Category — Operation Heads Up

Natural Miscarriage
by Lisa Blogger

First of all, if you’re reading this for advice, I am very sorry that you’re going through this. I’ve had two natural miscarriages, one at 8 weeks with a blighted ovum and one at 9 weeks with an embryo measuring only 6 weeks. I am not an expert on this by any means, and I do realize that every experience is different, but hopefully this will be of some help.

Pregnancy losses that occur prior to 20 weeks are called a miscarriage. While some pregnancy losses necessitate the use of a D & C, other pregnancies end without medical intervention or assistance. This write up is for a natural miscarriage.

Why You May Have a Natural Miscarriage (rather than using medical intervention)

Some doctors will take a “wait and see” approach once there is an indication of a potentially failing pregnancy, particularly if it is a first pregnancy. Other doctors are inclined to suggest natural miscarriage rather than a D&C due to the potential for post-D&C complications (scarring, for example, or if you are not good with anesthesia). If there is a possibility that you are off on your ovulation calculations, many doctors will not suggest a D&C until a second ultrasound a week later confirms that the pregnancy is not just progressing slower than expected.

What You Can Expect

While both of my natural miscarriages were different, there were also similarities. Both times, spotting was my indication that something was wrong, followed in both cases by an ultrasound that confirmed we were likely going to lose the pregnancy. After the ultrasound, things moved rather quickly the first time (I miscarried that evening), but more slowly the second (it took three days to complete).

In most cases, bleeding will begin to increase first. Cramps will begin, often mild but will intensify as the miscarriage progresses. My first miscarriage felt almost like what I’ve heard labor pains feel like, in that there was a rhythmic pattern to them and they were very intense at the end. When I was in the midst of one, it helped immensely to have a microwavable heating pad wrapped around my lower abdomen, and it was almost necessary that I was up and walking — sitting still seemed to make the cramps worse. Also — and this may sound odd — but I somehow knew when I was going to pass a clot or tissue, because I had the urge to go sit on the toilet. As a result I did not bleed as much on a pad as some people might.

The cramps will be the worst while you are passing tissue or large clots. After this occurs, the cramping will subside and the bleeding will begin to taper off, although this may still take a day or so. Your doctor will likely want to schedule a series of betas to make sure that your levels are dropping to zero (some doctors will only test to <5). Problems That May Arise and Ways to Troubleshoot

If you are bleeding so much that you are soaking a pad in an hour or less, you should go to the emergency room, as this could indicate hemorraging or other problems. Have someone drive you — rapid blood loss could cause you to faint or pass out. It is possible that you will still need to have a D&C if there is retained tissue; a sign of this may be that you are still bleeding heavily after most of the tissue has passed. Your doctor will most likely want to do an ultrasound or at least a repeat beta to see whether your levels are not dropping off.

Personal Tips

If you have seen your doctor for an ultrasound or other diagnosis prior to the miscarriage, try to remember to ask your doctor what their recommendations are and for a script for pain medicine if you think you’ll need it. I know that it’s an emotional time, but try to make sure you are looking out for your body as well. I was distraught the day of our ultrasound and was given no advice on what would be considered an emergency, when to call the doctor, or whether it was safe to take Advil or something stronger. Luckily I had online friends and resources that could tell me some of the things I describe here. When I was still reading loss message boards, I’ve seen many people ask whether they should try to get a tissue sample to their doctor for chromosomal testing. There are a few problems with that with a natural miscarriage, mainly that by the time you would be able to get the sample to your doctor it would likely be unusable, not to mention collection/storage and the emotional aspect of doing this.

I was extremely calm during my miscarriages, but extremely emotional afterwards. Be sure that you take some time for yourself if at all possible and just allow yourself to feel whatever you feel. It will help with the grieving process if you do not try to resume “normal” life immediately.

Diagnosis: Infertility Caused By Endometriosis
by Royalyne

What Endometriosis Means and Its Impact on Fertility

Endometriosis is a condition in which endometrial tissue (the tissue that lines your uterus during your cycle and is shed during menstruation) occurs outside of the uterus. It can be found pretty much anywhere inside your pelvic cavity: fallopian tubes, ovaries, bladder, bowel, etc. The adhesions can cause varying levels of pain during menstruation or intercourse, from no pain at all to debilitating pain. As the adhesions grow they can impact thetissues they are on. Endometrial adhesions on the ovaries can cause endometrial cysts (called endometrioma). Adhesions on the bladder or bowel can infiltrate and obstruct. Adhesions on the fallopian tubes can infiltrate or constrict and result in scar tissue forming. In addition, scar tissue on the fallopian tube can prevent eggs from passing into the uterus to implant (which can lead to an ectopic pregnancy). Endometrioma can affect ovulation and scar tissue on the uterus can prevent implantation or lead to miscarriage and premature labor.

There are varying levels of endometriosis, from level 1 which usually causes no symptoms to level 4 which can seriously impede fertility.

Diagnostic Process

Endometriosis cannot be seen on ultrasound or diagnosed with blood testsor pap smears. The only way to diagnose endometriosis is to undergo laparoscopic surgery. During the surgery, a small incision is made in the abdomen for a tiny camera and a second incision is made to facilitate a tube used to pump air into the abdomen. Inflating the abdomen allows more space and a better view of tissues. During surgery the adhesions can be removed.

Treatment Options

Many doctors will also recommend Lupron injections. Lupron basically “kills” the adhesions by halting the growth for 6 months. Endometriosis is also controlled with birth control pills. Birth control pills can be used to treat symptoms or to prevent/control a reoccurrence after surgery.

Personal Experience

My endometriosis was level 4, affecting one ovary with a large endometrioma. The endometrioma pulled that ovary down and behind my uterus and twisted the fallopian tube. There was also a small adhesion to my bladder. I had debilitating pain during menstruation–it was so bad that I couldn’t walk and often vomited from the extreme pain which was not reduced by any OTC or prescription painkiller. My laparoscopic surgery lasted over 3 hours (I was scheduled for 1 hour of OR time) to remove all the adhesions and re-anchor my ovary where it belonged. I had spent 5 years on triphasic birth control pills, which kept me symptom-free for the duration. I chose against Lupron because I didn’t feel the side effects were worth it for me.

Ovarian Hyperstimulation Syndrome (OHSS)
by Bronwyn

Why would you be dealing with Ovarian Hyperstimulation Syndrome (OHSS)?

Because you have undergone controlled ovarian hyperstimulation – either for IVF or IUI. Every time you undergo controlled ovarian hyperstimulation there is a small degree of risk. However, your symptoms are likely to be very mild, involving only a minor degree of swelling or discomfort. OHSS usually starts a couple of days after an egg retrieval – although, like everything, this can vary and your symptoms may start earlier or later.

Factors Which Increase Your Risk

1. Lots of follicles and high estrogen levels. This is the biggest risk factor, and one of the reasons why more isn’t necessarily better. You may be “coasted” to reduce the number of follicles/estrogen levels.
2. hCG seems to trigger, prolong, and increase the severity of OHSS. If you are at very high risk, your retrieval may be cancelled because the hCG trigger injection will be deemed too dangerous. If you are at slightly lower risk, you will be asked to trigger and undergo retrieval, but your transfer will be cancelled to avoid pregnancy in that cycle and the embryos frozen for later use.
3. Low body mass index. For some reason skinny women are slightly more at risk. No-one knows why.

What You Can Expect

Symptoms: Pain or swelling of the belly. Decreased urine output and pain when urinating. Nausea and vomiting. Thirst. Shortness of breath. Sudden increases in weight.

The average case lasts seven to ten days. Unfortunately, there is no way to make the OHSS go away. Instead, you need to support your body until the hormones settle down. Most of the time, adequate monitoring and treatment can be given at home – this is discussed in more detail under “troubleshooting”. If your symptoms become too severe for at-home treatment, you will be admitted to the hospital. Although the principles of supportive care and monitoring remain the same, both will be more aggressive for in-hospital patients.

Treating OHSS

1. Keep up the fluids. You will be losing fluids into your abdominal cavity. If you can’t keep up with this loss by drinking fluids, you will be put on an IV drip.
2. Keep up the proteins. You will also be losing proteins into your abdominal cavity. If eating protein-rich foods and drinking protein shakes isn’t enough, you can be given albumin via a drip. 3. Control pain. The type of painkiller you need will depend on your level of pain.
4. Control nausea. Anti-nausea medications may be used.
5. Control shortness of breath. Mild shortness of breath can be treated with rest. In more severe cases, intranasal oxygen may be used.
6. Maintain organ function and treat specific complications. If the pressure in your abdomen is too great, an in-dwelling tube can be placed under local anaesthetic to drain some of the fluid away. As the proteins in this fluid are lost to the body forever, and cannot be resorbed, this will only be done if the benefits are thought to outweigh the risks. If you are having trouble emptying your bladder due to the enormous swelling of your ovaries, you may need an in-dwelling urinary catheter placed. Other specific complications are treated as they arise.
7. Maintain circulation. You may find that fluid collects around your lower body. Flight socks can be used to prevent swelling around the calves. Heparin injections and aspirin may be prescribed to lower the risk of clotting and thromboembolism.

Monitoring OHSS

1. Daily weight checks.
2. Measurement of urine output and fluid intake.
3. Daily blood tests for in-hospital patients.
4. Monitoring vital signs for in-hospital patients (heart rate, respiratory rate, oxygenation, temperature).
5. X-rays and ultrasounds may be used for some in-hospital patients, depending on symptoms.

After OHSS

Most clinics advise taking a cycle off to allow your reproductive system to get back to normal. Opinions do vary, though – some specialists are willing to do an FET the very next cycle, and others advise a longer wait of several cycles. Most patients find their next cycle is longer than usual. It’s common to be anything from two to four weeks late in the cycle following OHSS. The cycle after that may also be prolonged.

Ways to Troubleshoot

You should report any and all symptoms to your specialist. This is important! Simple treatment for mild cases: 1. Drink plenty of fluids. Electrolye drinks (sports drinks) and protein shakes (eg sustagen) are especially good. This is because your body is losing fluid, electrolytes and proteins into your abdominal cavity. High-protein foods, such as chicken, are also recommended. 2. Take pain killers. Doctors usually prescribe paracetamol/acetominophen plus or minus codeine for mild pain. If these don’t work, consult your specialist. 3. Rest up. I promise this will make you feel better. 4. Monitor your symptoms. Check your weight on the bathroom scales each morning. Report any sudden increases in weight. Measure your waistline. If you are putting on inches each day, talk to your clinic. Take note of your urine volume. If it’s decreasing, or if you find you are going to the toilet very frequently without passing much each time, contact your clinic. If any other symptoms arise – nausea, vomiting, shortness of breath etc – contact your clinic.

Personal Tips

1. Don’t be afraid to talk to your clinic about your symptoms. If your symptoms are changing and progressing – talk to them again. Better safe than sorry.
2. OHSS is tough mentally and emotionally. There are an awful lot of hormones involved, and you are genuinely sick, which is frightening. The fact no-one can tell you how long it will last is frustrating – will it be a few days or will you be that rare patient whose symptoms go on for over a month? Supportive treatments, especially IV albumin, can make you feel better temporarily and lead you to think it’s all over – until they wear off. This is very different from illnessess or injuries you may have had in the past, where each day you can feel yourself getting a little bit better. With OHSS, you may be getting worse each day, or feeling up and then down again, with no clear ending in sight. Please remember almost everyone gets better in seven to ten days. During my ten days in the hospital, a couple of things were said to me which I clung to. A nurse said, “You will get through this – hour by hour, day by day, moment by moment.” And another said, “You’ll never stop putting yourself through these things for your kids.”

IM injections
by Lisa

Why would you be doing an IM injection?

While most of the stimulant drugs are administered via sub-cue injection, some injections, including progesterone in oil (PIO) and some “trigger” shots (Human Chorionic Gonadotropin, or HCG) are given by intra-muscular (IM) injection.

What to expect

For those of us scared of needles (even despite administering hundreds, if not thousands, of sub-cue injections), the prospect of an IM injection can be utterly horrifying. The needle is 1 ½ inches long and often 22 or 25 gauge (remember that the lower the number, the thicker the needle so an 18 gauge is much thicker than a 25 gauge needle.) But take it from a recovering needle-phobe, these injections are actually much less painful than the size and gauge of the needle would indicate.

As with any injection, get everything ready beforehand: extra needles, gauze pads, and, for IM injections, plug in a heating pad for post-injection. I always iced the area for 5-10 minutes (sometimes 15 when I was particularly nervous!) beforehand. I know people who didn’t ice the area beforehand—they are much braver than I, but it just goes to show you that it is possible to do without icing. Do what makes you feel most comfortable.

Often, you will draw up the medication with a larger (18 or 22 gauge) needle, and will then switch to a smaller (22 or 25 gauge) needle for administration. Since it is extremely thick, PIO typically needs to be drawn up and administered with a thicker needle. You can administer it with the thinner (25 gauge) needle, but it will take a little longer to inject the oil and I personally never felt any difference between the 22 and 25 gauge needles, so if you want the needle out of you as fast as possible, go with the thicker (22 gauge) needle for administration.

A couple of things to remember: first of all, switch needles after drawing up the medication and before administering it, even if you are using the same size needle to draw and administer. The needle can get just a little bit dull after it is placed into the vial of medication, and you want as sharp a needle as possible for administration—dull needles hurt a lot more than extra sharp ones! Also, remember to tap all air bubbles to the top of the syringe and depress the plunger a small amount to get the bubbles out (I usually pushed the plunger until a tiny bead of the medication came out of the tip of the needle, which indicated to me that the air was out.)

Now, for the dreaded injection. IM injections must be done in the large muscle of the buttock. To locate the correct area, imagine the buttock is divided into four areas (like an x/y axis). The injection should be given in the upper, outer portions. Another easy way of locating the correct area was demonstrated by my nurse: place your hands on your hipbone, with your thumb pointing toward your butt crack and your other fingers on the front of your hip, with the area in between the thumb and forefinger flat against your hip bone (like you’re putting your hands on your hips). The injection can be given below the thumb, but not past the tip of the thumb—that area gets close to your sciatica nerve and you want to avoid that area.

The easiest way to administer the injection is to have someone do it for you. However, it is possible to do it by yourself—I traveled on business during the 2ww and had to do it myself two nights in a row unless I wanted to as a business associate to help me (granted, she is also a good friend and knew about our IF treatments, so she even volunteered to help if necessary but I just couldn’t bring myself to have her injecting me in the butt.)

If you have someone to do it for you, the easiest position is to lean against a counter and put all of your weight on the leg opposite the side of the injection (you should alternate sides each night from left to right to avoid over-irritating one side). Don’t look back. The person administering the injection should hold the skin taut with his/her thumb and forefinger of the hand not holding the syringe, and should be holding the syringe in the other hand like a dart. Have the other person count to three if you’d like, and then go in at a 90 degree angle as quickly as possible­— you will feel a slow injection more than a quick one, so make sure they go quickly.

If you are doing the injection yourself, find a comfortable position where you can hold the needle steady and still keep all weight off of the side you are injecting. I leaned against the counter similar to when my husband did the injection, but you can also try sitting in a chair and leaning to one side. Twist yourself around so that the hand not holding the needle holds the skin taut between your forefinger and thumb. With the other hand holding the syringe like a dart, inject as quickly as possible at a 90 degree angle.

Once the needle is in (make sure all 1 ½ inches are in the skin/muscle), pull back the plunger just a small amount to make sure there is no blood, which would mean the needle is in the incorrect position. IF you see blood, DO NOT PANIC. Simply pull the needle out slowly, attach a new needle, and inject again in a different location. You do not need to discard the medication because of the blood. The blood is your own and can be re-injected (with a clean needle) along with the medication. I have a friend who wasted a lot of PIO because she thought she had to throw it away if she drew blood.

If there is no blood in the syringe, slowly depress the plunger to inject the medication. When done, quickly pull the needle out in a straight line. Do not panic if you have a little (or even a lot) of blood coming out of the injection site—just put pressure on with a gauze pad for a minute or so and the bleeding will stop. You can put a band-aid on the area if necessary.

Massage the injection area to help spread the medication (especially PIO) around. I always put a heating pad on the injection area for 10-15 minutes after the injection, especially with PIO because the heat can dissipate the oil so that it does not harden in an uncomfortable lump. I also made sure to walk around a bit to avoid any muscle soreness and, for PIO, to further spread the oil around. The few times I did not use a heating pad and/or walk around after the injection, I felt more soreness the next day.

Some problems that might arise (and ways to troubleshoot)

As mentioned above, there is always the chance that you will hit a blood vessel and draw blood when you draw back the syringe. Do not panic—just withdraw the needle, make sure to change the needle, and re-inject in a different spot.

You may also experience soreness—some people experience more soreness than others. The best ways I found to eliminate, or at least reduce, soreness was to consistently use a heating pad after the injection, massage the injection area, and walk around a bit. Soreness is more likely with PIO because the oil has a tendency to coagulate in the muscle and cause an uncomfortable lump. Massage, heat, and moving around can help the oil spread out and prevent these lumps.

Finally, there is a chance that you could hit a nerve when administering the injection. If you are careful, this will not happen (it never happened to me). To avoid this possibility, make sure you are giving the injection closer to the hip than to the middle of the buttocks. Remember the “thumb” rule mentioned above—put your hands on your hips with your thumbs pointed towards the back, and do the injection below the thumb and not past the tip.

My personal tips

I covered my personal tips above, but one additional tip would be to have a nurse do your first IM in
jection, if possible, with your significant other (or whoever will be administering your injections) present. We did this for our first IM injection and we both felt better knowing that a professional had gone over the procedure before we tried it ourselves. Remember, I was needle-phobic before this whole IF journey, and I found the IM injections very easy. I almost preferred them to the sub-cue injections because they were actually less painful (stung less than the stim drugs). So take a deep breath and just do it. You’ll realize that it isn’t as bad as you are probably imagining!

IVF (fresh cycle)
by Serenity

Why would you be doing In-Vitro Fertilization (IVF)?

IVF essentially means “fertilization outside the body.” People undergoing IVF can have the following diagnoses:

Blocked, damaged, or inoperable Fallopian tubes
Male factor infertility (low count, abnormal morphology, etc)
Women with endometriosis
Unexplained infertility
Immunological issues

In general, an IVF cycle consists of a phase where you will suppress your body’s tendency to ovulate with a GnRh agonist subcutaneous medication such as Lupron, then use a follicle-stimulating medication such as Follitism or Repronex to super-stimulate your ovaries into producing a number of eggs. When you have a number of mature follicles, you’ll “trigger” with a shot of HcG, and exactly 36 hours from that shot, your doctor will extract them in a retrieval which is usually done under general anesthesia. From there, embryologists will take the mature eggs and fertilize them with sperm. Transfers of the resulting embryos (6-8 cells) or blastocysts (multiple cells) take place either three (embryos) or five (blastocysts) days after the retrieval. Any excess embryos or blastocysts from the procedure can be cryo-preserved (frozen) for future frozen embryo transfers (FET).

What you can expect

In general, an IVF cycle involves a lot of needles – depending on your protocol, the agonist repression, follicle-stimulation, and trigger medications are delivered via subcutaneous injections. There are some agonists that can be delivered in an inhaler form – you “sniff” the agonist once or twice a day. But generally you will be required to give yourself daily injections.

When you begin your follicle-stimulating medications, too, you can expect ultrasounds and blood draws every other day and/or every day leading up to the retrieval. Additionally, as you get closer to the retrieval, you might become a little bloated and uncomfortable from the extra eggs that are developing in your ovaries.

For the retrieval, like any other procedure under general anesthesia you will be advised not to eat or drink after midnight. When the procedure is over you may feel some pain from the egg extraction and/or nausea from the anesthesia.

And because a doctor is surgically removing the egg from your follicles, there is no corpus luteum to generate progesterone. So after the transfer, you might also be required to have someone give you daily progesterone-in-oil (PIO) intramuscular injections, depending on your protocol (if you’re lucky like I was, you’ll just get the prometrium suppositories instead).

There are a host of potential side effects of the medications you’ll take during IVF cycle. During the repression phase, you may be prescribed birth control pills, which might cause headaches and PMS-type symptoms. In the stimulation phase, you might feel physically uncomfortable and have headaches (I had massive migraines with my Gonal-F until they reduced my dosage). After the retrieval, expect to stay home from work for a few days – you will be bloated and at least a little sore.

Problems that might arise

The biggest issue that might arise is Ovarian Hyper-Stimulation Syndrome (OHSS), where the follicles after the retrieval fill with fluid and leak into the abdominal cavity and into the chest. Symptoms of OHSS include rapid weight gain (2lbs or more per day), inability to urinate, fullness/bloating in your abdomen, and/or a shortness of breath. Mild OHSS will resolve itself in a few days, though if you get pregnant it might take longer. But moderate and severe OHSS can be life-threatening, though fairly rare – less than 1% of patients end up with OHSS this severe.
However, your doctor will monitor your estradiol levels (E2) via bloodwork just before the retrieval. Levels over 5000 are generally not recommended – if this is the case your doctor may have you “coast” (i.e. skip your injections) for a day to decrease your levels.

Personal tips

Take things a day at a time. I was totally overwhelmed with the number of needles and medication I needed for our IVF cycle at first, so I just focused on what I needed to do that day. Before I knew it my medicines were almost gone.

If you can’t do the injections yourself, have your husband do them. I have no issue with needles and did my own injections. However, most women seem to prefer it if their husbands do their injections, and it’s a nice way to keep him involved.

If you do your injection slowly, chances are you won’t bruise. I found that when I rushed my injections I ended up giving myself a bruise. Slower is better.

Drink plenty of Gatorade after the retrieval to replenish your electrolytes. The more fluid you drink, the better chance you’ll have at healing more quickly.

It takes longer than you’d expect to recover from the retrieval. Granted, my E2 was at 5178 when I triggered, so I had a moderate case of OHSS, complete with a burst follicle. But I couldn’t walk far at all for about 5 days after the retrieval, so I stayed home pretty much for an entire week. Just be prepared that you’re going to be uncomfortable and might need to stay home and rest up.