28 weeks

I used to get so annoyed when IF bloggers would get pregnant and then drop off the face of the planet. And here I am doing the same thing. The truth is, this whole "normal pregnancy" thing is almost a little boring even to me, so I'm having a hard time finding anything interesting to say about it.

But to bring you all up to speed...at the end of March I had another ultrasound to double check the baby's spine (they couldn't get a good view of it at the anatomy scan), and all looked good. Growth was on track and the tech double checked the sex for me (definitely a boy). Bonus cootercam u/s to check cervical length, which was something like 4.9 cm, so still looking great. I got a mild warning about weight gain (I had gained 6 lbs instead of the recommended 4 in 4 weeks) but everything looked good.

With the confirmation that this baby is, indeed, a boy (and I have the picture to prove it), I've been sorting through and giving away all of Bat Girl's girly clothes from the last 5 years. It's been hard--I now understand why my mom still has some of my Florence Eisemann dresses from the '70s tucked away in the attic. Even a little flimsy cheap Old Navy outfit brings back memories of BG wearing it, and I have to admit that I still cling to a vision of that second little girl that I thought I would have. Honestly, if I could guarantee another girl I would almost go for a third child--but I can say that another kid is 99% not going to happen for us, especially given our ages and financial situation AND the fact that I never want to go through fertility treatment again.

Anyway, luckily we have several little girls in our lives ranging in age from 6 weeks to 4 years old, so I know all the hand-me-downs are going to people who appreciate them. And we're getting boatloads of boy hand-me-downs in return, sweet little onesies with sailboats and dinosaurs on them and striped rompers that almost make up for the lack of little flowered dresses.

A week and a half ago (27 weeks) I had my 1-hour glucose test, which I passed, but it was discovered that I'm mildly anemic, so I'm taking iron supplements and eating hamburgers. That was also my first-ever OB appointment with NO ultrasound whatsoever--so bizarre! Never fear, next week I'm getting another scan to check growth (with the unicornuate uterus, we need to make sure there's no IUGR or other growth issues) and one more cervical measurement.

I'm firmly convinced that Baby Brother (as we've been calling him; turns out we are having a lot of trouble coming up with a boy's name) is and has consistently been breech, based on the movement I've been feeling. But my OB says it's still too early to tell, and she won't make the official call as to whether a repeat c-section is required until 33 or 34 weeks.

I'm torn about whether or not I actually want to attempt a VBAC, if that ends up being an option. The planner in me likes the idea of just having it all scheduled. And although the recovery from a vaginal birth is probably a lot easier, a c-section is a known quantity for me at this point. I'm not particularly wedded to the idea of having a "natural" birth experience--I made my peace with that long ago and I don't feel like I've missed out on something magical and important by not having had a vaginal birth.

And I don't want to try a VBAC and then end up with a c-section anyway, which is of course a significant possibility. If I'm really truly honest, deep down, I also don't want to fail at this. I've had enough breeding-related failures already. I feel vaguely guilty about not wanting a VBAC, or being chicken, or whatever this is. But I bet I'll get over it.

Reckless

I'm sure you will all be as pleased as I was to know that yesterday, CD8, my ovaries were back in their respective corners, keeping a chaste distance from each other as nature intended. I was directed to take 37.5 IU last night and come back in this morning.

This morning, CD9, I had two 20mm follicles on the right, one 19 or 20mm on the left, and whole mess of 15s and 16s lurking around on both sides. OK, well, sure. This is someplace we've been before.

The very nice female doctor who did my ultrasound this morning spent some time talking to me about it. I expressed some nervousness, then said something about lead follicles and she said quite frankly, "Well, they all ovulate into the fluid and then there's no way to control which ones and how many the fallopian tube picks up." Which is, I have to say, the first truly concise, hand-to-forehead, "ohhhhh now I get it" explanation of the total randomness of IUI (and hell, TTC in general) that I've ever heard. I mean, I guess if I had really thought about it, I would have realized that this is what happens. But there was a part of me that sort of visualized all available eggs pinging one-by-one down the tube like pinballs heading down the chute, biggest ones first, despite all experience and reason to the contrary.

The doctor told me that if I'd had a left tube, she would say that I had a very high chance of multiples. "With only one tube, though, it's really impossible to say. But you have to remember, this is not IVF. Your chances of getting pregnant at all are still only around 20 percent." Which echoes something Dr. SF said to me on my very first (successful) cycle, that the chances of not getting pregnant at all are still a lot greater than the chances of conceiving multiples

At any rate, assuming we were willing to go ahead, she said we'd trigger tonight, IUI Sunday morning. So I went ahead and asked the nurse to call in the Ovidrel script, and scheduled the IUI for Sunday. I can say with certainty that five years ago I would have pulled the plug on the cycle. But time and age and repeated failure can make you a little reckless.

When the nurse called with instructions for tonight, I asked her for my E2 level, and that did give me pause. Last cycle my E2 was 1128 on trigger day. Today it was--well, I left the Post-It I wrote it on at work, but it was just over 2000. If you take the E2 level as a general indicator of how many mature follicles there are, that's...a bit concerning. But I'm putting my head down and going ahead (and dragging my husband along with me). Like I said, a little reckless.

I've gotta say, the further in I get, the less I'm able to judge those families who end up with sextuplets. I can see a lot more clearly how it happens--and how once it does, it's hard to turn back. Because while we would definitely reduce higher-order multiples, I have to say that if I got pregnant with twins, there's a good chance I would continue the pregnancy. Even though twins in me is equivalent to at least triplets if not quadruplets in a normal uterus. And knowing this, I'm still willing to go ahead.

I'm just rambling at this point. I'm going to go do my trigger shot now. Hope this is the last time I ever have to inject myself with anything.

Eek [UPDATED]

"How do you feel?" asked the doctor on monitoring duty this morning (CD 12).

"Like I'm about to ovulate!" I chirped.

As the dildocam slid home, the doctor said, "Well, you've got a lot of eggs here, so I can definitely see that you'd feel bloated." (Bloated, yes, but there have also been more...um...personal symptoms suggesting imminent ovulation. Fellow veterans of the TTC wars, I trust you know what I mean.)

I watched, squinting at the screen as he clicked and measured...18...15...15...right...left...then it was over and I wasn't sure what had happened, but I had a pretty strong suspicion that there was a LOT going on. I'm used to seeing perhaps two large follicles on an ovary, and there were definitely more than two.

He told me that most likely I would trigger tonight for a Sunday IUI, bloodwork pending. Nurse called a few hours later to confirm that yes, I should take Ovidrel tonight and schedule my Sunday morning IUI. I asked her what my follicle count and E2 were. She told me:

Right side (where I have a tube): 5 @ 15 mm, 3 @ 17 mm, 1 @ 19 mm (and a bunch of littler ones)
Left side (no tube so not so much of a factor): 2 @ 17 mm, 1 @ 19 mm (and a bunch of littler ones)
E2: 1128

Yikes. Even if we assume the left ovary is not really in play (which isn't totally guaranteed), that is DEFINITELY more follicles than I have ever triggered with in the past. (Cycle I got pregnant I had one lead follicle and two close behind; last year I had three cycles and never had more than two over 16 mm a day before trigger.) Granted, I never had this level of detail about the follicle counts before, and I usually had my final ultrasound the day before trigger, not day of, so it's likely that I had some 15 mm guys hanging out at trigger in the past too.

But still. 1 19mm and 3 17mm follicles seems like a lot for someone who really, really does not want to have multiples. And we all know those 15mm follicles could decide to join the party at any minute.

Here's the thing: My doctor isn't actually in the office today. So the call to go ahead was made by one of his partners, who doesn't know me and my history. The nurse said she would email Dr. SF and he would call me back this afternoon so I could talk it over with him. If I was 32 and on my first cycle, I would almost certainly pull the plug and cancel the IUI. Too scary. But I'm 37, which while not ancient is old in fertility terms, and I had 3 unsuccessful IUIs last year with average 2 mature follicles on the right side each. And I once again reread this, which, while 10 years old, had this to say (emphasis mine):

For patients age 35 and older, pregnancy rates in HMG and clomiphene + HMG cycles were doubled when six or more follicles were > or = 12mm without a significant increase in twin or higher order implantations.

and

Conclusions:
Withholding HCG or IUI in clomiphene, HMG, and clomiphene + HMG cycles when six or more follicles are 12 mm or more in diameter may reduce triplet and higher-order implantations by 67% without significantly reducing pregnancy rates for patients under 35 years of age.

For patients age 35 and older, withholding HCG under the same circumstances may decrease pregnancy rates by half without significantly reducing multiple implantations.

Clearly more follicles does improve the chance of pregnancy; considering that I'm 37, and thus far have not been successful with fewer follicles, do we go for it and consider that the risk of multiples is probably less than for someone 10 years younger with the exact same numbers?

On one hand: I'm tired. I hate this shit, the needles and the slog. I don't want to do IVF, and I barely want to do another IUI. I want to just go for it and take home a baby.

On the other hand: THIS IS HOW PEOPLE END UP WITH SEXTUPLETS.

Nurse promised that Dr. SF would call me back later this afternoon. I will of course update then.

UPDATE: Dr. SF called right as I hit "publish" on this post. He talked me down. While of course, he said, we cannot avoid the risk of multiples with IUI, this cycle is actually pretty equivalent to the cycle I got pregnant on, maybe actually safer from an avoiding-multiples standpoitn. Apparently that cycle I had 3 follicles hovering around 17 mm the day before trigger with an E2 of 1074, so I most likely had a much higher E2 the day of trigger, and probably a bunch of 15mm follicles too. He thinks that we're not going to get a cycle much better than this, and recommended going forward.

So we're going forward. And you can all laugh at me when I end up pregnant with sextuplets.

All clear

Quick update: Had the HSG this morning. Tube is clear. So we're basically in the same place--no reason IUI shouldn't work, if and when we get the desire and/or money and/or insurance to try again.

The procedure itself was a little...pinchier than I remembered from when I had it in 2006. But it was a lot faster, because I had given the radiologist a heads-up about my unicornuate uterus ahead of time (and since it was the same facility where I had my previous HSG as well as the MRI confirming the UU diagnosis, he was able to call up the records), so he didn't have to waste time trying to get dye to flow through a tube that isn't there. I also haven't had really any cramping, again I think because I didn't have all that extra fluid pumped into my abdomen.

Also, my uterus looks exactly like a tiny banana. That is all.

Awake

I should really be sleeping right now. We have a preschool tour in the morning (gulp) and I should be getting some rest and I'm exhausted from getting up before dawn for u/s and bloodwork. But lately I've been having a lot of trouble falling asleep--last night I went to bed at 11:30 and lay in bed awake for an hour and a half. And trust me, for the last 2.5 years I have had NO trouble falling asleep whatsoever, so this is really unusual for me.

Oh yeah, about that u/s and bloodwork--I got my period yesterday. I guess I wasn't really surprised, since the chances of me getting pregnant this cycle were pretty small. But I won't lie, I was still having these fantasies that somehow it would work, and wouldn't we all be so surprised! Whee! But no. I guess this explains why I was UNBELIEVABLY CRANKY on Monday.

I went in for monitoring today, CD2, because I didn't think I'd be able to make it all the way down to the clinic and back before the aforementioned preschool tour tomorrow. So I'm back on 75 IU Gonal-F starting tomorrow, in for bloods and u/s Monday. Dr. SF specifically wanted me to start stimming tomorrow instead of today, so that my first check-in would be on Monday (when he's in the office) instead of Sunday, because he didn't want one of the other docs to drop my dosage without checking with him, since, as he said, "Your ovaries tend to shut down when we drop your dosage." I will say, my clinic is definitely a huge machine (you should see the number of women in the waiting room during monitoring hours), but it's little things like that that always make me feel like I'm well taken care of.

We'll be able to do one more cycle now, and then since we'll be traveling the week of Thanksgiving and the week before, we'll have to take a break. If this one doesn't work, I will probably request an HSG during my off-cycle, just to make sure that my tube is still clear. (I had an HSG in 2005, which is of course how my UU was initially diagnosed, but it's been four years and I assume it's possible things could have gotten gummed up a bit, what with getting pregnant and having a c-section and just generally getting older.) I actually asked the nurse about doing it this cycle (forgot to ask Dr. SF when I saw him) and she said they prefer to do it during an off-cycle anyway.

After Thanksgiving, if I can time it just right with Provera, we might be able to squeeze in one more try before we go away for Christmas. Then we lose our IF coverage and I don't know what we'll do next. I'll have enough time to stock up on meds while I still have the insurance, so a good chunk of the cost of a cycle would be taken care of. But obviously I'd much rather I just got pregnant now. Hear that, universe?

Meanwhile--preschool! Ack! This is one of two schools we're looking at for BG for next year. It'll amount to a little over $10K for full days, 5 days a week ("full day" for 3-year-olds meaning 9 am-3:30 pm). That's pretty affordable for Big City--typical preschool tuition is more like $13-15K for half days. Not sure where we're going to come up with this money, but we'll worry about getting in first. As soon as the preschool applications are done, of course, I have to start the apparently multi-year process of negotiating the city bureaucracy to get her into a decent public kindergarten--which we're going to have to do, because private school tuition past preschool ain't gonna happen. Or we could move to the suburbs...and pay the $14K/year in property taxes instead of private school tuition. Remind me again why I live here?

Hm, I guess it's not so surprising that I can't sleep, after all.

Back in the bitter

So, the facts first: My husband and I had a long talk Wednesday night, and we decided to go straight to IVF. I played phone tag with Dr. SF all day yesterday, and finally connected with his nurse, who is going to put me in touch with the IVF coordinator. I'm also supposed to schedule a consult with Dr. SF so we can discuss the IVF plan in more detail. I have a call in to the finance department to try to figure out exactly what my insurance will cover. (I have $10,000 in IVF coverage, not including meds which for some reason are covered for injectible IUI but not IVF. Not clear how many cycles--or what percentage of one cycle, given how pricey IVF is here--that would cover.)

Emotionally--bleah. The whole detached, not bitter, not caring too much thing I had going on? Quickly disappearing. See, given the fact that we want a second child but are not desperate to have one, if I were normally fertile we would just let nature take its course, and if I got pregnant, great, but we wouldn't feel this pressure to Do Something About It. Even if I were anovulatory but didn't have a fucked up uterus, we could feel comfortable risking another injectible IUI. But no--the only good option, given the necessity of avoiding multiples and our strong desire not to selectively reduce, is to do IVF. We could try another round or two of Clomid, but given my historically poor response to Clomid, we'd probably just be wasting time and money. And so even though just a week ago I was saying to myself that I didn't know how far I was willing to go to try to have a second child, the fact of the matter is that if we want another child, we pretty much have to plunge into an expensive, invasive, emotionally rocky course of treatment.

And yeah, I resent the hell out of that.

Alexa and JV mentioned letrozole, which to be perfectly honest I had completely forgotten about as an option (see how well the detached not-caring thing was going?). I'd had one follicle on the sole letrozole cycle I did four years ago, but that was at another clinic. I don't know what the latest is on letrozole--I remember I did that one cycle and then a study came out linking letrozole to birth defects and so my RE at the time decided better to be safe than sorry. But at any rate, I did ask the nurse and she said letrozole cycles are uncommon at my current clinic, but they have been done, so I will at least ask about that as an option when I have my consult.

In the meantime, here's a question for those of you who have done IVF: How much did your big box o'meds cost you, if you paid out of pocket? My insurance covers fertility meds for IUI but not for IVF, so I'm on the hook for that. The Follistim from my IUI only cost me $70 last time ($35 per vial, 1 vial of 600 IU and 1 vial of 300 IU), so I about had a heart attack just now when I went online to see how much it costs out of pocket.

All systems go

Day 3 bloodwork this morning. Phlebotomist missed the vein and had to go digging for it--ARGH! I don't want to take the bandaid off and see the bruised mess that must be underneath.

Anyway, just got the call from the nurse and everything looks good. FSH=7, which is great (though I had to look it up online to double check--time was I would have known off the top of my head). Start Clomid tonight, back next Saturday (day 12) for u/s and if we have the right number of follicles (1) in the right place (right side) they'll give me the trigger shot right then and there, and IUI next day.

I've been freaking out (A LOT) about this whole second child concept ever since we had the consult with Dr. SF. So much so that I was getting ready to say to my husband that maybe we should just call the whole thing off, that maybe I didn't want another child after all. Then I realized that what's really freaking me out are (a) thought of being pregnant and on bedrest and terrified again, (b) thought of having another newborn and attendant horrors again, and (c) financial worries. When I think about actually having two slightly-more-grown children--teenagers, school-age, even having one toddler and one school-age child--that actually sounds wonderful to me. (Those of you currently in hell because of one toddler and one school-age child, just smile and tell me I'm right.)

So I've been bucking myself up by trying to think of GOOD things about being pregnant and having a newborn (not many, but they do exist--I think) and also by addressing my fears logically. (a) I may not have any problems with a second pregnancy--perhaps my ute has stretched and won't give me grief again. (b) If I have another kid, I'll be more prepared for the psychological fallout of having a newborn, and will cut myself way more slack on the breastfeeding/pumping thing especially (i.e. will not make myself crazy over it). (c) No good solutions here, but people have 2 kids on a lot less money than what we have and survive. It will be fine.

Oh, btw, those of you who know me in real life (or at least on FB or Twitter)--I'm not "out" about trying for #2, so please don't make reference to this or to IF on FB or Twitter or anywhere else my non-blog-reading peeps might see. Not that you would, anyway, but just in case. Kthxbai!

Headbanging

I don't think I've ever mentioned this before, but Bat Girl has a flat head.

To be precise, she has mild positional plagiocephaly--the rear right quadrant of her skull is flattened and the rear left quadrant pushes out very slightly. We first noticed the flat spot when she was around three months old, but in retrospect it's likely she came out of the womb that way, given the cramped conditions and her breech positioning. (Her right ear was also smushed and folded almost double for the first few weeks of her life.) She has always favored turning her head to the right, so it's also possible that she had very mild torticollis, especially in light of her resistance to nursing on my right boob (i.e. turning her head to the left). If she did, it was very mild, as she has no problems with range of motion now.

At her four-month well baby visit, we pointed out the flat spot to the pediatrician. She was unconcerned and recommended that we do some repositioning (bolstering Bat Girl when she slept so she turned to the left, etc.), which we had already already doing, and we left it at that. However, by this point Bat Girl was already rolling over and mostly slept on her tummy or side. Everything I read about plagio said that mild cases usually resolved themselves once the child started rolling and crawling, so I wasn't worried and pretty much forgot about it. We made an effort to keep her off the flat spot when we remembered, but it wasn't an obsession or anything.

By the time Bat Girl was 9 months old, the plagio was definitely no better, and in fact I worried that it was getting worse. Was her head bulging out to the left? Were her ears still misaligned? (Earlier, her right ear was visibly set further forward on her head than the left.) I brought it up to the pediatrician again, who took another good look at Bat Girl and said, essentially, yes, she has a flat spot, but it's not that bad, she doesn't need a helmet, and once she grows some hair you won't even notice it.

But I kept obsessing about it, on and off. I'd go through periods where I thought, oh, it's not so bad, you can't even tell. Then I'd catch sight of the top of her head in a mirror and think, holy crap, and then spend two or three days googling pictures of pre-banded plagio babies' heads until I worked myself into a panic. But I thought it was probably too late to do anything about it, and to be honest, I really did not want Bat Girl to wear a helmet. I just didn't. So I stuck my head in the sand.

Over the last month or two, though, I've read about Statia's battle to get the Mini banded, and have emailed with her about her experience, and I started to think, why not just see a neurologist and get it checked out, just for peace of mind? So last week I prepared myself for battle and called the pediatrician. Who, of course, gave me no hassles at all about it and gave me the names of 4 pediatric neurologists. Only one of them accepts our insurance, so I called the office to make an appointment. Here is how it went:

Me: I'd like to make an appointment with Dr. Fancypants.
Bitchy Receptionist: What's the diagnosis?
Me: Plagiocephaly.
BR: And how old is the infant?
Me: Actually, she's a year old.
BR: Oh, Dr. Fancypants doesn't see plagio patients older than 10 months. Why are you just calling now?
Me: Our pediatrician felt it might get better on its own, but it hasn't really improved, so--
BR: Well, it's never going to improve. It's too late, her skull has hardened.

AARGH! Setting aside the fact that YOU, BITCHY RECEPTIONIST, ARE NOT A DOCTOR, AND IN FACT HAVE NO MEDICAL TRAINING WHATSOEVER, I have read of plenty of cases where children have been banded as late as 18 months and shown improvement--not as much as if they were banded before 9 months, true, but it's not totally unheard of. Also, WTF?!?!?!?!? Why not just tell me, "I'm sorry, Dr. Fancypants doesn't see plagio patients older than 10 months"? You could even add, "He feels that after 10 months is too late for treatment." There is no need for you, bitchy receptionist with no medical training, to editorialize and diagnose MY child over the phone. Ugh.

Unfortunately, my default reaction in cases such as these is to fall apart and start to cry, rather than opening up a can of whoop-ass as this woman so richly deserved. So instead of ripping BR a new one, I hung up and felt like the worst mother in the world. Why hadn't I pushed for a referral sooner? Was Bat Girl's head going to be fucked up for the rest of her life, and would she resent us forever for not fixing it?

I'm still debating whether to call around and see if one of the other neurologists our ped recommended will see Bat Girl. It will probably cost around $350 for the appointment (that's average for a non-insurance-covered office visit around here) and it seems likely that another doctor will tell us there isn't much they can do, given that BG has passed the optimal banding age. The money is definitely a factor--obviously if it would help BG, there's no amount of money I wouldn't spend, but if it's just to be told "Sorry," I don't know if it's worth it. The head shape looks bad from some angles, but other times it seems fine, and honestly I've been looking at it so much, I don't know what to think anymore. Her ears have definitely evened out, so maybe it's getting better.

My main concern is that it not cause other problems for her down the road, and it seems like long-term effects are usually in severe cases where there's facial asymmetry. BG doesn't have any facial asymmetry due to the plagio--back in September she was diagnosed with mild ptosis, but after the Bitchy Receptionist encounter I called the pediatric opthalmologist we saw back then (whom I LOVE, btw, if anyone needs a ped. opthalmologist in the Big City area) and he assured me that the ptosis was "100%" not caused by any head shape irregularities. (And I believe him, because I also have a slight asymmetry between my eyes, as does my dad.)

In the end, it comes down to the guilt, as always. Guilt for not noticing sooner, guilt for not being more aggressive with repositioning--we turned her so her head faced the other way when she was lying down, sure, but we could have also changed the way we held her during feedings, etc. etc. On the other hand...we did tons of tummy time, she spent no time in a car seat and very little in a bouncy seat or swing (was in-arms practically constantly her first three months of life), she rolled over and crawled early, so what else could we have done? Other than call a doctor and get her banded, of course.

At the very least, this is another fun thing we can blame on my stupid uterus. (Intrauterine crowding due to twinning, uterine anomalies, and/or breech positioning can lead to plagiocephaly. Too bad our pediatrician didn't know that, or didn't mention it when BG was two weeks old and I told her I had a UU and asked if there was anything we should watch out for in BG as a result--she said, "Nope, nothing!") And we like blaming things on my stupid uterus.

I don't know...forgive all the rambling. What would you do?