babymaking

Monitoring in IVF cycles - details

2008-11-30T05:47:00.000+08:00

MONITORING IN VITRO FERTILIZATION (IVF) CYCLES

E. Tawfik, A. Mastrorilli and A. Campana
Infertility and Gynecologic Endocrinology Clinic,
Department of Obstetrics and Gynecology,
University Cantonal Hospital, 1211 Geneva 14, Switzerland

The term " monitoring " means " close continuous observation ", so when we refer to monitoring an in vitro fertilization and embryo transfer (IVF-ET) cycle we mean close observation not only of a patient’s initial parameters and her own ovarian response to ovulation induction, but also events after completion of the therapy.

Why monitor the patient? Monitoring serves two purposes. On the one hand, it helps the physician to choose the most suitable protocol, or to modify the dose and/or the approach for the protocol being applied in an attempt to obtain the best possible outcome and avoid complications of therapy or of the procedure as a whole. On the other hand, monitoring our patients adds to the common pool of information which increases our knowledge and understanding of human reproduction.

In our opinion, monitoring IVF patients begins with the initial infertility work-up, and continues until after delivery. This chapter is concerned, however, with the time period of an IVF cycle which starts just before induction therapy and ends either by the establishment of a biochemical pregnancy, or failure of implantation. Before discussing different methods of monitoring, it is better to divide monitoring into three stages: before starting induction therapy, the period of induction and the period that follows completion of therapy.

Before induction therapy

During this period, one has to think about which protocol should be offered to the patient. This depends on many factors such as the patient’s endocrine profile and general health, her age and financial situation, and the physician’s previous experience.

Clomiphene citrate

Before prescribing clomiphene citrate (CC), the physician should be sure that the follicle stimulating hormone (FSH) is not abnormally elevated and that the patient is not hypoestrogenic. One should rule out disorders of the pituitary, adrenal and thyroid which require specific treatment. Liver function evaluation should precede CC therapy if history and physical examination findings suggest liver disease. Ultrasonography (US) should be done just before starting the therapy to exclude ovarian cysts.

Gonadotropin therapy

If gonadotropin therapy is chosen, it is of utmost importance to exclude ovarian incompetence because this type of treatment is very expensive and is not free of complications. Abnormally high serum levels of gonadotropins with low estrogen levels indicate ovarian failure which precludes induction of ovulation except in a few special cases. Non gynecological endocrine problems should be treated before starting the therapy. Hypogonadotropic function with galactorrhea requires evaluation for an intracranial lesion. It is important to know that hyperprolactinemia has no adverse effect on ovarian response to exogenous gonadotropin therapy (8). Ultrasonography should be done to exclude the presence of ovarian cysts and/or polycystic ovary disease (PCO) which require special care.

Gonadotropin releasing hormone analogue (GnRHa) combined with exogenous gonadotropin therapy

This approach is especially effective for women who either show no response to exogenous gonadotropins, or who develop premature spontaneous luteinizing hormone (LH) and progesterone rise. Indeed the major effect appears to be the prevention of premature luteinization which is a major reason for decreased success with other therapies. Patients with significant estrogen and gonadotropin levels, especially anovulatory women with PCO do not respond well to gonadotropins but the response can improve after GnRHa desensitization. Some protocols call for GnRHa use during the luteal phase of the preceding IVF cycle, others advocate its use during the follicular phase concomitantly with human menopausal gonadotropin (hMG) and/or pure FSH. At present there is no agreement as to which protocol is best, and the information available is rather conflicting.

If it is decided to prescribe the long term GnRHa protocol, the patient should be monitored for the criteria of pituitary and ovarian suppression. Complete suppression is verified by the onset of menstruation associated with a serum LH <2>10 mm in diameter. If all these criteria are not met on day 12, GnRHa should be continued and the patient assessed at weekly intervals until suppression is complete, then induction can be started.

Monitoring ovarian response to induction therapy

Monitoring ovarian response to induction therapy depends mainly on the biophysical parameters of follicular growth, and hormonal parameters, principally E2 levels.

Monitoring follicular growth

Sonography can depict developing follicles, beginning at the time they measure between 3 and 5 mm. As follicles spontaneously reach maturity in the natural cycle their inner dimensions range from 17 to 25 mm (9). Within the same individual however, the size of a mature follicle is relatively constant. Intrafollicular echoes may be observed within mature follicles probably arising from clusters of granulosa cells that shear off the wall near the time of ovulation. After ovulation, the follicular wall becomes irregular. The fresh corpus luteum usually appears as an echogenic structure with a small hypoechoic center. Patients undergoing ovulation induction are usually examined every other day beginning at day 10, but those undergoing IVF–ET are examined earlier, usually starting between day 5 and 8 of their cycles, and daily thereafter.

In CC-treated cycles, each follicle seems to develop at an individual rate, and at times may be accelerated or slowed down. Therefore the largest follicle on a given day may not be the same one that is the largest two days later, and it may not even be the one that is most mature. Furthermore, correlation of E2 and follicle size is poor and the maximum preovulatory diameter can range from 19 to 24 mm. However, the largest diameter in these cases estimated by Fossum et al. (12) ranged between 22 and 31 mm.

In hMG-treated patients, there seem to be two distinct patterns of follicular development (35). In amenorrheic women with dormant ovaries, a small number of large follicles develops. The growth rate and E2 production are linear, correlate well and are of equal predictive value. A high pregnancy rate is achieved in this group. In contrast, stimulation of patients with estrogenic activity requires less hMG and usually results in the rapid recruitment of many follicles with different growth rates and E2 secretory capacity. The rate at which E2 increases is exponential, increasing the risk of hyperstimulation. The growth rate and functional maturity are asynchronous. In this group of women, both E2 and sonographic follicular monitoring are essential.

The biophysical indicators that correlate best with the day of LH surge (12) have been found to be the follicular volume in spontaneous cycles (range: 3.4-5.6 ml), the cross-sectional area in GnRH stimulated cycles (range 1074-1382 mm2) and the largest diameter in CC-treated cycles (range: 22-31 mm). Because no significant difference was seen in the correlation among the various biophysical variables and the mid cycle LH peak however, it could be concluded that in women ovulating spontaneously, or in those induced to ovulate with CC or GnRH, any available biophysical index will have the same predictive value. In contrast, correlation analysis in cycles treated with hMG indicates that both the follicular diameter and E2 are required for optimal timing of human chorionic gonadotropin (hCG) administration.

Sonographic delineation of follicle size is crucial because hCG is best administered once follicles reach 15 to 18 mm in size even in non-IVF cycles when ovulation is allowed to occur, as the LH surge is less frequent when hMG is used for stimulation. For IVF, follicles are typically aspirated when they reach 15 to 18 mm in average diameter and when the E2 level is approximately 400 pg/ml per large follicle (20). Another sonographic sign of mature follicles is the presence of low level intrafollicular echoes, as mentioned earlier. When follicles >15 mm are aspirated, oocytes are at all stages of maturity (23). Therefore one can rely on follicular diameters alone if the patient’s previous cycles and her E2 response are known.

There is no difference in E2 production between follicles measuring 14 mm and those that are smaller, nor between follicles measuring 17 mm and those which are larger (32). The authors devised an equation to determine expected serum E2 levels depending on number and size of follicles in both ovaries. Thus the serum E2 level on the day of hCG injection is:

E2 = 291 pg/ml + 180 (x) + 64 (y) + 18.7 (z)

where x, y and z represent follicles measuring >17 mm, 15 to 16 mm and <14>9 mm thick) and group B (<9>300 pg/ml by day 8 of stimulation. Fast responders had their E2 levels >300 pg/ml by day 5 of stimulation. However because E2 levels can be augmented to comparable levels by increasing the dose of gonadotropins, a correlation between E2 levels and gonadotropin dose is needed. Ibrahim and co-workers (16) defined poor response in desensitization protocols as the need for 4 or more ampoules of hMG/day to induce ovulation.

The dose of gonadotropin should not be changed as long as serial E2 levels rise between 50 and 100% every other day (32). Dirnfeld et al. (6), showed that very slow or very rapid estrogen growth rates (EGRs), calculated from the 4 days preceding oocyte aspiration in CC/hMG stimulated cycles, were associated with a reduced pregnancy rate. EGRs of 0.31 to 0.41 were associated with optimal pregnancy rates. EGR is calculated by the formula:

EGR = e-B -1

where B is the slope of the least square line corresponding to the semilogarithmic plot of E2 values versus time and e = 2.718.

Using GnRHa and gonadotropin in a desensitization protocol, the ovarian response was evaluated in terms of E2 levels on the day of hCG injection, and 36 hours later at egg retrieval (23). Low responders, medium responders and high responders were those with E2 levels of <800>1500 pg/ml respectively on the day of hCG injection or <400>1000 pg/ml respectively at egg retrieval. There were no differences between the three groups in respect to development of mature oocytes and rapidly cleaving embryos. The pregnancy rate in the low responding group, however, was significantly lower than in the other two groups, despite replacement of an equivalent number of oocytes and cleaving embryos. Thus it seems that the receptivity of the endometrium depends at least partially on adequate E2 levels. It also seems that E2 levels do not directly correlate with oocyte maturity and embryonic growth.

An upper limit of estradiol of 3800 pg/ml for anovulatory women (with polycystic ovaries) and 2400 for women with hypothalamic amenorrhea produces a risk of severe hyperstimulation of 5% in pregnant cycles and 1% in non conceptional cycles (14).

Paltieli and colleagues (28) found that in hMG cycles in which ovulation was triggered by using hCG injections, at least 80% of pregnancies were achieved when the E2 rise (active phase) was 6±1 days, whereas only 15% of pregnancies were achieved when the active phase was >7 days. They attributed the high incidence of early abortion, when the active phase was >7 days, to be an expression of oocyte overexposure to hMG prior to hCG injection. Such overexposure may result in postmature oocytes and end in early abortion. The same group of investigators noted also that in good outcome cycles, E2 continued to rise until hCG was administered, but in nonpregnant cycles, E2 plateaued on the day before hCG administration, which suggests that luteinization or atresia of the more advanced follicles had commenced spontaneously.

Monitoring special situations

CC/hMG protocols

Although adequate follicular development occurs with CC and hMG combination regimen, it is thought that one problem with that regimen is premature luteinization (13). In general, it is believed that the rise in serum progesterone occurs 12 hours before or on the day of the onset of a spontaneous LH surge in a natural cycle, or in a controlled ovarian hyperstimulation for IVF-ET program (36). Fleming and Coutts (10) defined the criteria for premature luteinization to be: serum progesterone >1.5 ng/ml associated with a rise in serum LH concentration before maturation of the developing follicles, together with a decline or plateauing of the serum E2 concentration despite continued hMG administration. However, there were reports that a significant rise in serum progesterone occurs in advance of the onset of the LH surge in regimens using a combination of CC and hMG (30).

In 1992, Mio and colleagues (24) defined " subtle progesterone rise " as a fluctuation in the serum progesterone concentration of between 1 and 2 ng/ml from day 7 of the cycle until 24 hours before the hCG administration, or the onset of the LH surge. This is not coupled with a significant increase in the serum LH concentration, defined as an increase of <100%>17-18 mm in diameter. Patients with poor follicular development or with only one developing follicle are not given hCG. It is inadvisable to give hCG to patients in whom the serum estradiol level is seen to increase rapidly (i.e. doubling in 24 hours) in order to minimize the risk of the OHSS.

Just prior to hCG injection, a serum LH can be drawn and compared to values earlier in the cycle. This helps to identify women who have initiated a premature LH surge (LH value 2.5 times baseline). However, without frequent sampling of LH (every 3 hours), the onset of the surge cannot be identified with precision (33). LH sampling is not required in patients who are treated with GnRHa. If a spontaneous LH surge occurs in a stimulated cycle, some centres cancel the treatment cycle, whereas others give hCG if there is a satisfactory estradiol response and adequate follicular growth has taken place (37). In these cases, it is necessary to adjust the timing of oocyte recovery.

As a general rule, hyperstimulation is associated with the presence of many follicles. It is advisable that hCG not be administered if there are more than 3-4 follicles of 14 mm or more in diameter (33). Mild hyperstimulation has been associated with an increased number of intermediate size follicles and severe hyperstimulation with an increase in small follicles (2). A large number (11 or more) of small follicles should also preclude hCG administration.

Check and colleagues (4) used hCG to trigger ovulation in their patients in whom ovulation was induced by hMG. The timing of injection of hCG was influenced by the serum progesterone level as follows: if the serum progesterone was >1.8 ng/ml, then 10,000 units of hCG would be given as long as there was at least one dominant follicle with serum estradiol >200 pg/ml, even if multiple follicles were present and the serum estradiol was <200>25 mIU/ml is diagnostic and is confirmed by a rising titre 3 days later. When pregnancy is diagnosed, it may be necessary to support it by exogenous hCG administration until 12 weeks gestation. The diagnosis of a clinical pregnancy is made when one or more gestational sacs can be identified by ultrasound image 4 to 6 weeks after oocyte retrieval. Embryonic viability is diagnosed when the heart beats can be detected on the screen.

This is not the whole story. Pregnant patients still need close follow-up and special care in relation to an expensive precious pregnancy until after labour and delivery.

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Measuring estradiol levels before HCG to predict success of IVF treatment

2008-11-30T05:31:00.003+08:00

Found this article the other day while surfing the net - interesting read for those who are looking for quantitative methods to predict success rate of IVF treatment.

Association of estradiol levels on the day of hCG administration and pregnancy achievement in IVF: a systematic review Ioannis P. Kosmas, Efstratios M. Kolibianakis1 and Paul Devroey
Center for Reproductive Medicine, Dutch-speaking Brussels Free University, Laarbeeklaan 101, 1090 Brussels, Belgium
1 To whom correspondence should be addressed. Email: stratis@easynet.be
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BACKGROUND: Evaluation of the association between estradiol (E2) levels on the day of hCG administration and pregnancy achievement in IVF has so far yielded conflicting results. The purpose of the present study was to systematically review the above association in cycles down-regulated with GnRH analogues. METHODS: Literature search was performed using Medline, Embase (1978–2004) and the Cochrane Library. Additionally, references of retrieved articles were hand-searched. Only full articles published in peer-reviewed medical journals were considered for analysis. RESULTS: All the eligible studies (n=9) involved the use of GnRH agonists and were retrospective. Two studies (including 191 patients) suggested that the higher the E2 levels on the day of hCG administration, the higher the probability of pregnancy. However, five studies (including 1875 patients), did not support an association between E2 levels on the day of hCG administration and pregnancy rates. Moreover, two of the studies including (1286 patients) suggested that high E2 levels on the day of hCG administration are associated with a decreased probability of pregnancy. If we consider only studies in which criteria used for administering hCG include follicular development but not E2 levels (including 2687 patients), there is no study suggesting a positive association between E2 levels on the day of hCG administration and pregnancy achievement. CONCLUSIONS: Currently there is no high-quality evidence to support or deny the value of E2 determination on the day of hCG administration for pregnancy achievement in IVF cycles, where pituitary down-regulation is performed with GnRH agonists. Existing retrospective studies suggest that there is no positive association. However, in order to arrive at recommendations for clinical practice, there is a need to perform well-designed prospective studies in both agonist and antagonist cycles.
Key words: estradiol/GnRH agonist/IVF/pregnancy rate

Extension of lucin jabs

2008-11-13T08:22:00.003+08:00

Wed 12 Nov 2008
Did a estradiol bloodtest and scan today at 8am and was told to call back between 3pm and 4pm for the results.

The results will determine whether i can start on puregon the next day or the lucrin jabs have to be extended.

Time flew by as i was busy with reading up for my exams on Friday, before you know it, my mobile rang with Nurse Phua on the line.

She said that i have to collect the puregon meds on Sat 22 Nov and continue with the lucrin jabs as "hormones are not properly suppressed". I ask her how did they know that by 22 Nov, hormones will bor perhaps i am just being sensitive...but .. but.. my questions still left hanging in my mind.

I'm puzzled. there was no baseline test before i started on lucrin, so how did they know the hormones level is not suppressed properly? is there a fixed number that all women have to meet or is it subjective to indiv level?

there is no planned bloodtest 11 days later - so how do they know that 11 days later, the hormones will be sufficiently suppressed?

and how did they come up with 11 days, why not 7 days, 9 days or 12 days, it seems random to me since there is no blood test to test the level of estradoil again, how do they know that hormones will be suppressed by then?

another question, does the extension of the lucrin mean that the lining of the womb will be thicker and hence reduce the success of implantation?

so many questions and no answers.

Re start blogging again

2008-11-05T21:05:00.003+08:00

It has been quite some time since i last posted anything in here. In between Jan to Nov 2008, many things have occured.

Milestones
Feb: Quit FP after another failed FET cycle
Mar: Join BMC as their centre manager
May : Quit to start another FET cycle, decided to concentrate on IVF and continue my studies
Jun : Accepted into 3 yr degree program, classes to start in July.
Jul : FET Cycle 2 failed, started classes
Aug : decide to close down online business and reconsider other options
Sep : offered a couple of part time & freelance positions, but decided to re start IVF cycle
Oct : started IVF Cycle 2, lucrin jabs end of Oct and accupunture @ raffles medical hospital
Nov: prepare for exams, and 2nd stage of IVF: puregon

Life Cycle of an embroyo - From the start

2008-01-06T13:33:00.000+08:00

Early Hours
Fertilization begins when a sperm penetrates an oocyte (an egg) and it ends with the creation of the zygote. The fertilization process takes about 24 hours. A sperm can survive for up to 48 hours. It takes about ten hours to navigate the female productive track, moving up the vaginal canal, through the cervix, and into the fallopian tube where fertilization begins. Though 300 million sperm may enter the upper part of the vagina, only 1%, 3 million, enter the uterus.

At 6 hours
The sperm must make the penetration of the zona pellucida, a tough membrane surrounding the oocyte. Only one sperm needs to bind with the protein receptors in the zona pellucida to trigger an enzyme reaction allowing the zona to be pierced. Penetration of the zona pellucida takes about twenty minutes.

At 1 - 5 days
Within 11 hours following fertilization, the oocyte has extruded a polar body with its excess chromosomes. The fusion of the oocyte and sperm nuclei marks the creation of the zygote and the end of fertilization. The zygote now begins to cleave, with each division occurring into two cells called blastomeres. The zygote's first cell division begins a series of divisions, with each division occurring approximately every twenty hours. Each blastomere within the zona pellucida becomes smaller and smaller with each subsequent division. When cell division ungenerated about sixteen cells, the zygote becomes a morula (mulberry shaped). It leaves the fallopian tube and enters the uterine cavity three to four days after fertilization.

At 6 days
The blastocyst hatches from the zona pellucida around the sixth day after fertilization, as the blastocyst enters the uterus. The trophoblast cells secretes an enzyme which erodes the epithelial uterine lining and creates an implantation site for the blastocyst.In a cyclical process of hormonal stimulation, the ovary is induced to continue producing progesterone while human chorionic gonadotropin (hCG) is released by the trophoblast cells of the implanting blastocyst. Endometrial glands in the uterus enlarge in response to the blastocyst and the implantation site becomes swollen with new capillaries. Circulation begins - a process needed for the continuation of pregnancy.

At 12 days
Trophoblast cells engulf and destroy cells of the uterine lining creating blood pools, both stimulating new capillaries to grow and foretelling the growth of the placenta. The inner cell mass divides, rapidly forming a two-layered disc. The top layer of cells will become the embryo and amniotic cavity, while the lower cells will become the yolk sac. Ectopic pregnancies can occur at this time and sometimes continue for up to 16 weeks of pregnancy before being noticed. Diagnosed quickly, ectopic pregnancies can be treated pharmacologically without surgery, reducing danger to the mother, and preserving the site of the ectopic pregnancy.

At 15 - 18 days
The formation of blood and blood vessels of the embryo begins. The blood system appears first in the area of the placenta surrounding the embryo, while the yolk sac begins to produce hematopoietic or non-nucleated blood cells. The embryo is attached by a connecting stalk (which will later become part of the umbilical cord), to the developing placenta. A narrow line of cells appears on the surface of the embryonic disc. This primitive streak is the future axis of the embryo and it marks the beginning of gastrulation, a process that gives rise to all three layers of the embryo: ectoderm, mesoderm and endoderm.

At 19 - days
The embryonic area is now shaped like a pear, and the head region is broader than the tail end. The ectoderm has thickened to form the neural plate. The edges of this plate rise and form a concave area known as the neural groove. This groove is the precursor of the embryo's nervous system and it is one of the first organs to develop. The blood cells of the embryo are already developed and they begin to form channels along the epithelial cells which form consecutively with the blood cells

at 21 days
If you could look at the embryo from a top view, it would resemble the sole of a shoe with the head end wider than the tail end, and a slightly narrowed middle. Somites, which are condensations composed of mesoderm, appear on either side of the neural groove. The first pair of somites appear at the tail and progress to the middle. One to three pairs of somites are present. Every ridge, bump and recess now indicates cellular differentiation. A head fold rises on either side of the primitive streak. The primitive streak now runs between one-fourth to one-third of the length of the embryo. Secondary blood vessels now appear in the chorion/placenta. Hematopoietic cells appear on the yolk sac simultaneously with endothelial cells that will form blood vessels for the newly emerging blood cells. Endocardial (muscle) cells begin to fuse and form into the early embryo's two heart tubes.

at 23 - 26 days
Rapid growth and change as the embryo becomes longer and the yolk sac expands. On each side of the neural tube, between four and twelve pairs of somites can exist by the end of this stage. The cells which become the eyes appear as thickened circles just off of the neural folds. The cells of the ears are also present. Neural folds are rising and fusing at several points along the length of the neural tube concomitant with the budding somites which appear to zipper the neural tube closed. Neural crest cells will eventually contribute to the skull and face of the embryo. The two endocardial tubes formed in before fuse here to form one single tube derived from the roof of the nueral tube, which becomes S-shaped and makes the primitive heart asymmetric. As the S-shape forms, cardiac muscle contraction begins.

at 28 - 31 days
Thirteen to twenty pairs of somites are present and the embryo is shaped in a modified S curve. The embryo has a bulb-like tail and a connecting stalk to the developing placenta. A primitive S-shaped tubal heart is beating and peristalsis, the rhythmic flow propelling fluids throughout the body, begins. However, this is not true circulation because blood vesel development is still incomplete. At this stage, the neural tube determines the form of the embryo. Although the primary blood vessels along the central nervous system are connecting, the central nervous system appears to be the most developed system. If twenty somites are present in the embryo, the forebrain is completely closed.

at 32 days
The brain differentiates into the three main parts: the forebrain, midbrain and hindbrain. The forebrain consists of lobes that translate input from the senses, and will be responsible for memory formation, thinking, reasoning, problem solving. The midbrain will serve as a relay station, coordinating messages to their final destination. The hindbrain will be responsible for regulating the heart, breathing and muscle movements.Thyroid continues to develop and the lymphatic system, which filters out bacteria, starts to form. Otic placode invaginates and forms the otic vesicle, which will develop into the structures needed for hearing and maintenance of equilibrium. Retinal disc presses outward and touches the surface ectoderm. In response the ectoderm proliferates forming the lens disc. Specific parts of the eye, such as the retina, the future pigment of the retina and the optic stalk are identifiable. Primitive mouth with a tongue is recognizable. Thyroid continues to develop and the lymphatic system, which filters out bacteria, starts to form. Heart chambers are filled with plasma and blood cells making the heart seem distended and prominent. The heart and liver combined are equal in volume to the head by this stage. Blood circulation is well established, though true valves are not yet present.. The villous network is in place to accommodate the exchange of blood between the woman and the embryo. Aortic arches 4 and 6 develop and 5 may appear. Lung buds continue to form. Gall bladder, stomach, intestines, pancreas continue to form and the metanephric bud appears in the chest cavity. The stomach is in the shape of a spindle and the pancreas may be detected at the intestinal tube. The developing liver receives blood from the placenta via the umbilical cord. The amnion encloses the connecting stalk helping to fuse it with the longer and more slender umbilical vesicle (the remnant of the yolk sac). Upper limb buds are visible as ridges and the lower limb buds begin to develop. Folding is complete and the embryo is now three-dimensional and is completely enclosed in the amniotic sac. The somites will be involved in building bones and muscles. The first thin surface layer of skin appears covering the embryo.

at 35 days
The brain and head grow rapidly. The mandibular and hyoid arches are noticeable. Ridges demarcate the three sections of the brain (midbrain, forebrain and hindbrain). The spinal cord wall at this stage contains three zones: the ventricular, the mantle and the marginal. The ventricular zone will form neurons, glial cells and ependymal cells, the intermediate mantle will form neuron clusters and the marginal zone will contain processes of neurons. Adenohypophyseal pouch, which will develop into the anterior pituitary, is defined. Lens vesicle opens to the surface and is nestled within the otptic cup. Otic vesicle increases its size by approximately one-fourth and its endolymphatic appendage is more defined. Nasal plate can be detected by thickened ectoderm. Esophagus, the tube through which food is swallowed, forms from a groove of tissue that separates from the trachea, which is also visible. Semilunar valves begin to form in the heart. Four major subdivisions of the heart (the trabeculated left and right ventricles, the conus cords and the truncus arteriosus) are clearly defined. Two sprouts, a ventral one from the aortic sac and a dorsal one from the aorta, form the pulmonary (sixth aortic) arch. Right and left lung sacs lie on either side of the esophagus. Ureteric bud appear. Metanephros, which will eventually form the permanent kidney, is developing. Upper limbs elongate into cylindrically-shaped buds, tapering at tip to eventually form hand plate. Nerve distribution process, innervation, begins in the upper limbs.

at 42 days
s the brain has increased in size by one-third since the last stage, it is still larger than the trunk. Rostral neuropore is closed and four pairs of pharyngeal arches are visible now, though the fourth one is still quite small. The maxillary and mandibular prominence of the first arch are clearly delineated. The stomodeum, the depression in the ectoderm which will develop into the mouth and oral cavity, appears between the prominent forebrain and the fused mandibular prominence.Swellings of the external ear begin to appear on both sides of the head, formed by the mandibular arch. Lens pit has closed, retinal pigment may appear in the external layer of the optic cup and lens fibers form the lens body. Two symmetrical and separate nasal pits may appear as depressions in the nasal disc. Esophagus lengthens. Blood flow through the atrioventricular canal is divided into left and right streams, which continue through the outflow tract and aortic sac. The left ventricle is larger than the right and has a thicker wall. Lobar buds appear in the bronchial tree. The intestine lengthens. Ureteric bud lengthens and its tip expands, thus beginning the formation of the final and permanent set of kidneys. Distinct regions of the handplate, forearm, arm and shoulder may be discerned in the upper limb bud. Lower limb bud begins to round at top and tip of its tapering end will eventually form the foot. Innervation, the distribution of nerves, begins in the lower limb buds. The relative width of the trunk increases from the growth of the spinal ganglia, the muscular plate and the corresponding mesenchymal tissues.

at 44 days
Brain is well marked by its cerebral hemispheres. The hindbrain, which is responsible for heart regulation, breathing and muscle movements, begins to develop. Future lower jaw, the first part of face to be established, is now visible while future upper jaw is present, but not demarcated. Mesenchymal cells originating in the primitive streak, the neural crest and the prechordal plate, continue to form the skull and the face. External retina pigment is visible and the lens pit has grown into a D shape. Nasal pits are still two separate plates, but they rotate to face ventrally as head widens. Primary cardiac tube separates into aortic and pulmonary channels and the ventricular pouches deepen and enlarge, forming a common wall with their myocardial shells. Mammary gland tissue begins to mature. The mesentery, which attaches the intestines to the rear abdominal wall, holds them in position and supplies them with blood, nerves and lymphatics, is now clearly defined. Ureter, the tube that will convey urine from the kidney to the bladder, continues to lengthen. Proliferation of the coelomic epithelium indicates the gonadal primordium. Hand region of upper limb bud differentiates further to form a central carpal part and a digital plate. The thigh (rostrolateral part), leg (the caudomedial part) and foot areas can be distinguished in the lower limb buds.

at 46 days
Jaw and facial muscles are now developing. The nasofrontal groove becomes distinct and an olfactory bulb (sense of smell) forms in the brain. Auricular (ear) hillocks become recognizable. The dental laminae or teeth buds begin to form. The pituitary, which is the master gland responsible for growth of hormones that regulate other glands, such as the thyroid, adrenal glands, gonad) begins to form.Trachea, the larynx and the bronchi begin to form. The heart begins to separate into four chambers. The diaphragm, the tissue that separates the chest cavity from the abdomen, forms. Intestines begin to develop within the umbilical cord and will later migrate into the abdomen when the embryo's body is large enough to accommodate them. Primitive germ cells arrive at the genital area and will respond to genetic instructions to develop into either female or male genitals. Digital rays in appear in the foot plates and finger rays are more distinct. Trunk becomes straighter.

at 51 days
Nerve plexuses begin to develop in the region of the scalp. Eyes are pigmented and eyelids begin to develop and may fold. Within the heart, the trunk of the pulmonary artery separates from the trunk of the aorta. Nipples appear on the chest. Body appears more like a cube. Kidneys begin to produce urine for the first time. Genital tubercle, urogenital membrane and anal membrane appear. The critical period of arm development ends, and the arms are at their proper location, roughly proportional to the embryo. However, the hand plates are not finished, but develop further in the next two days. The wrist is clearly visible and the hands already have ridges or notches indicating the future separation of the fingers and the thumbs. Ossification of the skeleton begins.

FET day 3

2008-01-06T04:34:00.000+08:00

After what it seems like months on OCP and progynova (oestradiol), finally got the go ahead for FET on last friday.

It took only one scan on wed to reveal that the lining is primed sufficiently at 8mm to proceed with FET in 2 days time. - a lot less hassle than a fresh cycle.

was put on cylogest suppositories but had very bad bloatededness, and some nausea. switched to im progesterone instead for luteal support. the jabs are really painful. somehow though having gone thru the same jabs for a fresh cycle, this time round, the oil based jabs are less tolerable. :(

got to just grin and bear! perhaps it's the oestradiol acting as well, cause every pain seem to be magnified and am really super short fused. husband got the brunt of that..

what we did different this time - we did accupunture 3 days continuously before the FET (inluding on the day of the FET itself). and am taking 14 days of twice a day sachets of some TCM powder.

also avoiding all cold water and raw food. and taking chicken essence once or twice a day. trying to drink lots of warm water.

I have good feelign about this cycle, the law of averages should be on my side this time.

one month later

2007-10-13T09:41:00.000+08:00

i am just so tired..tired of living, tired of life. it's not as if there is no laughter and light hearted moments...but just that life is a trial. maybe i just need a holiday and break from work.

even thinking about planning a holiday...is exhaustive..i wonder what is wrong with me.

Post IVF

2007-09-10T14:03:00.000+08:00

It has been 2 weeks since the results are out. AF is already over and i am back at work, throwing myself into work which happens to be a busy period, enrolled in a gym and am going regularly *cross fingers* made plans to do more about the online shop and in fact met some pple over it. learning to write a biz plan, and figuring out the legal registration of the company.

i thought i was coping well with the failure.

on Sat, went for dinner at Yv, met a pregnant S and the whole bunch of kids and all of it came crashing back to me. looking at Yv younger boy and it came crashing to me that if my baby survive, he/she would be exactly that age.

Just why not me?

the pain is excrutiating. i wish i could cry and get rid of it once and forever, but no..it comes and goes..this empty feeling.

negative - THE END

2007-08-23T11:09:00.000+08:00

been testing since 7DPET and gotten negative all along. Decided to bring forward the beta hcg blood test to Monday, got the results at 1pm, it's a very miserable 2.4. the nurse was still saying that it's early, and it may rise..but who the hell is she kidding?

all articles and all ivf centres in the world will concur that 2.4 is very NON PREGNANT. in fact any level below 5 is NON PREGNANT. I must admit that i am pretty annoyed at being 'entertained'

tried contact SF loh but was unable to get through to him as he was in OT all day. emailed him but didnlt get a reply either. it's frustrating, frustrating frustrating.

called kkh ivf again and was told to continue the progesterone jabs till thursday and then take another blood test on Friday. what the '1 quarter fish, 3 quarter duck' for?

hubby was optimistic, said why not....so we end up trudging to KKH early on tuesday. I then asked another the nurse manager if it's really necessary to continue on the progesterone jabs - she took a look at the chart and said ' let sf loh see you later and he will let you know'

that answers everything.

we waited 30 min to see as he's in OT (again). sf loh explained the figures and went through the egg retrival process, how many eggs retrieved (22), how many fertlised through IVF (final figure ?) and how many fertlised through ICSI. roughly half of the eggs retrieved was via IVF and ICSI.

total of 7 fertlised embroyos with 3 at grade 4 and treated with ICSI which was transferred this cycle.

The balance of 4 embroyos are frozen and mostly grade 3.

we discuss about the next cycle FET. And he still works on the premise that if so long the embroyo survives the thaw overnight, it should be transferrred, rather than waste it trying to grow it to blastocyst stage.

he said the chances that the embroyo will grow to blastocyst stage in the culture medium is so much lower than the chances that it will grow in the womb, that it is considered like wasting the embroyos.

i mentioned about the fact that if the embroyo doesn't survive till blastocysts stage after thawing , what makes him think that it will survive in the womb? he replied with some analogy about SAF men in camp training in the desert (which i so didn;t get) but anyways.....the idea is that the culture medium though the best that KKH uses is still not the real womb environment.

why did this cycle fail?
there is no specific reason. we can do only so much, the rest is still unexplained medically.

will the next cycle work?
no one can answer that question. FET has been known to have at least 10% chances lower than a fresh IVF cycle. But then there are also women who didn't get pregnant via a fresh cycle but gotten pregnant with FET. There's always hope!

Article in ST

2007-08-23T11:06:00.000+08:00

Fertility clinics must disclose success rates by Andy HoThe Straits Times31 July 2007
A LOWER court had awarded a middle-age couple $32,000 for in-vitro fertilisation (IVF) treatment, but the High Court reversed this recently. The couple had lost both their teenage sons in a car accident and were asking for, among other things, IVF costs as replacement expenses in their effort to have a child.
The couple may appeal, so one may not comment on the case which involved, quite unusually, a motor vehicle insurer. But this tragic case does bring into focus the need for an IVF-specific law, which must address, if nothing else, two big issues.
First, given that Singapore needs more babies, it seems odd that there isn’t a law that requires (health) insurers to cover IVF treatment - or at least to offer coverage for it.
Insurers have argued that infertility is not an illness. Even if it were, they say, IVF does not treat the illness since it does not cure the underlying infertility. And, even if it did, coverage should be left to the market. After all, most plans here do not cover dental or psychiatric services.
Mandates to provide or offer coverage would distort markets, they say. That is, people who do not need IVF would have to bear part of the costs in higher premiums.
But I am pooled together with smokers anyway, so my insurance premium is already higher than it would be if my pool was smoker-free. After all, the essence of insurance is to socialise, or share out, risks.
Moreover, the lack of coverage means that health insurers are not helping to rein in IVF fees. It also means that IVF utilisation is probably less than that which would give Singapore more babies.
If so, instead of leaving it to the courts to decide piecemeal - someone must actually bring a suit for them to even consider the issue - Parliament should debate the question of coverage thoroughly.
And while Parliament is at it, it might also consider another issue, that is, how to regulate the sector.
Comprising mainly fee-forservice procedures, the sector is currently largely unregulated. Specifically, patients have no access to reliable information to help them choose service providers optimally, so they depend on word of mouth.
Most couples go through much pain for many years before they attain success, but many do not get that far.
IVF involves using drugs to urge a woman’s ovaries to produce eggs at each menstrual cycle, surgically retrieving the eggs, fertilising them with sperm in the lab to produce embryos, and then implanting the embryos into the woman’s womb. Women endure physical pain and couples are buffeted emotionally by the trials and tribulations the process puts people through. Moreover, each cycle of IVF treatment costs about $10,000.
Also, it is risky. Unlike most medical technologies, fertility treatments were introduced with little rigorous testing, except on animals. Most governments have simply left oversight of the sector to the medical profession’s self-regulation - and the courts.
Unsurprisingly then, it was merely five years ago that scientists were able to pin down the fact that IVF babies are six times more likely to have low or very low birth weights, and twice more likely to have major birth defects. Although clearer information has surfaced in the last dozen years, much is still unknown about the technology’s risks.
True, there is always some reluctance to regulate sectors where technology is rapidly evolving, since any law enacted today will have a hard time keeping up with the science tomorrow. But perhaps regulation can be targeted specifically to help with what customers really care about: results.
So whether we eventually pass a law to mandate insurance coverage or not, a law could be passed to mandate that providers report their individual success rates.
This is important because the infertile are very vulnerable and may persist in trying even when success is very unlikely. What they need is reliable data to make informed decisions that optimise their chances of getting a healthy baby.
However, providers in Singapore do not publicly report such statistics, so patients just go by word of mouth. And in jurisdictions where clinics do report their success rates, providers have been known to manipulate their data.
For example, some clinics count pregnancies rather than live births in their ’success’ rates, but some of those pregnancies end in miscarriages. Or, clinics may compare the number of live births to the number of embryos transferred, but this leaves out those cycles that are cancelled when eggs are harvested but cannot be fertilised.
However, the number of egg retrievals done does matter because the invasive procedure involved is painful and not risk-free. Any statistic that excludes failed cycles underplays the number of painful procedures (and risks) a woman might have to bear.
What to do?
We should pass a law to require service providers to disclose their success rates, specifying also how success-rate statistics are to be presented.
An unusually good model is that found in the American state of Virginia, where the law requires that before IVF treatment can commence, the clinic must give the patient a signed disclosure form detailing its success rates in specific ways. (This law specifies three statistics: First, the total number of live births, which is what couples care about most; second, the proportion of live births per menstrual cycle of retrieving eggs - which measures the true rate of success per attempt; and lastly, the numbers of both pregnancies and live births per retrieval cycle - which indicates the woman’s risk of miscarriage.)
The provider must also break down its data by age groups, since success rates drop as women age.
I urge Parliament to consider enacting a similar law. With uniform statistics among clinics, consumers can comparison shop and optimise the quest to make babies. And while Parliament is at it, mandate coverage of IVF services as well.

Implications of Blastocyst transfers

2007-08-19T18:59:00.000+08:00

FEWER RISKS, NEW HOPE:
THE REALITY OF BLASTOCYST TRANSFERS
Mark Perloe, M.D.
Michael John Tucker, Ph.D.

Introduction
The first thing that usually comes to mind when people hear the term, "infertility treatment," is the risk of multiple births. This worry has been fueled by the recent highly publicized multiple births in Iowa and Texas. While such cases are rare, the incidence of triplets or higher-order births as a result of assisted reproductive technology is of great concern to all infertility practitioners and patients. For countless couples, deciding against treatment may mean abandoning their dream of having a child.

But what if there was a way to reduce or even eliminate the risk of multiples? Not only would that help more couples become parents, it would also decrease maternal and neonatal risks. That possibility is becoming a reality, thanks to a new technique known as blastocyst transfer. With blastocyst transfer, fewer embryos are transferred while maintaining and even increasing pregnancy rates. This technique virtually eliminates the risk of triplets or greater.

The Significance of Blastocyst Transfer
In a typical non-blastocyst in vitro fertilization (IVF) cycle, a woman's eggs are retrieved and fertilized. If all goes well, the embryos are transferred into the uterus three days later. Due to the fact that it is difficult to predict on day three which embryos are more likely to produce a pregnancy, four or more embryos are frequently transferred in hopes that at least one will result in a live birth. Until now, this has been a reasonable approach in order to achieve acceptable pregnancy rates.

The downside is that sometimes all the embryos become ongoing pregnancies and the result is high-order multiple gestations (triplets or greater). In such pregnancies, there are considerable medical risks as well as financial and emotional considerations. So the couple is faced with the agonizing decision of whether to opt for selective reduction (the removal of one or more embryos) or to continue with a risky pregnancy. Although everyone agrees that every possible safeguard should be in place to avoid such unfortunate situations, the distressing reality is that multiple pregnancies sometimes do occur.

However, with blastocyst transfer, only two or three embryos are transferred, practically eliminating the possibility of triplets or greater. And the same pregnancy rates are achieved as would be expected when four or more embryos are transferred on day three. Some centers report achieving even better pregnancy rates with blastocysts. Implantation rates of 48-50% and pregnancy rates of up to 66.3% have been reported in patients who responded well to gonadotropins.

What is 1 Blastocyst?
A blastocyst is a highly developed embryo that has divided many times to a point where it is nearly ready to implant on the walls of the uterus. A blastocyst has come a long way from its beginning as a single cell.

During maturation, an embryo rests inside a protective shell called a zona pellucida. You can think of this protective shell as being much like a chicken egg. But, unlike chicken eggs, human embryos do not remain inside a shell. Instead, the embryo hatches (breaks out of the shell) on the fifth or sixth day so it can attach to the uterine wall (implantation). Just prior to hatching, an embryo becomes a blastocyst.

Embryos developing to the critical blastocyst stage have a much greater chance of implanting successfully and resulting in an ongoing pregnancy. That is because these embryos have passed an important test. During the first few days, the embryo relies on the mother's egg for all its nutrients. However, in order to 15 survive past day three or four, the embryo must activate its own genes. Not all embryos are successful. In fact, only about one-third of the embryos become blastocysts. Yet these embryos are more highly-developed, healthier, and stronger, and have a higher rate of implantation when compared to day three embryos. Due to the higher probability of survival, we transfer fewer back into the uterus.

Getting to Day Five
For many years, infertility practitioners have known that day three transfers were too early when compared to what is physiologically normal. In naturally conceived pregnancies, a day three embryo resides in the fallopian tube, not in the uterus. The embryo does not even reach the uterus until the fifth or sixth day. Yet traditional IVF has always transferred on day three because, up until now, we have not been able to delay the transfer to day five. Previous laboratory culture media could only sustain an embryo's growth for three days. Now we have the ability to develop an embryo to the blastocyst (day five) stage.

What has made the difference is the recognition that the nutritional requirements of the embryo change as it develops. That knowledge led to the development of different laboratory culture media for the embryo's specific developmental stages. This so-called "sequential media" attempts to reproduce the natural environment of the maternal reproductive tract. The nutrients are designed to meet the requirements of the rapidly developing embryo and have led to the development of blastocysts with better viability and higher implantation rates.

Redefining Developmental Potential
The ability to develop embryos to the blastocyst stage allows clinicians to have greater certainty about which embryos are more likely to implant. Interestingly, no correlation has been found between what is traditionally considered a "good embryo" on day three and a "good blastocyst" on day five. Previously, Dr. Tucker reported a "significant disparity between the two stages in embryo viability estimates," meaning that even the best embryologists cannot tell which day three embryos have the potential to develop into a blastocyst.

While the quality of blastocysts is determined by examining morphology and development, it is important to point out that blastocyst grading standards are currently under development. Although the ability for the embryo to grow into a blastocyst is a milestone, other factors also play a role in its further development. In the near future, we believe we will be able to accurately predict which blastocysts are destined for success. When that happens, single blastocyst transfers will be considered the norm, and IVF will likely be considered the first-line infertility treatment.

Who Does it Help?
Determining who is a good candidate for blastocyst transfer is another rapidly evolving area. As more information becomes available and our knowledge base grows, guidelines based on actual clinical experience will be developed. Until then, we can offer some preliminary observations.

In general, blastocyst transfer is more advantageous for patients who develop a number of eggs and embryos. A significant correlation has been reported between the number of eggs and the number of blastocysts developed, as well as the number of day three embryos and the number of blastocysts developed. Other candidates for blastocyst transfer include those who would not consider fetal reduction or those in whom delivering multiple pregnancies would be of particular concern. Blastocyst transfer is probably not advantageous for patients who develop few eggs or embryos.

A side benefit of a blastocyst transfer is the fact that the ability to generate a blastocyst provides important information about the likelihood of pregnancy. In general, pregnancy rates are higher in those whose embryos grow to the blastocyst stage. Conversely, pregnancy rates are lower in those whose embryos do not develop into blastocysts.

Maternal Age and Blastocyst Development
Does maternal age have any bearing on the production of blastocysts? Although some studies have shown advanced maternal age to be a factor in blastocyst production, Schoolcraft found "no correlation between percentage of blastocyst formation and increasing maternal age" in a population of women who responded well to gonadotropins. However, implantation rates and pregnancy rates in this study decreased with maternal age, with women over 40 faring the worst.

What Happens When Embryos Do Not Become Blastocysts?
Because only a few embryos develop to the blastocyst stage, it is possible to have no embryos survive to day five to transfer. This is especially true if the cycle begins with only a few fertilized eggs. When no embryos survive to become blastocysts, it is a tremendous disappointment. The looming question then becomes, "Would the embryos that did not survive to become blastocysts have implanted if transferred at day three?" Unfortunately, we simply do not have enough clinical data at this time to answer that question. In our opinion, pregnancy would have been unlikely in that situation. But since that outcome is not a certainty, day three transfers may still be a reasonable option for some patients.

Genetic Testing And Blastocysts
Another benefit of blastocyst transfer is the ability to perform biopsies on a more highly-developed embryo in order to test for genetic diseases. In the future, immunofluorescent testing techniques will allow practitioners to remove a few cells from the blastocyst, stain them, and examine them under the microscope to detect any genetic anomalies. While that type of testing is not currently available on a day-to-day basis, we believe it will be considered routine within the next two to five years.

Frozen Blastocyst Cycles
Blastocysts tend to have a very good survival rate after cryopreservation (freezing). Menezo and his colleagues have reported that "the recovery after thawing is equivalent, if not superior to, that of thawing of earlier embryonic stages."

Because blastocysts are superior to earlier stage embryos in terms of development, they are easier to freeze, store, and thaw. Additionally, because blastocysts have higher implantation rates, it is possible for a couple to go through IVF once and have enough blastocysts for the current cycle as well as any future cycles.

The Future
We are just beginning to understand the implications of blastocyst transfer for both practitioners and patients. ,We believe infertility treatment centers will soon be able to reliably grow blastocysts and accurately assess which embryos are destined to implant and develop into an ongoing pregnancy. When that happens, the transfer of a single blastocyst will become the norm. And today's risk of high-order multiples will become a memory. The future holds much hope, much promise, and considerably fewer risks.

trigger shot and HPT

2007-08-15T06:43:00.000+08:00

How long does it take synthetic hCG (trigger shot) to leave my body before I can test for pregnancy?

Every woman's metabolism is different, but as a general rule of thumb, you should allow 1 day for every 1,000 units of hCG you injected. The standard hCG dose is 10,000 units; thus, 10 days after the shot, the synthetic hCG should be gone and you should be able to test for pregnancy without detecting the shot. However, you should ask your doctor what the recommended protocol for your dosage is.
Some women choose to test daily to monitor the presence of the hCG in their bodies; once the synthetic hCG is gone, the tests become negative. If the hCG "comes back" and the HPT's turn positive again, it's likely due to a pregnancy and not the leftover hormone shot.

7 days post embryo transfer [7DPET]

2007-08-14T09:42:00.000+08:00

Tuesday 14 August 2007

just had p4 bloodtest yesterday, result is 92.5nmol. a level sufficient enough not to increase the dosage of progesterone jabs. thank goodness for small favours.

i am feeling so much better now. i got my appetite back on Sunday. had fried bee hoon for breakfast and pizza for a very late lunch/dinner. and i didn't throw up.

yet on the other hand, the bloatedness has gone away and i feel back to normal. too normal - hiaks - got symptoms also worry, got no symptoms also worry.

i read somewhere that the earliest one can test for HPT is 10DPET - can't wait to rec the strips HPT i bought online.

painful ER, drama ET, hospitalised

2007-08-14T09:40:00.000+08:00

Wednesday 8 August 2007

was hospitalised after ER on Monday, vomitting non stop , plus bloatedness, my belly grew like 8 cm within one day but it turned out not to be OHSS but sore ovaries, disturbed lining in the abdomen area due to the ER procedure.

ET was jeopardised and it was only this morning at 6.30am when Dr SF loh gave the go ahead for ET. and even so, he warned of the risk of going ahead with ET, increased risk of OHSS etc.

very drama, in the end ET went thru at almost 10am. it went smoothly and i was discharged from hospital at about 230pm. but it's a trying 3 days from mon to today - i snapped on monday night and bloody shouted everyone at the hosptial ward as i had to wait 5 hours in excruitating pain before the attending doctor saw me at 11pm.

all in all, i realised that the response from doctors in KKH is very subjective to which doctor is available. it so happens that SF loh was not around and he has already left the hospital on Monday evening.

so a piece of advise, when facing any emergency during the course of treatment, call ahead and make arrrangements to have your doctor waiting for you before you head down to the a & e dept. right now i am crossing fingers and toes that my 2www will go on smoothly.

p/s: today at KKH IVF, i saw a couple of gals who went thru ER at the same time as i did, they all look very healthy and painfree...guess it's just my bad luck to be the 1% that suffer through like crazy after the procedure.

My love will get you home - Christine Glass

2007-08-14T09:38:00.000+08:00

If you wander off too far, my love will get you home.
If you follow the wrong star, my love will get you home.
If you ever find yourself, lost and all alone,
get back on your feet and think of me, my love will get you home.
Boy, my love will get you home.
If the bright lights blinds your eyes, my love will get you home.
If your troubles break your stride, my love will get you home.
If you ever find yourself, lost and all alone,
get back on your feet and think of me, my love will get you home.
Boy, my love will get you home.
If you ever feel ashamed, my love will get you home.
When there's only you to blame, my love will get you home.
If you ever find yourself, lost and all alone,
get back on your feet and think of me, my love will get you home.
Boy, my love will get you home.
If you ever find yourself, lost and all alone,
get back on your feet and think of me, my love will get you home.
Boy, my love will get you home,
Boy, my love will get you home.

When does implantation happen in IVF?

2007-08-11T09:48:00.000+08:00

When does implantation actually occur in IVF or normal cycles? (We're not focusing on the "window" anymore, but on when real implantation does occur)

A very good study of implantation was published in 1992 by Bergh & Navot.
They studied 33 pregnancies from ovum donation or frozen-thawed cycles with serial HCG levels on the mothers to find the time of "first embryonic signal". The HCG assay used can detect very low levels.
Average first detection was at an embryonic age of 7.1 +/- 0.28 days (range 6.6-7.4 days).
This correlates with the studies of Hertig and Rock in the 1950's (hysterectomy studies) that showed the day of implantation to be day 6.
They did not find any evidence to support the concept of an embryonic diapause in humans.

IVF - Puregon - 2nd scan

2007-08-03T21:10:00.000+08:00

Friday 03 Aug 2007

2nd scan done today - right ovary - 13 follicles ranging from 7.5 to 14mm. left ovary - 6 follicles ranging from 9.5 to 14.5mm. was told to do ER on Tuesday and ET on Thursday

Then rec call from KKH IVF in the afternoon that ER have to be done on Monday instead, as the doc will be away on Thursday., so ET will be on Wednesday.

IVF - 1st scan after stimulation

2007-08-01T22:04:00.000+08:00

After being on Puregon for 7 days, I had my first scan, manage to see 9 follicles on right side from 7.5mm to 9mm, and 3 follicles on right side from 9mm to 12mm. Hope to see more follicles on Friday, I rather risk OHSS than not have enough eggs to fertillise.

although having said that the doc did advise that with the no of follicles so far and the nausea, there's a high tendency of 20-30% that the cycle have to be cancelled due to OHSS. the reasoning is that although it may be beareable now...after ET, the OHSS will worsen.

Costing of IVF

2007-07-26T11:07:00.001+08:00

i'm supposed to do a costing here but never got round to doing it.

total i estimated so far we have forked out more than $2000, excluding out of pocket expenses such as taxi fares to and from the hospital.

will do a break down later.

Start of Puregon stage

2007-07-26T11:02:00.000+08:00

Finally got the go ahead to start with stimulations stage. need to jab 200 units of puregon every day for next 7 days before heading for scan to check growth of follicles.

in the meantime, suppose to continue with lucrin as well, that means 2 jabs every morning. oh great!

the puregon injection pen takes some taking use to - i still prefer the old fashion syringe but then since puregon cost like $120 per jab, it's better to have a mechanised measurement. oh yeah, due to the longer time to jab lucrin, i had to get a new bottle of lucrin as well.

calculating ER should be on 3rd or 6th Aug....cross fingers, follicles grow well otherwise it's going to get expensive if need to increase puregon dose.

Am i doing too much?

2007-07-22T10:32:00.000+08:00

Am i having too much on my plate at this point in time? going through IVF cycle is tough enough, having to work full time and trying to run a business and expanding, geting new manufacturers, having to do the housework etc etc...

i can't give up any of the above, already outsource the housework...work brings in money, business is sucking up money as fast as i could earn it. i really hope that it will work out in the end, if it does..i can quit and work from home and look after the pregnancy. worse case scenario ..if both doesn't work out, at least i have my work to fall back upon.

Lucrin or Lupron as called in the US

2007-07-18T22:09:00.000+08:00

Clinical Policy Bulletin:Gonadotropin-Releasing Hormone Analogs (Lupron/Zoladex) and Antagonists (Plenaxis)

Number: 0501
Policy
Lupron
Aetna considers Lupron (leuprolide) medically necessary for the following indications subject to the specified limitations:
Endometriosis (see appendix)
To decrease fibroid size prior to surgery (see appendix).
To decrease endometrial thickness prior to endometrial ablation (see appendix).
For palliative treatment of members with advanced (Stage III or Stage IV) prostate cancer that has metastasized or has recurred after treatment, or member refuses orchiectomy (see appendix).
For true (central) precocious puberty, defined as sexual maturation before age 8 in girls and age 10 in boys, and tumor has been ruled out by lab tests, CT, MRI, or ultrasound (see appendix).
Infertility (used in conjunction with urofollitropin or menotropins) to suppress luteinizing hormone (LH) production in members with documented premature LH surge, or used in “super-ovulation” regimens associated with in vitro fertilization (see appendix).
For treatment of metastatic breast cancer, when the member is pre-menopausal and the disease has progressed or recurred after a trial of at least 3 months of tamoxifen (see appendix).
To suppress onset of puberty in cases where the adolescent meets medical necessity criteria for growth hormone supplementation and has early onset of puberty and is not within target growth range (within 1 standard deviation of mean height for age and sex) (see appendix).
For the treatment of women with chronic refractory pelvic pain (see appendix).
Aetna considers Lupron experimental and investigational for all other indications, including any of the following conditions, since limited information has been published and further research including randomized, controlled trials is required to determine its efficacy:
Precocious pubarche alone, or pseudoprecocious puberty (gonadotropin independent precocious puberty); or
Polycystic ovarian disease; or
Pre-menstrual syndrome; or
Endometrial cance; or
Ovarian cancer; or
Preservation (suppression) of ovarian function during chemotherapy; or
Preservation (suppression) of testicular function during chemotherapy.
Zoladex
Aetna considers Zoladex (goserelin) medically necessary for any of the following indications:
Advanced (metastatic) prostatic carcinoma; or
Advanced (metastatic) breast cancer in pre-menopausal members; or
Endometriosis, Stage III or IV; or
Uterine fibroids (leiomyoma uteri) (preoperative adjunct to surgical treatment) (short-term (less than 6 months) use); or
Endometrial ablation or hysterectomy (preoperative adjunct) (short-term (less than 6 months) use). (See also CPB 091 - Endometrial Ablation.)
Aetna considers Zoladex (goserelin) experimental and investigational for preservation of ovarian or testicular function during chemotherapy and for all other indications because its effectiveness for these indications has not been established.
Plenaxis
Aetna considers Plenaxis (abarelix) medically necessary for the treatment of the symptoms of men with advanced prostate cancer who cannot take other hormone therapies and who have refused surgical castration. Abarelix is considered experimental and investigational for all other indications. This policy is based on the FDA-approved indications for Plenaxis.
For gonadotropin-releasing hormone antagonists for infertility, see CPB 327 - Infertility.
Background
Lupron:
Leuprolide (Lupron) is a gonadotropin-releasing hormone analog, which may be indicated for treatment of certain conditions, which are hormonally regulated.
Leuprolide may be indicated in advanced cancer (palliative treatment) in patients who have inoperable prostate tumor, or refuse orchiectomy. The available literature suggests combined therapy with leuprolide and an anti-androgen (e.g., megestrol, flutamide) appears to produce additive effects and to be more effective than leuprolide therapy alone in the treatment of advanced prostate cancer. According to established guidelines, recommended dosing of leuprolide for palliative treatment of advanced prostate cancer is 1 mg given subcutaneously daily. According to established guidelines, if patient is receiving leuprolide acetate suspension (Lupron depot) dosing is 7.5 mg IM once monthly.
Leuprolide has been used in the treatment of true (central) precocious puberty, defined as sexual maturation less than age 8 in girls, and sexual maturation less than age 10 in boys. The available literature suggests tumors should be ruled out by lab tests, CT, MRI, or ultrasound. Leuprolide is not indicated for precocious pubarche alone or pseudoprecocious puberty (gonadotropin-independent precocious puberty). According to established guidelines, recommended starting doses are: Lupron Depot Ped: 0.3 mg/kg every four weeks (minimum 7.5 mg), or Lupron injection: 50 mcg/kg daily. Doses may be titrated upwards in order to achieve hormonal down-regulation.
Studies of leuprolide for endometriosis indicate that six months is an appropriate length for therapy. Because of lack of safety data with long-term use, and because of concerns expressed in the available literature regarding effects on bone density, treatment after six months is typically not recommended. According to established guidelines, recommended dosing of leuprolide for endometriosis is 3.75 mg as a single monthly IM injection.
Leuprolide has been studied for the treatment of uterine fibroids (leiomyoma uteri), as a preoperative adjunct to surgical treatment. Clinical studies have demonstrated the benefit of leuprolide in reducing vascular and surgical complications secondary to obstructive fibroid size. In tests, GnRH agonists have effectively reduced the fibroid size, but their use was accompanied by a rapid regrowth following discontinuation. The available literature states Leuprolide therapy does not prevent or replace the eventual need for surgery. If used as a pre-operative adjunct, the available literature states short-term treatment only is recommended (i.e., 1-3 months).
Leuprolide also has been shown to be an effective preoperative adjunct to decrease endometrial thickness prior to endometrial ablation. If used as a pre-operative adjunct, short-term treatment only (i.e., 1-2 months) is indicated.
Leuprolide is used in conjunction with urofollitropin or menotropins in patients with infertility. It has been used to suppress LH production in patients with documented premature LH surge. In addition, it has been used in “super-ovulation” regimens associated with in vitro fertilization. Treatment of infertility may be subject to limitations under some benefit plans. Some HMO contracts, with or without a separate infertility benefit such as the Advanced Reproductive Technology (ART) Rider, specifically exclude injectable infertility drugs.
Leuprolide has been shown to be useful in the treatment of metastatic breast cancer in pre-menopausal patients whose disease has progressed or recurred despite a 3 or more month trial of tamoxifen.
Leuprolide has been used as treatment for various other conditions (e.g., polycystic ovarian disease, hypermenorrhea, premenstrual syndrome, paraphilias, endometrial cancer, and ovarian cancer). At this time limited information has been published to show efficacy for conditions other than those mentioned in the clinical criteria above. Further research with randomized, controlled trials is required to determine efficacy in these other conditions.
The American Society of Clinical Oncology's recommendations on fertility preservation in cancer patients (Lee, et al., 2006) stated that sperm and embryo cryopreservation are considered standard practice. On the other hand, the use of GNRH analogs or antagonists for testicular or ovarian suppression is considered investigational. ASCO guidelines state: “At this time, since there is insufficient evidence regarding the safety and effectiveness of GnRH analogs and other means of ovarian suppression on female fertility preservation, women interested in ovarian suppression for this purpose are encouraged to participate in clinical trials.” The guidelines also noted that there is insufficient evidence of the effectiveness of GnRH analogues in preventing chemotherapy-induced gonadal damage in men: “The efficacy of gonadoprotection through hormonal manipulations has only been evaluated in very small studies in cancer patients.”
In a review of the literature, Sonmezer and Oktay (2006) explained that there are a limited number of prospective studies of GNRH analogues in preventing chemotherapy-induced gonadal damage, “which are flawed because of short-term follow-up and/or because of lack of control subjects.” The review notes that “[i]n addition to the lack of consistent support from clinical studies, there is currently no biological explanation for who GNRHa [GNRH analogues] can affect ovarian reserve.” The authors concluded that “[i]n the absence of a prospective randomized study with sufficient power, we do not rely on ovarian suppression as an effective means of fertility preservation.”
Zoladex:
Goserelin (Zoladex) is a gonadotropin releasing hormone (GnRH) (also known as gonadorelin and luteinizing hormone releasing hormone or LHRH) analog, which is indicated in certain conditions requiring suppression of estrogen or testosterone secretion. At this time it is available only in a continuous-release subcutaneous implant which releases drug over a period of about 28 days.
Goserelin is approved by the FDA for treatment of advanced metastatic prostate cancer and advanced endometriosis. Goserelin has also been shown to be effective for treatment or palliation of breast cancer in pre-menopausal patients.
Goserelin has been studied for the treatment of uterine fibroids. Clinical studies have demonstrated the benefit of leuprolide in reducing vascular and surgical complications secondary to obstructive fibroid size. In tests, GnRH agonists have effectively reduced the fibroid size, but their use was accompanied by a rapid regrowth following discontinuation. Therefore, the literature states that goserelin therapy does not prevent or replace the eventual need for surgery. If used as a pre-operative adjunct, the literature recommends short-term treatment (six months or less).
Goserelin has been shown to be effective for the short-term (less than 6 months) preoperative adjunct to endometrial ablation or surgery for leiomyomata uteri (uterine fibroids).
Goserelin is under investigation as a method of prevention of chemotherapy-induced gonadal damage. In a prospective pilot study (n = 5), Franke, et al. (2005) explore the effects of goserelin acetate in women with Hodgkin's disease (HD) receiving chemotherapy while taking a continuous combined estrogen-progestin preparation as add-back on the prevention of premature ovarian failure (POF). Pre-menopausal women with HD received goserelin and add-back until polychemotherapy was completed. Every 4 weeks during treatment and thereafter, a hormonal profile (follicle-stimulating hormone (FSH), LH, 17beta-estradiol, progesterone and inhibin B) was measured until resumption of menstruation or the development of a hyper-gonadotropic state (2 x FSH greater than 30 U/l). All patients reached pre-pubertal status during treatment. Following cessation of goserelin therapy, 1 patient developed a hyper-gonadotropic state and 4 patients resumed menstruation. One of those patients became pregnant and delivered a healthy son. These investigators concluded that the effectiveness of GnRH agonist plus add-back on the prevention of POF during polychemotherapy in women with HD needs further elucidation in randomized controlled trials.
Del Mastro, et al. (2006) noted that standard methods to prevent chemotherapy-induced early menopause in young, breast cancer patients are unavailable to date. Pre-clinical data has suggested that LHRH analogs given during treatment can decrease the gonado-toxicity induced by chemotherapy. In a phase II clinical trial, these investigators evaluated the activity of such a method in young, breast cancer patients undergoing adjuvant chemotherapy. Pre-menopausal patients received goserelin 3.6 mg every 4 weeks before and during chemotherapy. According to 2-stage optimal phase II Simon design, treatment was considered clinically interesting if it was able to prevent menopause in 19 out of 29 patients of the study population. The resumption of ovarian function was defined by a resumption of menstrual activity or by a FSH value less than or equal to 40 IU/l within 12 months after the last cycle of chemotherapy. A total of 30 patients were enrolled and 29 were evaluable. Median age was 38 years (range 29 to 47 years). All but one patient received CEF regimen (cyclophosphamide, epirubicin, 5-fluorouracil). Resumption of menstrual activity was observed in 21 patients (72%; 95% CI 52 to 87%) and a FSH value less than or equal to 40 IU/l in 24 patients (83%; 95% CI 63 to 93%). Menses resumption was observed in 16 out of 17 patients (94%) with age less than 40 years and in 5 out of 12 patients (42 %) with age 40 years or over. These researchers concluded that goserelin given before and during chemotherapy may prevent premature menopause in the majority of patients. However, the different success rate by age indicates the need of a prospective evidence of the effectiveness of such a strategy.
Plenaxis:
Plenaxis (abarelix) is a gonadotropin-releasing hormone antagonist approved by the FDA in November 2003. It is indicated for the treatment of the symptoms of men with advanced prostate cancer who cannot take other hormone therapies and who have refused surgical castration. Plenaxis is marketed under a voluntary risk management program agreed to and administered by the sponsor that will restrict the use of Plenaxis to patients with advanced prostate cancer, who have no alternative therapy, because of an increased risk of serious, and potentially life-threatening, allergic reactions associated with its use.
In a phase III clinical study (n = 269), McLeod et al (2001) evaluated the levels of testosterone and other hormones in men with prostate cancer treated with abarelix versus leuprolide acetate. The authors concluded that treatment with abarelix produced a higher percentage of patients who avoided a testosterone surge and had a more rapid time to testosterone suppression with a higher rate of medical castration 1 day after treatment and greater reductions in testosterone, LH, follicle-stimulating hormone, and dihydrotestosterone during the first 2 weeks of treatment compared with leuprolide acetate. The achievement and maintenance of castration was comparable between the two groups.
In another phase III clinical trial (n = 255), Trachtenberg et al (2002) reported that abarelix as monotherapy achieved medical castration significantly more rapidly than combination therapy (LHRH agonist and a non-steroidal anti-androgen) and avoided the testosterone surge characteristic of agonist therapy. Both treatments were equally effective in reducing serum prostate specific antigen, and achieving and maintaining castrate levels of testosterone.
Koch, et al. (2003) stated that abarelix provided a safe and effective medical alternative to surgical castration in symptomatic patients (n = 81) with advanced prostate cancer without the risk of the clinical flare associated with LHRH agonists.

Appendix
Medically Necessary Indications for Lupron
Limitations
Endometriosis
Up to six months - because of lack of safety data with long-term use, and concerns in available peer-reviewed medical literature regarding effects on bone density.
Lupron dosages greater than 3.75 mg per month or 11.25 mg per 3 months are subject to medical necessity review.
To decrease fibroid size prior to surgery
Up to three months - under accepted guidelines, does not prevent or replace the eventual need for surgery except in peri-menopausal women.
Lupron dosages greater than 3.75 mg per month or 11.25 mg per 3 months are subject to medical necessity review.
To decrease endometrial thickness prior to endometrial ablation
Up to two months.
Lupron dosages greater than 3.75 mg per month or 11.25 mg per 3 months are subject to medical necessity review.
For palliative treatment in members with advanced prostate cancer, defined as Stage III or Stage IV, that has metastasized or recurred after treatment, or patient refuses orchiectomy
1 mg given subcutaneously daily. If receiving leuprolide acetate suspension (Lupron Depot), dosing is 7.5 mg IM once monthly.
For true (central) precocious puberty, defined as sexual maturation before age 8 in girls and age 10 in boys, and tumor has been ruled out by lab tests, CT, MRI, or ultrasound
Lupron Depot Ped: 0.3 mg/kg every four weeks (minimum 7.5 mg).
Lupron injection: 50 mcg/kg daily. It may be medically necessary to titrate dosages upwards in order to achieve hormonal down-regulation.
Infertility (used in conjunction with urofollitropin or menotropins) to suppress luteinizing hormone (LH) production in members with documented premature LH surge, or used in “super-ovulation” regimens associated with in vitro fertilization
Note: Treatment of infertility may be subject to specific limitations under some benefit plans. Most HMO plans exclude injectable infertility drugs from coverage.
For treatment of metastatic breast cancer
Indicated where member is pre-menopausal and the disease has progressed or recurred after a trial of at least 3 months of tamoxifen
To suppress onset of puberty in adolescents with early onset of puberty on growth hormone therapy
Adolescent must meet medical necessity criteria for growth hormone supplementation, have early onset of puberty, and be below target growth range (within 1 standard deviation of mean height for age and sex)
For the treatment of women with chronic refractory pelvic pain
Indicated where attempts at medical therapy with analgesics and oral contraceptive have been unsuccessful.

CPT Codes / HCPCS Codes / ICD-9 Codes
Lupron (suspension and implant):
HCPCS codes covered if selection criteria are met:
J1950
Injection leuprolide acetate (for depot suspension), per 3.75 mg
J9217
Leuprolide acetate (for depot suspension), 7.5 mg
J9219
Leuprolide acetate implant, 65 mg
ICD-9 codes covered if selection criteria are met:
174.0 - 175.9
Malignant neoplasm of breast
185
Malignant neoplasm of prostate
218.0 - 218.9
Uterine leiomyoma
233.0
Carcinoma in situ of breast
233.4
Carcinoma in situ of prostate
259.1
Precocious sexual development and puberty, not elsewhere classified
617.0 - 617.9
Endometriosis
Lupron prior to endometrial ablation (see CPB 91):
ICD-9 codes covered if selection criteria are met:
626.2
Excessive or frequent menstruation
626.3
Puberty bleeding
627.0
Premenopausal menorrhagia
627.1
Postmenopausal bleeding
2 week Lupron kit:
HCPCS codes covered if selection criteria are met:
J9218
Leuprolide acetate, per 1 mg
Other HCPCS codes related to the CPB:
J3355
Injection, urofollitropin, 75 IU
S0122
Injection, menotropins, 75 IU
S0187
Tamoxifen citrate, oral, 10 mg
ICD-9 codes covered if selection criteria are met:
185
Malignant neoplasm of prostate
233.4
Carcinoma in situ of prostate
259.1
Precocious sexual development and puberty, not elsewhere classified
628.0 - 628.9
Infertility, female
ICD-9 codes not covered for indications listed in the CPB:
140.0 - 239.9
Neoplasms [when used for preservation of ovarian or testicular function during chemotherapy]
182.0
Malignant neoplasm of corpus uteri, except isthmus
183.0
Malignant neoplasm of ovary
198.6
Secondary malignant neoplasm of ovary
218.0 - 218.9
Uterine leiomyoma
256.4
Polycystic ovaries
625.4
Premenstrual tension syndromes
V58.11 - V58.12
Encounter for antineoplastic chemotherapy and immunotherapy [when used for preservation of ovarian or testicular function during chemotherapy]
Zoladex (Goserelin):
HCPCS codes covered if selection criteria are met:
J9202
Goserelin acetate implant, per 3.6 mg
ICD-9 codes covered if selection criteria are met:
174.0 - 175.9
Malignant neoplasm of breast
185
Malignant neoplasm of prostate
218.0 - 218.9
Uterine leiomyoma
233.0
Carcinoma in situ of breast
233.4
Carcinoma in situ of prostate
617.0 - 617.9
Endometriosis
625.3
Dysmenorrhea
628.0 - 628.9
Infertility, female
Zoladex prior to endometrial ablation (see CPB 91):
ICD-9 codes covered if selection criteria are met:
626.2
Excessive or frequent menstruation
626.3
Puberty bleeding
627.0
Premenopausal menorrhagia
627.1
Postmenopausal bleeding
ICD-9 codes not covered for indications listed in the CPB:
140.0 - 239.9
Neoplasms [when used for preservation of ovarian or testicular function during chemotherapy]
V58.11 - V58.12
Encounter for antineoplastic chemotherapy and immunotherapy [when used for preservation of ovarian or testicular function during chemotherapy]
Plenaxis (abarelix):
Other CPT codes related to the CPB:
54520 - 54535, 54690
HCPCS codes covered if selection criteria are met:
C9216
Injection, Abarelix for injectable suspension, per 10 mg (deleted 12-31-04)
J0128
Injection, abarelix, 10 mg
ICD-9 codes covered if selection criteria are met:
185
Malignant neoplasm of prostate
Other ICD-9 codes related to the CPB for Lupron, Zoladex, and Plenaxis:
253.3
Pituitary dwarfism
625.8 - 625.9
Other and unspecified symptoms associated with female genital organs
V58.11 - V58.12
Encounter for antineoplastic chemotherapy and immunotherapy
V66.0
Convalescence and palliative care following surgery
V66.1
Convalescence and palliative care following radiotherapy
V66.2
Convalescence and palliative care following chemotherapy
V66.7
Encounter for palliative care The above policy is based on the following references:
Lupron:
Olin BR, ed. Drug Facts and Comparisons. St. Louis, MO: JB Lippincott Company; 1992.
Conn MP, Crowley WF. Gonadotropin-releasing hormone and its analogues. N Engl J Med. 1991;324(2):93-103.
Higham JM. The medical management of menorrhagia. Br J Hosp Med. 1991;45:19-21.
Schriock ED. Practical aspects of pulsatile gonadotropin-releasing hormone administration. Am J Obstet Gynecol. 1990;163(5):1765-1770.
Gompel A, Mauvais-Jarvis P. Induction of ovulation with pulsatile GnRH in hypothalamic amenorrhoea. Hum Reprod. 1988;3(4):473-477.
Macdonald R. Modern treatment of menorrhagia. Br J Obstet Gynecol. 1990;97:3-7.
Dodson WC, Hughes CL, Whitesides DB, et al. The effect of leuprolide acetate on ovulation induction with human menopausal gonadotropins in polycystic ovary syndrome. J Endocrin Metab. 1987;65(1):95-100.
Adamson GD. Treatment of uterine fibroids: Current findings with gonadotropin-releasing hormone agonists. Am J Obstet Gynecol. 1992;166(2):746-751.
Brooks PG, Serden SP. Preparation of the endometrium for ablation with a single dose of leuprolide acetate depot. J Reprod Med. 1991;36(7):477-478.
Shaw RW, Fraser HM. Use of a superactive luteinizing hormone releasing hormone agonist in the treatment of menorrhagia. Br J Obstet Gynecol. 1984;91:913-916.
Schrlock ED. GnRH agonists. Clin Obstet Gynecol. 1989;32(3):550-563.
Hodgen GD. General applications of GnRH agonists in gynecology: Past, present and future. Obstet Gynecol Surv. 1989;44(5):293-296.
McEvoy GK, ed. American Hospital Formulary Service Drug Information 92. Bethesda, MD: American Society of Hospital Pharmacists, Inc.; 1992.
Bennett DR, ed. AMA Drug Evaluations Subscription. Chicago, IL: American Medical Association; Winter 1992.
Schrlock ED. GnRH agonists. Clin Obstet Gynecol. 1989;32(3):550-563.
Bucci KK, Carson DS. Contraception and infertility. In: Pharmacotherapy: A Pathophysiological Approach. JT Dipiro, RL Talbert, PE Hayes, et al, eds. Norwalk, CT: Appleton & Lange; 1993:1211-1130.
U.S. Pharmacopeial Convention, Inc. (USPC). USP Dispensing Information. Volume I -- Drug Information for the Healthcare Professional. 18th ed. Rockville, MD: USPC; 1998.
Medical Economics, Inc. Physicians' Desk Reference. 52nd ed. Montvale, NJ: Medical Economics Data Production; 1998.
Mosby-Year Book, Inc. Mosby's GenRx: The Complete Reference for Generic and Brand Drugs. 8th ed. St. Louis, MO: Mosby; 1998.
American Hospital Formulary Service (AHFS). AHFS Drug Information 98. Bethesda, MD: American Society of Health-System Pharmacists; 1998.
Levitsky AM. Pharmacologic treatment of hypersexuality and paraphilias in nursing home residents. J Am Geriatr Soc. 1999;47(2):231-234.
Vilos GA, Lefebvre G, Graves GR, et al. Guidelines for the management of abnormal uterine bleeding. SOCG Clinical Practice Guidelines No. 106. J Obstet Gynaecol Can. 2001;23(8):704-709.
Duckitt K. Menorrhagia. In: Clinical Evidence, Issue 9. London, UK: BMJ Publishing Group, Ltd.; June 2003.
Lethaby A, Hickey M. Endometrial destruction techniques for heavy menstrual bleeding. Cochrane Database Syst Rev. 2002;(2):CD001501.
Sowter MC, Lethaby A, Singla AA. Pre-operative endometrial thinning agents before endometrial destruction for heavy menstrual bleeding. Cochrane Database Syst Rev. 2002;(3):CD001124.
Rao GG, Miller DS. Hormonal therapy in epithelial ovarian cancer. Expert Rev Anticancer Ther. 2006;6(1):43-47.
Lee SJ, Schover LR, Partridge AH, et al. American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. J Clin Oncol. 2006;24(18):2917-2931.
Sonmezer M, Oktay K. Fertility preservation in young women undergoing breast cancer therapy. Oncologist. 2006;11(5):422-434.
Precocious Puberty
Brenner PE. Precocious puberty in the female. In: Reproductive Endocrinology, Infertility and Contraception. DR Mishell, VC Davajan, eds. Philadelphia, PA: FA Davis Co.; 1979.
Partsch CJ, Sippell WG. Treatment of central precocious puberty. Best Pract Res Clin Endocrinol Metab. 2002;16(1):165-189.
Mul D, Wit JM, Oostdijk W, et al. The effect of pubertal delay by GnRH agonist in GH-deficient children on final height. J Clin Endocrinol Metab. 2001;86(10):4655-4656.
Cara JF, Kreiter ML, Rosenfield RL. Height prognosis of children with true precocious puberty and growth hormone deficiency: Effect of combination therapy with gonadotropin releasing hormone agonist and growth hormone. J Pediatr. 1992;120(5):709-715.
Pelvic Pain
ACOG Committee on Practice Bulletins -- Gynecology. ACOG Practice Bulletin No. 51. Chronic pelvic pain. Obstet Gynecol. 2004;103(3):589-605.
Royal College of Obstetricians and Gynaecologists (RCOG). The initial management of chronic pelvic pain. RCOG Guideline No. 41. London, UK: RCOG; April 2005.
Infertility
Albuquerque LE, Saconato H, Maciel MC. Depot versus daily administration of gonadotrophin releasing hormone agonist protocols for pituitary desensitization in assisted reproduction cycles. Cochrane Database Syst Rev. 2005;(1):CD002808.
Al-Inany H, Aboulghar M. Gonadotrophin-releasing hormone antagonists for assisted conception. Cochrane Database Syst Rev. 2001;(4):CD001750.
Nugent D, Vandekerckhove P, Hughes E, et al. Gonadotrophin therapy for ovulation induction in subfertility associated with polycystic ovary syndrome. Cochrane Database Syst Rev. 2000;(3):CD000410.
Prostate cancer
Wojciechowski NJ, Carter CA, Skoutakis VA, et al. Leuprolide: A gonadotropin-releasing hormone analog for the palliative treatment of prostate cancer. Drug Intell Clin Pharm. 1986;20:746-751.
Debruyne F. Hormonal therapy of prostate cancer. Semin Urol Oncol. 2002;20(3 Suppl 1):4-9.
National Institutes of Health. The management of clinically localized prostate cancer. National Institutes of Health Consensus Development Conference 1987 June 15-17. NCI Monogr. 1988;(7):1-174.
Seidenfeld J, Samson DJ, Aronson N, et al. Relative effectiveness and cost-effectiveness of methods of androgen suppression in the treatment of advanced prostate cancer. Evidence Report/Technology Assessment No. 4. Prepared for the Agency for Healthcare Policy and Research (AHCPR) by the Blue Cross and Blue Shield Association Technology Evaluation Center. AHCPR Pub. No. 99-E0021. Rockville, MD: AHCPR; May 1999.
Seidenfeld J, Samson DJ, Hasselblad V, et al. Single-therapy androgen suppression in men with advanced prostate cancer: A systematic review and meta-analysis. Ann Intern Med, 2000;132(7):566-577.
Prostate Cancer Trialists' Collaborative Group. Maximum androgen blockade in advanced prostate cancer: An overview of the randomised trials. Lancet, 2000;355:1491-1498.
Wilt T, Nair B, MacDonald R, Rutks I. Early versus deferred androgen suppression in the treatment of advanced prostatic cancer. Cochrane Database Syst Rev. 2001;(4):CD003506.
Schmitt B, Bennett C, Seidenfeld J, et al. Maximal androgen blockade for advanced prostate cancer. Cochrane Database Syst Rev. 1999;(2):CD001526.
Leiomyomas
Lefebvre G, Vilos G, Allaire C, et al. The management of uterine leiomyomas. SOGC Clinical Practice Guidelines. No. 128. Society of Obstetricians and Gynaecologists of Canada. J Obstet Gynaecol Can. 2003;25(5):396-405.
Vollenhoven BJ. Uterine fibroids: A clinical review. Br J Obstet Gynecol. 1990;97:285-298.
Friedman AJ. Treatment of leiomyomata uteri with short-term leuprolide followed by leuprolide plus estrogen-progestin hormone replacement therapy for 2 years: A pilot study. Fertil Steril. 1988;51(3):526-528.
Farquhar C, Arroll B, Ekeroma A, et al. An evidence-based guideline for the management of uterine fibroids. Working Party of the New Zealand Guidelines Group. New Zealand Guidelines Group; November 1999.
Lethaby A, Vollenhoven B, Sowter M. Pre-operative GnRH analogue therapy before hysterectomy or myomectomy for uterine fibroids. Cochrane Database Syst Rev. 2001;(2):CD000547.
Breast cancer
Olin BR. Drug Facts and Comparisons. St. Louis, MO: J.B. Lippincott Company; 1992.
McEvoy GK, ed. Leuprolide. In: AHFS Drug Information. Bethesda, MD: American Society of Hospital Pharmacists; 1993:606-612.
McGuire T. Breast cancer. In: Pharmacotherapy: A Pathophysiologic Approach. 2nd ed. J Dipiro, RL Talbert, PE Hayes, et al, eds. Norwalk, CT: Appleton & Lange; 1993:1930-1945.
Dowsett M, Jacobs S, Aherne J, et al. Clinical and endocrine effects of leuprorelin acetate in pre- and postmenopausal patients with advanced breast cancer. Clin Ther. 1992;14 Suppl A:97-103.
Manni A, Santen R, Harvey H, et al. Treatment of breast cancer with gonadotropin-releasing hormone. Endocr Rev. 1986;7(1):89-94.
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Endometriosis
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Letassy NA, Thompson DF, Britton ML, et al. Nafarelin acetate: A gonadotropin-releasing hormone agonist for the treatment of endometriosis. DICP. 1990;24:1204-1209.
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Tummon IS, Pepping ME, Binor Z, et al. A randomized, prospective comparison of endocrine changes induced with intranasal leuprolide or danazol for treatment of endometriosis. Fertil Steril. 1989;51(3):390-394.
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Schmidt CL. Endometriosis: A reappraisal of pathogenesis and treatment. Fertil Steril. 1985;44(2):157-173.
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Premenstrual syndrome
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Mortola JF, Girton L, Fischer U. Successful treatment of severe premenstrual syndrome by combined use of gonadotropin-releasing hormone agonist and estrogen/progestin. J Clin Endocrinol Metab. 1991;72(2):252A-252F.
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Bancroft J, Boyle H, Warner P, et al. The use of an LHRH agonist, buserelin, in the long-term management of premenstrual syndromes. Clin Endocrinol (Oxf). 1987;27(2):171-182.
Muse KN, Cetel NS, Futterman LA, et al. The premenstrual syndrome. Effects of 'medical ovariectomy'. N Engl J Med. 1984;311(21):1345-1349.
Zoladex
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Vercellini P, Fedele L, Maggi R, et al. Gonadotropin releasing hormone agonist for chronic anovulatory uterine bleeding and severe anemia. J Reprod Med. 1993;38(2):127-129.
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Plenaxis
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baseline scan and bloodtest

2007-07-18T21:42:00.000+08:00

Tues 17 July 2007

went for baseline scan and bloodtest today. results out about 4pm. was told to conitnue with lucrin for another 7 days before going back for another scan and bloodtest. was also told that the endometrium is thick at 8mm.

normally by this time of the cycle, (day 5 of the cycle after AF), the endometrium shd be about 2mm only. yet mine is 8mm, not sure how this will affect the IVF cycle.

I am so diasppointed by the extension of the lucrin jabs and to top that now the point about the thickened endometrium..i wonder all thse additional hurdles is some omen that i should consider ending the cycle.

the side effects of lucrin/lupron is really beyond my control..it made me tempermental, frustrated at the slightest thing and short tempered, not to mentioned fatigue and nausea. I am not sure if it's the stress adding or the meds, but it seems to have triggered off a fibromyglia flare as well, my ribs, hips and knee hurts like hell.

lucrin side effects

2007-07-13T13:23:00.000+08:00

the days are getting harder to cope - perhaps it's the side effect of lucrin/lupron. been feeling moody, teary, and super tired. and guess what AF come by today which is only Day 25 of the cycle.

so far been on 11 days of lucrin jabs with baseline scanning next Tuesday. Hoping to be able to start puregon ASAP. i can't wait for it to end.

IVF Start of Lucrin cycle

2007-07-03T21:59:00.000+08:00

Finally 3rd July 2007 came around, today is Day 16 of the IVF cycle and officially i got started on Lucrin. I was pretty worried about the jabs, who wouldn;t be? it turn out to be less painful and less complicated.

will start to jab myself tomorrow.

IVF Status

2007-06-19T21:42:00.000+08:00

AF finally showed up, 6 days after the end of the 5 days course of duphaston. called KKH IVF and made an appointment to start Lucrin 16 days later on 3rd July 2007.

at the same time, made an appointment with Caroline for counselling.

in the meantime, suppose to start on Microgyon for the next 21 days.

looking eagerly to start the program.

KKH IVF - Pre IVF cycle Day 6

2007-06-12T08:57:00.000+08:00

Time seems to be crawling. so far completed the course of duphaston for 5 days at 2 tabs daily. now just waiting for AF to start. normally after a course of progesterone, AF will start like 3-5 days later. Let's hope this holds true again.

i wonder if it's the effects of the progesterone - i have been feeling teary, fatigue and unable to sleep well at nights. I am trying to relax but arghs....the lack of sleep is making me so tired. i worry if this continues that it will trigger of fibromyglia.

today is also the second day after hubby had his 2 teeth; 1 wisdom and 1 molar taken out. needless to say he is in excruitating pain and milking it completely. how i wish i am home looking after him now.

my mind is 1/4 at work, 1/4 in IVF and 1/2 at home.

KKH IVF

2007-06-11T13:25:00.000+08:00

Friday 08 June 2007 3pm

WE had an appointment with KKH IVF at 3pm. Staff Nurse Tan CK went through the details of the program. Basically it's more or less what we expected, except that the jabs went on longer than expected. I will be on lucrin for almost 21 days, in addition to Puregon for up to16 days. That's like 37 days of self inflicted pain.

a night jab of IM pregnyl and 4 days of HCG if egg collection is less than 15, or 17 days of IM progesterone if number of eggs collected is more than 15.

i really cannot imagine 17 days of progesterone jabs. last time we did alternate days and it was damn painful to the extent of numbed butts.

The actual schedule as follows:

Day 1 : start of menses - call KKH IVF
Day 2 - Day 16 : Microgyon (birth control pills) x 16 days
Day 16 - Day 21 : Microgyon 5 days + subcut Lucrin 10 units x 5 days Total Microgyon 21 days
Day 21 - Day 30 : subcut Lucrin 10 Units 9 days Total 14 days Lucrin - baseline scan & bloodtest for E2
Day 31 - Day 37 : subcut Lucrin 10 units x another 7 days
Day 38 - Day 44 : subcut Puregon 200 IU x 7 days + Lucrin 10 units
Day 45 (8th day of puregon)- Day 53 (16th day of puregon): subcut Puregon + Lucrin 10 units (dosage depends on growth of follicles) - 1st scan on 8th day of puregon; 2nd scan betwen 9th -12th days; 3rd scan between 13th - 15th day. When follicles reach 16mm, STOP Lucrin. Total 16 days puregon
Day 54 : IM pregnyl at night , ER 2 days later
Day 56 : Egg Retrieval
Day 57 - Day 58 : wait for fertilisation
Day 59 : Egg transfer / balance embroyo to freeze
Day 60 - Day 76 - return for progesterone blood tests (x3) - if more than 15 eggs collected, got to return for IM progesterone daily for 17 days. If less than 15 eggs collected, 4 x HCG jabs.
Day 77 : 17 days later, pregnancy test

Now the challenge is to put the estimated dates in
Day 1 : Mon 18 Jun
Day 16 : Tue 3 Jul - start of lucrin + appt at KKH + counselling session with Caroline
Day 30 : Tue 17 Jul - baseline scan & blooodtest
Day 38 : Wed 25 Jul - Start Puregon
Day 45: Wed 1 Aug - 1st Scan
Day 48 : Sat 4 Aug - 2nd scan
Day 51 : Tue 7 Aug - 3rd scan
Day 54 : Fri 10 Aug - IM pregnyl jab
Day 57 : Mon 13 Aug - ER
Day 59 : Wed 15 Aug - ET
Day 77 : Sat 1 Sep - pregnancy test

starting on IVF

2007-06-08T22:57:00.000+08:00

Starting on IVF is daunting - not just about the physical aspects, but also the emotional and financial aspects, not to mention how it will affect my work.

but then if we don't get started, nothing will happen.

after all the reserach done in the past 2 years, we decided the best place to do IVF would be KKH IVF

reasons as follows:
1) the medical team headed by SF Loh. His approachability via emails is huge factor in our decision, not to mention that he helped me get over the ectopic pregnancy. btw he's now the head of the reproductive dept in KKH and the director of the IVF program.
2) the success rate in KKH IVF exceeds the rest of the centres
3) the convenience of early morning clinics for scans and blood test - which means less time off work
4) the financial cost factor.

Our first appt at Clinic D didn't start of very well. the appt was at 430pm but we only got to see the doctor close to 6pm. and it was a very rush consultation as there are still quite a few patients after me.

the decision was made so swiftly by Dr Loh that we didn;t have a chance to absorb it. half an hour later while we were waiting to make payment, the doc happened to walk past us and he made an effort to talk to us about the rough time scheduling of this IVF cycle. that help to reliev some of our doubts about chosing KKH.

The next appointment will be on Friday at the IVF clinic for registration, counselling by the doctor, required blood tests, and counselling by the phychologist.

Start of a new cycle - this time IVF

2007-06-08T22:51:00.000+08:00

We tried 3 cycles of serophene in NUH but nothing happened. we thought that with the better HSG results and the successful ovulation, we will be able to achieve a baby by now, but no nothing happen.

i started a new job and am now in my 3rd month, wasn't planning to start TTC again so soon..except that MIL announce that SIL is pregnant.

That brought back a lot of memories, and not all good. It was all i could to control myself and not break out in tears on the spot.

life is so unfair.

ovarian drilling

2006-10-25T21:31:00.000+08:00

PCOS AND INFERTILITYPCOS (Polycystic Ovarian Syndrome) is a condition that affects as manyas 10% of all women, or more. While researchers have been able todefine a fairly consistent set of symptoms for PCOS, they have notfound a singe cause, as of yet. It is a leading cause of infertility,and no cure has yet been found. The most common symptoms include:* Irregular menstrual cycles, or even the lack of cycles* Multiple ovarian cysts in many cases* Elevated blood pressure* Acne* Insulin resistance, or even diabetes* Infertility* Increased body and facial hair, along with alopecia (loss of hair)* Weight problems(From the Polycystic Ovarian Syndrome Associationhttp://www.pcosupport.org/medical/whatis.php)Other conditions that a physician may consider are “Cushing’s disease(overactive adrenal gland), thyroid problems, congenital adrenalhyperplasia or increased prolactin production by the pituitary gland.”Blood tests ordered may include thyroid functions, prolactin levels,17-hydroxyprogesterone, and a dexamethasone suppression test. In manycases PCOS sufferers will have elevated androgen (male hormone) levelsso these hormones will be tested as well. Insulin resistance is also aproblem so a two-hour glucose tolerance test will probably beperformed. Women with PCOS also have a number of cardiac complicationsso tests such as cholesterol, homocysteine, CRP, and PAI-1 levels maybe obtained to assess their cardiac risk factors.(From the Georgia Reproductive Specialists, http://www.ivf.com/pcostreat.html)Both of these sites have information regarding basic treatments forPCOS as well as brief introductions into various reproductivetechnologies. Since you have asked about a few things in particular, Iwill focus my detailed explanation on these three.- - - - - - - - - - - - - - - - - - - -OVARIAN DRILLINGOvarian drilling is a laparoscopic procedure, where instruments areintroduced through very small incisions in the abdomen, and thesurgeon uses a camera to guide him or her. A small needle puncturesthe cyst in the ovary, and then an electrical current is used todestroy part of the cyst. At Pregnancy-info.net, they state thatsuccess rates are less than 50%, but they do not specify what outcomesdetermine “success” in their opinions. At any rate, side effects, suchas scarring, could further impact the ability to become pregnant inthe long run.http://www.pregnancy-info.net/infertility_PCOS.htmlA study published in the British Journal of Obstetrics and Gynaecologyin March 1998 discusses success rates in achieving pregnancy afterovarian drilling. The study enrolled 118 women with documented casesof PCOS and then performed the procedure on them over a five-yearperiod. The total conception rate within the first 12 months after theprocedure was 54%. Women who successfully conceived had had “a shorterduration of infertility, were treated with diathermy (rather thanlaser), had higher pre-operative luteinising hormone [LH] levels, wereyounger and were more likely to have ultrasonographic evidence ofpolycystic ovarian disease.” When considering only women who had beeninfertile for 3 years or less prior to the procedure, the success rateincreases to 79%.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9532997&dopt=AbstractIn March 2005 a study regarding laparoscopic ovarian drilling (LOD)was published in the European Journal of Obstetrics, Gynecology, andReproductive Biology. In this study 45 women who had beenunsuccessfully treated with clomiphene (Clomid) were selected toundergo LOD. “Serum testosterone (T), follicle stimulating hormone(FSH) and luteinizing hormone (LH), fasting insulin and glucoselevels, body mass indexes, modified Ferriman Gallwey (FG) hirsutismscores of the subjects are recorded before and after the procedure.”After LOD, 93.3% of the women reported normal menstrual cycles, and64.4% achieved pregnancy spontaneously. “The serum levels of T, freeT, LH, LH:FSH ratio, insulin and FG scores were significantly reducedafter LOD, although glucose levels and glucose/insulin ratio remainedunchanged.”http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15734089&dopt=AbstractA smaller study was performed in 2002 at the Ayub Medical College inAbbottabad and the Khyber Medical College in Peshawar, both inPakistan. Sixteen women with PCOS were selected to undergo LOD. Theyall had a full infertility workup before the procedure, including a6-month trial of clomiphene. After the procedure 14 (87.5%) women hadregular menstrual cycles and 11 (68.8%) achieved pregnancy.http://www.ayubmed.edu.pk/JAMC/PAST/15-4/Azizun.htmIn a study published in 2004 in Human Reproduction, they list factorsrelated to pregnancy success after LOD. They state that, “markedobesity, marked hyperandrogenism and/or long duration of infertilityin women with PCOS seem to predict resistance to LOD. High LH levelsin LOD responders appear to predict higher probability of pregnancy.”http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15178663&query_hl=6&itool=pubmed_docsumA study reviewed in the Cochrane Database in 2006 shows no significantdifference in pregnancy rates after LOD versus treatment withgonadotropins (LH, FSH, HMG, etc.). About 50% of women will have alive birth and about 16% will have a miscarriage after achievingpregnancy. There were fewer multiple births associated with LOD,however.http://www.cochrane.org/reviews/en/ab001122.htmlA 2003 review article in Reproductive Biology and Endocrinologydiscusses various treatment options for infertility and PCOS. Theauthors reviewed multiple studies and compiled the data to determineoverall success rates. They report that 82% of women in the studiesexperienced ovulation following LOD and 63% achieved pregnancy. Thisdata compares favorably with a similar Cochrane review. The authorsalso state that if ovulation has not been achieved spontaneously after2-3 months following LOD, adding an ovulation stimulator (likeclomiphene) is more successful at this point than it would have beenbefore LOD.http://www.pubmedcentral.gov/articlerender.fcgi?tool=pubmed&pubmedid=14617367Other patient information sites seem to report the same 50% successrate for LOD (although I did see rates as high as 75% after 3 years).For the most part, it looks as though they are using birth rate ratherthan pregnancy rate to determine this success. This is the statisticthat will be most important to patients.http://www.womens-health.co.uk/infertility6.asp http://www.ivf-infertility.com/infertility/treatment/ovarian11.phphttp://www.conceivingconcepts.com/medical/askthedoc/polycystic_ovaries/http://health.ivillage.com/gyno/gynoovaries/0,,677r,00.html

random post - poem

2006-06-08T13:01:00.000+08:00

oh little one
i wish i knew when i will be caring you.
feeling your kick hearing that heart beat.
knowing that you are mine.

oh little one.
How long do i have to wait
When will be our time to be Mommy and Daddy
to love someone else so much
with all our love and care

Oh little one
if you only knew how much we want you
to concieve you to make you
we love you so much
even if your only in our thoughts

Oh little one
I wanted to say.
Some day someday soon,
I believe i will be caring you
until than.. I just want to say I love you!

random post - incomplete d & c

2006-05-24T09:29:00.000+08:00

been in the a & e for 3 nights consecutively for pain

i have never ecxpierenced such pain before (other than the last time, the night before the d & c)

finally, on the 3 rd night, the a & e doc was able to tell me what's wrong...it's due to an incomplete d & c that causes the pain as the body is trying to expel the remaining tissue.

yes, sf loh did tell that the d & c is not thourough as it will be the second one i am doing in about less than half a year, and he said the body will expel the remaining tissues but i NEVER expected the pain to be beyond what i can bear; and i know i have a high threshold of pain.

it's been one week since the d & c, and the pain has not abated, will be seeing him again today, been reading on the net and came across this article.

i think i will ask him about this.

http://www.reproline.jhu.edu/english/2mnh/2pa/pac_proc/broek1.htm

Postabortion Care Workshop Proceedings: Workshop Presentations
Issues in Establishing Postabortion Care Services in Low-Resource
Settings: Workshop Presentations

Use of Misoprostol for the Management of Bleeding in Early Pregnancy
Fredrik F. Broekhuizen, MD University of Wisconsin

Background
Misoprostol is a synthetic PGE1 analogue which is available in tablet form. It is closely related to other prostaglandins used in obstetrical practice such as Dinoprostone (PGE2), Carboprost (15 methylPGF2alpha), Gemeprost (PGE1) and Sulprostone (PGE2 analogue). Misoprostol was developed and marketed
for prevention of peptic ulcer disease caused by prostaglandin synthetase inhibitors, but with its potent uterotonic and cervical ripening activity has found applications in the management of gynecological and obstetrical problems. In the United States it has been marketed as Cytotec, with 100 and 200 mcg tablets available.

Misoprostol:
is inexpensive (US$.36 per 100 mcg);
is easily stored (shelf life 7 years);
has, in comparison with other prostaglandins, minimal effects on
cardiovascular and bronchial tree smooth muscle (can be safely
used in hypertensive patients and asthmatics);
is not affected by ambient temperature; and
needs no refrigeration, needles or syringes for its storage and
administration.

Mechanism of Action
Misoprostol is a myometrial stimulant which binds to E-2 and E-3
prostanoid receptors. Its active plasma metabolite is misoprostolic
acid. It is rapidly absorbed after oral, vaginal and rectal
administration. With oral administration the half life is less than
30 minutes, and peak level is at 15 minutes. After vaginal
administration, there is a gradual rise to a maximum level at 60–120
minutes, but at 240 minutes the level is still at 60 percent of peak
level (see below).

Comparative Effectiveness of Vaginal and Oral Administration
of Misoprostol
More side effects with oral use
At similar dose:
95% (vaginal) success vs. 87% (oral) in first trimester
Failure 1% (vaginal) vs. 7% (oral)
Abortion within 4 hours: 93% (vaginal) vs. 78% (oral)

Source: El Refaey et al 1995.
It is assumed that rectal administration results in a similar
profile. Vaginal dosing therefore can take place with longer
intervals than oral dosing for similar desired uterine effect, and
accumulation above "safe" levels with undesirable side effects can
take place. With oral and vaginal dosing of up to 400 mg every 8
hours, no accumulation has been noted and no accumulation has been
seen with a maximum of three doses of 400 mcg 3 hours apart.
Potential hypertonus as a result of drug accumulation could lead to:
uterine rupture in the second or third trimester,
fetal distress in the third trimester, and
high rates of nausea and diarrhea in all trimesters.
For obstetrical use, the vaginal application has been studied the
most. Misoprostol in the first and second trimesters is an effective
pregnancy termination agent either as a single agent or as an
adjunct to methotrexate or mifepristone. Misoprostol will
effectively dilate the cervix prior to surgical abortion.
Misoprostol has been studied as a cervical ripening and induction
agent in the last two trimesters. Its use as an alternative to MVA
or suction curettage for management of incomplete abortion (first
trimester), as a uterotonic agent in the active management in third
stage and as a treatment of postpartum hemorrhage are currently
being studied.

Applications of Misoprostol
Cervical priming prior to surgical abortion
Labor induction 24 weeks to term
Alone/adjunct for medical abortion
Management of spontaneous abortion?
Management of uterine atony

Misoprostol offers a potentially inexpensive treatment for life
threatening bleeding in pregnancy in developing countries in the
hands of frontline healthcare workers.

Research Results
The following section summarizes the status of misoprostol use in
early pregnancy.
Fong et al (1998) demonstrated that 400 mcg vaginal misoprostol
will dilate the cervix to more than 8 mm in 96.7 percent of
patients when it is given up to 3 hours or more prior to suction
curettage in the first trimester.
Carbonell et al (1997b) demonstrated that for gestations less than
63 days, misoprostol, given in a dose of 800 mcg vaginally and
repeated at 48 and 96 hours, resulted in a 92 percent complete
abortion rate, with 77 percent complete after one dose and an
additional 13.7 percent after the second dose; there was a failure
rate of 8 percent. Hausknecht (1995), Creinin et al (1995) and
Carbonell et al (1997a) all reported a 90–96 percent complete
abortion rate with methotrexate followed by misoprostol at 3, 5
and 7 days in a dose of 800 mcg; 20 percent of patients required
two or three doses.
In a review of the literature, Grimes (1997) concluded that class
I evidence and class A recommendations for first trimester
abortion existed for misoprostol as the most effective
prostaglandin, either as a single agent or as an adjunct (most
effective at the seventh day) to mifepristone or methotrexate.
El Refaey et al (1995) compared oral and vaginal doses and found
vaginal misoprostol use resulted in fewer failures.
These studies clearly establish misoprostol as an effective agent to
"empty" the pregnant uterus in the first trimester. One could assume
similar effectiveness when it is given for a "failed" pregnancy or
missed abortion. Blood loss in all of these studies was acceptable
and comparable to blood loss during surgical abortion.
Misoprostol is associated with birth defects in "continuing
pregnancies," and this is an obvious concern with unsupervised use.

Failed Induction Using Misoprostol
Congenital defect
Moebius Syndrome
Limb reduction defect
Mechanism of action
Placental bed ischemia
Embryonic vascular disruption

Source: Gonzalez et al 1998; Hofmeyr et al 1998; Pastuszak et al
1998.
This association is confirmed by several studies in Brazil, where
misoprostol is readily available over the counter. Moebius syndrome,
characterized by equinovarus, cranial nerve defects, arthrogryposis
and terminal limb defects, has been described with exposure to a
failed single dose of 800 mcg. Localized ischemia in the placental
bed and vascular disruption in the embryo are postulated as the
operational mechanism for causing the congenital anomalies.

Misoprostol Use in Incomplete Abortion
So far, only five studies regarding the use of misoprostol for
incomplete abortion have appeared in the peer review literature.
Studies regarding the management of incomplete abortion must be
considered against the natural history and expectant management of
this condition and its complications. Nielsen and Hahlin (1995),
comparing surgical evacuation and expectant management over a
72-hour period, reported that completed abortion occurred in 70
percent of cases in the expectant management group. The complication
rate was also lower in the expectant management group (3 percent)
compared to the surgical treatment group (11 percent). In a pilot
study of 20 patients, Creinin, Moyer and Guido (1997) found an 800
mcg vaginal dose more effective than a 400 mcg oral dose, with 88
percent complete evacuation. As shown in Table 1 below, Chung et al
(1997) in two prospective observational studies (none prospectively
randomized) found that 66 percent and 79 percent of patients managed
over a 48-hour period with 400 mcg misoprostol orally in three doses
did not require a curettage. A reference group had immediate sharp
curettage (D&C) and the complication rates (infection, repeat
curettage) were higher in the curettage group. Blood loss was not
systematically evaluated.

Table 1. Misoprostol for Incomplete Abortion
PROTOCOLRESULTS
354 cases by ultrasound
225 products of conception (POC)
102 empty uterus
137 reference cases
Misoprostol
Orally
400 mcg every 4 hours for three doses
D&C if incomplete after 48 hoursCompletion rate: 70.6%
101 in <>

so many things have happened since....

2006-05-24T09:03:00.000+08:00

it has been a while since i updated this blog, so many things have happened since. i am totally numb, emotionally as well as mentally

i came across something that strike me just and i thought i post it here

cd 27 dpiui 13 blood test results

2006-04-25T17:51:00.000+08:00

i didn't make any sense out of this result despite googling it on the net.

HCG is 29
Progesterone is 180
E2 is 3156

to return on thursday to take another blood test in the morning.

results, YES IT WORKED

2006-04-25T12:30:00.000+08:00

yes yes yes it worked!!!!

the iui actualy worked. i was so weary of this cycle as i had bad cramps after the procedure, PT suggested i up the dose of the progesterone to 3 times a day, that made me really grouchy and tired and sleepy and the cramps didn;t completely go away as well.

met M for lunch the day of her IUI. and she is very encouraging. btu i didn;t have much hope for this cycle at all. the last 3 days of the 2www was hell, i couldn;t concentrate at work at all, i think effeiciency at work was down to 5%.

i tested on dpiui 10, which of course was a total BFN, dpiui 11 on sat which gave a super faint line 15 min after the test which hubby said he can;t see, dpiui12 on sun which gave a faint line that hubby could see...and dpiui13 on mon which has a faint line that both of us could agree we can see.

straight away i made an appt with PT to see him that afternoon, the cramps i am feeling can;t be good.

i was in two minds about telling my boss about the pregnancy since it;s still in such an early stage but i figured that it's harder finding excuses to stay off work and the numerous MC so far. also i figured it will give both of us more time to make alternative arrangements. between the baby and the job, needless to say when push comes to shove, the baby will come first.

thereforre i am so so glad that she is amendable to me working from home. that's a super huge relief off my mind.

the appt at 3pm went smoothly, the clinic took some blood and now i am waiting for the results. the nurse did ask if i want the results urgently, she said that it will cost an add $20 plus whether or not urgent, will onyl get results the next morning. as such i decided might as well save the money.

i called the clinic this morning but the results are not out yet, will only be available this afternoon, i sure wish i paid that add 20 bucks. i'm now sitting at my desk, un able to concentrate on anything, my attention span is like maximum 5 min, i don;t have appetite to eat either...arghs.

i really should ahve paid the additional 20 bucks!

the rest of this cycle

2006-04-24T17:53:00.000+08:00

It has been a while since i have updated on the status of this cycle. After the scare of a stuck ovary and the mini lecture by LA, i realised that a gynae is still the best person to analyse the situation.

made an ppt to see PT at TMC and got scanned, yes the ovary is behind the womb but it's not stuck and it's un likely to be stuck cause of no previous history of addominal surgery. a huge phew. a little knowledge is a dangerous thing. remind me to get a christmas hamper for LA!

follicles at 18mm and not ready to do IUI yet, will re schedule another scan on Monday at CARE.

on Mon, PT deems ready to go with the IUI the next day, i didn;t ask about the follicles size, figured whether i knew or not doesn't make any difference. anyways got the HCG jab done by eileen, ouch it's as painful as the last time.

i got back to work, but didn;t feel so good, took half a day off and went home to rest.

the next day is the big day. went to CARE in the morning at 830am with hubby to provide the sample, paid the bill of 500 plus and had a couple of hours to while away. we had breakfast at delifrance, then went down to sph to collect the free fryer....and it took us all of half an hour. at 9am, we still have 2 hrs to spare.

in the end we went down to borders and spent the next hour or so browsing, i ended up buying 2 books, a novel by robin cook and guess what a infertlity book, the latest one to print. a flip thru it is pretty informative, will update more later. during this time, another friend sms me saying she's going for IUI the next day. good for her.

we still got half an hr to go, so we decide to head back to paragon, went to metro and decided to look at shoes, well i didn't get any shoes but i got a blouse from dorothy perkins. :P shopoholic u may say but hey retail therapy always worked.

finally 1130am, got the sample and headed straight to TMC. we waited about 10 min before i was told to prepare for the procedure. like the last time,n it was done in a separate room. i was all prepped and ready when PT came in. the procedure itself was pretty fast with the usual equipment not staying where it should stay. the doc commented that i had a lot of CM which i suppose is good rather than bad.

anyways after the procedure, hubby came in and we rested for 20 min. settled the bill of 257 and took the medicine before going home. now is the start of the 2ww.

the 2ww is the worst part of the whole cycle. it's a waiting game from now onwards.

Cycle 4 - CD9

2006-04-06T08:49:00.000+08:00

06 April 2006 Thur

angela did the scan this morning, commented the following:

retroverted uterus - that's new!
one of the ovaries stuck behind the womb - no known cause, no way of prevention, not due to d & c, will affect egg retrival if doing IVF.

the good news
2 follicles on L/R? ovary - 10mm each
1 follicle on the L/R stuck ovary - 13mm

lining is thin for CD9 - at 5.7mm, ideally should be 9mm by now. she prescribed estrodiol to be taken 3 times a day.

clomid can cause anti estrgenic effects which means that there is not enough estrogen in the body to make a thick lining.

the body creates further resistance to clomid after each cycle, hence even after a break of a few months, clomid will no longer work to induce ovulation.

this is where it becomes anti estrogenic and cause the cervical mucus to be hostile to sperm and as well depreciate in quanity.

to return on sat for scan, to test LH surge on fri, twice a day, AM and Eve.

IUUI probably on Mon or tue depending on Sat scan, will update later.

The Private Suite at KKH

2006-03-17T20:09:00.000+08:00

Called on Mon 13 Mar to make the appt to see Dr SF Loh. He had very good reviews at the Motherhood forum for successful IVF cases. I was prepared to do IVF.

After being put on hold for ages, i was half expecting that the appt would be 3 weeks down the road (KKH efficiency) but was pleasantly surprised that there's an available slot that Wed evening. confirmed the appointment.

Was pretty impressed with TPS, the set up is so totally differnt from the normal clinics at KKH, for 6 bucks more, you get shorter waiting time, a beautiful and comfortable waiting area replete with magazines and hot drinks, a sms system that inform you of your appointments, the designated doctor that you want to see and super friendly nurses and service staff. overall impressed by the service rendered.

the doc was good, i;ve seen him before almost exactly a year back, this time round he didn't suggest IVF but to continue to try with clomid and IUI. He started me on metformin, 3 tabs of clomid and med to induce AF.

basically he put me on ovualtion monitoring at KKH IVF centre..and thats' where things start to go wrong.

When i called KKH IVF, i found out that they didn;t have a evening or a weekend clinic, the clinic which opens at 730am doesn't do scans till 8.30am and it takes approximately 1 hour waiitng time in the morning.

for ovulation monitoring, each cycle will need approx 3-5 scans, i cannot possible afford the down time from work. i am relunctant to take time off from work nor prepared to let my colleagues know about this yet.

enquiring further, I found out that besides the infelxibility in fixing appointments for scans, th scans are done by the sonographer on duty and the results reviewed by the team of doctors, not necessarily the designatd doctor.

the IUI procedure itself is also not necessarily done by the designated doc but by which ever doc who was on duty on that day. i wasn't prepared for that. the reason why i chose KKh was because of the good reviews about SF Loh, i trust his expertise not the rest of his team!

the last factor was cost. The package to do IUI at KKH IVF is not at any way subsided, which means one pay full price.

The scanning package is $300 for unlimited scans, urine tests at $15 per test (usually need about 3-4 tests), for IUI procedure which includes sperm washing (enhancement) and hcg jab cost another $300.

Before IUI can be done at KKH IVF, both parties need to go for blood tests to screen for AIDS, STD and rubella for the female, that will cost another $50 per pax plus $23 for the rubella test.

add together, the full package will cost about $780.

that sounds very expensive as compared to being done elsewhere or perhaps even in the private practice.

because i can't take that much time off from work, i got to look for other alternatives.

I thought of the CARE centre at paragon where we did the sperm washing for the last IUI, i remembered that they did IVF procedures as well, surely they do IUI as well.

and bingo they do. Their package comes to about $600 which includes everything above plus they do a additional scan at CD2 to rule out cysts. fantastic, this seems especially value for money, since they are able to scehdule the appointments before i start work or even during my lunch time. it helps that the centre was 10 min walk away from my working place.

according to the lady, each scan should take less than 30 min from stepping into the clinic to stepping out. thank goodness, indeed this is a lifeline. this would mean that i only need to take one day off which is on the day of the IUI itself.

Angela from the CARE centre was an absolute help. She suggested that since we were on 3 cycles of clmoid and still not preggy, we should consider other options. I would agree if the last IUI had not worked, but since it worked on clomid the last time round , i am willing to give it a try again, esp since i am now on metformin as well.

so currently my plan is as such

taking medicine to induce AF - for 10 days starting 15 Mar Wed
AF expected within 3 days
CD2-CD6 - 3 tabs of clomid

on CD2 to go to CARE for scan

total expenses so far
$90 for first time consult at the TPS
$42 for 3 months worth of metformin, clomid and folic acid (hoping that I donlt need 3 months of supply)

expected expenditure
$600 for CARE package

restarting the TTC process

2006-03-17T19:57:00.000+08:00

The last attempt at TTC was the IUI done in Sep 04, the d & C was done on 18 Oct, since then, nov was a shattering month, coping with the loss as well as coping with the loss of the job, the company having closed down, tying up loose ends.

Started the new job in Dec with great enthusiasm and throwing myseklf in work to get over it. got confirmed in the job in early Feb and toyed with the idea of restarting the TTC process again.

in early march, had a bout of stomach flu which triggered the thought that perhaps i got miraculously pregnant as i was throwing up a lot. turn out that well it was stomach flu after all. that got me to seriosuly think about TTC again.

2 months and some down the road

2005-12-30T17:59:00.000+08:00

it has been some time since i last updated this blog.

i posted somewhere that YV is preggy, so is her unmarried sister. what luck!

It all started with Yv good intentions to try out TCM as it worked for her. What it resulted for me was 2 weeks of abdominable powdered chinese medicine and stomach upset and nausea.

forget abt the 2 months, the 2 weeks were enough to put me off TCM for life.

not to mention, being told that her sister is preggy too.

oh well, life do suck that way.

time really flies when one is busy. i can;t believe that it is almost the last day of the 2005. it has been almost one month since i started on this job.

The learning curve is steep and there are loads of details to take care of, but it sure is a good learning experience.

it also kept my mind off the negative stuff and hey, life seems brighter after all.

will post more later.

exactly 1 month since the d & c

2005-11-19T05:21:00.000+08:00

it was exactly one month since the d&C yesterday. i felt the loss more acutely these couple of days.

had a review with LA, he says everything looks pretty ok. and i can start to TTC anytime soon once the first AF comes which shd be by the next 4 weeks. If it doesn't, then to take AF inducing medicine.

He doesn't recommend metformin at this point in time. metformin alone does nothing much to help ovualtion, it's only metformin with clomid that works. He recommends starting metformin one month before TTC, and to continue with clomid.

something i found out is that high LH and FSH levels is common in PCOS women and those will lead to poor quality eggs being released, hence the higher risk of miscarriage.

clomid + metformin helps to achieve ovulation but not neccesarily good quality eggs.

being on injectibles (synthetic FSH jabs) on the other hand works to create better quality eggs. as the proctocol requires suppression of own levels of LH and FSH via medicine/jabs.

at this point in time, there is nothing much LA can do as first AF have not come and i don't intend to TTC now s i will be starting a new job in a couple of weeks time.

in the meantime, i decided to see TCM and see where that takes me. hopefully, the TCM will be able to tame the hormones and restore balance.

we see where TCM takes me in a couple more months.

follow u_ today

2005-10-27T15:15:00.000+08:00

keyboard is still s_oiled.

guess which key?

was at LA at 11.30am, only to be told that he had to go away for an emergency delivery for an hour. by chance met Y who was there to get an MC as well. Y is now in her 8th week.

In the end, we had lunch and talked abt stuff in general. having gone thru a miscarriage before, she said something very striking - when commenting abt a friends friend who became hostile after knowing her friend was regnant not once but twice.

what she said was, there is nothing one can do to ease the erson out of her misery, only she herdelf can walk out of the (self constructed) cage. indeed how true. one can only move on by means of one strength.

LA did a scan and said that the inside is retty clean, excet for the bleeding everything seems fine.

he gave some medicine to sto the bleeding as well as the same dose of the other medicine to make the womb contract.

i was retty wary abt taking that other medicine, it was just last week that the same medicine caused such awful cram_s.

He gave me some _ainkillers to take at the same time.

Y was still waiting for me, and we went to NTUC to get some grocery. I got the feeling she didnt want to leave me alone. I did tell her i am ok, and she waited till i got a cab before heading home.

total damage
62 for just medicine alone.

exactly one week since the loss

2005-10-25T06:12:00.000+08:00

It is exactly one week since the D & C. i thought i would have gotten over it already. whether Physically or mentally or emotionally.

Physically i am still having cramPs and bleeding from time to time. the doc said it will be like this for the next 2-3 weeks until the womb is clear of any remaining tissues. at tmes, i feel light headed and at other times just Plain tired.

mentally, i have accePted the fact that the baby no longer exists. and i should move on and concentrate on new job as well as other areas in life. like PerhaPs learning new reciPes, make some new dishes, Plan an excercise routine, etc etc.

emotionally, at certain times, i feel that i am ok, coPing with the loss well, after all i reasoned that the loss is still early and if its healthy then nothing i do could make me lose the baby. its Precisely that its unhealthy and not meant to be. hence i should feel better emotionally.

yet unlogically, i wondered if we could have waited and PerhaPs, just PerhaPs, soemthing would have haPPened and the baby will survive.

then the thought that we forced nature to haPPen via forced ovualtion and IUI and all those jabs and medicine made me wonder if we didnt just ask for all this suffering. PerhaPs we arent meant to have children, hence therefore we are forcing nature by medical intervention. all that talk abt survival of the fittest, PerhaPs theres something innately wrong with our genes that isnt suPPosed to be rePlicated in the next generation.

emotionally, i asked myself..what did we do wrong? mentally, i KNOW that we did everything Possibly anyone could have done.

the blame is on no one, but the guilt is hard to bear. the Physical side effects is a constant reminder of what haPPened. i hoPe it go away sooner.

an article from the doctor - ExPlaining miscarriage

2005-10-21T06:15:00.000+08:00

this is an article from the doc, i thought i tPye it here so that it can be found.

Each year more than 50,000 Pregnancies end in miscarriage or stillbirth, in Australia. Hannah Dahlen exPlains that while it is hard to make sense of miscarraige, there can also be life after tragedy.

I will never forget the look of emPtiness on my mothers face, tear streaked face, after she lost what would have been her seventh baby. And she will never forget the thoughtless words of the doctor who Patted her hand and said *you ahve nothing to cry about, you have six healthy children*.

Miscarriage imPacts the lives of so many women and their Partners but this imPact is so often underestimated by health Professionals, family and friends. Just because miscarriage is a relatively common event doesnt mean it is a minor exPerience or that it should, or will, soon be forgotten.

Why does miscarriage haPPen?
Miscarriage is a term used for the loss of a baby before 20 weeks of Pregnancy. It tends to be divided uP into early miscarriages (before 12 weeks) and late miscarriages (between 12 to 20 weeks). Every year in Australia more than 50,000 Pregnancies end in miscarriage or stillbirth. It has been estimated that-
*half of all concePtions end in miscarriage before 12 weeks, although many women will not be aware that they are even Pregnant.
*around 2-25 Per cent of known Pregnancies end in miscarriage. Eight er cent of these occur in the first 12 weeks of Pregnancy.
*around 1-2 Per cent of couPles exPerience recurrent miscarriages.

*Common causes of miscarriage
The majority of spontaneous miscarriages are due to major fetal or genetic abnormalities. Other causes are an unusually-shaped uterus, exposure to certain drugs, early opening of the cervix, hormonal imbalances, immunological factors, direct trauma to the lower abdomen, poorly controlled illness like diabetes, and environmental factors such as smoking, alcohol, radiation, infections and exposure to certain chemicals. As a woman's age increases so does her risk of miscarriage, mainly due to the fact that the incidence of genetic abnormalities increases with increased age.

It is important for women to realise that it is very rare for a miscarriage to occur because of something they have or have not done. Unfortunately, for the majority of miscarriages the cause will not be known and this can make dealing with the unanswered questions difficult. This lack of information can make couples feel frustrated and fearful about future pregnancies. Tests can be done to determine some causes but in most instances no cause is found.

Types of miscarriage.
The most common signs of miscarige are vaginal bleeding followed, or preceded by cramping. Many women also reported a decline in pregnancy symptoms such as nausea or the softening of previosuly tender breasts. There are several different types of miscarriages-
*a threatened miscarriage is where vaginal bleeding may occur over several days or weeks in the first half of regnancy. The cervis remains closed and the baby remains in the mothers uterus. Bleeding occurs in around 30 er cent of regnancies and roughly half of these women will miscarry. The rest will continue the regnancy.
*An inevitable miscarrige is where the cervix starts to oen but the baby is still in the uterus.
*an incomlete miscarriage is where some of the tissue from the baby stays insides the uterus and some is assed through the vagina. Bleeding and craming will continue where this has occured and an ultrasound will reveal the remaining tissue in the uterus.
*a comlete miscarriage is when the baby, membranes and lacenta have come out of the uterus. Bleeding and craming occur as the uterus emties and then the cervix will close and bleeding eases off over the next few days.
* a missed miscarriage is where the baby died but it continues to stay in the uterus. The cervis is usually closed and the size of the womans uterus does not grow. The babys heart beat will also be absent and the woman may notie that her symtioms of regnancy have disaeared (nausea, sore breasts etc)
* a miscarriage can also be unnoticed as it resembles a heavy eriod and goes unnoticed, escially if it occurs early on in regnancy and the woman isnt aware she is regnant.
*a blighted ovum is where an egg is fertilised bit it doesnt go on to divide or develoe into an embryo. The regnancy test will be ositive and miscarrige usually occurs around seven to 12 weeks.
*Ectopic pregnancy can also result in miscarriage and is potentially quite serious for the mother. It occurs when the fertilised ovum implants in the fallopian tube or some other place outside the uterus (1:100 pregnancies). pain is almost universal with ectopic pregnancy. The affected fallopian tibe will not need to be surgically removed but this is still the mainstay of treatment.
*in rare cases the lacenta develoed into a mole full of fluid filled sac and no baby exists. This occurs in 1:1000-1500 pregnancies.

WHat happens with miscarriage?
The general course followed when miscarriage occurs is - a missed eriod, regnancy symtoms, a ositive regnancy test (followed by days or weeks of vaginal bleeding), lower abdominal craming, backache and miscarriage of the baby.

Generally a doctor will take your history and examine you. They will take blood for a regnancy test and suggest an ultrasound to see if there is a baby in the uterus, if there is a heartbeat or whether there is tissue left inside.

Most miscarriages in the first few weels of regnancy are comlete and women rarely need admission to hosital or intervention. After 6 weeks there can be an increased tendency for some tissue to remain in the uterus causing continued bleeding and infection.

*management for miscarriage
For years, the routine management for women having a miscarriage, where some tissue was susected to remain in the uterus was to have a surgical emtying of the uterus (commonly referred to as D & C - dilation and curretage). This aroach is now being challenged and women have three otions-
* they can wait and see if all the tissue asses throgh the vagina ont heir own. where the wait and see aroach is used, articularly when the women are less than 12-13 weeks regnanct, around 80 er cent of women will not need surgical intervention.
*the medical evacuation aroach - where hormones like rostaglandins are used to encourage the tissue to be assed.
*surgical evacuation where the tissue is removed by gentle scaring or suction to the uterine lining, under a general or local aneasthetic. When suction is used, rather than traditional scraing of the uterus, the rocedure seems to be faster, less ainful and associated with less blood loss.

any tissue from the regnancy assed through the vagina or removed during d & C is usually sent to athology for examination to see if they can determine the cause of the miscarriage. Unless you request for the tissue to be return to you, it will be disosed of by the hosital after it has been examined. It is imortant that you know you may not be able to identify the baby in the tissue after a d & C.

* identifying the baby
whether or not you will will able to identify the baby following a miscarriage deends on how big the baby was before the miscarriage, how long it may have been dead for and whether it came out by itself or through a d & c. A baby will be aroximately 7-9cm in length at 12 weeks and 16-17 cm long (the size of an adult hand) at 16 weeks.

Seeing the baby and sending time with it can hel you exress your feelings and deal with the reality of the miscarriage. you may be able to take a hoto or even obtain rints from the babys hands and feet if it miscarries late in the forst 20 weeks of regnancy. This is entirely individual and arents need to do what is right for them in their circumstance.

What haens after miscarriage?
It is imortant to have medical follow u a coule of weeks after the miscarriage to ensure you are healthy. If you lost a lot of blood during your miscarriage then the iron levels in your blood can be checked. It will also enable you to ask questions and talk about your feelings and the future, if you feel ready.
*breast milk
Breast milk is roduced from 16 weeks onwards so if you had a late miscarriage you may find your breast roduce milk. This can be very distressing for some women but for others it can actually be comforting. The best way to suress breast milk is to avoid stimulating your breasts, wear a firm bra and use cold comresses.
*vaginal bleeding
Vaginal bleeding continues for 1 to 3 weeks and rogessively becomes lighter. Women who exerience ongoing heavy bleeding, ass clots or have ain should seek medical advice. Sanitary ads are better than tamons for the first coule of weeks after a miscarriage to reduce the risk of infection.

Generally waiting ti ahve sex a coule of weeks until the bleeding has ceased reduces the risk of infection. After this, some coules gain great comfort from resumtion of sexual intercourse, whlist others refer to exress their love in other ways for a while.

*regnancy symtoms
regnancy symtoms should subside two to three days after the miscarriage and disaear within one week.

Coing with loss
It has been said that while the loss of an adult reresents the loss of the ast, the loss of a baby reresents the loss of a future. It is not just memories that cause grief but lost hoes and dreams can have a huge imact.

Miscarriage often reresents a major loss to women and their families, and reactions can be very similair to those that follow the death of any close friend or family member. arents describe the feelings of disbeleif, sorrow, anger,ain, guilt, exhaustion and confusion. It is common for hysical changes to occur such as roblems with sleeing, eating and concetrating. These are all normal grief reactions to loss.

*different aroaches to grief.
It is imortant to remember, though, that the range of emotions is vast, and while one woman may be feeling devastated over the loss of her baby, another woman may be feeling guilty that in fact this wasnt a wanted regnancy and erhas her emotions even caused the miscarriage. It can also be hard when one artner aears to be getting on with life and resolving their grief and the other is not.

arents often have feelings of sadness resurfacing around the date the baby would have been born. Getting regnanct again, or someone else announcing their regnancy, can also bing back ainful memories. Seeing regnant women, or families with babies can also be distressing for some arents.

One of the hardest things for many arents following miscarriage is the lck of societal rituals such as a funeral, hotos, hand and footrints (esecially if the baby is too small). arents can be left wondering if they were really regnant. They often feel there is no way to mark the significance of the event or cature the memories.

*do what is right for you
arents ahve the right ti mourn for their baby as they see fit. This may involve lanting a secial tree, or even a lant that flowers around the time of the exected birth date, or time of the year the miscarriage occurred. Naming the baby that was lost can hel, as can deciding on the babys sex if this is unknown. While you do not have to have a funeral for a baby that miscarries under 20 weeks, you can if you choose to.

Journals, eotry and drawings can all hel arents to work through their grief. For some arents, however, moving on is the most imortant and this may mean doing none of these things. There are no right ot wrong ways to mourn or coe with your loss there is only your way and you know best what that is.

Future regnancies.
One of the most common questions women ask following a miscarriage is *will it haen again?* the good news is womens chances of not miscarrying agin are excellent. Around 97 er cent of coules who exerience a miscarriage end u having a baby in the future. Even after several miscarriages your chances of having a sucessful oregnancy are higher than miscarrying again. It is advisable though if women have had three consecutive miscarriages to see a doctor who will recommend further investigations to try and determine a cause.

As to when to get regnant again following a miscarriage, this is entirely u to you. There is no evidence that waiting for a certain eriod is advantageous, unless you have been advised to do this by your doctor. future regnancies do not negate the losses of the ast. They give hoe and meaning to our lives and a reason to move on beyond grief and into joy once more.

creid myself to sleep again

2005-10-20T06:11:00.000+08:00

i dont know what i am crying for?

the loss of our baby?
the emotional pain we went through?
the physical pain i went through?
the fear of whether it will happen again?
just plain hormones?

all i know is that there is a hard mass in my chest that prevents me from breathing. and the only way to release it is through crying.

am i going crazy?

i cant sleep but i can eat though, i take comfort in eating, though when it comes to night fall, my appetite just disappears. dinner always forms a lump in my throat and i cant wait to vomit it all out again.

there is pain and THERE IS PAIN

2005-10-18T06:10:00.000+08:00

you cant believe the excrutiating pain that 2 tiny pills can cause.

i took the pills at 8.30pm and the cramps started coming in at almost 11pm. tried hot pack, tried painkillers, nothing worked. then started vomitting everything out over a period of an hour, everything that ive eaten yesterday went out into the toilet bowl.

even water and the ponstan that i took. well, the painkillers never got a chance to work.

started to panick, and got hubby to call LA. The doc response - it will get worse before it gets better. after vomitting for the 4th time, and 2 hours later. hubby got worried and called LA again, LA then said theres still another day of this to go as i have to take another dose tomorrow night.

two days and nights of this?? there is no way i am going to survive the pain and the vomitting. my throat is rubbed dry already and i feel as if someone caught my inwards in a vise and twisting it.

LA then say theres always D & C, which will clear up the cramps and the bleeding. he said that the medicine i took, is the same one which D & C patients take anyways, so if i want to , i can go for D & C and end all this pain.

it wasnt until the third time when LA said that whether i had taken the pills or not (let it come naturally) the pain will still be the same, it is either tolerating it for 2 days with the pills, or 2 weeks + dun know how many days letting it come on its own, or a D & C which means the pain goes away in 2 hours. i wish i had known this earlier, nothing he said could have prepared me for tis pain i am experiencing now.

given a choice when one is doubling over the toilet bowl, well, it wasnt too much of a difficulty.

the D & C is arranged at 8am today. i am supposed to be at the hospital by 7am. it is 6.20 am and i am here typing this down while waiting for hubby to change and get ready to drive me down.

the D & C is surprisingly painless, the joys of GA. Its the waiting part thats pretty terrifying. alone on the hospital gurney, placed at the side of a busy passageway, with no spectacles, and blurred images of people in green rushing to and fro, some pushing carts that clang with metal instruments, the alternative was staring at the ceiling boards and the bright overhead lights.

it was all over in 2hrs, the d & C was scheduled at 9.15am and by 11, i was already back at the ward and getting over the GA. the first thing i felt was no pain, thats a huge relief. the pain didnt come back either, even better.

i got two weeks MC, and a follow up next week to make sure everything is ok.

actually physically, one only need 2 days of recovery time, but the womb will take time to contract as well as the emotional and psychological aspects of getting over a miscarriage.

going for a D & C after a miscarriage is the same physically as going for an abortion. The only difference is the pschological effect, the former doesnt give you a choice, the latter is YOUR own choice.

the physical risks are the same
A perforation of the uterine wall caused by the tip of the surgical instrument. This injury rarely requires treatment (additional surgery) and heals on its own.
Excessive bleeding is always a risk during surgery.
Another rare complication is infection with pain and fever.

as to psychological fears of a D & C affecting fertility...that one i need to ask the doc abt it.

cost tracking
D & C - $798.15
of which should be able to claim from insurance - or otherwise will be paid via medisave.

there was a hiccup during initial registration whereby we found out that we had to place a 400 deposit. thk goodness, i brought along credit card. never leave home without it, even if you are doubling over in pain at 6am in the morning.

we were told there is no cash required, everything shd be done via medisave. the woman at the counter said we got our information wrong, being in pain, i couldnt be bothered to find out more. you need 400, heres the card and get it over with.

it was only after the D & C, during discharge, that another lady realised the mistake made that a rebill was printed, so all that hassle this morning was just a hassle.

its not going to happen

2005-10-17T10:55:00.000+08:00

just got the blood tests results for sat back. hcg has dropped to 141.1 and progesterone has increased to 122.6 due to the jabs and the medicine.

from 202 to 141 is not good news.

despite all that puking.

now waiting for FY to call back with advice.

the doc called back and said to stop all medication and let AF come, it should come within 2 weeks.

this should be the end of this saga.

will take a break from TTC and concentrate on new job.

some of the gals where saying that a D & C will ensure that everything is cleared out and pave the way for a better next pregnancy.

went to see LA for advice, he said at this stage a D & C is not neccesary. he gave some medicine called cytotec which will induce AF. the bleeding will be about a week, then all things should return to normal physically.

at this point in time, reality sets in.

i wont have a chance to name this baby
i wont have a chance to talk to him
i wont be able to hold him in my arms ever

spotting or no spotting, pantang or not pantang

2005-10-16T06:34:00.000+08:00

keeping track is driving me out of my mind.

imagine having to fear going to the loo, just in case one sees the spotting again.

like the above, this other thing has been on my mind as well. pantang or not pantang.

some gals are pantang (superstitious) about telling people whether or not they are pregnant before the pregnancy is stabalized at week 12 (3 months down the road).

the fear rises from soemthing happening to the baby if the announcement is made before the three months.

in my view, this is just plain hogwash. but if it makes one feel better to believe in it, then go ahead and believe in it.

one website states this -

When to tell others is a hotly debated topic. Sharing the joyous news of your pregnancy is a very personal decision. Some choose to share the good news early and often. They will tell anyone who will listen. Before the pregnancy test stick has dried they are on the phone calling their friends and family.

The other extreme is to tell no one. This group may also wait to tell until they have reached a predetermined point in their pregnancy. Then they may tell only on a need to know basis, often waiting until their expanding abdomen shouts the news for them.

Both sides of this coin have a point. Here is a break down of some of the issues on each side:

Advantages to Telling Early
Lots of support early in pregnancy
Able to share your good news and excitement
Earlier offers of physical help
More advice from others about practitioners
Help with early decisions
If you miscarry, you will have support from everyone

Disadvantages to Telling Early
Too much advice
Good news travels fast, you may not be the first to tell someone
If you miscarry everyone knew you were pregnant

Advantages to Waiting to Tell
Time to digest the news
Make decisions without input of others
If you miscarry you don't have to retract the pregnancy announcement

Disadvantages to Waiting to Tell
No help/support from others
If you miscarry everyone wonders why you are sad, and you have to backtrack your explanation

As you can see there is not a clear-cut answer. You might choose to tell early, knowing that if you had a pregnancy loss that you would need the loving support of family or friends in the grieving process. You may wish to wait until the risk of miscarriage or ectopic pregnancy has past before sharing the news of your pregnancy. There is not one right answer. What works for your family is the right way for you to share the good news.

so dont be influence by other people on whether to tell or not to tell. like in Y case, she told another friend first before telling me knowing that my pregnancy is not stable and not sure how i would react to the news. but yet on the hand, she has not told her family members yet as she is not sure of their reactions and their support.

had a long chat with Y last night

2005-10-15T17:42:00.000+08:00

found out that she is pregnant as well and is now 7.5 weeks along into the pregnancy. if calculated correctly (based on first day of last menses 24/08), she shd deliever on 03/06/06. I am so happy for her and hope she will be able to see the baby heartbeat at LA next week.

actually she found out before her trip to genting, but didnt know how to break the news to me in case mine didnt work out. whether mine work out or not, i am genuinely happy that she is on her way to her second baby. if all things goes smoothly, we may have kids that will grow up the same time together. How nice.

things are not looking good for me. from the gynae visit on thur till today, there have still been some spotting as well as cramping, almost as if AF is coming. This cant be good.

Had blood drawn as well as another jab (on the other side of the butt). and another 2 days MC with a stern warning from the gynae not to go anywhere this weekend.

Will know the blood test results next Monday. I hope that it goes up. double, quadraple, shoot up, just bloody go up.

cost tracking
$147.00

useful avenues to ask questions/get more information

2005-10-14T14:47:00.000+08:00

http://www.pregnancy-info.net/f/newsletter_a_forum.php

summary
http://www.pregnancy-info.net/QA/questions-Possible_Complications/

deatail threads which are useful at this pt in time
http://www.pregnancy-info.net/QA/answers-Low_HCG_Level_at_7_Weeks/
http://www.pregnancy-info.net/QA/answers-Low_HCG_Levels_at_4_and_5_wks_pregnant/

start of twice weekly jabs

2005-10-13T20:22:00.000+08:00

official start to the twice weekly jabs.

had the first jab this afternoon, i am getting used to the jabs now.

clarified with FY abt the hcg level thingy, he said that 10,000 is the value to see a viable sac & feotus.

the sac can be seen at 1,000 but it may not be viable.

another interesting information to keep somewhere.

felt giddy this afternoon after the jab, had slight spotting as well. came home and fell into bed.
called FY in the evening and he said the giddiness could be to the jab and it shd not reoccur again.

as for the spotting it could be due to walking a bit too much, and i jokingly reply that it was just a bit only. he then say that we are doing whatever we can for the pregnancy, so just hope for the best.

on the practical side of matters
the jabs cost 26.30 each, at twice weekly till week 12.
the pills which cost like 50 for 5 days supply.
blood tests $70 twice a week
scans done weekly at 40 each
consult at 40 each week

estimated cost till week 12
jabs $400, pills $250, blood tests $ 840, scans $240, consult $240
total cost $1970 (wow)

cost tracking
26.30

serious discussion last night with hubby

2005-10-13T10:40:00.000+08:00

from what we know, at this present point in time, what are the chances that the baby? foetus? embroyo? will have a growth spurt from 202 to 10,000 in terms of hcg within this week?

i asked hubby how long do we want to keep trying to prolong the inevitable. He didn't want to give up, neither do i. but i dare not have raised hopes that he/she/it will survive and grow well.

we agreed to wait till week 8 before deciding whether to continue on with the expensive injections and the agony of waiting.

have to go back to the doc for another jab later today.

blood test results

2005-10-12T16:30:00.000+08:00

HCG at 202 as of 11/10/05 and progesterone at 45 (which is on the low side) which means i need jabs twice a week to support the pregnancy.

oh boy.

HCG is still low but at least it did doubled.

Saw FY today - no reassurance given

2005-10-11T17:40:00.000+08:00

i am so tired, so tired of this waiting and uncertainty.

FY ruled out ectopic pregnancy based on the blood HCG results, he said that its unlikely that it will be an ectopic pregnancy as the numbers did double, although its a little on the low side. I think he was very much understating the situation.

anyways he did another blood test, this time for beta HCG as well as progesterone. an interesting fact * synthetic progesterone like Duphaston cannot be measured in the blood stream, hence the progesterone blood test will really show the actual (natural) level of progesterone in the body.

The idea is that progesterone will help support the pregnancy, if one has insufficient progesterone, there will be indications like cramping and spotting, both very bad signs. He also gave me utrogestan (which is a natural progesterone).

FY was unable to giveme any reassurance as to how the pregnancy will developed other than saying that the numbers are really too low. I asked him how low is it actually, he hesitated a bit and then replied that at this stage (of about week 5 and a half) - the HCG level is supposed to be at the 10,000 plus range (mine is only 88 as of 07/10 fri).

Only when the HCG rises to above 10,000, then the sac can be seen. and the sac is usally seen at around week 5. heartbeat at week 6.

he said that the baby could be developing slowly, as long as the HCG levels do double very other day, there is still hope that it will catch up.

I asked if it will affect the baby development in the future, he hesitated a bit before replying that its unlikely so long the baby continues to developed and be monitored in the next couple of months. for that moment, the thought of having a mentally slow child because of us trying too hard to keep the pregnancy scared me out of my wits.

i am so tired of the waiting and the uncertainity. i need to talk to the other company about the job offer. i need to sign and return the letter by the mid of next week. what should i tell them? what shd i do?

on a bit of humour, FY suggested just sign and accept the offer first, they will never know u are preggy as it wont show yet. eh great advice from a gynae. lol.

on another bit of humour, this morning hubby tried on his suit made for the wedding, the suit shrunk quite a bit from the dry cleaning - until we realised that we got the wrong suits back. and this was like almost a year back.

We sent the suit for dry cleaning at the bridal salon and didnt checked it when it was returned to us. after a frenetic search for the invoice, we then sheepishly realised we got the wrong suits back.

Thk goodness, we managed to contact the gal at the salon. she kept our suit and we did an exchange. that was hubbys boo-ha number 1.

subsequently we went for breakfast at that food centre in chinatown. hubby got up to get additioanl ice and then when he returned, sat down at a completely different table and startled not only me but also the poor woman at that table.

poor hubby, i couldnt stop laughing, neither could the woman too. we looked at each other and just continued laughing. fortunately we finished our breakfast already and quickly left. boo ha number 2.

it was still early for the gynae appt, even after we ran all the errands we started to do. so we went shopping at paragon. We got some nice checked boxers from M & S, hey they do carry super sizes.

We then decided to head to toy r us, and we walked together to the escalators upwards, and of course hubby walked onto the one leading downwards and look startled when i am going up and hes well not going anywhere on a down riding one. boo ha number 3.

the caucasian guy who was sitting at the bench opposite the escalator just laughed and laughed, i m glad we made his day. *wryly*

i will be going back to work tomorrow, the spotting has already stopped and the rest is just up to fate. i never did believed in fate and i still dont believe in fate. whatever will be, will be. nothing more nothing less.

a couple of the gals sms me just now. i really appreciate their concern. Thks S and J. tks for your thoughts.

tracking cost
FY 156.50

some technical stuff about Beta HCG

2005-10-08T07:58:00.000+08:00

From all the websites i have covered, the general idea is that one HCG blood test is not enough to indicate the status of the pregnancy.

Normal HCG blood levels vary widely between different women and in different pregnancies for the same woman. Be very careful when trying to 'interpret the numbers'. During the first 12 weeks of pregnancy, the level itself is NOT as important in how much it is rising every few days. Some normal pregnancies will have quite low HCG levels and still progress, ending in the birth of a healthy baby. The best way to confirm if a pregnancy is progressing is to repeat the blood test in 2 to 3 days time, and perhaps again 2 to 3 days after that. This is aimed at seeing if the HCG level is rising adequately.

what exactly is the indicative range, normal HCG blood levels vary so widely that the indicative range can be quite meaningless. For eg, these are the values i got from different websites. (all are measured in terms of miu/ml or iu/l)

Weeks of pregnancy after last period
Days after conception
HCG level for single baby (mIU/ml or IU/L) (i havent figured oout how to do tables here- so bear with this)

Week 3 - 7 - 0 to 5
Week 4 - 14 (next period due) - 5 to 426
Week 5 - 21 - 18 to 7340
Week 6 - 28 - 1,080 to 56,500
Weeks 7 to 8 - 35 to 42 - 7,650 to 229,000
Weeks 9 to 12 - 49 to 70 - 25,700 to 288,000

(taken from http://www.birth.com.au/class.asp?class=6620&page=8)
as compared to this other one taken from (http://www.babyhopes.com/articles/highhcglevels.html)

Normal Human Chorionic Gonadotropin (hCG) levels:
0-1 week: 0-50 IU/L
1-2 weeks: 40 - 300
3-4: 500 - 6,000
1-2 months: 5,000 - 200,000
2-3 months: 10,000 - 100,000
2nd trimester: 3,000 - 50,000
Non-pregnant females: <5.0
Postmenopausal: < 9.5

which one to follow? - the best guide will still be your gynae.

some reassurance needed

2005-10-08T07:34:00.000+08:00

Fri 7 Oct 2005 - hit the big 3-0

after a sleepless night and waking at 3am to test if the line is still there, i decided that i cant wait till next tuesday. tues is like another 5 days to go which feels like 5 years to me.

I recalled what LA said about normal HCG levels doubling every two days. and called him to make an appt. i think i got him on the phone while he was brushing his teeth. in between gurgles and what not, i got an appt to see him at 9.45am and got the blood test done.

i got it right abt the HCG values doubling every other day, but the best indictation of a healthy pregnancy is when the HCG level hits 100. whcih means that my original estimate of 60 is way far off the healthy mark (mon 03/10 was 15, so if the HCG is suppose to double every 2 days, by fri it shd hover around 60)

by the time the blood sample was done, it was close to 11am. results are expected within 4 hours. though it wasnt till almost 5pm when i got the results.

it was 88. below 100 but it did more than double since Mon. the doc called and suggested i visit his clinic in the evening for another jab. he reinforce that if its a healthy pregnancy, HCG will continue to increase.

He did point out something that the jabs and medicine may not aid in keeping the pregnancy if its unhealthy to begin with, but at least we are doing everything we can to keep this precious one.

Those words strike a deep chord in me. After all that we been thru, this pregnancy is so very precious to us. while i hope and wait that it will be healthy as the days pass by, there is always a real and persistant nagging fear that it will leave us.

how much it cost us so far in follow up
LA Mon blood test $45
KL Wed visit $211
LA Fri AM $35
LA Fri Eve jab $60

faint positive again

2005-10-06T06:11:00.000+08:00

i know KL said not to test again but i did anyways.

the line appeared faster this morning, it is still faint but appeared with the control line.

i am just thankful that it did not disappear.

Day 17 - faint positive HPT

2005-10-05T11:53:00.000+08:00

i cant believe it, its a faint HPT when i tested this morning at 6am. i didnt realise the faint line till 15 min when i saw it again.

i couldnt believe my eyes. didnt even tell hubby incase it was a false alarm.

decided to see the gynae. called FY emergency service and got KL at woodlands. went to see him around 10.30am

did a v scan and he cant see the sac yet. he then did a UPT and the faint line was still there. He then gave a progesterone jab and hormones pills to take. advice to take a weeks rest and see FY again on next wed.

all in all, quite a out of the mind experience.

will update some more later.....been told by the gals that bed rest means ..exactly that resting on the bed - not sitting upright and chatting.

ok, i heard you gals.

thks for all your thoughts and prayers.

Day 16 - blood test results

2005-10-04T18:13:00.000+08:00

called the clinic at 3pm, results not in yet

got a friend to call at 3.30pm, results still not in yet

called at 4.15pm, result not in yet.

clinic called back at almost 5pm, saying that the results is with LA and to call back in half an hrs time.

i called back at 6pm, result is between 10-15. now normal result is supposed to be below 2, LA explained that it could be residual from the HCG jab before the IUI.

to confirm, HCG levels are supposed to double every day, so a HPT by tomorrow or thursday should confirm the result.

a normal HPT shd be able to trace min 20, so if am really preggy, HPT shd be positive by tomorrow or by the very latest Thursday.

found an article which clarifies some doubt. (http://www.babyhopes.com/articles/highhcglevels.html)

Do high HCG levels always mean you are pregnant?

Human Chorionic Gonadotropin (hCG) is the "pregnancy hormone" or "announcer of pregnancy" that keeps the corpus luteum producing progesterone when you conceive. It is produced by the placenta during pregnancy and is measured by home pregnancy tests (HPTs). A woman normally produces 25 milli-international units per milliliter (mIU/ml) of Human Chorionic Gonadotropin (hCG) 10 days after conception. As a general rule, Human Chorionic Gonadotropin (hCG) levels should double every two to three days after conception. Accordingly, the concentration of Human Chorionic Gonadotropin (hCG) rises rapidly, frequently exceeding 100 mIU/ml by the first missed menstrual period and peaks in the range of 30,000-200,000 mIU/ml by 8-10 weeks into pregnancy. A Human Chorionic Gonadotropin (hCG) level of less than 5 mIU/ml generally indicates that one is not pregnant.
There is great variation in Human Chorionic Gonadotropin (hCG) levels. It isn't the absolute value that matters in these results, but the change in values. In a normal pregnancy, the level of this hormone approximately doubles about every two days during the first 10 weeks. However, high levels of Human Chorionic Gonadotropin (hCG) may indicate choriocarcinoma of the uterus, ectopic pregnancy, Downs syndrome in fetus, hydatidiform mole of the uterus, normal pregnancy, or ovarian cancer. Once you have had an ectopic pregnancy, you have an increased risk for another, so your HCG numbers may be monitored more carefully.

Normal Human Chorionic Gonadotropin (hCG) levels:
0-1 week: 0-50 IU/L
1-2 weeks: 40 - 300
3-4: 500 - 6,000
1-2 months: 5,000 - 200,000
2-3 months: 10,000 - 100,000
2nd trimester: 3,000 - 50,000
3rd trimester: 1,000 - 50,000
Non-pregnant females: <5.0
Postmenopausal: < 9.5

Injections
If you have been given an Human Chorionic Gonadotropin (hCG) injection (Profasi, Pregnyl) to trigger ovulation or to lengthen the leutal phase of your cycle, trace amounts can remain in your system as long as 10 days after your last injection. These can give you high Human Chorionic Gonadotropin (hCG) levels. Two consecutive quantitative Human Chorionic Gonadotropin (hCG) beta blood tests can circumvent this problem; if the level increases by the second test, you are likely to be pregnant.

geez, after the nerve wrecking wait and its still not 100% confirmed, and another blood test??

let me think abt it.

Day 15 - Mon - blood test

2005-10-03T15:12:00.000+08:00

found out that FY is overseas, hence decided to go to LA for a blood test.

that test will be more definitive than waiting another week till FY returns on 7 oct.

will know the result by 4pm tomorrow.

Day 13 Sat - well, still negative HPT

2005-10-02T07:54:00.000+08:00

been having cramps and slight spotting on Sat - guess thats AF on its way.

While i was prepared that this cycle may not work, its a totally different feeling KNOWING that it didnt work.

DH said something very touching - despite his urgent need for offspring, he suggested that we should take a 6 mth break to relax and pursue other things.

the past 6-8 weeks have been ultra stressful due to news of company closure as well as TTC leading to short tempers and insomnia - all mine and poor DH.

We had a wedding dinner in the evening to attend, but i really do not feel like socialising today - in the end DH went alone.

and came back still hungry.... which meant I had to get him something to eat at 11pm on a saturday night that doesnt include instant noodles.

He got a loaf of garlic bread.

Day 12 - still negative HPT

2005-09-30T05:50:00.000+08:00

Was chatting with a grp of friends about symptoms of pregnancy and we concluded that sore breasts means a high chance of being positive.

but no, tested this morning at 5am and its still a negative.

i wish i could know earlier.

The earlier i know, the earlier i can make the decision as to which job offer i should take up.

Job Offer 1

established co - no worries of it closing down
new job scope/position - no precedent (as good as being in a start up)
sales - targets - stress
travelling SEA - not good if pregnant
will not pay maternity benefits (as per employment act in singapore)
higher pay - cld use it
good benefits - perks of the job

JOb Offer 2

New start up - prospects?
familar work - setting up an office/systems etc
no travelling - a definitie plus
lower pay - 20% less - we cld do with more money
willing to pay 3rd mth maternity benefits even if not covered by govt
nearer to home
flexible working hours

after listing down the points, im still undecided.

Day 9 - negative HPT

2005-09-27T07:57:00.000+08:00

tested this morning at 6.37am.

did i say i was on mC today? oh yes, the GP gave me a couple of days off - the cough mixture is supposed to make me sleepy - think it works, i woke up at 6.30 instead of 4am, major improvement.

the first thing i did was to test, the test is negative. (as expected) - its a little bit too early.

oh well.

prepared breakfast for hubby, and got online to blog. oh dear, can it be called obssessive blogging?

i noticed that 1 got a blog almost every day and sometimes twice in a day.

Night 8 - baby names

2005-09-27T07:42:00.000+08:00

just before bedtime, out of the blue, DH started talking abt testing HPT...it is only Day8, i think its too early to test, decided to do it tomorrow morning instead.

the talk then went on to baby names. the conclusion was if its a gal, she will be called le qi, kelly, and if its a boy jun hui, ??.

now both of us couldnt agree on what the boy english name will be...i suggested kieran, which hubby says sounds like ki xiao (i was like huh), i like the name kelvin, and he said all the kelvins he knows are yandao arragont (spello).

he suggested Gavin (which sounds like brand), might as well call him Louis V. we tumbled thru derrick, calvan (from not having kelvin), solomon (might as well call him methusaleh), we went thru a few more names but cant remember them off hand now.

one name we sort of agreed on was kaeran (doesnt that look like kieran - my original choice?) ha ha.

and we drifted into sleep.......Zzzzzzzzzzzzzz.

Day 8 - went to see the GP

2005-09-26T15:57:00.000+08:00

thats it, another night of waking up at 4am and not being able to get back to sleep.

add to that a mix, a cough that wouldnt go away and only appears at night *arghs*

went to the GP, he refuses to give me anything for the insomnia, diagnose it as *stress* and it will go away.

but he gave me cough mixture and advice me to take that to go to sleep instead. *right* i guess i am going to need more than 1 bottle.

day 7 - nightmare

2005-09-25T20:58:00.000+08:00

When am i going to get really some nice uninterruppted sleep?

had a nightmare that woke me up. I dreamt that i shot someone in the afternoon and hid him rolled up in a carpet under my mums bed. and when it comes to nightfall, tried to dispose the body by chopping him into sashimi slices - nicely arranged on a platter.

of yeah, i even dreamt that i couldnt finsihed the job and then decided to confess to the police. thats when i woke up. traumatic decision. *wryly*

i wonder what can those professional dream interpreters read into that??

weird, really weird

2ww The language of babymaking

2005-09-24T22:50:00.000+08:00

It is Day 6 of the 2 week wait (2ww), and hell it has been a long 6 days, how am i ever going to survive the next 8 days?

random thoughts
all over the online forums, women who are ttc form support groups with other women who are also in their 2ww. i now can fully empathise the need to express every single thought, fear, wish during this period of time - otherwise how else to survive the emotional roller coaster ?

sore nipples, pre PMS symptons or cld it be conception? tender breasts, PMS or BFP? loss of appetite, sleeplessness, pimples, moodiness - whart does all those symptons fall under?

the language of babymaking
its a whole new world out there, hell a whole new species of womankind, which i am slowly evolving into.

lets put it this way, i am beginning to understand the language. and use it. too.

for those who are reading this blog and have no idea what i am talking abt, let me give you a sample of the abbreviations that is used.

starting with something relatively easy like

2ww
BFP
BFN
LP
O
BD
ML
DH
DS
DD
RE
AF
IUI
IVF
SOIUI
HCG
BHCG
AIH

im sure you get the picture now.

if anyone wants to know what they mean, write me. lol.

i got the time to reply and explain during this 2ww, perhaps it can keep my mind off the 2ww.

sperm enhancement and IUI

2005-09-19T16:21:00.000+08:00

D day is today. couldn;t sleep well (obviously) so what's new??

We got a 9.30am appt at CARE to produce the sample. Hubby was directed into a room with oh yes, porn videos and porn magazines....now this must be the only place in singapore where the men are encouraged to do porn.

thk goodness hubby did not have performance anxiety, he did it pretty fast while i was in the reception area reading thru the informative booklets (btw i got some pretty informative reading material on fertilty and mtds)

after producing the sample, we were told that it takes 2.5 hrs for it to be processed. ok, we decided to go for breakfast. we went over to centrept for breakfast. we finished breakfast 10am. we took a stroll at centrepoint 10.15am. we walked to robinsons (ground floor; still not open) 10.17am. we walked to marks and spencers (3rd floor; still not open). we went to the loo 10.30am (the loo is open). sat at macdonalds for another 10 min. went up to robinsons (finally opened 10.45am. shopped a bit, looking at everything and not registering anything 10.55am.

we decided to go back to CARE. now the nice lady at the counter did say 11.30am and we are half an hour early. but nvm abt that, hubby insisted we go up at 11am. so we went up, and the nice lady said it's not ready, will call us once it's ready for collection.

fine, 11.10am, Metro is open, we went shopping (or i went shopping and hubby tagged)...in the space of 20 min, i managed to get 2 shirts for work. LOL. call it retail therapy but it works, time flies. the lady called at 11.30am and we paid for stuff in a hurry and got up to CARE.

With the sample came a report and a bill of $147. now, i was a bit curious abt how we were going to transport the sample there. it has to be kept at body temperature. well i found out soon enough - the lady said just stuff it in yr bra. i was like ???? well ok.

she directed me to the same room hubby was in earlier - the porn room. ooh..interesting, the porn video was still showing..japanese porn...kinky.

got the sample stuffed in bra and left CARE to proceed to TB. in the meantime, we were vry curious about the report we got abt hubby's sperm sample.

The report wasn't good. the volume barely made it to 20, the normal form is only at 4% pre treatment. but then it's a 100% improvement compared to the last sperm sample at 2% normal form. Hubby was very worried that the sample is so bad that IUI cannot be done.

Our worries were for nothing, Dr Fy went ahead with the procedure. first the nurse prepared me for the procedure, which means removing clothes and getting into a hospital like gown, positioning into that gynae chair.

she got me quickly enough and then we had to wait about 10 min for Dr FY. The procedure itself took less than 10 min, i know i am very tensed then and it didn't make things better, in fact, the doc had to reposition the instruments again as i was so tensed that i kept pushing it out.

the procedure itself was painless, the doc then left the room and i was told to rest for 20 min. hubby then came in and sat besides me while we waited. after 20 min, the nurse came back in and hubby got to go out while i got dressed.

i was telling the nurse that i could feel wetness and she said it's normal. some of the sample is expected to flow out. i hope that not all of it flowed out. *cross fingers*

we waited for a while to see the gynae for him to explain abt the sperm sample results. the results aren't good per se. having a normal count of 4% for form is definitely not good. but he said he has seen instances where the gal got pregnant anyways.

He said there are various reasons why the form is not good, some of which are genetic factors, lifestyle factors (losing weight), overly tight pants, and swollen veins called varicoleous or soemthing like that. which cld be determined via a physical exam and an operation.

i asked what shd we do next, whether he can do the physical or shd hubby be started on some medicines. both the guys said they will start with the medicines first. lol. now hubby knows how awkward it is, having another person up yr privates.

anyways, dr Fy prescribed some male hormones for hubby and it's expected to take 2 months before any results can be seen.

back to the IUI, it will take 14 days before the results are out. and it's going to be a long long 14 days wait.

we got the medicines and the bill of $ 270 and left the clinic with hopes that this cycle will work.

on other matters, we got some good news - i got a job and i got credit card approval as well. so far, cross fingers, things are looking up.

Virgin Posting

2005-09-18T08:28:00.000+08:00

wow, another new blog..i wonder who has babymaking.blogspot.com

brb

I'm going to transfer some/most of my previosu blogging into this one. This blog seems more user friendly. *cross fingers that i dun mess it up*

CD16 Sat & jab

2005-09-17T16:06:00.000+08:00

was very anxious, so much so that i couldn;t sleep well for the past 4 days, been waking up at all times.

it's hard not to worry, though the circumstances is beyond our control. tahnkfully, i met a group of gals online who are facing thru the same problems and they offer great support thru out this trying time.

organsing a gathering online for a grp of 15 persons who mostly have not met each other before takes a lot of worry off my mind about TTC. (btw the gathering was this afternoon and 4pm, and it went off swell {if i may say so})

so eh back to the gynae visit, we were there very early, at 9am although we had a 9.30am appt and had to wait for a couple of patients before being seen.

Dr Fy didn;t say much till after the scan. he said there was a follicle that is big enough at 20mm which can mature. and then he became a lot more approachable as he talked what to do next.

next step
i'm supposed to get a hcg jab to encourage the egg to release from the follicle. and there's specific timing to follow which is between 9 to 9.30pm tonight. The jab can be done at any GP since FY clinic is close and most GP are not open at 9 plus, we decided to go to a 24 hr clinic instead.

my next qn was, will the jab be painful? Dr FY said no, it will not be as the jab is supposed to be on the butt which is fleshy, to which i joked that i'm fleshy all around. which kinda lightened up the mood.

so the plan is that i get a jab on sat nite, and the egg will be released on Mon. Hubby has to produce a sample on Mon Am at CARE, and then bring the sample to TB, where Fy is at on Mondays and he will perform the IUI procedure.

we got the stuff we needed from the recept and off we go. did i mentioned that we got a gathering at 4pm this afternoon?...that really took our minds off the jab that evening.

evening time came round, we went to the 24 hr clinic at yishun. Dr FY said it wouldn;t hurt rite? in a pig's eye, that jab is bloody painful. and it took a bloody long time to administer as well. It cost 36 bucks for the GP's service as well.

CD12

2005-09-13T15:01:00.000+08:00

appt with the FY on CD12 for ovulation monitoring - he couldn't cfm the growth of the follicles - the largest is only 9mm and it's already CD12 - not very good considerng that i'm already on the maximum dose of clomid this cycle.

made another appt to see him on CD16 to see if the follicles did develop - if it didn't grow any more, this cycle is shot as well.

i really dun know what to do if this cycle is shot as well, with the news that the co will be closing down means that i am in the market for a new job by nov. and in singapore law one need to be employed for at least 180 days before maternity benefits kicks in.

i hope that this cycle works, or not.....

of course it doesn't take 3 days with me

2005-09-02T15:55:00.000+08:00

rite..3 days after last dose of AF inducing med - the doc said..

well AF didn't come till almost 8 days later (today) - while PMS symptoms started like 2 weeks earlier. duhz really.

in the end called FY to chk why..and if it still doesn't come by the following week, to go back and see him.

the next day, it came. and here we go, starting on the 3rd cycle in 5 months. I can't believe that we have been trying for 5 months with medical intervention.

It has been a very trying period.

p/s: of course since AF is late, i got to change the appt already made on my last visit to the gynae. and yes, it's a painless process. no dragon lady, no hang up..and guess what, even personalised reminders one day before the appt to ensure that you do turn up. now that's service.

next appt 13 Sep tues - CD12

Starting on 3rd cycle in 5 months

2005-08-21T15:52:00.000+08:00

Started taking med to induce AF today - this will tkae 5 days instead of the usual 10 days. AF supposed to come within 3 days.

CD 15 Tuesday

2005-08-02T15:30:00.000+08:00

Saw LA in the morning at 10am, surprisingly didn't ahve to wait long as i was the 1st appt of the day.

He did a scan and said the largest follicle he could see is only 6mm, which is not good news as they need to be like 18mm and above to mature.

i asked him about puregon and he said that could not help in my case. after suggesting metformin and ovarian drilling, he suggested that i see a sinseh instead, that really put me off him. he has not even exhausted the medical means, and yet he already want to give up.

i headed off to paragon. spent half an hr walking about paragon since i was too early.

reached the clinic at 11.30, in the end got to wait while he sees another patient. the waiting area is so spacious compared to LA, no longer that claustrophobic feeling. the recep is so friendly and professional. that really sounds like a good start.

FY himself is rather well aloof...he doesn't seem as approachable as LA. and perhaps because i'm nervous and stressed as well, the exchanges were kinda awkward.

in the end, he did another scan, and found that both ovaries are PCOS, the womb/lining is fine. He printed the scans for me to keep. He said the largest follicle he sees is about 8mm and since it's already CD15, it's unlikely this cycle will work, hence this cycle is shot as well.

He gave me med to induce AF to be taken 14 days later after testing with HPT. He also prescibed clomid at the max dose which is 4 tabs per day.

If this time, it doesn't work, then it's going to be a huge problem

CD 11

2005-07-29T15:30:00.000+08:00

Friday

took the day off, went to LA for scan, still no visible follicles - to return next tues for another scan.

it doesn't look good.

decided to look up Dr FY clinic. made an appt to see him on Tuesday after LA. If LA offers good news, then i can skip FY, if not, then i need a second opinion.

CD 8 and well life goes on

2005-07-26T15:27:00.000+08:00

saw LA yesterday, did a scan, classic PCO ring of cysts around ovaries but none of them mature big enough to be distinguishable.

got to go back on Fri to re scan, hopefully by then got some visible follicles.

Talked abt metformin and ovarian drilling.

metformin is a medication used to treat insulin resistance. supposedly can also used in PCO cases to correct hormonal inbalance as well as weight control. side effects includes nausea n stomach upset.

Ovarian drilling is done via Laparoscopy, where a portion of the ovary is burn away by laser to adjust hormonal imbalance. side effects include ovarian failure.

advice from LA regarding IUI, skill of doc involved will affect chances of success.

sleepless nights

2005-07-11T15:25:00.000+08:00

been having sleepless nights, full of dreams. ever since realisedt that both e and l are on clomid, and conceived, yet lost both their babies in 1st trimester is scary to say the least.

pple say that miscarriage happen because it's not meant to be or because of some genetic fault which makes the foetus unvaible to life.

sometimes i can't help but think perhaps it's because in our search for a baby, we are forcing nature by medical intervention.

perhaps we really shouldn't force things, and then suffer unneccesarily the pains of a threatened pregnancy and ultimately a miscarriage.

CD donkey days

2005-07-04T15:23:00.000+08:00

saw the gynae tonight, reached his clinic at 8.50pm and didnt get to see him till almost 10pm for a short 5 min visit.

conclusion: got medicine to induce AF - the same one as before - 2 tab a day for 10 days. and then start cycle 2 of clomid - same as before - from CD2- CD6.

this cycle however will do ovulation monitering (a great improvement) - from CD7 - which means that got to fix appt to see gynae from CD7 to CD14 every other day?? for scans.

if everything goes to plan, means that ovulation will occur at CD14 which will be like 29 days from now.

10 + 5 + 6 (cd1 + cd2-6) + 8 (cd14) = 29 days. which is on 3 Aug + 14 days = 17 Aug will know if this cycle works or not.

total cost $12.50 for med. gynae didnt charge for consult. :)

Fertility Procedures - Part 2 (AIH, IUI, SO-IUI,clomid)

2005-06-24T15:21:00.000+08:00

Before one consider IVF & ICSI, there is AIH, IUI, SO-IUI and clomid to consider.

Clomid is basically hormone medicine to trick the brain into ovulating. this is the cheapest form of fertitlity treatment and the only non invasive one, and also the first course in treating fertility issues.

Taken from kkh website.

How Is Clomid Given?
Your doctor will usually start you off on the smallest dosage which is 50 mg (1 tablet) daily. This is taken for 5 days either from the 2nd or the 5th day of your menstrual cycle.
The doctor will check for the effectiveness of this dosage by taking a blood test (serum progesterone) on the 21st to 23rd day of your menstrual cycle. The dosage can then be increased if necessary.

You are advised to have sexual intercourse between the 6th and 21st day of your menstrual cycle.
After 4-6 cycles of clomid, one has to consider other alternatives, which involves artificial insemination. There are various types to consider depending on the situation one is in.

AIH - Artificial insemination by Husband.

IUI - Inter utarine insemination (not neccesarily using husbands sperm)
and SO-IUI - which involves taking hormones to ensure super ovulation where more eggs are produced.

AiH and IUI basically work the same way as SO-IUI without the super ovulation bit.

What Is Superovulation & Intrauterine Insemination (SO-IUI)?
Superovulation is a procedure where two to three ovarian follicles (eggs) are stimulated and brought to maturation and ovulation.
It is usually combined with intrauterine insemination in which the prepared sperms are placed directly into the uterus. This procedure will enhance conception for the couple.

Who Is Suitable For SO-IUI?
Any couple who has unexplained infertility, mild male factor infertility, cervical factor infertility and mild endometriosis can undergo this procedure. The patient must have normal fallopian tubes and her husband should have sufficient good quality sperms.
If the husband requires chemotherapy or radiotherapy for cancer treatment, he may have his sperms cryopreserved (frozen) for future use by this procedure.

How Is The Procedure Done?
The procedure is done on an outpatient basis.
Fertility drugs are given for 10 days or more to produce between two to three mature follicles. These drugs may be either injections (gonadotrophins) alone or a combination of tablets (Clomiphene) and injections. Ultrasound scans are done at intervals to determine the number and size of the follicles before another injection (HCG) is given for final maturation and subsequent ovulation of these follicles.

On the day of the insemination, the couple has to bring the husband's semen sample to the hospital. The semen is prepared and the motile fraction is then placed into the uterus using a fine catheter through the cervix.

The patient is then started on medications to help improve the chances of implantation and thus pregnancy. A blood test (serum progesterone) is taken seven days after the insemination to monitor the effectiveness of these medications. The patient should return to KKIVF 17 days after the insemination for a pregnancy test.

Useful Information

Success rates (KKIVF rates)
Natural conception in a fertile couple aged about 35 years old occurs about 15% per month. When infertility factors are present, this is much reduced.

SOIUI improves the chances of conception for infertile couples and the average success rate is about 12-15% per cycle or 26% per patient after 3 cycles.

The overall success rate varies with the cause of infertility and the age of the female partner. For some conditions, the pregnancy rate can be as high as 36% per patient.

Fertility Procedures - Part 1 (IVF & ICSI)

2005-06-24T15:15:00.000+08:00

Did some research on the net over the past few months, decided that i better collate them in ine place. and perhaps having it all written down somewhere means i dont carry all that info in my head.

even when im writing this, i ask myself where exactly do i start? Fertility is soemthing that we all take for granted.When one is single, talking about making babies is certainly not acceptable social behaviour here. Even if one is married, specifics is still a taboo topic.

Ive always thought that getting pregnant should be a done deal. well at least almost everyone i know has kids, and those who dont have, do it out of choice. so fertility..well infertility is not something that i expect to encounter.

that brings me back to where do i start? one of the websites that i found useful was www.kkh.com.sg

it contains most of the basic terms of fertility, some treatments and procedures. its a good place as any to start.

the most common term would be test tube babies, or clinically known as IVF.

What Is IVF?
In-Vitro Fertilisation (IVF) involves putting the eggs and sperms together. By natural selection, the egg will usually allow only one sperm to enter and this usually leads to the fertilisation process in the laboratory. After fertilisation, the embryos are allowed to grow for a short period of time before being placed into the uterus. A successful pregnancy can be confirmed about 2 weeks later

Who Is Suitable For IVF ?
IVF is the only fertility treatment for women with irreparably damaged or blocked fallopian tubes. IVF is also offered when infertile women cannot conceive with simpler methods of treatment for conditions such as endometriosis, ovulatory dysfunction, unexplained infertility, sperm disorders and immunological problems.

What Is ICSI?
Intra-Cytoplasmic Sperm Injection (ICSI) involves injecting a single sperm into each egg to allow fertilisation to occur in the laboratory.

Who Is Suitable For ICSI ?
ICSI is recommended if your husband has poor quality sperms or if you have had difficulties with fertilisation in the past. If this is your first ICSI cycle, it may also be combined with regular IVF.

IVF / ICSI Prgramme
IVF programmes utilise Controlled Ovarian Hyperstimulation which results in more eggs and hence a better chance of pregnancy. Controlled Ovarian Hyperstimulation is carried out with GnRHa (e.g. Lucrin, Buserelin or Nafarelin) and gonadotrophins (e.g. Metrodin HP, Gonal F or Puregon) injections. Various protocols are used. The protocol using GnRHa and gonadotrophins is described here.

1. Controlled Ovarian Hyperstimulation and Monitoring
a.
GnRHa InjectionGnRHa treatment is given daily to prevent a spontaneous ovulation and to ensure that the ovarian follicles grow in synchronous fashion. It usually starts in the 2nd half of your menstrual cycle and continues for about 14 to 20 days. Some patients may need to take this medication for longer periods.
Blood tests and ultrasound scans will be done to ensure that the optimum response is reached. Once this is achieved, you will proceed to the gonadotrophin injections.
b.
Gonadotrophin InjectionGonadotrophin is injected daily into the muscle/subcutaneous tissue of your thigh or buttock to stimulate the growth of the follicles in the ovaries. After several days of gonadotrophin injections, an ultrasound scan is performed to determine the number and size of the growing follicles. You will need additional injections if the follicles have not reached the desired size.

When the follicles have reached the desired size, an injection of HCG is given and GnRHa and gonadotrophin are discontinued. The HCG is required for the final maturation of eggs before the egg collection. The egg collection is scheduled about 36 hours after the HCG injection.

2. Sperm Preparation
During the gonadotrophin injections, your husband need not abstain from sexual intercourse before the egg collection. On the day of the egg collection, your husband needs to produce a fresh masturbated semen sample.

3. Egg Collection (Oocyte Pick Up)
The egg collection is performed at KKIVF. The eggs are collected through a special needle attached to an ultrasound vaginal probe. A mild sedative will be given to you, as only minimal discomfort will be experienced during the procedure.
After the egg collection, you will be observed for a few hours before going home. It is important to understand that not all follicles will necessarily contain an egg and that some of the eggs may not be ripe enough for fertilisation. An overnight fast is required before oocyte pick-up procedures.
Hormonal stimulation induces superovulation; eggs aspirated from the mature follicles transvaginally with ultrasound-guided needle

4A. Fertilization
The sperms are added to the collected eggs in a dish to allow fertilisation to occur by natural selection in the laboratory. A check to confirm that fertilisation has occurred is carried out the following day.
Unfortunately, in about 10% of couples, there is no fertilisation at all. The nurse coordinator will inform the patient of any successful fertilisation.

4B. Intra-Cytoplasmic Sperm Injection
ICSI will be performed on the day of oocyte pick-up. During the procedure, a single sperm will be injected into each egg via a microneedle. On the following day, a check is made to confirm that fertilisation has occurred. The nurse coordinator will inform the patient of this result.

5. Embryo Transfer
A few days after the egg collection, you will need to return to KKIVF to have the embryos placed into your uterus. An overnight fast is recommended before the embryo transfer procedure.
Embryos are re-placed into the uterus using a fine catheter. This is usually painless and takes only a few minutes. Usually, three embryos are transferred. A smaller number may be transferred if there are insufficient embryos or in younger patients. We encourage your husband to sit in during the embryo transfer.

Eggs fertilized in-vitro (IVF) with sperms. Embryo transferred directly into uterus, bypassing tubal occlusion.

You may go home shortly after the embryo transfer. You will be given daily medications (progesterone or HCG) to support the lining of the uterus and to enhance the chances of the embryos implanting.

There is no restriction on activities including sexual intercourse.

6. Freezing of Extra Embryos
A proportion of patients may have excess good quality embryos. These may be frozen for future use. Patients do not need to undergo Controlled Ovarian Hyperstimulation and egg collection again for these future thaw cycles.

7. Pregnancy
You will need to come to KKIVF 17 days after the embryo transfer for a pregnancy test. You should call KKIVF if you are menstruating so that further instructions can be given.
If you are pregnant, subsequent ultrasound scans and blood tests will be arranged to ensure that the pregnancy is proceeding normally.

8. Useful Information
Success rates (KKIVF rates)
Our overall clinical pregnancy rate is about 30-35% per cycle and the take-home-baby rate is about 25-27%. Additional embryos frozen further enhance the pregnancy chances in many of our patients.

Generally, patients who are below 36 years old have a better pregnancy chance. However, your chances of success will depend very much on your own individual circumstances.

Besides IVF and ICSI (these are considered the final steps in the trying to concieve ladder), there are other options to try. like AIH, IUI, SO-IUI.

will post these in another entry - this entry is already far too long.

CD 64 supposed to pick up med to induce AF

2005-06-24T15:13:00.000+08:00

it has been a while since i last updated this journal.

where did we stop? on CD42 - where we saw LA and he said to wait 2 more weeks.

about 2 weeks later 17/06, LA called to enquire on status, still perplexed over it. in the end, went to
see him the next day and got 2 blood tests done. one for HCG and the other for progesterone.

got the results on tues. confirm no pregnancy, no hcg at all. progesterone level has dropped so AF is suppose to be due soon.

LA suggested if it doesn;t come by Fri - to get some medicine from him to induce.

i think it's the same medicne that took 15 days to work, if that's the case, have to time it to take it later as DH is not around till thrid week of July.

will discuss with LA later.

CD42 No AF still, saw LA

2005-06-04T15:00:00.000+08:00

AF is now two weeks late. saw LA again to get medicine to induce AF. He didn't give me any and wanted to wait for another 2 weeks before seeing him again.

He's baffled that AF did not come at on its own as it should as i have ovulated.

Three possible scenarios - 1) KKH mixed up the blood test results 2) spontaneous miscarriage (should have AF though) or 3) i may really be pregnant even though the HPT is negative.

A blood beta HCG test is unlikely to detect hormone if a HPT cannot do so, as the strip ones are already very sensitive.

so well, it's back to the waiting game again.

CD 33 and no AF, negative HPT

2005-05-25T15:00:00.001+08:00

looks like AF is not going to turn up on time. tested a couple of time on CD28, CD29 and CD33, negative HPT.

this cycle is shot.

emailed KKH, got a terse reply to continue with clomid and get duphaston to induce AF.
will wait till this sat CD36 and then decide what to do.

dun know how this duphaston thing work and how long it takes effect - if it takes too long to work, then the fertile period will fall when hubby's on reservist and then it all goes to waste.

CD 33 and no AF, negative HPT

2005-05-25T15:00:00.000+08:00

CD21 blood test results is out today

2005-05-16T15:00:00.000+08:00

got the results for the blood test this morning from KKH IVF.
I've ovulated. the numbers are 72.3 nmol. no idea what that means but i'm glad that i've ovulated nevertheless.

did some research on the net and came up with these links. will keep them here.
http://www.findarticles.com/p/articles/mi_m3225/is_n5_v44/ai_11666518

PROGESTERONE
Serum progesterone testing has been used as a screening tool to identify patients at risk for ectopic or other abnormal pregnancy. [16,17] With follow-up ultrasound scanning used for definitive diagnosis, a quantitative serum progesterone level of more than 25 ng per mL (80 nmol per L) proved 99 percent accurate in predicting a living intrauterine pregnancy. Sixty percent of the patients with progesterone values below 25 ng per mL had abnormal pregnancies.
and this other one
http://www.fertilityplus.org/faq/hormonelevels.html#progesterone
which has a chart with all the blood work required and the intepretation.

saw LA this evening as well. He said that almost 99% of his patients husband have low sperm count and they can still get pregnant. oh well, let see how it goes.

he named 6 factors of infertility. can't remember them all - no ovulation, blocked fallopian tubes, low sperm count, fribriods, unexplained infertility. can't remember the 6th one. he suggested to try a couple of months on clomid and if it doesn;t work, to go for a HSG to check for blocked tubes. he eliminated all except for fallopian tubes which he doesn't know till after the HSG.

(it was some time later with a new gynae that we found out that the CD21 blood test is an inaccurtae mtd to confirm an ovulation)

CD21 KKH sperm test results

2005-05-13T15:00:00.000+08:00

went to KKH to get hubby sperm test results - the results are not promising. both density and form is way below normal. density at 6% per 10 million and form is 2% per 10 million. am rather shell shock by the results, and it's worse off for hubby.

saw a different doc this time round - Dr S. She's very professional and eh not very encouraging though in terms of what we can do to improve sperm quality. She suggested we do another sperm test in three months (late july) and we see what we can do from there.

was suppose to do a blood test for protestergone on CD23, but she said we can do it today which is CD21. so we headed to IVF for the blood test.will get results on mon afternoon.

after doing the blood test, we are suppose to make payment and get the next appt, we got a number and there were like 20 pple ahead of us in the queue. i didn't want to q and suggested that we go to the cafeteria instead, he refuse and i almost blow up in tears at that point in time.

in the end, he found a seat at the waiting area and after waiting 10 min, the q only moved by one person. i gave up and spoke to the counter gal to make fast payment. will get an appt via phone.
we headed back to see Dr LA with the intention to tell him about the sperm test results.

despite being told that we didn;t need an appt, his clinic was full. and we were told to wait for another half an hour. hubby was upset as the queue doesn't look like it will disapte within 2 hours, much less than half an hour. We left the clinic and i was upset.

anyways to make a long story short, i manage to call the doctor later in the afternoon, explaining to him the results. He claim that in his nine years of experience, he had only 5 good results from SA, and yet the gal still got pregnant. I donlt know if he's trying to reassure me or what. but i do know that this is a huge blow for darling. but nevertheless i told darling what LA said, hopefully this will kick him to start leading a healthier lifestyle.

CD14 Ovulation?

2005-05-06T15:00:00.000+08:00

making love last night was just like having sex - didn't feel like it at all and feeling like crying after it all.

this is not working at all. i don't know why i am feeling this way. perhaps it's the idea of 'having' to do it. perhaps it's the stress of knowing that one 'have' to do it.

CD13 and baby names

2005-05-05T15:00:00.000+08:00

today is CD13, well we were supposed to start badydancing every other day since CD10. but then as i got a bad case of UTI and then subsequently got a sore throat and flu, hardly in the mood to baby dance.

got a scare last week, sun, got high fever and pain in lower back. saw the doctor at 5am in the morning, got a urine test done and then realised i got a bad case of UTI, well so much for following advise not to wash up immed after baby dancing. how embarrassing to see a doctor for that sort of infection.

anyways he gave some antibiotics and turned out im allergic to those as well, had a rash through to monday. what a lousy weekend.

the only up side? - got an MC for 2 days.

and well, it;'s CD 13 and we really should not waste this cycle. so maybe tonight is when we make our baby.

if it's a gal, her name will be leqi, if it's a boy, his name will be lei something (i've haven't really think this through yet)

other names which are already taken, kai ling & kai wen

AF finally here - end of clomiphene cycle

2005-04-29T15:00:00.000+08:00

this should be posted like a week ago but hadn't got the time to do it.

well, AF finally came on Fri 22/04, for once in my life, i was jumping with joy that it came. surely there's some irony there.

anyways, full bleed started on Sat, and i'm suppose to take clomiphene on the second day. started first dose on Sunday, no symptoms whatever, so far so good.

symptoms started kicking in during the working week, AF stopped by Wed, which is rather startling as mine never stops when it should.

A nagging pain in the lower right abdomen and blurred vision by Wed made me panic. not to mention a total lethargic, not enough sleep me walking in the office.

gave a call to the gynae to list out symptoms - he said he had never in all his years of practicing had patients who experienced these symptons before and laughed it off.

i jokingly replied that perhaps i've been reading too much into it.

but then after i put down the phone, i felt kinda silly. am i imagining it all?

a post on a online forum, however came up with other women who have experienced blurred vision/mood swings/ sainzness etc. Thank goodness. i'm normal.

Perhaps it's really time to change gynae.

CD0 AF started Fri 22/04 (late at night)
CD1 Sat 23/04
CD2 Sun 24/04 - CD6 Thu 28/04 clomiphene 2 tabs per day
Most fertile period CD10 - CD20Mon 02/05 - Thu 12/05 - loads of baby dancing in store.

AF still not here yet. What cld be wrong?

2005-04-22T15:00:00.000+08:00

finished the last dose of medicine on 18/04 Mon, and was hoping to see AF within the next couple of days - it's Friday 22/04 and still no sign or symptoms.

called the gynae yesterday but no reply from him or his office. as usual the dragon woman gets on my nerves.

called at 10am plus, she said will pass on msg, called at 2pm plus, said already passed msg to doc, called at 4pm plus said will remind doc, called at 6pm, kena tsf to voicemail, called at almost 8pm, someone answered and said doc in surgery till10pm, guess that's it. another sleepless night.

went to KKH with DH to give the SA. and it took us 41 min to drop off the sample. arghs. talk abt efficiency and following previous instructions given.

poor hubby, took ages to produce the sample at home...that despite not doing it for the past 3 days. i guess it doesn't help that i was laughing :P

by the time i reached the office, i decided to wait till 10am to call my gynae. in the end, called him at 945am, couldn;t wait any longer. he gave all reasons why he didn';t return call. i already guessed so but didn't have the patience to reassure him. LOL. i need assurance here.

anyways, he said to wait a couple more days and to do a UPT before heading to his office on Mon. so i could be pregnant - i asked abt the probability and he says he won;t know. right, i can;t wait for the weekend to be over.

oh yes, he said the medicine i've been taking is not of any harm to the baby if i;m really positive.

Thk goodness. IF.

a bit puzzled though, we did a UPT on the 08/04 and it was a negative, last week 15/04, the KKH gynae did a scan and he said the uterine lining is thick - as it shld be due to the AF inducing medicine - so how can be pregnant?

and if not pregnant - then why didn't the AF induce medicine work as it should work the last time?
will know by monday i suppose.

anyways anyways do i ahve a choice. someone suggested a blood test, shd i go for that?

still deciding or can we wait till monday? arghs.

actually didn't wait till monday to find out, during lunch time, wen to get a HPT form watsons and did a test - it's a negative, so there goes the hope. for a short time on friday like for 3 hours after the doctor's phonecall, i got high hopes that perhaps i didn't need to go thru all those fertility medicine,

oh well, it's not to be.

http://www.babycenter.com/pregnancy-calendar/getinfo?_requestid=326251

anyways i found this amazing website, all you need is to input some stuff and it give a day to day break down of what is happening now.

AMAZING.

Appt at KKH

2005-04-15T15:00:00.000+08:00

Friday 15 April 2005

Was debating whether to go or not for this appointment after the horrendous polyclinic wait and feedback from posters in TTC that nothing much will be done as referred patients will be seen by a MO (medical officer).

in the end, i've still decided to go - my rationale was perhaps the diagnosis would be different (better?) - illogical. or perhaps the other doctor will confirm on what LA said and give the go ahead for treatment which will reassure us that LA knows what he's doing. anyways it's kinda convoulted.

been cranky and moody for the past few days, not sure if it's the medicine or just the waiting.Oh well, in the end did see the doctor at KKH. Lucky me, despite being a subsidised case, the doc on duty that day was the senior consultant. and he's really efficient and straight to the point. the type of doc i like.

despite waiting for over an hour to be registered, i reach there at 8.45am for a 9.10am appt, i didn't get to see the doctor till about 11am. by the time he's through with me and i got to collect prescription and stuff, i left the hospital close to 1pm. a looong looong day. i was totally exhausted by then.

how did the appt go?well, after being registered, you are suppose to go to another station where they take yr ht/wt and blood pressure. so you queue for that. 20 min or so.and after they done that, you go and wait for the doctor. eh this one is like an hour or so, judging that i got the first appt of the day.and then consultation is like 20 min (which is long, considering that other doctors are going thru their patients like 2 every 15 min)consultationThe doc is a nice guy, straight to the point and efficient. i don;t know why, but i wasn;t expecting efficient. maybe the concept of public hospital. therfore i wasn't expecting to be examined physically, expecting the first visit to be basically 'taking of medical history etc etc'The gynae said he will do a scan to confirm diagnosis. and his nurse appeared to tell me what to do. i was expecting a abdominal scan until the nurse told me to strip and put underwear 'in that drawer' - whoops.

I wasn't expecting a internal scan and frankly was rather embarassed. and certainly not mentally prepared for it. while being in that vulnerable position, he asked if i had a pap smear done before and i said no. He asked me why not? the gynae i'm seeing now says it's low risk hence not necessarily. He wanted to do one and called the nurse, and then asked me if i wanted one now?

in that position, the last thing i wanted is a pap smear. and i told him i will go back to my gynae for that. He nodded and inserted the probe in. He mentioned that the uterine lining is a little thick (which is normal as i'm taking medication to induce AF).he showed me the left polycyctic ovary and said that he can;t see the right one clearly. He ended up manipulating the probe about, trying to see the right ovary and was casuing me some pain. to his credit he did asked, if he was causing me pain. and i said yes, he gave up saying that my right ovary was too far away, and then printed some ultraounds.He then took the probe out. finally. The total scan didn;t take that long, maybe 5-10 min max but it felt like aeons to me and i ended up feeling brusied for the next couple of days.

the nurse came in and helped me off the table. got dressed and got his diagnosis. well he confirmed that i have PCOS (great surprise).he suggested that i see my currnet gynae for the clomiphene treatment for 3 months, and if that doesn't work to come back and see him for other alternative methods.

He then prescibed some vitamins for hubby, clomiphene for 3 months at 1 tab per day. and oh yes, a sperm analysis for hubby. I;m sure hubby is jumping with joy at the prospects of doing the sperm sample.

the sperm sample appointment.so after the consult, i'm suppose to go get a appt for hubby to deposit his sperm. to KKH credit, i am allowed to choose an appt, i wanted to know the results as soon as possible and picked the earliest appt next friday 830am. got detailed instructions and a small plastic container.

to anyone who is reading, it's nothing gross. just awkward. Hubby's suppose to clear his stuff on the 18/04, no activity for the next 3 days and produce the sample on 22/04 am into the sample before bringing it in within an hour.

The drop off is suppose to take less than 10min, all you need is drop of the sample and go. results will be given to ya via the doc at the next appt.

remember these instructions. so well, so i thought.

as you can imagine, hubby's like...into that small container, oh well, got to do what a man got to do.

Seen the doc

2005-04-08T18:00:00.000+08:00

it's not so bad, didn't have to wait more than 20 min top.as usual, he asked for history - er doesn't he keep any records? anyways it's hard to be upset with him as he's a pretty nice guy, LOLanyways after the history, he asked if i could be pregnant, i told him abt the home pregnanancy test and he said it should be a clear out positive or negative - i guess a little part of me was wishing that the negative was a mistake. strange isn't? *wryly*

he did a short abdominal ultrasound and said everything is normal, PCO is still there. and went straight into explaining that PCO is hormonal imbalance and that i need to lose weight - yes we all know that. If i could lose a kg each time he said that to me, i would be kate moss.

so the plan is this , get AF coming again by taking sonulut for the next 10 days at 2tabs in the morning. it should come within the next week. then take clomiphere (fertility medicine) from D2 to D6 (5 days at 2 tabs in the morning), have coitus (sex) from D10 - D25 and between D20-D25, i can go back for a blood test to see if the fertility medicine is working - ie if i'm ovulating.

he took my word for it and i didn;t have a urine pregnancy test, so saved some bucks there. a short visit of 20 min consultation and there goes 75.20. i sure hope that this one cycle will do the trick.*keeps fingers and toes crossed*

*reminds myself - no caffiene
*Sat 09/04 - Mon 18/04
2tabs sonulut in the morningD2 - D6
2 tabs clomiphere in the morningD10-D25
BDD20-D25 blood test

Had a call from a GF

2005-04-07T20:00:00.000+08:00

Friday

i've forgotten that M is going to be 1 yr old in May, how fast time flies.I don't think i can wait any longer to have kids. been reading up that the chances of conception gets lower and lower once past 30. do we have the time or the money to wait till later to try?i don't think so. hopefully the sooner we start trying means that we will spent less time and money on it.

did i tell ya about the dragon of a lady - eh the recept at the gynae - well she's one of the reasons why i'm so hesistant about making an appt to see the gynae. From galfriends and other posters who see him, they all agree that she's a bit of a dragon, but that she's a nice person to those who are pregnant which obviosuly i am not. sighs.it looks like i got to deal with her. let me muster up enough courage to call her.

i called her ard 2 plus to arrange for a appt, tentatively 12pm on friday. mentioned to her that i would like some time to discuss some issues with the doctor about having a baby and would appreciate an appt when the doc has time to talk things through.She said anytime in daytime can, cause day evenings, the doc is fully booked with 48 patients to see. wow - being a gynae is lucurative. :P

i told her i will return call and confirm with hubby first. and she just hang up the phone :??bother - i really hate this. i'm so tempted to just forget abt this. but then he has all my records.anyways, i discussed with hubby and we decided to give him another try. i wasn;t too sure that public is the way to go, esp since reading online that subsidised patients are usually seen by an MO or a registar only and it will take a longer time in public sector to get anything done. - the 3 hr wait at the polyclinic convinced me of that.

we don't have time to waste.so i called the clinic up again and was surprised that the call is picked up by the gynae himself. i thought i got the wrong number. :P. anyways got the appt fixed and yes, i'll be seeing him in a few hours time.

It's 5am in the morning and i couldn;t get to sleep. hubby is not sleeping well either and rather than having 2 persons tossing on the bed and waking each other alternatively, i figured that i could use the time on the computer to do up medical history and the questions i wanted to ask the doc.

Had this feeling that perhaps.....

2005-04-06T15:00:00.000+08:00

perhaps i'm pregnant after all.

After chatting with a galfriend, thought that perhaps since menses is late, just perhaps i could be pregnant after all.

got myself in a frenzy and hurry to get back home to test.

it was a negative.oh well, life goes on

Step 2

2005-04-02T16:03:00.000+08:00

I wonder what made me think that sat is a good time to go to the polyclinic. the opening hours are from 8am to 12.30pm. I reached the place at 8.45am and even before i got out of the taxi (yes, i took a cab, got no idea how to reach the place via MRT), i saw a long queue snaking out of tthe building.

woah, i didn;t know that many people go to polyclincs - i've always visited pte doctors. ok, i resigned myself to the long wait. Ok a side point which i think is funny.The queue was kinda funny - it stuck straight out in a straight line from the registration desk - and right out of the building into the rain (there was a slight drizzle) - i don;t understand why people were queuing in the rain when they could have moved sideways and took shelter under the corridor instead. that's singaporean for you.

As i was in the rain, i wondered if i should say something, but then fortunately the queue moved forward, and i got out of the rain. I turned backwards to see if anyone would move sideways out of the rain - but no, instead i saw a couple of umbrellas being opened.

well singaporeans.anyways, the queue (i thought it was for registration but no, it's pre-registration) - took about 15 min and i passed my IC to the lady and got a number. i looked at the number i am holding on to and the one that is flashing n the disply and i freaked out. i'm like 200 numbers behind.I managed to snag a corner chair while resigning myself to the wait. Thank goodness i got a trusty novel with me. As i read my book, i did some people watching and there are loads of new borns (crying babies) around. what an irony.

Ok, while i try to concentrate on my book, the numbers went flashing by and surprisingly within 45min, i got registered. by then it was almost 10am. that was a painless process.

now as i waited to see the doctor - there's a board that says it takes an hr and 4 min - why the precision, i'm so amazed. and that estimated time doesn't change at all.

so i settled down to wait and inbetween there was some drama going on with other people who were seeing the doc as well. oh well it puts for interesting reading, but not now. ( never got round to writing abt it - oh nvm)

i watch the numbers jump and noticed that each consultation didn't take more than 15 min max. and the queue numbers jump like 8 to 10 numbers each time. i was thinking like not too bad, it's going to my turn soon - perhaps within the 1 hr and 4 min promised at registration.

almost to 1hr and 4 min, my number flashed and i finally saw the doctor. a young lady, she sounded like she's from the philipines, OK, a foreign talent. :P i got nothing against foreign talent but surely there are enough doctors to go round in Singapore? - loads of kids out there wanted to be doctors.anyways back to the topic, I told her that i wanted a second opinion since i've been diagnosed with having PCOS a couple of years back and treatment at a pte clinic has not brought any results as i have not concieved since trying for a baby for 1 yr and a half.Guess what, the next question she asked was ' when did you get married?' - now that was a bummer question. We gotten married about 4 mths ago. Eh, i got nothing against pre marital sex but duhz, need i spell it out in black and white? btw She asked this question twice.

anyways, the next thing she asked was if i ever was pregnant - she asked this twice as well. and this was AFTER i explained that the pte doc said it's unliekly i can concieve due to PCOS.I'm just thankful that there was no physical examination.She wrote me a referral letter and asked me which hospital i prefer. Eh, KKH? isn't that where these sort of matters are sent to? or is there another women's specilaist hopsital around that i'm not aware of?i got the letter and was sent with a patient clinic assistant to make an appointment. She pointed me out to where i could get a seat. i figured that it's going to be another long wait. in 20 min time, i heard my name being called and finally managed to see someone who can get me a appointment.

that 20 min was rather interesting actually, i overheard a conversation between two ladies in their early thirites - well aunties, conversing in Mandarin about the inefficiency of the system. Evidently one of the ladies had to go for a blood test and a scan but she had her blood test done and told to see the doctor, after waiting ages to see the doc, she was told by the doc to go get a scan at another place, and had to wait for another appt. and after she got an appt, she had to go for the scan and the results will be sent to this doc. So she came back to see the doctor and was told that she had to make another appt to get another scan. and that's why she's waiting to get another appt.Sounds confusing? it sure is for me. and you know what, it's one and a half month since that first blood test.

I sure hope that whatever she's suffering from doesn't spread fast, in one and a hlaf months, a patient could be dead by then.anyways, after 20 min or so, my name was called out and someone helped me make an appointment for 2 weeks later with the fertility clinic in KKH.

I'm so eagerly waiting for the appointment. not.

Step 1c

2005-04-02T16:02:00.000+08:00

his only encouragement was to lose weight - which i have to say is sound advice. PCOS patients tend to be overweight and overweight poeple tend to have PCOS. while it's uncertain to say which causes the vicious circle, suffice to say is that when one have PCOS it's a tough battle to lose weight.

and loosing weight is a real battle - i don't eat that much, i'm not fussy about food, i wonlt q more than 10 min to buy food, and where i work, it's common to queue that long to have food, which explains why i prefer to skip lunch.

So despite all of that, i still am putting on weight - i say that's because i'm happy. Everything seems to be going fine in my life right now. We got a flat, did the renovations, got a wedding package, got the gown, did the invites, had the wedding, did the honeymoon bit (ok it was just across the sea, but it's still a deliciously cool break) and the bedminton and the only dark spot is the lack of vomitting and the cravings for coke.

sighs. life is never smooth.

So that brings me to the next step.

Step 1c

Public hospital - that the only one that comes to mind is KKH. everyone i know in my generation is born in KKH. well, it can;t be that bad - despite all that i heard about it. It's the national women's hospital after all.

I surfed the net a little bit more and found out the various things that they do there. well, they have a centre for infertility - there you go, that word again.

ok, there are two ways one can go about seeing a doctor at KKH. To call their one number hotline and make an appointment and get charged non subsidized rates which cost slightly more than pte doctors without the service. now that's ridiculous.

the other way is to get a referral via a polyclinic.

NOw this is where i kinda barked up the wrong tree - i assume that there will be doctors specialising in women's health in the polyclinic - so i called the one nearest to me, i got the number via the MOH website.
It was an answering service and after watiting 15min and pressing buttons, i got a operator who didn't understand what's women wellness is and what's a pre conception screening is - the only thing i got out of her was pap smear - well i suppose that's as close i can get to women's screening, until she asid she can;t make an appt until she knows which day i started my last menses. - well i told her it's not regular and she went on about surely i know when was the last time i had my menses and she can;t make an appt with the doctor until i tell her.

That's when i gave up.

perhaps a personal visit to the polyclinic will be better.

that brings to Step 2

Step 1b

2005-04-02T16:01:00.000+08:00

Step 1b

normal pte gynaes - i'm seeing one now. He's a pretty nice guy - professional and his rates are reasonable and he's like 10 min walk away from home. galfriends i know are seeing him an dpraise him for his bedside manners.
so all in all, he's a good gynae altogether. I've been seeing him for the last couple of years for various women's issues - irregular menses, those that do not come and those that when they do come, forever never ending menses as well.

There's a saying to describe menses - 'yee mah (auntie) come to visit' - i don't think this is refering to anyone's favourite auntie.

so while i used to be relatively happy that there's non of the inconvenience of having menses most of the time, yee mah only visits like once in 3 months or she even goes on vacation for longer periods of time. that surely don't restrict my activities.

sometimes she visits and with a vengence stays for a couple of weeks or even once a couple of months. i thought i would have died of blood loss before i saw him about it. a jab later and a couple of days later, he managed to stop it.
so my visits to him is limited to him trying to regulate my menses and me trying to make sure that it doesn;t affect my life.

menses is a bane in my life. there's a joke to beware the one that bleeds a week and don't die of bleeding, well i should say, one should beware the one that bleeds for weeks and don't die.

It's a draining process. literally. getting drained of blood as well as energy. though usually by the second week or so, one gets used to the tiredness and just hope that it will go away on its own.

not to mention the grouchiness and the short temperedness. i know i'm grouchy, i know i'm short tempered. and i know that PMS is not an excuse to give in to all those 'feelings' - and i believe in mind over body. chemical reactions or not, i'm going to rein in my grouchiness and temper - which i think i do successfully most times - which results in a swollen tougue and retarded responses.

swollen tongue when one just bites on the tongue to keep that remark from slipping out, and retarded responses when one just have to find another diplomatic reply to that REALLY STUPID question.

ok, that gynae, why didn;t we start with him instead? well , come to it, we did start with him. i remember asking him about the chances of concieving with all that menses irregularity - even me, in all my attempts to decieve myself - know that something is wrong.

it got seriously wrong - he did a ultrasound scan- the sort whereby you donlt wish it on anyone else. He put a probe via the vagina and he moves it around to see the various reproductive organs. the good news is that it's all intact, the bad news is the cysts on the left ovary and the heavier than normal lining of the womb which he said will clear.

Now he's not hopeful that the cysts will clear and he said it's probably PCOS - polycystic ovary syndrome - a serach on the net will tell you that a zillion women acorss the world have that and they sure talk about it.

I'm not too shattered back then, i wasn;t planning to have kids. i'm sure i didn't want to have kids. the only thing that plagued my mind was the higher possiblity of having cancer due to the irrgeular menses.

so half heartedly, i took the medicine he gave, which was meant to regulate the menses cycle. after months of having it and not having it, it got put on the back burner while i prepared to get a flat and do renovations and prepare for our wedding.

Step 1

2005-04-02T16:00:00.000+08:00

Step 1

One would have thought that THE WAY to go about is is to make love loads of times - to the point of having sex for the sakes of it. but NO, it doesn;t work. I'm still not preggy yet. it's quite unbelievable - for one who abhors preganancy terms and avoids them like the plague and now i'm like head over water in them. and i consider preggy a pregnancy term, why can't pple say that they are pregnant instead of preggy?

after spending a couple of nights pondering over the next steps, I've concluded that we need external help. not a another woman nor another man - our sex life is pretty ok (in my opinion) - it better be his opinion as well.

ok, external party - professional medical parties - that's what i was refering to.

I spent some time surfing through the various websites - let's ttry to recall.

The first place is to check with my friends and contacts as to pte gynaes - that surely has to be the first place to start with, or so i thought, until i got some numbers and start making the calls. from scanning through some posts at a local forum, there are some 'famous' gynaes that pop up consistantly and a coincidence that one of them was recommended by a contact. He's known to have higher than average success rates, has a posh clinic in a pte hospital in singapore, and sky high charges. after ascertaining the sky high charges and the would you believe it 2 hrs waiting time to see him, i decided that as good as he is, he would be one of the last options to consider.

and to boot, he's attached to one of the most expensive private hopsitals for delivery expenses and post natal care.
so while he's the 'best', he's put on hold till things get worse.

ok, that was rather negative. i'm trying to have positive thoughts here. after reading through, or shd i say sifting through the myariads of postings on trying to conceive, i can;t help but be negative about it all.

If nature deems that you are suitable to have a child, surely it's nature that one will have one? and perhaps if one can;t have one, sirely it's because it's all part of the survival of the fitess kind of thing?

i've tried explaining this to hubby and all he did was to look at me and say there's no way you are getting out of this one - parents are getting old and isn't Y's baby so cute? wouldn't you like to have a baby like that? and my reply is still - only if i can return him.

as you can see, having a baby is really not top on my list of to do things. Having enough money to go on a long vacation trip sure sounds more enticing than having a 'bundle of joy' - especially so if we got to go out of our way and most probably get loads of strangers poking me in all the places that i wish never get exposed in public.

ok, back to choices. after pte gynaes which cost the bomb, there's other pte gynaes which don't specialised in fertitliy cases - the normal pte gynaes - i donlt know what they are called, but i suppose that because they do not have a reputation for fertility cases - that's another bad word.

Yes fertility is a bad word, i'll say more about it later. (later i found out there's another worse word - call sub fertility)

Thinking about babymaking

2005-03-30T16:00:00.000+08:00

Been married for 4 months and doing you know what for months before, and yet still no sign of baby coming along.

Left and right, friends already have bouncy cute babies and little devils, friends of friends are already on their third kid, and even perfect strangers lugging their pregant bellies all over the place.

it's time to do something about it and i mean now