conventional fertility therapy.

Is it safe?

There have been several studies (SourceSource) that suggest taking Vitex will have no substantial adverse effects.

This study (Source) suggests that an adverse events are mild and reversible. The most frequent complaints are nausea/gastrointestinal disturbances, headache, menstrual disorders (such as cycle irregularity), acne, itchiness, dizziness and skin rashes.

Where do I get it? How much do I take?

Vitex comes in many forms, loose herbs, capsules, tea, tincture and powder. Capsules and tincture (a liquid extract) ensure you can control the dosage. It’s quite bitter, so a capsule is often preferable to tincture.

For optimal results, Vitex should be taken for three – six months. In regards to dosage, it’s strongly suggested you visit a neuropath or herbalist to discuss what dosage would be right for you.

Warnings

  • Talk to your doctor. Talk to your doctor. Talk to your doctor. Or even your clinic’s nurse. Or send your clinic an email. It’s always better to ask than to guess. Even better to talk to a medical professional rather than take advice from the internet.
  • As vitex affects hormone levels – if you are pregnant, stop taking it. The level of progesterone may alter the development of your baby.
  • This goes for anything that is particular hormone-sensitive conditions like breast cancer or oral contraceptive use.
  • Don’t combine with fertility drugs or IVF, as it will interfere with your doses.
  • Don’t take it if you’re under 18. At that age, your pituitary-ovarian communication system is still growing.
  • Vitex can make depression worse, and possibly promote suicidal ideation. If you have a history of depression be VERY cautious with it.

As always, I’m not a professional or a doctor – my experience is just that, my experience. I’ve done an awful lot of reading and research which I’m happy to share. If you do have concerns about low progesterone or Vitex, please talk to your doctor.

Happy New Year

By Personal No Comments

The break has been nice, the downtime of eating whatever and finally, what feels like the first time in forever relaxing. Proper relaxing.

That doesn’t mean not worrying about TTC, though. Zee and I have being fast and free with contraception. We’re in that weird spot of trying not to worry, but worrying at the same time. That epic rollercoaster that happens month to month. We’re not trying very hard. It’s like we’re giving ttc the side eye – I know ish when I’m ovulation. I don’t say anything when we BD around that mark, and I know when AF is meant to show. 

We’re not trying, but still have that weird moment of both relief and disappointment when AF shows up. 

Relief because our doctor wants to do another round of IVF. At some point. Some point this year. Maybe. Maybe we’ll change some things. Maybe we won’t. Maybe we’ll transfer instead of freezing. Maybe maybe maybe.

Relief because there are so many things to do, and I’m still on the am I ready? Am I not? IVF originally was a back up plan, a just in case. I prepare for the future, but at this point, we’ve been on this journey for so long that the end goal seems less scary than it did a year ago. 

Disappointment because at the end of it, I want children. It’s hard to see the single line on the test. 

We’ll see. I’m trying to plan for other things this year, IVF occupied a large portion of my 2015. This year, I’d like to do more, see more. Create more.

Fingers crossed that this year is our year, right? 

How to reasearch scientific fertility studies

By Research No Comments

With IVF there is an awful lot of information online and I’m not always sure what is valid and true and what is hearsay.  I’m a UX designer by trade, which means I typically make my decisions based on data, numbers and studies… but I found that most articles didn’t include their sources. They discussed numbers but didn’t follow it up with references. It made it difficult to know what information to trust.

So, I started doing my own research and reading scientific studies. 

It was intimidating at first. I wasn’t sure where to look or how to find studies or how to know if they were statistically significant, or even relevant to me. First things first though. I knuckled down and just started searching.

1. Write out a list of questions

Sometimes it’s hard to find a starting point. There is so much information it can be overwhelming. To make it easier, I like to structure my research with a series of questions. Typically:

  • What is my body supposed to do?
  • What causes x?
  • What can I do so help x?

If my research was focused on, say, thin endometrium lining, I’d write down:

  • What part does my endometrium lining play in my cycle (ie, what is it supposed to do?)
  • What counts as thin?
  • What effect does a thin endometrium lining have on my fertility?
  • What causes thin endometrium lining?
  • What can I do to help thin endometrium lining?

2. Brainstorm (ie, Google everything)

At this point you want to start collecting ideas. Not everything will be scientifically correct or have supporting research, but that’s okay. Read wikipedia articles, blogs and clinic websites. Visit forums, and ask questions on instagram. 

For everything you find, write bullet points underneath your questions with what you discover. You’ll get a long list of things, hopefully.

For example, whenever I came across anything that suggested it might cause thin endometrium lining, I’d write it under the ’cause’ heading with a link so I could find it again. 

Here’s the beginning of a list I started when I was researching acupuncture:

 

 

3. Verify with Research

This is the tricky bit. For every item on your list you want to verify that there is scientific research supporting the truth of what you’ve got.

Visit NetPubMed. URL:  www.ncbi.nlm.nih.gov/pubmed

This is the go-to place for research studies. There are so many journals and scientific research publishers and PubMed is the place all the summaries are consolidated. For everything. Every study, whether about fertility or not. You can put in a search term and hey presto, you’ll get research back. 

Be generous with your search terms, and try several variations. For ‘thin lining’ I might pair the correlation I’m looking for (eg ‘uterine fibroids’) with other variations like: ‘uterine lining’, ‘endometrium thickness’, ‘thin endometrium’, ‘thin uterine lining’, ‘uterine lining growth’. 

You’ll get lots back, often animal studies too. It takes some practice to find what’s relevant and what’s not, and this is where the effort is required – wading through all the research to find what you need. Where possible, filter by human studies.

If there is a correlation, you’ll often find half a dozen studies on the link. Go slow, and make sure to google the medical terms until you understand what each sentence implies. You want to make sure there is a correlation between your subject matter (thin endometrium lining, say) and the cause/fix (eg ‘uterine fibroids’). The study should be explicit in it’s results. 

If it’s not, I wouldn’t take it as a correlation, and I’d strike it from your list. Take your time, this is where you separate the truth of what helps and what is just hearsay. 

For every item in your list, you want to find two or three studies that support it. The studies ideally should be double blind, with a large sample across several different populations. They’re not always going to be like that.  

For each point on your list, see if you can find find studies that support and studies that don’t. You’ll get an idea whether the point on your list can be crossed off as unreliable internet myth or if it has some scientific truth and can be taken to the next point. 

4. Talk to your doctor. 

I think this is the most important. For every study I read, for everything I wanted to try, for every forum thread that sounded interesting, I took a list of questions to my doctor to discuss. I wanted to make sure that anything I tried wasn’t going to cause harm. I wanted to make sure my Doctor  was aware of the possibilities (and she always was, which I found comforting) and I wanted make sure that we were trying everything we possibly could.

We changed up my plan a few times because of my research and lists of questions. It made me feel like I was part of the planning process. It was incredibly helpful to talk it out with someone who was in the fertility profession, who equally wanted the best for me.

So. That’s how I research IVF, and how I come up with almost every research based post there is here. 

What are you favourite IVF research tips? How do you guys make your IVF decisions??

THE 3 Books YOU SHOULD BE READing IF you’re DOING IVF

By Research One Comment

There’s a huge learning curve with IVF. I remember being at the very beginning of my journey and completely overwhelmed with all of the information. There were acronyms I didn’t get, I wasn’t sure what the best route for me was, what kind of things I should be doing or not doing… it was tough.

I’m not the kind of person who does well with not-knowing, or not feeling like I have a firm grasp of a situation. As there are so many factors in IVF you can’t control, so I was very keen to educate myself and get a handle on what I *could* control. My kindle was filled with books about IVF. Some were better than others, I have to say. 

Here’s my top three.

1. It Starts with the Egg. Rebecca Fett

During my first round when I was at my most determined to ‘beat’ infertility, this book was hands down the most helpful in terms of “what can I do right now?” help. All the advice is based on academic research (and studies are shared in the index).

It gives clear and easy to follow actions of things which will make a difference – the positive AND the negative of all sorts – supplements, lifestyle (think: cleaning and beauty products), diet. It also debunks a few myths (example – turns out there is no evidence to suggest that royal jelly improves egg quality or has a higher incidence of pregnancy).

Overall, pretty interesting and well worth a read for anyone TTC, whether you’re starting out or you’re three IVF rounds in.

(Available on amazon.com or amazon.co.uk). 

2. Get A Life: His and Hers Survival Guide to IVF. Rosie Bray and Richard Mackney

This is such a great book – it’s essentially an IVF 101 guide, with what to expect at each stage of IVF and how best to handle it. It’s written by a wife & husband duo who share their unique perspectives on their three rounds of IVF. For each chapter there is a guys and a girl perspective which helps get your head around how different the experience is for each person. This was super helpful for me with my guy – it took me a long time to understand we were processing at different rates. So when Zee  didn’t want to talk about IVF, or would watch TV instead of fill out his forms – it wasn’t that he uninterested in IVF. He hadn’t processed yet. When I realised, I felt like a light bulb had gone off in my head.

They did a great job of highlighting the ups and downs of IVF. It was quite anecdotal but was very readable. There was just as many giggles as tears and you really felt for them. Their initial IVF experiences weren’t too far from mine and it was comforting to know I wasn’t alone. It also has a handy guide of things to ask at your first appointment. 

Well worth a read – especially if you haven’t yet been through a round of IVF and would like to know what to expect. 

(Available on amazon.com or amazon.co.uk).

3. IVF: An Emotional Companion. Brigid Moss

Oh this book. It’s the best example of how not alone we are. There are so many paths that lead to parenthood and this book covers the personal stories of large chunk of them – adoption, IVF, male factor infertility, single mums by choice, gay IVF/adoption, older couples, OHSS, diminished ovarian reserve, giving up on IVF, surrogacy… it shares the real life stories of people who have struggled their way through, and the decisions they’ve made.

It was pretty moving –  it was heartbreaking, uplifting and parts were even pretty gory. I realised how often I’ve read the side effects of IVF and dismissed it as if it couldn’t happen it me. When I read the stories of women who it DID happen to I was shocked at how callous I had been. There were plenty of highs, but a lot of lows too. A very honest look at infertility.

It’s a fantastic resource. Each section has a theme, an honest story and resources to find out more. 

(Available on amazon.com or amazon.co.uk)


Other mentions.

I read many and while I wouldn’t put these in the top three, they were helpful in providing perspective.

The Complete Guide To IVF: An inside view of fertility clinics and treatment. Kate Bain.

This book has a good overview of the IVF process and a brief look at the various causes . It was a great behind the scenes look at how clinic’s operate, and what happens outside of the rooms we typically get to see in. I also really enjoyed the technical breakdown of the processes (like ICSI) but wished it could have taken it a step or two further. I wouldn’t call it a complete guide, as it discounts lifestyle choices (like diet) as irrelevant and not helpful. It didn’t provide the tips or the details/studies I was looking for. Side note, it was published in 2010, so parts of it (like freezing) are a little out of date.

(Available on amazon.com and amazon.co.uk)

The Baby Making Bible. Emma Cannon.

This was a pretty interesting read. Essentially it talks through Eastern Medicine (think: Chinese herbs and philosophy with acupuncture, diet and visualisations) with Western Medicine. While it does have a few nods towards research studies, a lot of the supporting evidence was anecdotal. I enjoyed the ‘look after yourself’ message, as often when trying to conceive there is pressure on the ‘conception’ segment but very little thought given to the rest of your cycle. The idea is that you remove that pressure to conceive and spend some time building up your body. I’m not sure I understood the Chinese type casting and found it quite difficult to take in. I also got the impression that this book is essentially an ad for her clinic.

(Available on amazon.com and amazon.co.uk)

The Fertile Female. Julia Indichova

I… struggled with this book. I’m very scientifically driven and like data and research and studies. The Fertile Female is not like that – it’s very spiritual. If IVF is about taking care of the medical side of things, this book provides insight into how to take care of your emotional/spiritual side. I found it difficult when I first approached IVF, because I wanted to know what I could do physically to improve my chances. It wasn’t until much later (Round #3) that I cycled back to this book and gave it some proper thought. It encourages you to trust your body and advocate what is best for you. Our doctors often take a very medical approach and it’s up to us to take care of our lifestyle approach.

The most telling for me is that I read this study about how visualising an exercise can make a significant difference. With that in mind, spending the time to visualise what was happening with my body seemed like a good use of time. 

(Available on amazon.com and amazon.co.uk)

The Essential Fertility Guide. Professor Robert Winston.

This is a good beginners book, if you’re new to the world of infertility. He does a great breakdown of what to expect and what to ask, over several different types of infertility. I think the best bit is that Professor Robert Winston suggests you really understand what is happening with your body before you jump to IVF. He mentions the great costs (and thus potential profits) associated with IVF now that it’s so commercialised and provides the information so you can advocate for yourself. 

(Available on amazon.com and amazon.co.uk)

How to Improve Egg Quality: The Smart Way to Get Pregnant. Darja Wagna. 

I really wanted to like this book. I did. It seemed great at first – clear and concise actions you can take to improve egg quality. However there wasn’t enough scientific evidence to back up what she was sharing and I found that parts of what she was suggesting didn’t go into enough detail. An example would be call to take the supplement CoQ10. Yes, you absolutely should take it, but the book didn’t mention that you should be taking the form ubiquinol (and NOT ubiquinone, which is the cheaper and more widely available).  I found it difficult to trust what was being advised.  

(Available on amazon.com and amazon.co.uk)

The Four Hour Body. Tim Ferris. 

This book has nothing specifically to do with fertility. It’s more about about understanding the relationship you body has with food in a weight loss context. Bonus, the low carb diet is pretty IVF friendly, too – because there are some pretty strong correlations between BMI and fertility. I thought it might be relevant. I lost 15kg with the four hour body method, and found it relatively easy to stick to. Essentially, you cut out carbs, dairy and sugar (easier than it sounds, promise!) for 6 days out of 7. .

(Available here on amazon.com and amazon.co.uk)


Sharing is Caring

By Personal No Comments

I was asked to talk at my clinics open day. I wasn’t sure, exactly what would be helpful. It seems so long ago that I was at that point – not really sure what the next steps were. Still, I had lots to say, so I went. Talked.  It went well, a few couples came up after to pick my brain and ask questions. It was good.


Hi, I’m Sae. I’m a patient here, and have been for the last year or so. Last October I was diagnosed with diminished ovarian reserve. My AMH, which is my Anti-Mullerian hormone was low. It means that I have less eggs in my reserve than I should at my age. My FSH, my follicle stimulating hormone was high – meaning of what eggs I did have weren’t of great quality. Essentially, I’d just turned 30 and I was already at the end of my fertility season. 

I won’t lie, it was pretty hard hearing that. I felt all sorts of things. I felt like my body had betrayed me, like my right to be a mother was threatened. I felt guilty – I may not ever be able to give my partner the family he wants. I felt broken. Infertility is hard.

I’m not sure where you are in your journey. I found out about mine with a blood test with my GP. When I found out my results, I essentially called her a liar and started looking for a second opinion. 

I’m a UX designer by trade – which means that it’s my job to design applications that meet the user need as well as the business needs, and I do that with data and research. Essentially, I used those skills to find myself the best clinic in London. I did three things.

1. Scoured the Internet for data. Most clinics post their success rates, and I was able to verify rates with what HFEA – the fertility authority in the UK posted. I looked at everything in detail, how many transfers they’d done, for what age bracket, for what kind of infertility. I found my top three – here, lister and ARGC.

2. I then looked for reviews independent of the clinics. This felt a little less scientific. I visited a million forums, reached out on Instagram and looked in half a dozen Facebook groups. You can be sure that all the horror stories you’ve ever heard are on the internet somewhere, right along with the clinic and the name of the doctor.

3. Lastly, I went and I sat in the waiting rooms of my top three, usually in my lunch hour on a Friday, which ironically was when almost all of the clinics were under pressure. This was the most revealing for me, I knew I’d be spending hours in whichever waiting room I chose. And in person, you can see how the clinic supports it staff. If the front of house and the nurses are frazzled, surely that trickles down to behind the scenes. Did they greet patients by name? Were they polite, friends with their patients? Could you hear private information that perhaps you shouldn’t be able to hear? Some waiting rooms were better than others.

Needless to say I ended up here. As you can see this particular waiting room is quite nice. And the front of house staff is pretty amazing. 

I don’t know what your story is, or why you’re checking out clinics, so it’s a bit hard to know what to tell you. In the last year I’ve been through four rounds of IVF, and I’m hopeful. My hope takes the form of 6 frozen embryos waiting in a freezer downstairs. I’m so hopeful.

In the meantime, I thought it would helpful to share five things I wish I’d known this time last year. 

1. Do your research.
Get your numbers and test results, and then read everything you can. Books, research papers. Do more than Google, or hang out in forums, there is so much more than that out there. You’ll get more out of your rounds if you do. First, I’d suggest you read It Starts With the Egg, by Rebecca Fett. Also, check out NCBI PubMed – It’s a place where all the research and studies are consolidated with an excerpt. It’s an easy way to discover research studies. 

As each round is super expensive – you want to do everything you possibly can to make it successful. From your diet, to what chemicals you’re exposing yourself to in paper receipts or perfume. There’s a lot out there that affects fertility, it’s important to educate yourself on more than just the medical processes, but your lifestyle choices too. 

2. Ask questions.
This follows on from the research. I’m not a doctor, or a scientist. For everything I learnt I’d come back to my doctor with a list of questions to ask. Sometimes Nurse Izzy would roll her eyes at me and ask why I didn’t email them ahead of time, but I found It was helpful to talk things out and I was lucky that my doctor always made time for me. You also learn from each round you do, about how your body reacts to the drugs and what you can expect, so asking questions helps dig up other things to try. My first round looked nothing like my fourth round.

3. Find support.
This was the hardest for me, because I didn’t know anyone going through it. My friends told me to relax, or just adopt, or did I ever consider not being a Mum and that was hard. I felt well and truly alone until I looked up #ivf on Instagram. There are blogs, forums and a ridiculous number of people going through what you are. I found it infinitely more helpful to message someone who truly understood. It got me through. 

4. Make friends with nursing stuff and receptionists. 
It won’t get you special treatment, but it will make your time here easier. Truth is, they’re all caught up in our journeys just as much as we are, and you’ll find it much easier if you feel like you’re among friends.

It’s not hard to start conversation either, Nurse R is from NZ and almost always brings up the rugby. Nurse I is a massive frozen fan, and Nurse M is the nicest conversationalist. The front of house staff are equally lovely – J has a great fashion sense, and S and K are the nicest. Even behind the scenes – the anaesthetist T will let you change the location of the drip, and the embryologist will show you the embryoscope where your embyos will be incubated. It makes a different.

5. Be gracious.
Infertility is hard, and it hurts. Sometimes the clinic is busy, and you’ll wait longer than you expected. Sidenote: don’t try fit appointments into your lunch break – you’ll always be late. Often the reason is because something has happened to another patient and the staff are dealing with it. At the time it’s frustrating, but then it happened to me. In my very first round, after about a week and a half of stims I ovulated when I shouldn’t have. No one could have known and instead of shunting me out at the end of my appointment I was looked after. I was so grateful for their compassion. So when I’ve had to wait longer than expected I’ve tried to be gracious. 

So, just a quick recap. Do your research, Ask Questions, Find Support, Make friends with the staff and be gracious. 

That’s me done, if you have any questions feel free to come chat.  My name is Sae, you can find me at hopeandhopscotch.com – thanks for listening. 

GM-CSF Media Improves Embryo Development

By Research No Comments

We’re on round four, so when I sat down with my RE to plan out this last and hopefully final round of IVF I wasn’t expecting anything new. I asked anyway: was there anything we could do to improve the quality of our blastocysts that we weren’t already doing?

I was pretty shocked when she came back with GM-CSF Media. How had I not heard about it before? (That’s always my response – if it helps, why didn’t we do it in the first round?)  Still, I checked it out and was easily convinced – it should help our embryos make it to blastocyst stage. We’re definitely incorporating it this next round.

I couldn’t find a lot of information online that was easily digestible, so I wrote up my notes in the hope it helps someone else.

What is GM-CSF Media?

GM-CSF stands for Granulocyte Macrophage Colony-stimulating factor. Check out that mouthful. As I understand it (and remember, I’m not a doctor or a scientist in anyway shape or form) the GM part – granulocyte macrophage – is a protein that contains a type of white blood cell that protects your body by eating any foreign cells. The last bit, colony-stimulating factor is because this protein is important in cell signalling – it’s released by cells and affects the behaviour of other cells. I think, anyway. The literature is all written in extreme scientist. 

Typically it’s secreted into the fallopian tubes and the uterus a few days after ovulation – when fertilisation is due to take place. The level of GM-CSF will fluctuate throughout your cycle, but is typically at it’s highest in the mid-luteal phase (a few days after ovulation).

GM-CSF  is key in early pregnancy, particularly in embryo development and implantation. It’s thought that GM-CSF inhibits the stress response of the embryo cells, stopping cells from dying due to stress (Source). This helps embryo growth and survival as it cleaves, all ready for implantation.

Why use it with IVF?

Typically, an embryo is naturally exposed to a large number of hormones, proteins and growth factors that are present in a woman’s reproductive system. We know that with IVF, a petri dish is not as good as a uterus. Part of that is because the nutrients in the body can’t always be replicated in vitro. Without the right nutrients there is an effect on the development (Source) and quality of embryos. The lack of these nutrients in the culture medium contribute to the high rates of implantation failure and miscarriage with IVF.

In some clinics, proteins like GM-CSF are considered just fine-tuning agents which can be omitted in the lab.  But, the research shows the lack of growth factors like GM-CSF in the culture embryos are incubated in is a major cause of environmental stress. We know that embryos are highly sensitive to their environment – any stress is bad. If the cells are severely stressed, it will alter the rate of cell division or kill the cell, causing the blastocyst to arrest. 

As GM-CSF prevents cell stress, by adding GM-CSF to the culture which the embryos are stored in, it’s thought that the embryos have a better chance of survival. 

What does the research say?

First things first – adding GM-CSF to the culture does no harm to the embryos. This multicentre, prospective placebo-controlled and double-blinded study (Source) found that embryos incubated in a solution of GM-CSF, they had the same chromosomal composition and similar number of top quality embryos and development on day three than embryos incubated in a solution without GM-CSF. That’s good to know – essentially, there was no increase in chromosomal abnormality in embryos cultured with GM-CSF.

Several studies have found that by adding GM-CSF to the culture, you’re likely to get a two fold increase in the number of embryos that develop into blastomeres (Source).  Embryos cultured in the with GM-CSF reached blastocyst stage on average 14 hours quicker and contained approximately 35% more cells (Source).  

In one study (Source), they took a sample of cells from the uterus lining and added it to the culture with the embryos. The tissue secreted GM-CSF and this was measured post transfer. They found the more GM-CSF that was secreted the more likely a successful pregnancy was after embryo transfer.

This large scale study (1332 patients across 14 fertility clinics in Sweden and Denmark – Source) found that there was a significant increase in the number of embryos that implanted and survived to week 12 (23% for GM-CSF vs 18.7% for control).  It also found that of a subgroup of 327 women who had previously miscarried, the women who had GM-CSF media had a much higher ongoing implantation rate (24.5% for GM-CSF and 17.0% for control). 

In a nutshell?

Adding GM-CSF to the medium embryos are cultured in:

  • Doesn’t hurt your embryos in anyway.
  • Has been shown to protect embryos from cell stress.
  • The research suggests it helps embryo development and implantation.
  • May improve the chances of implantation in women who have miscarried in the past. 

Overall, adding GM-CSF to the medium embryos are cultured in may help establish a successful pregnancy and increase the chances of a healthy infant.

Sources:

  1. Granulocyte-macrophage colony-stimulating factor (GM-CSF) acts independently of the beta common subunit of the GM-CSF receptor to prevent inner cell mass apoptosis in human embryos. (link)
  2. Granulocyte-macrophage colony-stimulating factor promotes human blastocyst development in vitro. (link)
  3. Culture of human oocytes with granulocyte-macrophage colony-stimulating factor has no effect on embryonic chromosomal constitution. (link)
  4. Granulocyte macrophage-colony stimulating factor production by autologous endometrial co-culture is associated with outcome for in vitro fertilisation patients with a history of multiple implantation failures. (link)
  5. A randomized clinical trial to evaluate the effect of granulocyte-macrophage colony-stimulating factor (GM-CSF) in embryo culture medium for in vitro fertilization. (link)

 

OHSS + Watching our Embryos Grow/Die

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A few days after my retrieval I expected to be up and about. The previous two retrievals I recovered quick smart and figured it would be the same again. Oh, infertility. I should have realised that any expectations are there to be dashed.

I got mild OHSS (Ovarian hyperstimulation syndrome) and let me tell you – that shit is not fun. Urgh. At the clinic I rushed through the boxes I know I needed to tick to get home: drink something, eat something and pee. No problem.

After I’d got home and slept off the meds it was a different story – I was in so much pain. Even more when I tried to go to the bathroom. I read somewhere once the muscles you use to stop peeing are the same muscles you use to push a baby out of your body. Turns out those particular muscles hurt like a mo-fo if you have OHSS. So much so that I fainted. On the toilet. I woke up with a massive bump on my shoulder where I’d hit the tub and a bigger lump on my head where I’d hit the wall. I felt indignant when I came to – as if I hadn’t had a bad enough time with infertility, now I had to pass out from pain on the toilet too? Siiigh.

It took me a while to figure out it was OHSS and not just my body being slow to recover. There were a few key ah-ha symptoms:

– Weird bloating and tenderness. I looked like I was pregnant. Really pregnant.
– I couldn’t breathe deep. It felt weird to take a big breath.
– I couldn’t lie on my side comfortably – I’d almost always roll onto my back.

I did some reading (expect a proper research laden post coming soon) but realised that as we weren’t transferring I’m not at risk of it getting worse. As soon as my body realised I’d ovulated, wasn’t pregnant and my levels of hCG went down it’ll reverse itself and I’d cover.

Which meant that the biggest part of the week was me hanging out in bed, waiting for the daily calls about our embryos.

Of six retrieved, five were mature. Of the five that were mature, four fertilised. 

They cleaved into four cells. And then eight cells. One went off early and became ten cells. We got daily calls, we got pictures. There was that feeling of relief and then I’d get all worked up thinking about the next call. There is just so much hope – so very much hope. 

On Day 5, when we were hoping for 4 beautiful blastocysts – we had 4 compacted morulas. 

Oh. We know that embryos that don’t grow to plan aren’t always viable, but to have none of embryos make it to blastocyst level is terrifying. The embryologists are as keen as we are for them to grow and gave us another day.

We had one blastocyst (one beautiful, hatching, blastocyst). They said they’d give the other three another day – just in case. Sadly none of them survived.

It’s pretty heartbreaking to go through the IVF process. All the drugs, stims, retrieval and OHSS and then spend the week watching all your hard work drop off one little miracle at a time. 

I feel guilty. Like I could have done more. I could have taken the weeks pre-IVF off. I could have stuck to the diet, rather than relaxing it. I could have been more diligent with the morning supplements, and excercised and avoided BPA laden bottled water. Watching my little embyos stop evolving, I feel guilty. 

Because it’s my fault – all development at this point is powered by mitochondria found in the egg – the egg quality is all on me. So when they stop developing… that’s on me. 

One blastocyst. Oh. I know we only need one, but heartbroken doesn’t even cover it. Diminished ovarian reserve – it’s horrid. I’m still hopeful, though. That this little guy will be chromosonally normal and it’ll all work out. I’m so, so hopeful.