Back on the big dipper

Why do people voluntarily ride roller coasters? Perhaps if the aliens land tomorrow they will think that, if they base their assessment on the roller coaster riding alone, the people who inhabit this planet are bonkers. The creatures from Mars will see that, before the earthlings climb into the buckets, they are trembling and, once seated, they will scream, nausea will rise from their guts and, if it's a good one, even cry. However, once it's over, you will hear the riders say how thrilling it was, oh it was such an adventure, they'll say; get right back in line and hop on again for one more go. In short, the exciting, thrilling, exhilarating, wonderful feelings outweigh the fear, vomit and scream-inducing gut-wrenching stuff. Maybe that is why couples keep on putting themselves through one IVF cycle after another: the hope that, one day, after all the rain they'll get a turn at dancing in the sunshine.


This week I had the first scan of my current, it's my third if your counting, IVF cycle. I tried to remember how many scans I have had throughout my infertility journey  but I can't, there have been just too many. After the first scan of my last frozen cycle I wrote down my thoughts on the scan process and, lucky reader, you can read all about it below:

 
"On the train back home from my clinic I couldn’t help thinking about how odd these scan sessions are. Maybe it is just me but they are weird, aren’t they? I find it all so awkward and slightly hysterical at the same time. I spend a good ten minutes in the morning checking everything downstairs looks okay, like anyone cares, and the thought that it isn’t pops into my head many times during the day. Then, once I get to the clinic, I spend several moments debating whether it should be socks on or socks off, wondering if it matters, and trying to remember if my nail varnish would be suitable if I do dare to go socks off. Finally, I make a socks on decision, clamber onto the chair, or maybe it’s a bed – I am not sure what it is – and I attempt to maintain some semblance of dignity whilst desperately trying to balance in the stirrups. Once I think I’m safely in, I have to call out “I’m ready” at which point I panic wildly, think Mr T won’t hear me so call out two more times with increasing volume and desperation. The whole humiliating process culminates with, what can only be described as, an eye-wateringly large dildo like probe which, to add insult to injury, gets lubricated and covered with a condom! Then the lights go down, I half expect Barry White to start playing, and we get to spend several minutes examining my inadequate innards. Like I say – odd!"


I had the exact same feelings again this week - nothing changes. Except this time, instead of excited anticipation, I am nervous and a little bit scared. The scan went well, I have 8 resting follicles (that's okay, apparently) and none of my internal organs had left the building - I wouldn't blame them if they had, I think they've had enough. But this time I have prior knowledge of what lies ahead; I know that IVF is hard and it makes me feel like this:

Oh before I forget, the financial round up:

1. IVF meds:    £1092
2. IVF cycle:   £3275
3. HEFA fee:    £75
4. Train fares: £28
   Total:       £4470

Smoking and IVF: it's just plain old bad news

As I was driving home from work on New Year's Eve in 2007 I smoked my last cigarette; I remember it well. The smell and taste of those last few drags can still easily be recalled from my memory. My decision to quit was fuelled by my concern that an increasing proportion of my pay check was flowing into the pockets of the tobacco giants and, of course, the fear of cancer. What never crossed my young mind, even as the last stump burned to the end, was the possibility that my favourite bad habit was damaging my fertility. I am not saying that my choice to spend my youth puffing away has left me infertile, I don't know whether anyone could tell me if that is true. However, a review of recent scientific literature performed in 2008, and another published in 2011, both concluded that cigarette smoking compromises every aspect of the reproductive system. Whilst the results are clearly not wonderful news for a smoking lady hoping to make a baby au naturel, they don't really tell you whether smoking will ruin your eye-wateringly expensive and hope-laden IVF cycle. 

Yes, you guessed it, we are here again, taking another step forward in the research journey that is Operation Big Belly. And, as you may already know, we have so far investigated the possibility that food, alcohol and caffeine could reduce your chances of an IVF baby. Now that we are getting started I should remind you that the ground rules can be found here.


So, even though the clues seem to be screaming at us "Of course smoking is bloody terrible, you fools", let's ask the question anyway, we might be pleasantly surprised: will smoking screw up your chances of a successful IVF cycle? One health authority in Scotland is so sure that cigarettes are completely atrocious that it has banned couples who smoke from having IVF treatment on the NHS (see here). Now, what the Scottish choose to do might be extremely fascinating (if I were cynical I would say their decision was swayed a teeny weeny bit by the desire to spend less of their health budget on the not-so-election-busting infertile couples), but what can science tell us about smoking and IVF? 


This time at least there is a respectable body of data to get yourself excited about. As far back in time as 1996, there was a healthy level of research interest in IVF and smoking. The first review of published studies that investigated the role of smoking in IVF success, found seven papers worth examining and revealed that, although there was variability between the studies, the conception rate was lower and the miscarriage rate higher in women who smoked.


A year later, a research group from Austria published the results of a meta-analysis that investigated the effects of smoking on IVF results. The data review comprised of eight studies, including the authors own, and analysed the outcomes of 2314 IVF treatments. The studies reviewed yielded conflicting results and with some indicating that smoking didn't impact the IVF success rate. However, when all the data were taken together, the meta-analysis revealed that non-smokers were significantly more likely to get pregnant during their first cycle than smokers, and that smokers require twice as many attempts to achieve pregnancy.


If you step forward just a few years more, this time to 2005, you will reach a pretty thorough review conducted by Hilary Klonoff-Cohen (we met her before here). This lovely lady has gone to the trouble of reviewing 22 articles, including the studies mentioned above, and the data, as with the previous reviews, was somewhat conflicting. She did not conduct a meta-analysis, so it is not possible to say if the studies which demonstrated no effect on IVF success rates for smokers would have remained significant when the body of evidence was examined as a whole. However, she did conclude that "despite the variations between the studies, there was compelling evidence that smoking had a negative influence on IVF outcome".

If you manage to pick yourself up from those revelations and roll forward a few years, you will find that you have landed at the feet of a second meta-analysis conducted in 2009. On this occasion, a collaboration from the UK (yay!) analysed data from 21 studies to investigate the impact of smoking on IVF outcomes. The investigators found that smokers had a lower chance of pregnancy, a higher risk of miscarriage and ectopic pregnancy, and a lower live birth rate. Non-smokers were found to be twice as likely to get pregnant and have a baby at the end of it all. Not only that but the analysis went deeper, smoking was shown to be bad for every step of the IVF process; smokers required greater stimulation, had fewer eggs, lower fertilisation rates, and a higher chance of implantation failure. The authors concluded their paper by stating "There is particularly overwhelming evidence for a decreased clinical pregnancy rate amongst smokers, in addition to the strong implication of a negative effect on live birth rate, miscarriage rate, ectopic pregnancy rate and fertilisation rate". Phew! They weren't messing about, were they?
 

I could find no more reviews or meta-analysis studies since the one performed in 2009, described above. However, there have been more experimental studies that have investigated the relationship between smoking and IVF success. Since 2005, I realise I have gone a little further back than the last meta-analysis, researches have discovered that smoking is associated with lower delivery rates and higher miscarriage rates, decreased uterine receptivity and increased numbers of multiples, a lower number of fertilised eggs and correspondingly lower pregnancy rates, reduced ovarian reserve and, once again, correspondingly lower pregnancy rates, poorer ovarian responses to stimulation and impaired embryo development.


Well, if that wasn't quite enough to put you off your cigarettes for good then maybe the final study will convince you. In 2011, a research group based in Israel discovered that, when women smoked, even if the doctor put great quality embryos back into the uterus, the pregnancy rate was lower for smokers than non-smokers. Oh dear, even an excellent embryo can't help you!


In the interest of fairness, I should point out that, since 2005, there had been one, yup just one, study that found no difference between smoking and non-smoking groups of women undergoing IVF treatment.


So there you have it. If you are planning to do IVF and you enjoy a smoke, you might want to think about enjoying it a little less often or, preferably, not indulging at all.


Writing this post has made me a little sad; I wish I could go back and plead with my younger self not to pick up that first cigarette. And, yes, there was an adolescent boy, who I was attempting to impress, connected to the decision to take my first puff. But I doubt that young lady would have listened to a word of it. Babies seemed so far away and she comes from one of the most fertile families on the planet: three brothers, three sisters and thirteen nieces and nephews. I know you shouldn't regret the past, and on many occasions smoking gave me real joy, but, as the great Cher once said, if I could turn back time.......

Could I be pregnant?

Every 28 days, always around this time in my monthly cycle, my hope gene starts working overtime. Yes I do have a very regular cycle, thank you for noticing. In case you are unaware, I can tell you that the hope gene encodes the hope protein which, in turn, triggers the hope activatory pathway. Even though many doctors have told me I almost certainly won't get pregnant, the hope gene has not been switched off and it certainly hasn't resulted in, what I'd really love, hope protein down regulation. Which, in an ideal world, would bypass the hope activatory pathway altogether.


Nine days ago an egg, or ovum if you want to be all fancy about it, left one of my ovaries, travelled down a fallopian tube (I'm betting it was my right one) and, whilst on its journey, may or may not have met up with one or more of my husband's sperm. What we can be pretty sure about is that, if they did meet, the big egg and the little sperm almost certainly didn't hit it off. I don't know who's got the issue and, if I could, I would get them together in a room or, as my embryologist does, a petri dish and force them to be friends or, better still, lovers.   


And now, one week and two days after the magical release, I can't stop thinking "could I be pregnant?", even though deep down inside I know I'm not. This treadmill of hope and despair has continued now, with a brief interlude for an ill-fated pregnancy, for two years and seven months. It doesn't seem to matter how many times I sit on my toilet seat and watch transfixed, with tears in my eyes, as the blood red spots fall onto the soft white paper. But every single flaming time I pick myself up and I get over it. I promise myself that when it happens again, which it inevitably does, I will be stronger, better, harder, tougher. Blow it, I say to myself, next month I am going to be the Jane Eyre of infertility - there may be a crazy lady in the annex but it ain't going to phase me - until, of course, it does.


Last month I promised myself that, when I finally yield to the call of the little white siren hiding in the bathroom cabinet, I wouldn't dream of two perfect pink lines popping up instead of the usual lone crusader. I don't want to fantasise about a pregnancy that never happens, even if it is for just five minutes. But here I am dreaming on my sofa once again and, even as I am typing these words, my internal voice is whispering "this time you really might be". And of course it's right, I might be - except I know I'm not. So I could be pregnant. I could, I really could.

Operation Big Belly: Food glorious food

Before you read this blog post, I would like you to try an exercise for me; don't worry, it won't hurt. Take a few moments out of your hectic schedule, close your eyes and think of food.

Did you just carry on reading? I do hope not.

What pictures came into your mind’s eye? If you are like me, you just visualised a glorious spread of triple-layered chocolate cakes, sugary sweets, calorific candies and all things scrummy. If, on the other hand, you are more similar to my virtuous husband, you pictured grilled chicken, salads and rice. No, I don't get it either - why think salad when you can think chocolate? The point is, there are many different ways to fill your tummy but, when it comes to artificially making babies, does it really matter?  


First off, before we get started on our mission, I would like to introduce the ground rules. Well, all serious operations require rules, don’t they?

Operation Big Belly's ground rules:

• Only scientific data from peer reviewed journals  will be included
• All studies discussed will be available on PubMed
• No-one shall take my opinion as anything other than the ramblings of a fool – I am not a medical professional
• When the rules are broken, all good rules need breaking, it shall be noted

Okay then, if you are ready and sitting comfortably then let's get started.


The first important thing to note is the surprising scarcity of scientific data on the topic of IVF and diet. Type "IVF" and "diet" into PubMed and you will be rewarded with only 47 abstracts and, when you examine the results closely, most of the results are not really relevant. In fact, after quite a serious search, I found a only three studies which examine the role of diet in IVF success. Not very impressive, is it?   


During my investigations, I found that all three studies were conducted at the Department of Obstetrics and Gynaecology at the Erasmus University of Rotterdam. Now, I have always liked the Dutch but I was beginning to like them even more and I was keen to know all about this group of researchers. So, I dug a little deeper and discovered that most, but not all, of the work was done as part of a PhD thesis by a wonderfully intelligent student named Marijana Vujkovic. She really is a clever girl; I have read her thesis, although not every single word, so that, if you don't want to, you don't have to. Let's take a look at what I found out:


The most recent study, published in 2012, found that following the Netherlands Nutrition Centre(NNC)dietary recommendations could increase the chance of ongoing pregnancy, after IVF or ICSI, by as much as 65%. Amazing, right? Just so you know what to be eating, the NNC's recommended dietary food wheel is below: 
  

And, in 2010, our friend Marijana Vujkovic published a paper, in the Journal of Fertility and Sterility, which described a study indicating that following a Mediterranean diet, i.e. one with a high intake of vegetable oils, vegetables, fish and legumes, increased the probability of pregnancy, in couples undergoing IVF or ICSI, by a pretty respectable 40%. Wow, that's good too, isn't it?

What more can these Dutch scientists tell us?


Well, in their third, and final, study the Dutch researchers revealed a link between women with diets high in omega-3 and potentially improved IVF outcomes. Women with diets rich in omega-3, which is primarily found in fish and fish oils, had higher day 2 estradiol levels, which corresponded with embryos that had improved morphology, than women with with lower levels of omega-3.

I think we have learnt quite a bit from our Dutch friends but I am not quite finished; I am about to break two of Operation Big Belly's ground rules. The study I am about to discuss hasn't been formally published in a peer reviewed journal and can't be found on PubMed, but the results were presented at the European Society for Human Reproduction and Embryology's meeting and widely reported in the British press (see below), so I am going to include it too.

An analysis by a team at Harvard School of Public Health, they must be very clever people, identified that women who consumed high levels of saturated fats, such as animal fats, produced a lower numbers of mature eggs during IVF cycles. Whereas, diets that were high in unsaturated fats, such as olive oil and avocados, were associated with an increased number of, and when I say increased number I mean more than three times as many, live births.

Well, wait a minute, isn't that almost the same result as the researchers from Rotterdam found when they looked at Mediterranean diets? Do you know, I think it is.

Without further ado,I would like to take this opportunity to unveil Big Belly's IVF diet tips:

Words of caution: The results discussed here come from very small studies, we are talking about hundreds of women not thousands. So, it is entirely possible that, in the future, larger studies may prove these studies to be entirely false. However, at the moment, there are no other data so we're just going to have to take their word for it. Also, there is no evidence in any of these studies that changing your diet before an cycle IVF helps. It is possible that you may need to be on these beneficial diets for a long time, maybe even a lifetime, for you to get a better IVF outcome.


I should also mention, there are several other studies that have investigated links between diet and infertility, rather than IVF. However, that was not my topic here and, for that reason, I have not included them. Also, there are many, many animal studies that, whilst very interesting, can't really tell me if eating donuts will stop my IVF from working, so I chose not to discuss them either. But, do feel free to investigate these other studies yourselves.


One final thing before I sign off; what is all this stuff about pineapple? I mean, I get the theory - pineapple contains bromelain which aids implantation - but where, oh, where did the theory come from? It is a very widespread notion; a quick search on a popular trying-to-get-pregnant website yields 1088 hits! Nearly all posts by people who swear by it. I have searched high and low and I can't find the source of this "fact" anywhere. I did find a paper published in 1969 which examined the impact of bromelain on the uterine lining, but it didn't indicate that it would help with implantation. I can really find no scientific evidence that pineapple helps people get pregnant at all - I wish I could, I really wanted this one to be true. If you can find any papers on the subject, please send them my way.

 

 

Operation Big Belly

There are many ways to get pregnant; IUI, IVF, ICSI, IMSI or, as some people still do, use a good old fashioned turkey baster. Even though are so many high tech options available, according to a study published by The Guttmacher Institute in 2010, it has been estimated that 41 percent of pregnancies in 2008 were unintended. Yes, you read that right, 41-flaming-percent! Which means that, assuming not much has changed in the last five years, of all the pregnant ladies walking around the world, nearly half of them didn’t even mean to get knocked up. These women didn’t take supplements, eat more veg, cut out the booze, or the cancer-sticks and they certainly didn’t have a whole team of people working behind the scenes to get a sluggish sperm to penetrate an evasive egg. Unfortunately, I am not those one of those lucky ladies, maybe you aren’t either, and I need all the help and advice I can get.

Let me welcome you to Operation Big Belly. Over the next few weeks, whilst waiting for my IVF stims to start, I will be researching, reading and sharing all the information I can get my desperate little hands on to super-charge the following transformation:

From this:

 

 

 

 

To this:

Let the journey begin and, if you are starting your own journey, supporting someone who is, or are just plain curious, why don't you come along for the ride? Hold on tight now, here we go!


Note: this blog post was edited on 21 Apr 2013 to include links.

Am I really, though?

There’s been something on my mind. It was lurking in the darkest corners of my unconsciousness and crept up on me when I wasn’t paying attention; always a dangerous thing that, taking your eye off the ball. It never occurred to me that it would burn or that once the words had tumbled onto the screen they would sting. You might be wondering what could have got me quite so rattled. Well, ponder no more, I can tell you that my nerves have been jangled by my last, and first, blog post. Not all of the post, that would be quite exhausting, just a very teeny-tiny portion. Most of the words fell out of my consciousness as soon as they tumbled onto the screen but three little words remained imprinted on my mind: I am infertile. Just to be clear, in case you’re still confused, it really only one of those words that seems to be bothering me. To be completely precise, which is always the best way I feel, just three small syllables: In-fer-tile.


Prior to my last post, I don’t think I have ever said, typed or even thought that I might really be infertile. I know, I know, after 2 years, six months and no babies I might have got the message but, really, I hadn’t. After the opening gambit of my first blog entry spelt it out so crisply, I couldn’t get the thought out of my head – am I infertile? Maybe I am, maybe I’m not - I just wasn’t one hundred per cent sure. Perhaps I am just a little bit sub-fertile, or possibly, just a touch below par in the fertility stakes. I desperately needed to find some clarity. Well, dear reader, we already know that I am not an A grade student in the baby making class but am I in a completely new category?


As with most unanswerable questions in my life, I went to the only water-tight, fool-proof resource I know, the infertile lady’s friend, the World Wide Web and here’s what I found;


The National Institute of Clinical Excellence (NICE) in the UK have published guidelines which define infertility as “failure to conceive after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology”.


Oh dear, this wasn’t looking good. I have definitely passed that entrance exam to the infertility club, at least that is, to be included in the United Kingdom’s gang. Hmmm…..not good enough for me…… I needed to expand my search and go further afield. Well, just to be thorough, I went global and turned to the World Health Organisation (WHO) for some concrete answers. Surely the clever bods over in Geneva would solve this tricky conundrum for me. Let’s take a look at what they’ve got to say on the subject; the WHO defines infertility as “the failure to conceive following twelve months of unprotected intercourse”. Blimey, it’s not better, it’s worse; I’ve aced that test several times over!


So, I’m satisfied I have my answer; I am a proper, no doubt about it, infertile lady. Turns out, it’s not so bad. In fact, I’m feeling liberated; released from my confusion and desperation of the endless baby-making attempts and justified in my quest for a medical solution. And, as those handy bods at the WHO tell me, I’m not alone; worldwide infertility affects between 50 and 80 million people. Phew, that’s an awful lot of us.

Note: this blog post was updated on 21 Apr 2013 to include links.
 

Lessons learned

My name is Ana and I am infertile woman – there I’ve said it! I am infertile. For whatever reason, and we haven’t quite got a handle on what the problem is yet, no matter how hard I try I don’t make babies. Never did I think I would be sitting where I am today. When I was just a young  girl in her twenties, my dreams  of the future where full of beautiful daughters, wonderful sons and long summer days running together through a scent filled garden – oops, sorry, just made myself a bit queasy there – I was full of such naivety and arrogance. I can’t even say that my nightmares were filled with the fear of infertility or barrenness, they weren’t. To put it quite simply, the possibility that I wouldn’t get to choose when, where and how many children I would be blessed with didn’t exist. However, quite painfully, my current reality is not the idyllic scenes played out in the dreams of my youth but, in their place, are long, heart-breaking trips to infertility clinics to poked, prodded and pricked.

So, why start writing now? After all, I am not at the beginning of my infertility journey. Far from it, I am now two and a half years in. I’m deep in, very deeply in; you might even say that, if you felt like it, I’ve got stuck in the trenches.  Although, the first six months I spent on the road to conception don’t really count as I was bouncing along, still blissfully unaware of the trouble that lay ahead, very contentedly. I was completely happy about my fertility status, although I was getting a bit weary of all the extra sex, and I would spend my waking-hours day-dreaming about my future babes, who were clearly going to be turning up very shortly. Hang on a minute; I’m digressing – slipping back into the memory of the happier me.  Well, it’s so easy to do, isn’t it? To get back to the question I asked myself (honestly, this is going to be hopeless if I can’t answer even my own questions), I am writing now because I am staring down the barrel of a failed frozen embryo transfer, completed with my last two embryos, and I, quite frankly, need to talk.

Eight days ago I carted myself, along with my lovely husband, onto a train bound for London with as much enthusiasm and excitement as I think it is possible for any single person to bear. We nervously chatted and smiled together like two young lovers, complete with packed lunches, skipping school. We were off to get our embryos back! The two little blighters had been spending quite a while messing around in liquid nitrogen together. Don’t be too harsh on them, it wasn’t their fault; in between their creation and our reunion their siblings got to have the first go at developing into new-borns. So very sadly, their siblings failed on their mission, they won no prizes, and they didn’t manage to make it all the way to their first breath.  The little babies’ hearts stopped beating 16 weeks and 5 days after their particular miracle of creation began. So, you see, the two little embryos we went to collect had been waiting in the wings for their chance to grow and we couldn’t have been happier to oblige. We were warned not to get too carried away, that there was a chance it would fail, that we should cushion our hearts against the almighty blow that could be dealt. But, perhaps unfortunately, but I am not sure anyone else would have done it differently, we didn’t listen to a single word. We believed, maybe foolishly but definitely whole heartedly, that in nine months we would be saying hello to our little balls of cells, clearly there would be many, many more cells than started out, in person. Now here I am, eight days since the transfer of our embryos into my unyielding uterus, and it doesn’t look like those chicks are going to be coming home to roost. We are down five of the best pregnancy tests money can buy, no point scrimping at the end, and not a single positive among them. The negative tests, along with increasingly uncomfortable period cramps, are screaming at me, loud and clear, that this ship has sailed. And, although she might not actually be singing just yet, that fat lady has finished her warm up, is facing the bright lights and heading on out to the stage.

So, to deal with the title of this post, – don’t you just hate it when you can’t figure out how the title relates to the post? – what lessons have been learnt? Well, I’ve discovered, albeit a little late in the game, that fertility shouldn’t be taken for granted. And, that no matter how hard you wish, or visualise, or pray, or even beg, sometimes the universe, or God if you prefer, just isn’t listening. And, finally, I suppose I’ve learnt, very begrudgingly, that even if you get knocked down again and again you just got to get up and get on…….dreams, apparently, don’t come easy or, now I think about it, cheap. So, onwards and upwards and here’s to looking forward to another fresh cycle.