My Ovarian Follicle Stimulation & Removal Journey
Listen on my Podcast "Life as a Patient Doctor"
See Previous Blog Post on Preparation for Follicle Stimulation and Embryo Preservation
Early Cycle "Baby Follicle" Count:
First step is undergoing an intra-vaginal ultrasound to see the follicles that have the potential to grow during medication ovarian stimulation
A Last Minute Surprise Cost to Embryo Freezing
I learned I had to pre-pay the same amount of 1 months rent in order to freeze embryos (which is the one thing not covered by the mandate nor insurance). This facility had me pre-pay before giving me the amount of each medication I will be taking during the cycle. During the previous follicle stimulation the hospital just provided the bill at the end of the cycle which gave us time to plan how to pay it.
Thankfully we were able to split the cost between two credit cards and then submit the the medical expenses receipts to Financial aid to increase my loans. Unfortuntlay, it took the school a couple weeks to refund the money so we were very close to not making rent.
This situation once again demonstrates the social-economic barrires to IVF treatment, infertility care, & fertility preservation…
The first week I took Estradiol pills 3 times a day (TID) to increase the baseline of estrogen in my system (which started pretty low)
I freaked out when I realized these pills were not part of my previously acquired IVF medications. As some of you know (from my medpsycmoss.com & EndoFound blog posts) these IVF meds cost over $10k & I worked forever to get my school health insurance to pay for all of them - as the State of IL mandates!
Thankfully these little aqua-blue pills were just sent to a regular pharmacy to pick up & were covered (with a $60 copay). It is usually the injectable medications that get tricky & $$$ making them go through a “specialty pharmacy.”
Comparing Prenatal Vitamins to Take:
There are so many, how do I possibly choose?
Doses of each type of vitamin?
Wait, I thought prenatal vitamins are only if you are trying to get pregnant not for freezing?
Apparently not! According to a 2019 review of studies on micronutrient status The Impact of Preconceptional Multiple-Micronutrient Supplementation on Female Fertility by Schaefer and Nock "adequate levels are important for oocyte quality, maturation, fertilization, and implantation, whereas antioxidants are vital to reduce oxidative stress, a process known to impair fertility."
"Folate levels are important for oocyte quality, maturation, fertilization, and implantation"
"Zinc has been implicated in ovulation and the menstrual cycle"
"Vitamin A levels are a factor in oocyte quality and blastogenesis."
Zinc and certain B vitamins improve "DNA synthesis, which is fundamental to the development of oocytes,"
Folate and zinc influence "apoptosis (ie, normal cell death), essential for regulation of follicle atresia, degeneration of the corpus luteum, and endometrial shedding"
"Folate, vitamins B6, B12, and D, and iron all have roles in mechanisms that could affect fertility, including homocysteine metabolism, inflammation, oxidative stress, and embryogenesis."
One study reviewed found: "Folic acid supplement in women undergoing IVF helped optimize the homocysteine pathway in follicular fluid, which was associated with better embryo quality and a greater chance of becoming pregnant; a 2-fold increase of monofollicular fluid folate was associated with a 3.3 times greater chance of becoming pregnant."
Check out the Review Article at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6480978/pdf/10.1177_1179562X19843868.pdf
Prenatal Vitamin Information from the CDC:
https://www.cdc.gov/nutrition/micronutrient-malnutrition/about-micronutrients/pdfs/MicronutrientFactsheet-April2020-508.pdf
Menopur Injection Preparation Videos I created: Part 1 & Part 2
Exhaustion seems to be the main theme during this current cycle. Possibly because I was also doing a clinical rotation during some of it. Thankfully, my residents usually let us go early so I usually got in an hour nap each afternoon before dinner.
"Ugh I am not feeling well. I have a headache and feel out of breath from just walking up a couple stairs. There is so much pain and swelling over my abdomen. It was just one injection this morning, but I feel like i have been doing them a lot longer"
If I was doing a Physical Exam on myself I would describe my abdomen:
GASTROINTESTINAL: Abdomen diffusly tender with maximal tenderness in lower quadrants, voluntary guiding of lower quadrants, bruising surrounding the umbilicus, decreased bowel sounds, no rebound tenderness
To deal with the pain, I used my heating pad, took baths, and took Acetaminophen and the 81mg Aspirin. NO IBUPROFEN!
Maternity clothes as an infertile individual
- Wear for endometriosis belly flare days
- Wear for follicle stimulation
- Wear for hypertonic pelvic floor pain
"It is emotionally painful and embarrassing to need such clothing because it makes me feel fat and makes me remember that I can’t actually have kids naturally and that my bump won’t magically become a baby. It will just become more painful. I also don’t want people to ask many weeks I am on it’s just that I’m flaring up. "
It doesn’t look like much. but I feel like I am 3 months pregnant or stuffed with little water balloons…
It is actually not that far off as each follicle on my ovary is growing to a goal of 18 to 20 millimeters (2 cm in diameter) and I have 12-14 follicles on each ovary
From a medical perspective I have to be careful not to twist, run, or overwork myself which could increase my chance of my ovarian arteries twisting - Ovarian torsion!!
From an endometriosis perspective, the follicles are touching my hormone sensitized lesions & it HURTS!!
This stimulation round my doctor is following another regimen that more slowly increases my hormone levels so I don’t get to as high as I did last time (estrogen over a 1000 at it’s peak)
This time I purchased “maternity pants” which don’t have a band around my abdomen which causes me so much pain throughout the dayNo jeans, some of my leggings and even some scrubs is a defiantly NO
A lot of mixed emotions while having to purchase “maternity pants” while dealing with infertility and not planning on having kids in the near future
"It is so painful to have to look at myself wearing these pants because it is not like I am pregnant nor “fat” just in pain..."
Week 3: Continued Injections & Increased Protein
I need to eat 100g of Protein a day to prevent the rare side effect of hyper-stimulated ovarian syndrome which is when fluid leaks out of blood vessles into the abdominal cavity. I had this side effect happen last time so I want to prevent it this cycle.
For Breakfast: 30g protein smoothie or 10g late w/ 20 g of protein bar
Mid morning snack: 10-20g protein bar
Lunch: Protien healthy lunch ~ 20g of protein
Afternoon snack: 10-20g protein bar
Dinner: Protein healthy ~ 10g of protein
Dessert: protien cookie ~ 10g of protein
Some protein heavy meals we have made include omelets, chicken and bean enchiladas, bean and meat chili, and greek yogurt with nuts
"It has been hard to stay on top eating this much protein. I am eating when I am not hungry which ends up making me feel nauseated and bloated."
Here is a great Spreadsheet by John Hopkins on the different levels of protein in common foods:
Is "hormone brain" a thing? If not, it should be...
They were growing slowly (which we wanted) but also not fast enough....possibly because I wasn't following the medication recipe correctly
"I have been so stressed with school that I have messed up my injection cycle. I was positive I only had to take 175 units of Follistem each night but then I realized that it was supposed to be 300units. I kept making silly mistakes like this, and now I have slowed the growing of the follicles and will not get them removed on the planned day. This messes up the rest of my week because I have planned meetings, clinic, and a conference out of state I am planning to go to. Now I just have to practice patience and wait for my next ultra sound on Monday to see how big my follicles are. That will then help the OBGYN/Endocrinologist decide what day to remove them."
Toward the end of the week I started Ganirelix at PM - GnRH-Anatgonist
My Estradiol levels had risen above 600 which is around the levels that ovulation could occur! Therefore, the GnRH antagonist inhibited my pituitary from releasing LH, leading to an LH surge, which would stimulate my ovary to ovulate.
This week the theme has been nausea especially while in the passenger seat of the car. I usually do not like to take Ondasterone (Zofran) because constipation is not a fun side effect, but I have been taking it almost twice a day to get through the day.
Two nights before Removal:
I barely slept because I couldn't find a comfortable way to sleep. While laying on my right side my larger left ovarian follicles would weigh me down causing a mix of sharp and dull pains over my abdomen. I then seemed to wake every couple hours to urinate because my bladder did not like the extra stimulation either.
I am thankful I had my maternity pants to wear to my blood draw and ultrasound!
Monday Follicle Count found:
9 follicles on my Left ovary and 5 on my right!!
Apparently they only count the follicles that are over 17mm (1.7cm) in diameter because they have a greater chance of containing a mature egg
1.9 cm (19mm) is the diameter of a penny
1.3 cm (13 mm) is the diameter of a marble
Based on the diameters of the 9 follicles total I am carrying 22.27 cm^3 in volume on my left side
There will hopefully be 14 follicles to remove, about the same as last stimulation!
Endometriosis Symptoms Flaring:
My current Estradiol level is above 1200 and it is the most painful, nauseating, and uncomfortable experience. Walking up the stairs to my apartment from the appointment almost caused me to topple over..
After the above ultra-sound and blood draw, my procedure was rescheduled for Wednesday! This meant that tonight I will do the Leuprolide trigger shot! Leuprolide is a GnRH agonist which tells the pituitary to release a surge LH & FSH and to trigger final egg maturation and ovulation. Tuesday morning I will get my progesterone level checked and might do a second leuprolide shot depending on my hormone levels.
Progesterone level is adequate so I do not need a leuprolide shot! Spent the day relaxing and doing some TLC- like finally getting a hair cut!
Emotions during OBGYN rotation:
"I can’t believe the emotional rollercoaster I have been through during this OBGYN rotation. I have gone from pure joy and happiness to jealousy to sorrow. I am frequently reminded of my own infertility and medical conditions. Sometimes it makes me want to jump to start having children just like them. My upcoming stimulation reminds me I could just place the little embryos in my uterus to grow. However, intellectually I know that having a child right now is not the financially nor cognitively good decision for my career as a physician. No residency will want a pregnant pt or a new mom. I have already seen the mess it can cause interns when they have to stress between breast feeding during charting between patients. "
8am- Arrive at Surgery Center for checkin & provide sperm to lab
8:30 am- Taken back to pre/post-op room
8:45am- gowned & given IV in with Lactate Ringers & Antibiotics
8:50am - met anesthesiologist and sergeron
9:00am - emptied bladder then walked to procedure room and laid down on the bed
9:05 am - given anesthesia through my IV
9:30am - woke up and texted my husband in the waiting room I am "dome and loopy"
Removed: 30 follicles and 23 eggs!
Wait to see how many Embryos form
Day after the removal I heard that 9 embryos were formed so will need to wait 5 days to see which ones are able to progress to a blastocyst to then freeze!
5 days later learned: 4 Embryos were able to go to blastocyst stage!!
30 Follicles --> 23 Eggs ---> 9 fertilized to Embryos ---> 4 Blastocysts
There was still some pain around my umbilicus and low abdomen so I used my Intimate Rose pillow while driving and maternity pants!
Check out these resources I have used during my infertility and endometriosis journey.
Check out this new article in JAMA by medical students and physicians regarding barriers to family planning in medicine.