How can you not feel like a failure? Well, to be honest, I actually feel like I was failed by my medical team. It is also soooo hard to feel supported when the people around you just don't get it. (Un)fortunately, I have a good friend how gets it. Yes, we are 1 in 6, but we are also not alone. We understand that no one else understands. To try to be hopeful for each other is to be hopeful for ourselves. Every body is different. Again, I was on FB today. There were some ladies who were asking about estrogen priming. Well, estrogen priming didn't work for me, it over-suppressed me. I had an AFC of 8 on my baseline scanning, and after Estrace priming for 3 and a half weeks, it was 2. So, that was part of the failure - I got the wrong protocol to start with for my body. Failure number 2 was when the nurse told me to cancel everything. To have someone in your medical team put you down like that was just as devastating as seeing the #2 on the piece of paper. After discussing with my doctor, we agreed to try IUI. I was hopeful that my RE understood that I was tired of waiting. Six months of waiting and tests, and more waiting, and more blood tests. Failure number 3 came when the Sunday ultrasound technician failed to see my follicles that were larger than 10 mm in diameter. Failure number 4 came when my estrogen was noted to be high, but I was not given an antagonist to prevent ovulation prior to my IUI. Failure number 5 was when the nurse told me that likely my timed intercourse wasn't going to work. That it would be pointless to use progesterone during the early stages of 'pregnancy' because I wasn't going to get pregnant. You know how the say 3 strikes and you're out? Well, I'm not out but that medical team is!
My husband and I moved across the country during the COVID-19 pandemic. We arrived in BC in the middle of December. We were hearing about cases of COVID-19 going up. People boarding planes while knowing they had the virus. Sadly, we cannot rely on people to be honest and forefront. Since I was PUPO when we left Ontario, my doctor told me not to fly while undergoing treatment. One reason was due to the possibility of ectopic pregnancy, but the other reason was that air travel was not recommended and not safe due to SARS-CoV2. As soon as we knew that our protocol was being changed from IUI to TI (timed intercourse), I put the ball in motion. Booked a rental vehicle. Mapped out our drive across country. Booked hotels or motels along the way - avoiding all of the major city centres that had positive COVID-19 cases. I thought, hey, hubby has not seen Banff, let's make a short jaunt there and then he could see real mountains. Scheduled a UHaul box for pre-loading to empty the storage locker. Scheduled a UHaul box and hauling to BC. I had already shipped my hubby's vehicle, so shipping my vehicle was going to be the last item on the list. Sent information to my realtor about renting out the condo. Everything was organized in less than a week! Last minute, hubby needs to make a stop in Vancouver to pick up some equipment for his new job. You can imagine that I was a bit disgruntled since I had everything already planned! So, that little stop in Banff was brief. He didn't get to experience anything in the daylight and we drove past my dad's place to get to Vancouver, and then drove back the next day. I started at my new job on Dec 14th. I can tell you that the Okanagan folks are not nearly as strict as those in Toronto, but I am at least glad that people are being forced to wear masks if they are coming into the clinic. The last thing I want is to get SARS-CoV2! I just thought I would share a couple photos from the trip. My phone had gone crazy, so I'm not sure how many I actually have left, but there are a few at least!
Follicle Stimulating Hormone and Empty Follicle Syndrome
If you’ve been following along in my blog, you probably have learnt that I did my Master’s research in reproduction. We used a lot of follicle stimulating hormone (FSH) in all of our protocols, whether we were collecting oocytes for IVF (in vitro fertilization) or for oocyte quality parameters (oocyte competence). We collected mature and immature oocytes. We collected from cattle and bison in the projects I worked on. So, let's take a look at the steps that are required for oocyte collection. A transvaginal ultrasound probe is inserted to the vaginal fornix - this is the region surrounding the cervix. You can then see the ovary, with its follicles on the ultrasound machine. In cattle, we are able to hold those ovaries in our hand per rectum (as you would if you were doing pregnancy checks in cattle). You can hold that ovary, feel it, turn it, roll it, and position it so that we can collect the oocytes. In humans, this is not possible - adding to the difficulty for ultrasound guided follicular aspiration in people versus cattle and bison. On the ultrasound probe there is a needle guide, a long thin tube that fits a needle that is attached to some silicone tubing, which is attached to a filter system on the other end. Again, in cattle, while holding on to the ovary with our non-dominant hand, we take the needle and insert it into a follicle using our dominant hand (that's the hand you write with). We use suction with a vacuum pump to empty the follicle, then we turn the needle slightly so that the bevel of the needle scoops the inside of the follicle as it drains allowing the oocyte to be scraped from the inside of the follicle and suck down with the follicular fluid onto a filter. We then take this to the laboratory and rinse the filter into a petri dish, and do our searching for oocytes. As researchers, when we troubleshoot why we didn‘t collect 100% of the eggs, it varies with the experience of the practitioner - how many animals have you collected? It can vary with the size of the bevel (short bevelled needles collect better than long bevelled needles). It varies with the amount of suction (to be honest, I forget the exact amount of vacuum suction). It is not because there is no egg. It is a function of technique, the skill of the practitioner, the pressure of the suction applied on the machine, or syringe if you are doing single aspirations, and perhaps over maturation and death of the oocyte prior to aspiration. Empty Follicle Syndrome What is Empty Follicle Syndrome? This is when no egg has been collected during egg retrieval when a women is undergoing IVF treatment. Even in the medical community it is under debate. It seems rare (<2% of women under going IVF, with women who have low AMH and low AFC being over-represented within that <2% affected). There is also something called False Empty Follicle Syndrome (Kim and Jee, 2012). These women did not receive the appropriate dose of hCG for their 'trigger shot' or the oocytes were collected too soon after the hCG administration. The oocyte is there, but it was not retrieved. This could be due to failure of expansion of the cumulus-oocyte-complex (COC). Ok, you need more details on what the COC is. Prior to the LH peak, the support cells called cumulus cells are tightly surrounding the oocyte and we call this a compact COC. After the LH peak and prior to ovulation, these cumulus cells spread out and become sticky - we call this expansion. You have to have expansion of the cumulus cells, a sign of maturation of the oocyte in order to have fertilization. (Photos below from Ratto et al 2005 - (C) Partial expanded COC from llama; (D) Fully expanded COC from llama). Note that this is a continuum from compacted to fully expanded, with the clumps of cumulus cells showing up darker, then spreading out into an even and lighter group of cells. Expanded COC are sticky. The sticky cumulus cells help the oocyte travel in the female's fallopian tube (oviduct) towards the uterus. In human IVF, the majority of COCs undergo in vivo maturation and expansion following a 'trigger shot'. Hopefully that helps clarify things! During follicular aspiration (also called OPU or ovum pick-up) the oocytes may or may not be mature, and the cumulus cells may or may not be expanded. Sometimes we get oocytes with no cumulus cells, which we categorize in a separate category - denuded. It bothers me when people say and believe that not every follicle contains an egg (or oocyte). These are words that my RE has spoken to me, and the mean nurse (as described in a previous post) repeated it. I just do not believe it. I think in a normal follicle, each contains an egg. You can over-stimulate, and get oocyte apoptosis from oxidative stress. You can also have apoptosis from FSH starvation (see the image below). But prior to over-stimulation or 'coasting' protocols, you have an egg! So I really do not believe when someone says that not every follicle has an egg. Histologically, if you take the ovary with its follicles, preserve it and slice it into tiny slices and look at it under the microscope, you will see that each follicle has an oocyte associated with this. The truth is, you will not always retrieve 100% of the oocytes! Many doctors are Type A, high achievers, and they do not want to fail. Failure is less than 100%. So why set yourself up for failure? FSH Stimulation Protocols in cattle In our research lab, we have done a lot of studies on a short or standard FSH protocol of 4 days, and a longer FSH protocol of 7 days. The time from LH peak to oocyte collection (or AI for timed insemination protocols) is an important variable (we usually used GnRH as our injection for maturation - or trigger shot). Prolonging the duration of FSH stimulation from 4 days to 7 days improves the oocyte quality after collection. Stopping FSH injections for a prolonged during prior to LH peak reduced the oocyte competence (the ability for the oocyte to become fertilized) (Dias et al, 2013). Remember that cattle can be used as a model for human reproduction because clinical trials can be performed with more control over outside factors. Gonal-f Pen I started FSH stimulation on day 5 of my predicted cycle after estrace (estradiol) suppression. The Gonal-f pen came in a total of 900iu. The concentration ends up being 66ug/1.5mL. So if I am taking 150iu in the evening, this works out to be 11ug per dose. As previously mentioned, I had an AFC of 2, grew 3 follicles total, and then had 2 follicles that were 13mm. I was not on an antagonist, and therefore, started to ovulate on my own. In our cattle protocols, were would use an intra-vaginal progesterone releasing device (called a CIDR) to suppress LH release. Sadly, I was not able to go ahead with the IUI and had yet another failed cycle. It's my first post for 2021! This past year has seen so many struggles. So wishing everyone health and happiness for this up-coming year!
This week I had another pyometra. Pyo Queen strikes again! This particular dog was an almost 11-year-old doodle. The key thing is that I looked at her file prior to presentation and she was listed as an unaltered female. This means she still has a uterus. Presenting Complaint: Our patient presented to the ER due to a slight decrease in appetite over the past 4 days, not feeling herself, and then had an episode of vomiting. I immediately put pyometra on the top of my differential diagnoses, because she was an intact female. When my patient presented, I had two other veterinarians around me. I did my physical examination, and other than maybe some mild abdominal splinting, she had a fever of 39.8 degrees Celsius. For those that do not know, the normal dog temperature per rectum is 38-39 degrees. I get on the phone with the owner and tell them that an intact female has a pyometra until I can prove it otherwise. I would like to do an A-FAST (an abdominal ultrasound, quick assessment) and blood work to see if there is an elevation in white blood cells. We have blood work from 4 months ago to compare to as her normal. The owner gave me the go ahead, and I had the staff shave some of her abdomen so that I could get a better look. Sure enough, I see fluid filled cystic structures inside her abdomen, consistent with pus in the uterus. Our new graduate says, I think I would have missed that she was a pyo. My answer to that is, I missed one - and now I never miss one! Did I pigeon-hole the case? Yes, absolutely. But keep in mind that for any vomiting dog, blood work and an A-FAST is actually a good start to get some information on your patient! Now, remember, not all veterinary clinics have an ultrasound, sadly. I love ultrasonography - it's why I did my Master's in it! I am fortunate that my new clinic has a better ultrasound machine! In the absence of an ultrasound machine, you can take an x-ray of the abdomen. As you may recall, I wrote a blog post about this as well! So, I guess my post is just that... How do you not miss the closed pyometra? Tips: 1) Ensure you know your signalment. Remember that any intact female that is presenting with any symptom of not feeling well could have a pyometra. 2) Don't forget to take a temperature - and take it rectally. All of my cases of pyometra have had a fever. The aural temperature is not as accurate in our patients. 3) Remember that a pyometra requires surgical correction! This is not a matter of does your patient need surgery or not. It is a matter of are you going to cut today or tomorrow, or the next day? You have to use your clinical judgement with the patient. If they are stable, they can wait until tomorrow or even the next day. If they are in septic shock, showing those signs of shock such as tachycardia, hypoglycemia, or even low normal glucose in a clearly stressed or sick patient, you may want to go in sooner rather than later. Remember that a chance to cut is a chance to cure! 4) You can start IV antibiotics prior to cutting. It's a good idea to get your patient on IV fluids prior to surgery. Get them settled, ensure that their vitals are doing well. It also doesn't hurt to have some dextrose on hand for these patients, especially the smaller ones. 5) Take your time in surgery. The last thing you want is to try to rush and have the uterus rupture or disintegrate in your hands. Now I know, even if it does. Don't panic. Soak up what you can, and flush what you can.
Christmas was this past week. I have been at my new job for two weeks now, hence the delay in getting some blog posts out! I worked Christmas Eve which spurred my thoughts on this topic: Chocolate Toxicity in Dogs. Not too many people dislike chocolate! Many people bake over the holidays, and sometimes dogs decide to take a sample of those tasty treats. We had a 2 year old pup come in on Christmas Eve. She had gotten into some Christmas baking, and had potentially eaten up to 225 grams of semi-sweet baker's chocolate some time between 1 and 1:30 pm. The owner had come home to vomit and the evidence was in plain view on the floor. However, her pup continued to vomit on and off for hours. She could not even keep water down. The owner believed that there was no more chocolate left in her belly, but was getting anxious as the vomiting would not stop. Gastrointestinal signs, vomiting or diarrhea, are some of the signs a dog may experience when they consume chocolate. A dog with continuous vomiting will become dehydrated. The size of the dog will determine the severity of the dehydration, as if a dog cannot keep its body water at a normal level, their blood volume decreases, dropping their blood pressure. Patients with continuous vomiting will become hypovolemic, and if the dehydration is severe, their body can go into shock. The severity of the hypovolemia will be dependent on the size of the dog. Vomiting in a small breed dog will cause more issues than in a larger breed dog, as the smaller dogs tend to lose their percent body water faster than larger dogs. When our patient presented, she was still regurgitating water. On physical examination, the pup was a little hyperactive and had an elevated heart rate at 160 beats per minute (her normal at a previous visit was 120). Fortunately, she was clinically stable with no arrhythmias or seizures. How do you determine if your dog has consumed a toxic dose of chocolate? Well, if you're a veterinarian or veterinary student, then you can pull up the chocolate toxicity calculator on VIN (if you have access to VIN) Here you will see that if a 16 kg dog consumes 225 grams of semi-sweet baker's chocolate there is risk of seizures, collapse and possibly death. If your dog consumes dark chocolate or semi-sweet baker's chocolate, these are the more potent chocolate types. The toxic part being the methylxanthines, caffeine and theobromine. Most toxicities are dependent on the mg ingested per kg of body weight. So if the dog is a small dog that consumes a lot of dark chocolate, the toxicity will be higher and there will be more severe clinical signs. Since we could not be certain how much our patient had consumed or absorbed, the owner elected for in hospital monitoring. It is fortunate that our patient had vomited most of the chocolate prior to it being absorbed through the gut, however, the toxin (methylxanthine) can be reabsorbed through the bladder wall when it is excreted through the kidneys into the urine. This can contribute to prolonged duration of toxicity. Placing the patient on IV fluid therapy can help flush the toxin out of her system faster. Since we were able to support the patient over night, she was placed on IV fluids both to flush her system and to rehydrate her from the prolonged vomiting. She was given an injection of an anti-nausea medication as well as a low dose of diazepam for the agitation and hyperactivity. Since the dog had already vomited, and presented to our hospital 4 to 5 hours after ingestion, we were past the decontamination part of the treatment plan and on to supportive care. Supportive care is treating symptoms as they present. If the dog consumes chocolate and hasn't vomited on its own, then induction of vomiting could be part of the treatment plan, but that tends to be if you get the patient within 30 minutes of ingestion of the chocolate. After setting our patient up on fluids, with the anti-nausea medication on board, we were then able to give activated charcoal that was mixed with some wet food. If you give a benzodiazepine medication (diazepam or midazolam), then your patient will likely feel hungry and eat the wet food-charcoal combination, saving your staff from having to force-feed charcoal - not so fun! So, when do you bring your dog to the vet if they have consumed chocolate? Well, the sooner they are seen the better. This will again be dependent on the type of chocolate, the size of your pup and the amount of chocolate that they consume. The amount of methylxanthine differs with the type of chocolate that is consumed, with none in white chocolate, a small amount in milk chocolate, and a hefty amount in unsweetened baker's chocolate. Here is a basic chocolate toxicity calculator for you to review. What should you do if your dog consumes chocolate? Aside from calling your veterinarian, and seeking emergency care, you can also call the ASPCA poison control hotline. For more information on Chocolate Toxicity in dogs, see the article on the Veterinary Partner.
Follicles that ranged from 12 to 19 mm on the morning of the trigger shot were more likely to produce mature oocytes (Abbara et al, 2018). So, remember when I was talking about my IVF cycle being converted to an IUI? Well, someone, or multiple people, really made me lose my faith in our clinic's ability to assist us in our baby making process. I actually had started this entry a while back, because when I had initially gone through my cycle monitoring, the nurse had said that they like for the follicles to be around 18 mm prior to the trigger. Ahhhh, if you're not in the TTC community, you probably don't know what the 'trigger shot' even is. Ok, let's take a few steps back... If you can recall, in a natural cycle, the pituitary produces LH which causes luteinization of the follicles leading to ovulation of the oocyte or egg. In most human females, there is one egg released during each cycle, while the rest of the cohort in that cycle die off. LH is the natural trigger. Your trigger shot in your protocol may be a GnRH agonist - which causes the LH surge. During IVF and IUI, you can do hyperstimulation or superovulation and produce more than one follicle large enough to ovulate an egg. The stimulation comes from the injections of FSH. In my particular protocol for IUI I was using gonal-f, but there are others. So, you have more FSH from your injections and this FSH binds to more follicles, which prevents atresia of these follicles (atresia is the process of death of the follicles). Your AFC or antral follicular count - the number of follicles on your day 3 assessment - will show you roughly how many follicles will grow to be a large enough size to ovulation or be available to collect for IVF. So, disappointingly, my AFC was 2. Once my doctor saw that my AFC went from 8 to 2, this was the start of the problems. I had a nurse whom was incredibly discouraging - I will call her the mean nurse. She was telling me to cancel the cycle altogether. I had already been waiting over 6 months to get started! I had to convince my doctor to let me go ahead with something. You just feel like you have wasted so much time! So, we converted from an IVF protocol to an IUI. I started out with 150IU gonal-f, and went in every 3 days for cycle monitoring which was an ultrasound and blood work. Just so that we can compare, not that you should compare your protocol with mine, but everyone wants to know that they are not alone! Cycle monitoring: As you can see, I had 2 follicles on the right and 0 on the left. After going in for an ultrasound on Nov 19th, the nurse mentioned that I had three follicles. So hey, 3 is better than 2, I guess! After this, it was decided that I would take a smaller dose of the FSH to prepare for an IUI, instead of the heavy doses of FSH that were initially planned for my IVF cycle. I started gonal-f. Hubby did well with doing the injections, and then I went in for cycle monitoring (CM), an ultrasound (U/S) and blood work. It was good having an app to get an update, but I think it would have been really nice to actually speak to my doctor regarding my protocol. I really feel like they dropped the ball on my entire cycle. So anyway, after a few days of stimulation, I started to get a lead follicle of 5 mm. It's good to get something measurable! I even had my case transferred to a nice nurse for a little bit! So, I was told to continue with the FSH injections... Three days later, my lead follicle was 8 mm. This is good! I thought, yea, the follicles are growing slowly, but they are still growing! Roughly 1mm per day - while in my readings the average was 1.3mm per day. I was scheduled to go in on the following Sunday (three days later). I expected to have at least one 11 mm follicles on that Sunday. But here is the report... I sit down with the nice nurse after my ultrasound report and I look at the sheet and see that my lead follicle is not measurable. What happened to my 8mm follicle that was supposed to be at least 11mm???? The nurse discusses with me, that it's not looking good. I don't have any follicles that are over 10 mm and that they want something around 18 mm before triggering for an IUI. My second devastation of this process. The nurse says to me, we will likely have you come back on Tuesday or Wednesday. I am to take my gonal-f and wait for instructions on the app. I email my doctor's secretary asking if I can speak with my doctor. I'm wondering if I should cut my losses now and cancel this altogether. I check my app on Sunday evening and receive a last minute booking for an ultrasound on Monday morning. Geez!!! I have to scramble, I logged into my work system to see who was coming in for my appointments on Monday morning. I managed to send an email to one, and reschedule the other one. Talk about stressful!!! I go in again on the Monday morning, another ultrasound and blood work. I sit down with the nice nurse again (this is the nice nurse, not the mean one). She says, the reason we had you come in today was because your estrogen was really high. Over 600. It didn't make sense to have zero follicles above 10 mm and have estrogen this high! Ahhhh... So that ultrasound tech that worked the Sunday missed these follicles. The nurse says, things are much better, I feel relieved. I'm still going to continue with gonal-f and likely come in Tuesday or Wednesday at the latest. I go to work, feeling a combination of disappointment from the missed ultrasound on Sunday and relief. Monday was its usual hectic schedule, and I had three missed calls - one from the secretary, one from the nurse and one no voice message - that turned out to be from the doctor. I check my app. I look at it again... my IUI is cancelled and my app now read timed intercourse. What??? So, I leave a voice message for the nursing line, and the mean nurse happens to call back when I'm at my desk. She says my LH is high. I'm ovulating on my own and my IUI is now being converted to timed intercourse. That we have to do the deed tonight and tomorrow night. Then come back in 16 days for blood work. I am now angry. I am ovulating on my own because no one prescribed me an antagonist!!! WTF?! Why wasn't I on a antagonist? Why did the technician and nurse miss this? Why wasn't my doctor involved more?!? So many questions unanswered. I already know I have a luteal phase defect, so I tell the nurse that I will need assistance with this, that it doesn't make sense to just do timed intercourse, since this is what my husband and I have been doing all along! So, I ask for some progesterone. She mentions that she will send the script to the office. I had an acupuncture session the next day, so I would pick it up them. The script wasn't there, but the gentlemen at the office gave me enough for two weeks - to get me to my beta test. The male parties who are part of the TTC community know all about the struggles to perform when you're told you got to get it done now or never! Yes, that is the easy part fellas. No pressure right?! So a few days afterwards, I start progesterone suppositories - 200 mg am and pm. I'm to take it until I have a negative beta test. My hubby didn't have faith in our fertility clinic. As soon as the mean nurse told me to cancel, and my doctor gave up on our IVF cycle, he was done. He says, there is a reason that they are discouraging us. They just do not want to do IVF. If you're on Facebook, you know there are several TTC groups on there. There are a lot of women who express their frustrations with clinics who do not know how to handle women with low AMH. That they refuse to do IVF with a small number of follicles. A clinic's success rate is dependent upon only taking cases that they know will have a higher chance of success. With low AMH, my success rate is already low. What I didn't like is that they have this belief of empty follicles. All follicles have eggs at some point! It just means that the protocol chosen was incorrect for that individual, or the suction for follicular aspiration was incorrect. I know. Because we do histology on the ovaries in cattle and there are eggs in those follicles. I also know that there is a technique to trying to get the egg from each follicle. Sometimes you do not get all the eggs. So, we gave up on that clinic, and moved across the country. We arrived in BC on Dec 13th. I had to go to a walk-in clinic during the COVID-19 pandemic for my beta test. My doctor's office called on Dec 17th to let me know that the beta test was negative.
I connected with one of the counsellors on our FB group this past week. She always brings a weekly theme. This week was self-care. I can tell you that I have not done a lot of self-care these past weeks. I have been doing acupuncture, which is 20 minutes of guided meditation. But 20 minutes a week is probably not enough given the amount of stress I have been under. I was thinking the other day that I should find some free yoga classes online. Conveniently during this week's session, the counsellor had recommended Bettina Rae for Fertility Yoga. I'm going to use this page to link my fave videos: For Beginner's: This is a longer video, maybe about 50 minutes of yoga for beginner's. Many women, including Bettina, say that the number one thing you can work on for your fertility is to reduce your stress. I was watching another one of Natalie Crawford, MD's YouTube video's the other day, and she was describing cortisol levels. How in nature, this was built so that you can run away from a bear, which nowadays, this stressor has minimal existent for most people, but the stress response is still there. Cortisol lowers your blood flow and nutrients to the reproductive organs, because if you are getting chased by a bear, or another example would be during a season of drought and low resources, you don't want your fuel sources going towards reproduction when you may need it to survive. Here is one that is gentle for when you are preparing for IVF. I think this was a good one for these past few days of FSH stimulation medications. Don't forget to drink lots of water to flush your body and make you feel refreshed!
Well, this happened. I went in for a follow up ultrasound and blood work today. Then I spoke with a different nurse. She was much more friendly and kindly answered my questions. Tuesday I had two follicles, but I wasn’t told about my blood work results until today. So turned out my estrogen was also higher than it should be prior to starting IVF. The above was the Day 3 assessment from Tuesday. I had ordered one of those trendy and cute letter boards everyone is using on Instagram these days. I was excited to get going! But, today I chatted with my doctor, my FSH had increased to 13 and my doctor didn’t think I would be able to get more follicles recruited. Then the ones that are there may not respond. So instead, we decided to go ahead with an IUI. So. I had to change up my letter board a bit. Sometimes things just do not go according to plan! Everyone likes to know what protocols are being used. So, I am starting Gonal-F at 150iu once daily in the evening. I had my hubby do the first injection. The only thing to note is to hold the pen perpendicular once the needle goes in. Otherwise the needle starts to bend around inside your body. There was only some mild stinging. The medication smells like Cerenia though - which is gross. Oh well! We started!
For those folks in the GTA and paying out of pocket, Glen Shields Pharmacy is more affordable. Very small mark up and no dispensing fee! The fertility medications are so expensive. This one pen of 900iu cost over $900. Anyway, I have four days of stims, and then go in on Monday for the next ultrasound and blood work. Wish us luck!
I went in today for my Day 3 assessment after stopping my priming medications: Estrace, Androgel and Prometrium on Saturday. My AFC went from 8 in June, to 2 - TWO!!! Mini panic... Do I start to cry now? Wait... the nurse is now telling me they are going to cancel my IVF cycle? Wait, what?! What is happening?? No!!!!! Let me tell you what it feels like. First, you get a wave of emotion equivalent to hearing that someone has died, then you're supposed to grieve. Yet, now someone is telling you that it's not a big deal. We'll just cancel and start all over. No time to grieve those other 6 follicles that could have been. Then you feel angry, because you've been waiting six months just to start your IVF protocol. Cancelled? No, no, no... We're going through with this! Let's recap the conversation that we had with my RE when we discussed our IVF protocol. We're starting with 8 follicles. Ok, so let's play the hypothetical game and say we don't have 8, let's give a cut-off of 4 follicles. If there are 4 follicles, then we will for sure go to egg retrieval. If there are 3 or fewer, then we (my husband and I) can decide if we want to go ahead with retrieval, or convert to an IUI. As the nurse is telling me that she is just reading what the doctor's notes say - it clicks in my head that this is not what the doctor meant. The nurse was not there for the conversation. Going through fertility treatments without speaking to your fertility doctor directly is like playing a game of broken telephone. I am on a timeline. I turn 40 at the end of this year. I do not have time for the doctor to regroup and come up with another plan. I wrote about Dr. Crawford's advice previously. You have 4 resources: Time, Money, Physical Health and Mental Well-Being. I am running out of time! I relay my conversation regarding the protocol meeting to the nurse, and she discusses the medications for stimulation. She says she will call the pharmacy later when they open (since I have there early morning for diagnostics). Ok, perfect! I asked for the medications to be filled at an at-cost fertility pharmacy, since I am paying for the medications out of pocket. I leave the nurse's office and head to get some acupuncture done. My naturopath is positive and up-lifting. I have a good session. I'm feeling a little bit more relax. It only takes one. I stop and pick up a chai latte and head on my way home. Fast forward to this afternoon. The IVF nurse calls and says that I need to go in again for an ultrasound and blood work on Thursday. She had spoken with my doctor and that she wasn't pleased with the results. Thursday - great ok. So now I have to last minute rearrange my work schedule. It's ok! My manager is understanding... we got this. But, Thursday is the morning that I am supposed to start the stimulation medications. I contemplate how I am supposed to juggle getting all this done and get to the pharmacy, while also working. Things are not looking good for me now. If you're like me and you have low AMH, you will understand. If you do not have low AMH, then you will probably not understand. Women with low AMH are not expected to have a lot of follicles. Many of these women will still go to egg retrieval for a couple of follicles, because it only takes one to make a baby. The focus is on quality versus quantity. There are some women who have 20 follicles and get nothing at the end. While others with 1 or 2 and get to take a baby home. I was trying to turn my loss of 6 follicles into a positive. This can still work. We can still get a baby from 2 follicles! My husband on the other hand. He doesn't like it. His gut is telling him that whatever the reasons are behind them stopping my cycle is because they are not positive. It would be different if they were hopeful, and excited, but they're not. So if they are going in, expecting the worst case scenario, then they are not going to help us. So I get it. My hubby says he'll do whatever I feel like doing, but I get where he is coming from. It doesn't make it any easier to handle though. As always... stay tuned for the next post on what actually happened! For more on my fertility journey click here.
We have had a LOT of coughing dogs this past week. A few of the owners that have come in saying that Kennel Cough is going around the dog parks in North York/Toronto. I cannot seem to find any current news on this - except this article from PEI. Most are young dogs that present to us with a history of coughing, maybe coughing up phlegm, seemingly trying to cough something up. Their coughing is keeping these pups up at night, but also waking up their owners. Often they had visited a dog park where friends of theirs mentioned kennel cough is going around. What is Kennel Cough? Kennel Cough is a complex typically with viral and bacterial component. Viral infections do not have specific treatments. However, most dogs are vaccinated for a few of the viruses that can be part of the Canine Infectious Respiratory Disease (CIRD) or infectious tracheobronchitis - commonly known as Kennel Cough. Some of these viruses are canine parainfluenza virus, canine distemper, canine adenovirus 2 (these three viruses are in your standard vaccines for dogs), in addition to canine herpes virus, canine respiratory coronavirus, canine influenza amongst others. Which viruses are part of the CIRD complex will be dependent on where you live. Either way, they are highly contagious. On top of these viruses, we add in bacterial organisms: Bordetella bronchiseptica and Streptococcus equi subsp zooepidemicus, and Mycoplasma spp. In Canada, we have a vaccine for Bordetella - which can be administered intranasally, orally or by subcutaneous injection - depending on your veterinarian's supplier. Vaccination of your dog does not mean that they cannot get Kennel Cough, it just means that they will have some antibodies to target these organisms, allowing their immune system to respond quicker. This tends to allow them to not be ill for a long duration of time, and not have severe symptoms of lethargy and fever (Ellis et al, 2001). Additionally, there are asymptomatic carriers (just as there are for COVID-19 in people). Approximately 50% of dogs with no symptoms will test positive for one of the viruses or bacteria, with about 13% of them carrying at least two of these bugs (Lavan and Knesl, 2015). How do we treat Kennel Cough? Most of the time, these patients do not require antibiotics. If you think about the common cold in people, similarly, you do not need antibiotics for these people either. Many of these cases are due to viral pathogens that do not respond to antibiotics. However, if the patient is at a higher risk of development of secondary opportunistic bacterial pneumonia, then we may do a short course of antibiotics. Many of these puppies that come in are healthy, happy, bouncy puppies ages ranging from 6 to 10 months, with likely first time exposure to Kennel Cough. When they are willing to eat treats and socialize with our staff, but cannot sleep at night due to their cough, I will prescribe a cough suppressant medication. These pets have clear lungs, and their only symptom is a cough. Most clear the infection on their own after 7 to 10 days. What about Older Dogs with a Cough? Also this week, I had a 14-year-old FS Shih Tzu mix present with a cough. The owner mentioned that kennel cough is going around, and she had a new puppy that had a runny nose. Perhaps the new puppy gave the older dog kennel cough. The difference with this case is that the patient had other clinical signs that are not typical of kennel cough. She had vomited some clear fluid and she was not eating her regular meal. On physical examination, she had a tense abdomen, and her cough was elicited by pressure on her abdomen, but not on palpation of her trachea. Therefore, in this case, chest x-rays and blood work are warranted prior to any cough suppressant medication. In another case of an older patient with a cough, we have an 8-year-old MN Samoyed present with coughing with activity and not able to go on long walks. On examination, when I pushed on his abdomen he started to have increased issues with breathing. No coughing was observed during his examination. After x-rays and sending these off to a radiologist, he was diagnosed with a spontaneous pneumothorax from a partial rupture of an air sac (bullae) in a lung lobe. This is a lesson to future veterinarians. Always take a thorough history and then use that in the context of your physical exam findings prior to making a decision on your diagnosis. Prevention of Kennel Cough Ensure your pup is up to date with its core viral vaccines. If your dog is at high risk, then have your pup vaccinated for Bordetella. If your dog has a sudden onset of coughing, do not take your dog to the dog park. Please do your due diligence and avoid social contact with other dogs. Let other dog owners know in your neighbourhood that your dog has been coughing and could potentially have Kennel Cough. Do not let your dog go on its walks with the dog walker. Do not let your dog go to daycare. Do not let your dog go into another dog's bubble. Nose to nose contact is all it takes to spread the disease. Do not assume it is Kennel Cough - especially if you have an older dog. Take your dog to your veterinarian for an assessment. Any other signs like loss of appetite, vomiting, fever, or lethargy should be assessment by a veterinarian. More coughing dogs - head here. Don't forget that coughing can also be heart failure.
Megan, I just watched your video, and I was literally crying midway. We have to be so brave to put ourselves out into the public eye with our journey. Women should not have to silently suffer. For those brave women on this journey with us. You are not alone. Stay tuned for my interview with Megan! Until then... please click through and follow her journey.