And we’re back!

I absolutely did not intend for this to become an IVF-only blog – I have, in fact, been working on a post about something else for about six months already – but so many things have happened and keep happening and there hasn’t been time to sit down and catch up! I really respect and admire people who deliberately carve out time to write on a regular basis. I keep telling myself, this is the year I will write more! but you’ve seen how well I’ve done on that front already.

Anyway, we’re back! We’re back! On Monday the 7th I had my first appointment of the cycle at my regular fertility clinic. Looking back at my old post about the same point last time round, it’s weird (to me) how different my emotions were this time. I wonder why? Perhaps having “failed” back in March/April has taken the pressure off somewhat. Perhaps the fact that I had another appointment at another hospital later that same day took my mind off things (headaches, probably Long Covid).

This time when I rolled up to reception they asked me to confirm whether or not I wanted to use health insurance. Old blog friends, you may remember that last time I deliberately chose to go through IVF before the Japanese government officially covered IVF under national health insurance because of the partial refund policy (prefectural and city governments combined to give back a total of ¥400,000, which now no longer exists) and we weren’t entirely sure how much would be covered by insurance/whether or not it actually would be financially beneficial in the long run, rather than reducing the amount that needed to be paid upfront. My doctor was clear about the differences in available treatment the last time I spoke with her, so I went on Monday with the expectation of having to pay for everything myself but just in case, I asked the receptionist if I could decide after having consulted with my doctor. Sure, no problem, they said.

Since it would take a while to process, they drew blood from me first (how many ml will they take this time! Get your guesses in now!). One of the nurses was new and very professional but the other one has known me since 2018 and is always very friendly, so we had a quick catchup chat. Then it was back out to sit in the corridor until it was time to be called in for the first of many transvaginal ultrasounds. It’s been a good 7 months(?) since the last time I saw Dr. O, so when she walked in to me sitting in the examination chair she visibly brightened with recognition, “omg hi!!! How’ve you been!! Long time no see!!!” which is always hilarious when you’re sitting with your legs held open in an OB/GYN chair and it’s the start of your period so things are definitely gross. I suspect they’re so used to this kind of situation that the weirdness bypasses them now, but it always makes me laugh. Thank you for your enthusiasm! It’s infinitely better than “oh, you again,” I suppose.

After that, I finally got a consultation with the doctor herself. And honestly, she surprised me!

“I think we can get away with using insurance for this round,” she said.

“But I thought the number of eggs we would be able to retrieve would be way less?”

“Yes, less, but…”

“But I only got one before, and two last time, of which only one was any good! Less than that is…”

“Yeah, but I still think we can get some! It’s worth a shot! And if this doesn’t work, we can go for the out-of-pocket option next time. The only inconvenient thing is that your husband has to come in for a very brief information session/consultation thing to meet insurance requirements, and a blood test… oh, but he had a blood test back in March so we can skip that part this time.”

Well, I mean, sure, why not. “If you think it’s worth a try… Alright, let’s give it a go!”

After the consultation it was back out into the corridor again to wait for the nurses to call me in to give me this round’s set of medicine: a five-day course of letrozole again, and more injections. This time, the injections were to be self-administered at home.

“Is that because of insurance?” I asked.

“Nah, because of covid,” my friendly nurse said. Last time I was still able to go to the clinic for my injections, but they seem to have opted in general to get people to come in less, which does make sense. The nurse gave me a whole rundown on how to administer the subcutaneous medicine, and gave me a little sharps box for all the discarded needles. “Keep the medicine in the refrigerator and hang on to it after this course is over, because you might still need it,” she said.

Well, I know that self-injection is pretty common for various different types of medical treatment so I won’t go into it too much, but what with all the covid and flu jabs I’ve had this month, as well as the acupuncture I’ve been trying for my headaches, my friends let me officially declare I am SO tired of needles right now! I am sure friends with diabetes will look at me pityingly, and I apologise, but ugh. I didn’t particularly care about needles one way or another before this month, but I am pretty fed up with them now!

Anyway, with the pills taken and the injections injected, on Saturday the 12th I went back for another ultrasound inspection to see how we were doing on the follicle stimulation front.

“Not quite there yet,” the Dr. O said. “A few more injections, come back again on Tuesday.”

She then pulled out some paper from my file. “About your blood test from the other day, though,” she said. “Your AMH levels have gone up! In 2018 they were 2.87, and now they’re 3.26.”

“Wait, what?”

I was under the impression that one’s AMH – Anti-Müllerian Hormone – was an indicator of how many eggs you had, and was therefore only ever likely to go down as one got older. I turned 31 in 2018, so the AMH count suggested I had slightly lower egg reserves than would be expected for my age. How could mine possibly have gone up?

“Oh, it’s something that changes with your hormones!” she said, and I nodded without really understanding, determined to look more up later. “The nurse will give you some more injections today, and then if you inject yourself again on Sunday, I’ll see you again on Tuesday.”

Got it. The nurse gave me a shot of Cetrotide (which prevents premature ovulation – this is necessary under the insurance-type IVF since the number of appointments they can offer is reduced) and another type of follicle stimulant, and off I trotted back home to go and ask Dr. Google about this AMH thing.

Since AMH is only secreted by follicles that have started to develop but that are less than 9 mm in size, the information provided by this test is limited.  Therefore, AMH is only a reflection of how many follicles are in the early stages of development. A normal AMH can indicate that there are a normal number of follicles in development between resting and 9 mm.  A high AMH can indicate more than average egg follicles in this stage.  Women with PCOS have a high AMH because their follicles are stuck in the early stages of development due to the hormonal imbalances that accompany PCOS.

A low AMH was thought to indicate a low number of remaining egg follicles (resting/primordial follicles or ovarian reserve) and therefore, decreased odds of conception.  Recent research has disproved this assumption.  Therefore, all that a low AMH means is that not many follicles are in the early stages of development. However, there are many factors that influence how many follicles are developing at a given time.  Negatively interpreting a low AMH, particularly in a younger woman, creates a false and unnecessary sense of despair.

https://fertilityhelp.ca/low-amh/

When I was searching around, nothing really seemed to help me understand my situation until I stumbled upon the link above. It was indeed, as Dr. O had said, something that chances with hormone levels! I had gone for four years thinking that my egg reserves were lower than average (in addition to my anovulatory periods and overall half-assed hormone levels) and being glumly convinced that I was just a sub-par human being, so this was truly revelatory. I suddenly feel less automatically doomed to failure? I am beginning to feel less pessimistic about this whole thing? This tentative sense of optimism may come back to bite me in the arse later, but there you go.

Anyway, Tuesday rolls round and I go in for my third checkup. Blood was drawn again – I forget why – and then another ultrasound scan. The screen shows so many follicles that look like they’re getting bigger (I’m getting used to understanding the black, white and grey blurs now!) but that was the case in previous rounds of IVF too and is therefore no guarantee that my crappy-ass ovaries will actually have eggs that are ready to be collected. “Looking good,” Dr. O said. “Seems like retrieval day will be the day after tomorrow!”

Now, last time when I underwent retrieval there was a nasal spray that I was able to use in addition to our old friend the trigger shot, and since I was told to keep the spray in the fridge ‘in case you need it again’ back in March, I brought it up with my doctor this time. “I was told it keeps for a year, so should I use it this time…?”

She winced. “I’m not allowed to advise using the nasal spray under this round of insurance-covered IVF,” she said. She saw my curious expression, and expanded further: “We’re allowed to administer it from the second round onwards, but for reasons unknown the bureaucrats who set this thing up didn’t see fit to cover it from the first round.” I can sense the frustration radiating from her. “So I can only advise you use it after this cycle. Which is not what I want to do, but…”

When I spoke to the nurse afterwards, she too had a few words to say about the current insurance system. “It was designed by people who have no idea what they’re talking about! If they’d asked a single professional who actually works in this field, things would be different and more would be covered!” This is the nurse who was super professional a few days prior, by the way, so you know shit’s real that she’s ranting to me. “We feel so bad when the best course of action is right there in front of us and we aren’t allowed to take it!” I feel so bad for them, being bound by rules written by idiots. I guess doctors in the US who have to battle against insurance companies and the financial restrictions of their patients have it even worse! Poor people.

Still, here we are, finally caught up with everything that’s been going on on the IVF front, the afternoon before egg retrieval. How will it go? Will I have weird dreams again this time? Stay tuned!! I’ll try to post asap to let any invested parties know (I know there’s at least one of you, anyway). Wish me luck!