My Infertility Timeline (#2)

Synopsis: We realized how much of a miracle our first pregnancy was when the same protocol that worked on the first try two years previously, failed three times this go around!

After the birth of my first child, I decided not to prevent another pregnancy -- no birth control whatsoever. If the first one was so hard to come by, I would happily take another one "too early"! I have heard of some women's bodies "resetting" after a pregnancy, and of being super fertile after a long struggle getting pregnant the first time. If that was to be my destiny, I would accept it!

I had no such luck!

Around ten months after giving birth, and after a couple of months worth of charting anovulatory cycles and using OPKs, we returned to our fertility specialist for help. To make matters more urgent, we had just learned we would be moving out of state in a few months, and our insurance would be changing.

Our fertility specialist, understanding our concerns about losing our coverage for infertility, decided that we could at least fit in a few attempts at IUI before our move. She recommended I wean my baby so that breastfeeding would not limit the effectiveness of fertility treatment.

For my first cycle, we did what had worked the first time: 5 days on Femara, an HCG trigger shot, and an IUI. My uterine lining was not as thick as desired at my follicle ultrasound, so I was prescribed Estrace, administered vaginally, for the two days leading up to the IUI. The day after the IUI, I began my Progesterone suppositories. And two weeks later, the results of my blood test were negative.

For my second cycle, we tried the same protocol: 5 days on Femara, an HCG trigger shot, and an IUI. No need for Estrace. I had 3 good follicles. The day after the IUI, I began my Progesterone suppositories. My hopes were high, imagining triplets, or twins, or at least a singleton! And two weeks later, the results of my blood test were negative. This was extremely crushing news, after such a hopeful follicle ultrasound. At my baseline ultrasound for the next cycle, I cried. I felt so defeated. And it felt so unfair that I had to get right back on that horse, without a chance to grieve.

For my third cycle, we adjusted the protocol slightly: 5 days on Femara, a Gonal-F injection to give a boost to my follicle development, an HCG trigger shot, and an IUI. Again I was prescribed Estrace leading up to the procedure. Only one good follicle. The day after the IUI, I began my Progesterone suppositories. And two weeks later, the results of my blood test were negative. I kind of expected it this time.

For my fourth cycle, we again adjusted the protocol: 5 days on Femara, a double Gonal-F injection to give a boost to my follicle development, an HCG trigger shot, and an IUI. No need for Estrace. Only one good follicle. Following the follicle ultrasound, we met with the doctor, who recommended that if we didn't get a positive result this time, we should move onto IVF. My caring, wonderful doctor performed the IUI herself this time, which meant a lot to me! I thought it was so kind of her to show that kind of interest in me, and I appreciated her support. The day after the IUI, I began my Progesterone suppositories. And two weeks later, the results of my blood test were POSITIVE!!!! HCG was 173. We received the happy news 3 days before leaving for our cross-country move. Truly miraculous!

Dealing with Hirsutism

Synopsis: If your extra hair due to PCOS bothers you, here are some things you can try.

Women with PCOS often have excess hair growth (hirsutism) due to an overproduction of androgens. This results in sometimes dark, coarse hair growth, most commonly on the upper lip, chin/beard area, breasts, lower abdomen, inner thighs, and lower back, and less commonly on the chest, upper abdomen, and upper back. I know from personal experience that this hair growth can negatively impact one's self-confidence and body image! It can be challenging to look and feel feminine.

If your hirsutism bothers you, there are various solutions you might like to try.

Accept Your Body

While hirsutism can be annoying, it is not harmful in itself. It is certainly possible to love and accept your body and its appearance! Your hair growth may make you look different than some people's standards of beauty; however, the natural variance of human bodies lends to beauty! Do not be afraid to be different. Social pressure is not necessarily a reason to alter your appearance, and if you like the way you look, you will be confident, which is always an attractive feature. Hold your head high, be generous with your smile, and you will look and feel great!

Treat The Cause

Birth control pills can alter the hormonal balance in your body, slowing the growth of unwanted hair. Obviously this is not a good solution if you are trying to conceive.

Spironolactone is an anti-adrogenic prescription drug that can help treat hirsutism. It can take several months to see a noticeable difference in hair growth. It should not be used in pregnancy or breastfeeding. See the ASRM guide on Hirsutism and PCOS for other drugs that serve a similar purpose. 

Remove The Hair

Plucking unwanted hair is an option; however, in my experience, it often results in infection, causing acne. Waxing is a similar option with the same downside. 

Depilatories, which dissolve hair, may also be an option; however, they may irritate sensitive skin. 

You can bleach hair; this is most effective for small areas, such as the upper lip. The hair is not actually removed, but is less visible as a lighter color.

Shaving is another option; it may cause stubble, but is "probably the simplest and safest way to temporarily remove hair," according to the ASRM guide.  

Electrolysis permanently destroys hair follicles; however, this is done one hair follicle at a time, so may not be practical, and is fairly expensive.  

Laser hair removal is another option. I was told by a doctor that it was not a good option, because it is expensive and not permanent; however, the ASRM guide claims that it is effective (but not necessarily over the long-term). 

Ultimately, the best remedy for hirsutism is a combination of the three methods above: accepting your body, treating the cause, and removing unwanted hair. It may take some experimenting to figure out the right combination for you, but if you do not want to be a "bearded lady," you have options!

Choosing a Fertility Specialist

Synopsis: Choose a doctor with good credentials, with success rates near the national average, and, most importantly, that you like!

Before we went to a fertility specialist, I had seen three different gynecologists and had had both positive and negative experiences with them. I knew I wanted a fertility specialist who would take my case seriously and treat me with respect; I did not want my treatment to be delayed or impeded any further!

Luckily, I found a wonderful doctor that was recommended by my gynecologist AND whose clinic was in-network on my insurance plan. She also listened to my concerns and made me feel like I mattered!

If I were in the process of finding a new fertility doctor, here is what I would do:

1. Check my insurance network. I would see if there were any fertility specialists in-network for my insurance plan. Not all insurance policies offer coverage for infertility, but if yours does, it may be worthwhile to choose an in-network doctor.
2. Get a recommendation from my primary care physician/family doctor/gynecologist. If you have been seeing a doctor for fertility-related issues, or for anything else, ask if they have a recommendation for a fertility specialist. Chances are, they will know of a good specialist in your area.
3. Check the SART website. The Society for Assisted Reproductive Technology is a professional organization of doctors who perform IVF. Clinics that belong to this society meet high "meet the highest standards for quality, safety and patient care." You can compare the IVF outcomes of different clinics on their website. It is advisable to seek out a clinic with outcomes near the national average. 
4. Seek out reviews and ratings for the clinics and doctors I am interested in. If nobody has anything nice to say about a particular doctor, that might be an indication that there is a problem! However, keep in mind that "you can't please everyone" -- even a doctor that might be perfect for you has probably not been a good fit for someone else. 
5. Meet the doctor. I think it is extremely valuable to consult with your doctor face-to-face. Do you feel that he or she is concerned about your situation? Is the doctor willing to answer your questions in a way that you understand? Do you feel comfortable with the doctor and the staff? Do your personalities clash? This doctor and staff will be intimately involved in the creation of your family. It is worth finding someone that you like!

Healing Cracked Nipples

Synopsis: You don't have to endure a cracked nipple when you are breastfeeding!

Unrelated to my PCOS, I dealt with a cracked nipple for a time when I was beginning to nurse my baby. It was so painful when the baby would latch on that side that I avoided nursing on that side. Ultimately it was the reason I went to a lactation consultant.

What finally helped was:

Taking a few days off of nursing on that side, and instead solely pumping
Rinsing the nipple with salt water a few times a day
Applying breast milk to the nipple
Newman's Ointment
Lanolin

As long as the baby was still nursing on the damaged side, the nipple would not heal. Pumping allowed me to relieve engorgement and maintain my milk supply. It also helped me avoid further damaging my wound. Once it healed, we were able to recommence breastfeeding on both sides.

Breastfeeding with PCOS

Synopsis: PCOS can affect how much milk your body produces after your baby is born! Who knew?!

Before my baby was born, I had no idea having PCOS could impact breastfeeding!

Two weeks post-partum, I went to a lactation consultant for help with an injured nipple. I left devastated after learning my supply was not adequate to sustain my child (who was still half a pound shy of birth-weight).

Estimating my supply with a rented pump, I found I was producing about half the quantity of milk that my baby probably required. I was given instructions to nurse my baby every 2 hours, pump afterward, and supplement with formula and whatever I was able to pump. (As a new mom, this was completely overwhelming. Nursing my baby took an hour and pumping took probably half an hour altogether -- when was I expected to sleep?! Not a great solution!)

The lactation consultant suggested, and my own research confirmed, that taking Metformin could help my supply. Prior to my pregnancy I had been prescribed Metformin, so with the green light from my doctor, I recommenced taking it.

Although I still supplemented with formula, my supply seemed to improve. My nursing routine looked like this:

• Nurse on one side and simultaneously pump on the other
• Burp the baby & switch
• Bottle-feed the baby the pumped milk
• Bottle-feed the baby additional formula if she still seems hungry

I found that I was able to pump more if simultaneously nursing. Additionally, this resolved any pain from engorgement and limited possible leakage from a let-down.

While I was very disheartened to not be able to exclusively breastfeed, I continued to nurse my baby and supplement with formula until weaning at 10 months. My original goals had been much loftier, but I am glad I was able to provide immunity and at least some of her nutrition in this way!

What I will do differently next time:

• Go on Metformin right away after the baby is born
• Allow the baby to nurse longer at birth
• Start pumping in the hospital
• Weigh the baby more often the first couple of weeks to chart weight loss and re-gain
• Not give the baby a pacifier
• Just accept that a newborn wants to nurse ALL the time!