1000 Needles: How to Increase Your Odds and Take Control of Your IVF Journey 2020952716, 9781641704502, 1641704500

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Praise for 1000 Needles Fertility treatment is never an easy journey, and unfortunately, Karissa’s was harder than most. But good sometimes comes out of arduous journeys. If Karissa had conceived on her first attempt, we may never have seen a book describing her tortuous path to the much-desired baby! There is a dearth of well-researched information for couples trying to conceive through assisted reproduction, and this book will go a long way in educating fertility-challenged couples as they start their journey. ART is a partnership between the couple and their doctor, and trust is an important component of the relationship. Unfortunately, there is still a stigma associated to infertility, and couples are reluctant to talk about their problems with friends and families. The internet is not always the best source of information. 1000 Needles gives insight into the emotional turmoil, the strain on relationships, the deep despair associated with failure—things that no doctor can possibly discuss with an infertile couple at length. I would highly recommend this book to couples embarking on their fertility journey as a starting point to discussions with their doctor. No two couples are the same, and every couple should have individualized fertility treatment, but this book will tell you what to expect and what to ask. —Pankaj Shrivastav, MD, director of Conceive Fertility Hospital

 

Copyright © 2021 by Karissa Stelma All rights reserved. Published by Familius LLC, www.familius.com PO Box 1249, Reedley, CA 93654 Familius books are available at special discounts for bulk purchases, whether for sales promotions or for family or corporate use. For more information, contact Familius Sales at 559-876-2170 or email [email protected]. Reproduction of this book in any manner, in whole or in part, without written permission of the publisher is prohibited. The material in this book is for informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health-care provider with any questions you may have regarding a medical condition or treatment. Never disregard professional medical advice or delay in seeking it because of something you have read in this book. Library of Congress Control Number: 2020952716 Print ISBN 9781641704502 Ebook ISBN 9781641704861 Printed in the United States of America Edited by Katharine Hale and Ashlin Awerkamp Cover and book design by Brooke Jorden 10 9 8 7 6 5 4 3 2 1 First Edition  

1000 NEEDLES

This book is dedicated, with love: To those longing for a little person all their own. To Kyle—my rock, my partner in crime, my beginning and my end. It was one crazy road to our little man, and I would do it with you all over again in a second. And to Ava Grace, Anna Sofia, and Axl Blazej— you fill every day with magical chaos.  

1000 NEEDLES How to Increase Your Odds and Take Control of Your IVF Journey

KARISSA STELMA

Contents Preface: IVF Is Simple . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

PART 1: PREPARATION | 7 Chapter 1: Down the Rabbit Hole We Go . . . . . . . . . . . . . . . . . .9 Chapter 2: The Chicken or the Egg? . . . . . . . . . . . . . . . . . . . . . . 29 Chapter 3: Great White Whales (Sperm) . . . . . . . . . . . . . . . . . 51 Chapter 4: Become Your Own Compounding Pharmacist (Vitamins and Antibiotics) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Chapter 5: Acupuncture and Other I-Told-You-So’s . . . . . . . . . . 85

PART 2: LET THE GAMES BEGIN | 99 Chapter 6: Drug Protocols, Hormones, and Depression . . . . . . . 101 Chapter 7: My Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Chapter 8: Medical Minefields and Innovations (It’s a Brave New World) . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Chapter 9: The Big Five . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Chapter 10: This Is Not the Missionary Position . . . . . . . . . . . . 165 Chapter 11: You Are . . . Pregnant! (And Scared to Breathe) . . . 179 Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 About Familius . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

Ladies and gentlemen, after you take the plunge to start IVF and before you start reading this book:  

1. Decide that the next three months (in a best-case scenario) are not yours. They belong to your to-be child. You will be optimizing your bodies for that ultimate success. 2. Recognize that higher costs in the short term will save you time, money, and emotional turmoil in the long term. 3. Buy your vitamins. Women: Get on a prenatal vitamin. Men: Get on a multivitamin plus additional vitamin C. Jump to Chapter 4 for more info, but you need to start the basics yesterday. 4. Start an organic and low-carb/high-protein diet. You’ll build your eggs, change your sperm, and maybe even lose a bit of weight—win, win, win! 5. Eliminate alcohol and caffeine completely. (Dear parent-to-be, do you want a baby or a glass of wine or craft beer? Yours truly, a hedonistic wine aficionado.) 6. Discard all toxins that you can, from beauty products to home cleaners. Phthalates and BPA are the enemies. You needed a new conditioner anyway, and your natural musk is far better than that French cologne you picked up randomly at the airport. 7. Begin acupuncture. Yes, both of you! Here’s a little tip: Try home service. You can bond with your partner as you sit there with needles in your body for thirty to forty-five minutes every week. Lovely. 8. Educate yourself. Get the lay of your land! Who goes into battle without knowing the terrain? Men, get your sperm and blood tests. Women, get your physical exams and blood tests. The tests are expensive and they’re not fun (some may consider it overkill), but this baseline is essential to shortening

your timeframe. (You would do anything to get back the time you could lose on IVF.) 9. Discuss when you will stop IVF. Have the conversation with your partner and with yourself. The hope IVF breeds is addictive, and you need a game plan for when (if ever) you’ll walk away. If the answer is never (it became so for me), get a handle on your finances. If you’re doing this with a partner, be absolutely certain you’re speaking the same language on this one. Be prepared to revisit your decisions as the months progress. 10. Prepare for the aftermath of success. The ramifications of this path do not stop at pregnancy. It’s hard to take a victory lap when you are emotionally drained, your relationships have suffered, your body has been run through the mill, and you’ve lost your sense of self and purpose. Take stock of what you’ve achieved and remember what all that heartache was for! 11. Write a letter to yourself. (This one may just be the most important!) Tell yourself why you are doing this, how you feel about your partner (if you have one), and why you want a baby. Remind yourself of your own strength and who you are as a person. Then tuck away your letter in a safe place—you may want to laminate it or write it up as an email for safekeeping. Later on, when all hell breaks loose and you’re sick and tired of being on those egregious, toxic hormones that are tearing through you, you can revisit your letter for something to hearken back to. You will need it.  

PREFACE:

IVF Is Simple

Make everything as simple as possible, but not simpler. —Albert Einstein

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am totally kidding. IVF is not simple. IVF is sadistic, isolating, and life-altering. But what if, for the sake of argument, we acted like it is simple? What if we armed ourselves with enough knowledge beforehand to eliminate 90 percent of the trial and error that IVF entails? What if we could control a lot more than we thought possible and therefore start IVF knowing that we were far, far ahead of the curve, perhaps even cutting our journey by more than half? Grateful and brutally honest, I write to you with a little miracle named Axl sleeping peacefully in a BabyBjörn beside me. Buckle up.

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This book is a raw, hard look at my IVF struggle. It could never fully convey what IVF did to me and to my relationship, or how it affected the two children I already had. But it will tell you how we finally got pregnant, and what we learned along the way. It is not intended to speak to every reader at every turn of the page. It does not address every potential medical issue or variation thereof. It is not mushy and sentimental. I may challenge your sensibilities at times and elicit judgment at others, but from each and every chapter you will walk away with a few more tricks up your sleeve to bring to the fertility battlefield. More often than not, you will nod your head and make a note. You will learn something to accelerate your path to that miracle baby, that rainbow baby, that first baby, that final baby. From acupuncturists, to homeopaths, to fertility specialists, to other women who fought the good fight many a cycle more than I (and probably have more combined knowledge than any doctor I met on this dark desert highway), you will take away golden nuggets of wisdom that may just turn into your little guy or gal some months down the line. This book is written in such a way that you can choose to take it all at face value, or you can delve further into suggested readings. Any time you want to dive deeper into a topic, you’ll find that each chapter ends with a recap and a list of supportive studies or books to engage in further research. Through a majority of my IVF journey, I found myself growing frustrated when every source I turned to told me the same basic things over and over again. I already knew the basics; that wasn’t what I needed. I needed non-textbook answers, advanced knowledge, hard-won secrets—not generalized hand-holding. This book is for the “me”s out there. I’m assuming you already know the basics—you know your IUIs from your ICSIs (and if you don’t, you can look them up in the glossary). You want more information; you want quick, actionable advice you can take and use. You want the good stuff that is not disbursed over 33 blogs and 11 specialists. If something is moving too fast for you, take a break. Refer to the glossary and the further readings; look things up online. When you’re ready, you can come

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back. I’ll be here when you get there. It’s all here for the taking; all the knowledge you need to arm your arsenal is now at your fingertips. I had two beautiful little girls from a previous marriage. Nearing thirty-seven, with a five- and seven-year-old, I never dreamt of having another child. In fact, I did not want one. My two girls were beautiful, independent, amazing creatures who went to school in cute little uniforms and had their own budding lives. I was back at work and moving on from those first five years of motherhood where I felt like I could never catch my breath. Happily remarried, I was having sex every day, enjoying traveling again, and relishing a new phase of both adulthood and motherhood in an amazing, fulfilling relationship. On the other hand, my husband desperately wanted a baby. With me, his chosen bride. It was his first (and—I sincerely hope—only!) marriage, and he had no biological children. Eventually, my lack of desire for more children was replaced by a desire to create a life with the love of my own. So, we quietly started trying shortly after we tied the knot. We weren’t getting any younger, and although I still maintained reservations, the more we tried, the more I wanted to bring another little miracle into this world. It is a beautiful thing to create a life, whether it’s with that special someone or by going it alone, as many parents now choose. Though I harbored suspicions after several months of not being careful, I knew two months into officially “trying” that something wasn’t working just right. Historically, I had zero issue getting pregnant. My first daughter was an accident. My second happened on the first attempt. The miscarriage between the girls, and the one after my youngest was born, both happened on the first try. Sure, more than seven years had passed since I was last pregrant. But did that really matter? Was it me? Did I fall off the thirty-five-plus cliff? Was it him? He had never impregnated anyone before. Was it both of us? Which scenario would be worse? Unsure of what the issue was, we decided to get some answers (little cup, anyone?), starting with my husband. Some men get funny about

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testing their sperm. They erroneously correlate their manhood with the oddest of things, one of which is their sperm count and ability to reproduce “unassisted.” Fortunately, my husband is a bit more evolved on this front. However, the blow when those tests come back negatively is crushing for any man. And in our case, the tests soon revealed that we had male sperm factor issues. Did we have any other issues we were unaware of? Within days, we headed straight for a well-known fertility specialist, and within that very menstrual cycle, we moved right along with IUI (remember that all acronyms are in the glossary, so refer to it liberally). There was no fanfare or pussyfooting around. We wanted a baby together, and come hell or high water, we were going to make that happen. When IUI brought us no luck, we moved straight to IVF with ICSI. We went into it bright-eyed and bushy-tailed, positive and ready to go, just knowing we would have a baby any minute now. How naïve we were, to approach making a baby as we did our business lives—thinking that because we willed it so strongly and worked so hard, we could defy our infertility with our dedicated time, optimism, and checkbook. After over thirteen straight months of hormones, failures, and miscarriages—along with frozen transfers, fresh transfers, high doses, low doses, PGS testing, no PGS testing, many a consultation, and one doctor change—we finally got our little guy. How did we do it? We threw the kitchen sink at it. Then the bathroom sink. Then the whole damn house. Each cycle ripped me apart with anger, disappointment, resentment, and exhaustion. I know it did the same to my husband, who took it in the gut, hid it, and held me up as high and hard as he could. I refused to give up. And my husband refused to let me. It takes two, no matter what style of baby-making you have chosen. Each unsuccessful cycle must be treated as a lesson. It took me a few cycles to learn that. Hindsight is a bitch. You know the cliché, “I wish I knew then what I know now.” It’s a cliché for a reason. However, if you start armed with knowledge of your issues and your body, if you use your voice and question every procedure and protocol, you will optimize your

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success so you don’t lose years of your life trying to complete your family. I wish someone had told me to do the things I’m about to tell you. I would have been pregnant ages ago . . . and used the majority of the money spent on IVF for a long stay at the Four Seasons in an exotic babymoon location. (Or to further seed three kids’ college funds—either way.) But of course, better late than never. The following pages offer my humble advice, gathered from limping along a treacherous road that made no promises and held no mercy. You can be delusional. You can be naïve. You can be weak. You can weep. You can yell and scream. But you have to find pockets of hope, glimpses of strength, and forge ahead. IVF can—and will—destroy parts of you. Some of this destruction is temporary. And where it is not, you will control how you rebuild in a beautiful way. If someone had told me it would take almost a year and a half to be able to tell the world we were expecting, I am not sure I would have done IVF. If I knew the depths of depression I would have to traverse on the elephant doses of hormones, I may have further considered adoption. If I knew how it would ravage my mind and body, I may have decided to “just say no.” If I knew . . . But IVF is addictive. Hope is addictive. That vision of the little guy or gal we’d made together, pitter-pattering down the hall with our two older girls, was addictive. My year and a half could easily have turned into seven years, as it does for so many others. Do I regret IVF? Do I regret the emotional and physical duress? The miscarriages? The needles? Simply, no. Of course not. Looking at my little guy take in the world around him through those beautiful blue eyes, how could I? But that doesn’t mean the process was without its excessive trials and heavy tribulations. IVF is certainly not for the faint of heart. Each chapter will give you something we changed, or something new we tried, before ultimately making our last retrieval and transfer a success. I am not a medical practitioner. The advice in this book is in layman’s terms, based on my own personal experience and copious quantities of reading and research (smacked with that ever-elusive

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element of common sense). I will always wonder: if we had done this all the first time, would it have saved us over a year of hell? Yes! A million times, yes! Otherwise I would not be writing this “love letter” to you now. Just know that it is not the same for everyone. Some women are lucky on the first try, while others go on for years. Prepare yourself for some degree of trial and error, but also be ready to take control and make sure you give it all you have up front. Educate yourself. You are your own best advocate within your fertility treatment. Read this book! Read others, too. Take advice from everywhere. Talk to friends who more often than not will surprise you with their own stories. Unless you talk to people about IVF, you will never know who has done it or is going through the same. (It will be more people than you think!) You may be missing out on support that could be so incredibly invaluable to you along the way. Speak to many doctors. Look at protocols in different countries. Then filter, filter, filter. Above all, listen to your body, find your voice, and never stop asking questions! You will tell yourself more than anyone else can. I did not just take what my doctor said at face value after the third failure. I told him what I wanted. I asked why. We fought and disagreed, then forged a path forward—together. Your doctor is your partner, not your god. Luck is just one small part of success. You have to do the work. After much blood, sweat, and tears (literally), we got lucky. I hope you do, too. —K.S. P.S. One note about the language used in this book. Dabbling aside, I am a cisgender woman married to a cisgender man. But not all families look like ours—thankfully! How boring would that be? However, rather than do verbal backflips to try to keep this entire book gender-neutral: When I refer to women, I’m talking about the person who will provide the egg for and/or carry the baby. When I refer to men, I’m talking about the person who will provide the sperm for the baby, whether that’s a partner or a donor or anyone else.  

PART 1 Preparation: Diligence Is the Mother of Good Fortune  

CHAPTER

1:

Down the Rabbit Hole We Go

Some succeed because they are destined to, but most succeed because they are determined to. —Henry Van Dyke

So what is ART? IUI? IVF? ICSI?

A

RT (assisted reproductive technology, or treatment) essentially refers to all the glorious procedures used to address infertility. From IVF to ICSI, surrogacy to donor conception, ART covers the spectrum of possibilities utilized to assist in achieving a

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pregnancy. IUI (intrauterine insemination), IVF (in vitro fertilization), and ICSI (intracytoplasmic sperm injection) are all procedures that fall under ART. Enough acronyms for you? I am going to assume you know the basics. However, a quick recap is never a bad thing. (And please do continually refer to both the glossary and the further reading sections at the ends of each chapter.) IUI is what I like to think of as the pre-party cocktail to IVF. It’s light. It’s easy. But it sure as hell does not brace you for the hangover you will have from IVF. Basically, the sperm donor’s (whether that’s your partner or the educated, handsome man from the catalog) little swimmers are washed, separated from seminal fluid, and injected into the woman’s uterus approximately thirty-six hours after she is given a trigger shot. Commonly used for male factor issues, the purpose is to get that sperm up as close to the egg as possible, either just before or as it pops. The pros: IUI is less expensive, less invasive, and requires lower doses of hormone treatment. The cons: efficacy rates are low; it addresses only some male factor issues—and not well, at that—and the chance of multiples is higher, should it work. We will delve further into why I (and a growing consensus) think it’s an utter waste of time in Chapter 10. IVF is when a woman voluntarily ravages her body in order to ensure a little bundle of joy deprives her of sleep for the next five years. This starts on CD2 (I’ll help you out this time: cycle day 2) with a lovely hormone cocktail that will continue through to retrieval day (approximately CD17–19) and beyond, should she have the good fortune of conceiving. On retrieval day, the good doctor will transfer one or more two-, three-, five-, or six-day embryo(s) back into the uterus in hopes of successful implantation and eventual live birth. The variations (donated egg or retrieved egg, frozen embryo or fresh, genetically tested or not, and a number of others) abound. Heavy drug cycles, invasive procedures, and the hemorrhaging of your savings top the cons list

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on this one. Optimized success rates (if you have prepared your body beforehand) and the circumvention of a multitude of infertility factors at once are the obvious pros. IVF with ICSI is the process by which a single “vetted” sperm is injected into the egg in order to increase the odds of successful fertilization. While I philosophically tend toward “natural selection” and allowing the sperm to penetrate the egg on its own, I learned through that beloved trial and error that we needed ICSI. ICSI all but eradicates male factor issues, except in cases of heavy fragmentation, which requires complementary treatment (discussed in Chapter 3). Whether you start out with IUI or jump right into IVF, we all go into this process totally unprepared. Generally, participants are shellshocked and wounded from the news of being genetically imperfect and unable to procreate unassisted. In this less-than-optimal mindset, they attempt to formulate the right questions and traverse the fertility quagmire they have suddenly come upon. They head to a recommended doctor or the most “well-known” in their vicinity and do exactly as they are told. More often than not, some preliminary questions will be asked, some initial tests will be done, and the woman will be subscribed the general set of protocols that have proven successful for 60–80 percent of the doctor’s other patients at some point during their IVF sojourn. Perhaps there will be some slight deviation from the norm, but not invariably. The doctor, “sure” of his procedure, is instructing the patient, who is not sure about anything anymore. Cycle by cycle, failure after failure, that is usually when one finds their voice. Desperation, fear of yet another failure, and hopelessness are a powerful cocktail to turn up the volume in your voice box. Don’t wait for that.

The Industry and Business of Infertility Let’s confront the landscape of the hole you’re about to go down. So, you are one of the approximately one in six women facing fertility issues.1 Darling, you are not alone. Before we go through the blow-by-blow of

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immediate and required changes to your (previously) comfortable life, let us first review a few basics. The IVF industry is akin to big pharma. I say that because hundreds of millions of dollars are spent a year on IVF drugs alone. By 2022, it is estimated that in the US alone, $4.47 billion will be spent on IVF and IVF-related procedures.2 Many hundreds of millions more are estimated to be spent on the growing utilization of supplements and vitamins that can affect IVF. And by 2024, the overall global fertility services market is expected to reach over $40 billion.3 Ancillary to the basics, there is an additional market for sperm donors, egg donors, and surrogates. Then further afoot, there are the innovations (and all the money they may generate) such as mitochondrial donation and gene editing, which pair tech and medicine in a highly marketed tango. If this isn’t big business, I’m not sure what is. This industry also benefits from the nonexistent market cap on hope. When it comes to that dream of a new little baby, the Energizer Bunny in most of us will just keep going and going and going . . . until we, along with our egg supply and finances, collapse. IVF practice, protocols, and regulations may not have evolved much since its inception in 1977, but as fertility struggles rise, its practice and development are not going anywhere but up. What are the IVF “norms”? Let’s put the whole process in perspective and look at the averages: • Average number of tries it takes: 2.7. One study found that for women of all ages, success rates after three IVF cycles were between 34 percent and 42 percent.4 • Average age of the woman when she starts IVF: 35.3 years old in 2018.5 • Average cost per cycle: An oft-cited figure is $12,000 in the US, although most new research puts actual costs at around $23,000 in the US,6 around $6,300 in the UK (if it isn’t covered by the NHS),7 and $5,500 in Spain.8 (This often doesn’t include all medication and additional add-ons.)

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• Average total money spent: Typically $50,000 to upwards of $132,000, depending on number of cycles.9 • Average miscarriage rates during IVF: One study found that miscarriage rates in IVF were only slightly higher than for natural pregnancy. The study found 22 percent of IVF pregnancies miscarried. In contrast, natural pregnancies typically have a 15 to 20 percent chance of miscarriage.10 So, these are some of the stats tossed around. However, as with most data sets, there is always another set that confuses you even more. A UK comprehensive study showed the following:11 • Women had the tendency to stop IVF after three to four cycles. However, there is a 68.7 percent chance of pregnancy after nine cycles. (Nine cycles! You do the math on the money and heartache that will cost.) • After six cycles, the cumulative odds of pregnancy were 65.3 percent • Five IVF cycles took approximately two years Then, there are even more statistics on infertility itself: • 25 percent of couples have more than one factor contributing to their infertility12 • 40 percent of couples have male factor as part, if not all, of their infertility causes13 • 20 percent of infertility cases have no identifiable cause14 • 85–90 percent of infertility cases can be treated by conventional methods15 (proving that there absolutely is hope, especially when you educate yourself on all your options!)

Clinics and Doctors Specialists will often run their own clinics. The success of those clinics will be based on a variety of parameters and decisions that can skew

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the bottom line. For example, some clinics will “choose” their patients. Over forty with PCOS? No thanks. Twenty-eight with recurring miscarriages? You may not be an “ideal” candidate for this particular clinic. Though success rate metrics may vary clinic by clinic, the CDC publishes seven parameters that are further broken down by the usage of frozen and fresh eggs or embryos—still further, by donor or non-donor.16 It gets pretty confusing—so confusing, in fact, that you may find yourself seriously questioning the accuracy of stated success rates, given the endless variables. The Society for Assisted Reproductive Technology (SART) is an industry association of IVF clinics that can be referenced for general industry data. Even though the data are there, SART discourages using success rates to compare fertility clinics.17 Not only may clinics tend to cater to one particular profile, but results vary so greatly by individual circumstance and over several cycles. What you are left with are statistics derived heavily from a focused fertility situation. Know your own unique situation, and from there, ask about a clinic’s success rates and experience with your particular issue. Don’t let clinics choose you—you choose the clinic.

Decisions, Decisions, Decisions . . . You will need to make several key decisions as you traverse the world of infertility. This book is structured around those choices, which will need to be made (ad nauseam) throughout the process.

DO WE START DOWN THIS PATH? Once you do, there is no going back. There are only two ways it can end: baby or no baby. You can sit and overanalyze all you want, but you need to be prepared to go the distance, whatever your predetermined or yet-to-be-determined distance may be. If you’re not prepared, don’t start down the path. (And if you haven’t hashed and re-hashed all these

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key elements with your partner and agreed on a way forward, definitely don’t start!)

CAN WE AFFORD IT? I am assuming that if you are reading this book, one or two cycles is within your grasp financially, even if it’s a stretch. Still, take a long, hard look at the costs. Over 70 percent of women going through fertility treatments go into debt doing so.18 People mortgage their homes, take loans at absurd interest rates, and max out credit cards to make this happen. And they do it willingly and gladly, firmly ensconced in the belief they will take home a little bundle by the end of it. We did.

WHEN DO WE STOP? This depends largely on your visceral response to “Do we start down this path?” and your practical response to “Can we afford it?” We almost put a “walk away” number, which for sanity’s sake probably makes a ton of sense. If your answer is “I don’t know,” that’s okay. Reality will eventually set in, and “I don’t know” will likely turn into “I will stop when I have a baby, or no eggs left, or no access to additional funding.” Whatever your answer is, make sure you and your partner are crystal clear on all the implications and get comfortable with what you choose.

WHICH IVF CLINIC DO WE USE? HOW DO WE DECIDE? A good place to start is with recommendations—backed up by research and confirmed by lengthy consultations with multiple prospective doctors. The internet is a powerful tool for finding recommendations and doing your research. Use it. Keep in mind that for every woman who thinks her doctor is a fertility god in a white cloak, there is another who thinks he can’t tell a penis from a vagina. This is why it is so important to back up your decision with excessive due diligence and one-on-one time

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with your prospective doctors. If you have found your voice and done your reading before heading into that office (or are at least 80 percent there), you will know right away whether that doctor is right for you. How you choose your doctor should largely depend on their philosophy, their approach, and your rapport with them. Don’t choose a clinic or doctor because they are the most heavily advertised in the area. Start by doing your homework on the top three or four practices you have access to and find out which general methodologies they utilize. Once you know your issues (which you will largely uncover by educating yourself and undergoing some tests), you may find that you need to switch doctors because their process or experience isn’t necessarily complementary to your directives. This is par for the course. As you search for your ideal clinic and doctor, keep in mind that there is not much publicly available information that will go into the true details of clinic success rates, and even less that is of use to help you make a decision on what methodology is proprietarily important to use. It’s not like you can just price-compare on Amazon and look up clinics on Wikipedia. You actually need to go through the legwork of meeting the doctors and visiting the clinics one by one. It’s time-consuming but essential.

IS OUR DRUG PROTOCOL MILD OR AGGRESSIVE? We’ll cover this in Chapter 6. It depends on your particular problem set and your philosophy on this issue. Historically, best practice in the US prescribes higher amounts of drugs to produce a higher number of eggs per cycle, theoretically resulting in higher chances of pregnancy. (In comparison, European protocol generally involves milder stimulation, striving for an average egg yield of no more than fifteen.) But we have come to see it’s not that simple. Aggressive medication can often destroy the quality of your eggs. Bear that in mind as you think over the age-old quality-versus-quantity conundrum.

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DO WE TRY A FRESH OR FROZEN CYCLE? Yes and yes. Unless you are lucky on your first shot, you will likely try both. If you go for mild medication, thus avoiding OHSS, you can opt for fresh. Fresh means less trauma to the embryo, but it limits the diagnostic testing options. This limitation is not always a bad thing. We will discuss this further in Chapter 8.

DO WE TEST THE EMBRYOS? Our tested embryos never worked, so I am biased in favor of nature taking its course. That trauma to an embryo with five to eight cells (at three-day testing) or 200-plus cells (at five-day testing) can weaken an already-fragile chance at life. By the time we finished our threemonth stint of rehabilitating our bodies, we didn’t need testing. (Not to mention the crazy number of mosaic embryos discarded that may have fared just fine, thank you, due to their self-corrective mechanism. We will cover this in Chapter 8.) Frankly, in the endless quest to control this largely unpredictable process, we may just have reached a tipping point in pushing embryo testing as a necessity. Testing, moneymaker that it is, is not for everyone and should not be recommended so readily, as if to imply the potential consequences are negligible.

WHAT DAY DO WE TRANSFER THE EMBRYOS? Most doctors will prefer a day five blastocyst transfer in a frozen transfer cycle. Tested blastocysts are deemed the most viable, as they a) survived to blastocyst stage, b) were tested (and the one(s) being transferred are presumably normal), and c) survived thawing. Frozen cycles also allow the body to calm down hormonally from the previous cycle and retrieval. However, it’s just not that simple. What if you don’t want to test? What if your embryos are not doing so well and they are simply better in utero than “in petri”? Your doctor being on vacation is not a reason to opt for a certain transfer day over another. We will discuss later on what

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the differences are between day two, three, four, five, and six transfers. Ultimately, it will be your choice.

HOW MANY EMBRYOS DO WE PUT IN? WHAT DO WE DO IF WE HAVE MORE THAN ONE IMPLANT? One potato, two potato, three potato, four . . . After many variations and unsuccessful transfers, we stopped at three embryos, which resulted in our (one) son. I won’t bore you with stats on the minutiae of increased odds of conceiving with two or more embryos. Nor do I want to wholly dismiss the risk of multiples when transferring more than one. This is a definite conversation point that should be discussed with all involved. It comes down to multiple factors, not limited to how many children you want, how many children you can have (for medical, financial, and personal reasons), and how you would handle the outcome if all embryos “stuck.” Once a firm believer in eSETs, I changed my tune after a miscarriage with a perfectly tested embryo that had implanted. After that, to me, each embryo meant a shot at holding my son or daughter in my waiting arms. It meant potentially not going through another gut-wrenching cycle and heart-crushing loss. If you opt to transfer more than one embryo, prepare yourself for the possibility of multiples, and truly question what that may mean to your health and your general circumstances. Reductions carry their own risks. After a year of IVF, I was okay with the possibility of twins, but absolutely not triplets. Even those with closely held beliefs one way or the other (i.e., “I could never remove an embryo!”) may find themselves challenged when confronted with multiple miscarriages or a multiple pregnancy, so make sure to discuss it with your partner up front. There are many challenges and dilemmas in deciding how many embryos to transfer.19 Do your research and some soul-searching.

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HOW MANY CYCLES DO WE COMPLETE BEFORE TRYING SOMETHING MATERIALLY DIFFERENT? The hope is, by throwing all your weight at it up front, you don’t have to go through more than two to three cycles. You’re thinking, three cycles?! (I am laughing.) Yes. Three cycles is a blessing. If you can start your first cycle clear on what your protocol is and why it’s best for you, if you and your partner have optimized your bodies for this challenge, and if you have chosen a highly competent medical team that you have faith in, you already have a tremendous head start. Every cycle will color what you do on the next cycle should you have to continue. Go into it open-minded, willing to learn, and fervently hoping for the best!

DO I TAKE OFF WORK? DO I INFORM MY BOSS? My boss was an anomaly. I will forever be grateful to him in the most profound way. His wisdom and life experience (he disclosed to me his own experience with IVF) gave me the opportunity to keep working at my career at a less aggressive pace and not stop working on my family. Work saved me. My salary gave us cushioning and added to our savings. It was tough, but for me, it was worth it to do both. I know several couples who, after years of unsuccessful IVF cycles, decided that the mom-in-waiting would take off work as a last-ditch effort. All of these couples eventually conceived and largely attributed their success to finally “letting go.” That final elimination of stress (in addition to many other things that were tweaked and changed along the way, I’m sure) seemed to do the trick. If you choose to work during IVF, you need a supportive partner (or at least not a detracting one), or a great support system. We’ll touch on that some more in later chapters.

The Cost I bring up cost here, and in other chapters, because it is a consequencebearing (and, in some cases, mitigating) factor. Do not delude yourself.

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You will go far above the sticker price. This kind of expenditure causes additional worry at a sensitive time when any stress is the ultimate enemy. You need to analyze your finances before you even start this journey. Do we have the funds? For how many cycles? Where will the money come from if we run out and simply must continue? Do we even start if we can’t keep going? This, like all conversations around money, is such a personal topic. I hate talking about money, and, believe it or not, it took IVF for my husband and me to truly take stock of our finances and get used to communicating openly about them. It forced us to become better savers and far more aware of how lax we had been around expenditures. Looking back, we could not afford to jump on the IVF bandwagon with the naïve rigor with which we did. But we were older (thirty-seven and forty-five), we wanted a baby, and we were sure we would be successful the first (possibly second) time around. Neither of us is the type to not try, or to give up on anything we want, so the question of whether to begin was both moot and (on paper) irresponsible from the onset. I vaguely recall talk of one or two IUIs and one or two rounds of IVF, at a maximum. We had so much going on in our lives that required financial attention, albeit temporarily, that we knew we could not afford more without seriously jeopardizing ourselves and our family. In hindsight, I think we were in part unaware of—and voluntarily ignorant of—the potential financial consequences. Things did not quite work out the way we planned. Funny how that happens. One explosive night, I angrily told my husband we had to continue at all costs and that I hated him for giving up, and I would never forgive him if we didn’t find a way to continue. I largely blame the hormones for this one. Our one $15,000 cycle turned into nearly $120,000 by the time we were done, including all the extras outlined on the next page. And that’s just money, folks. We paid a hefty sum from the emotional wallet as well. It was a damn good thing we had a lot of savings on that front.

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Here is our breakdown: • • • • • • • •

IUI: $4,500 IVF: $56,000 IVF drugs: $7,500 Procedures (hysteroscopy, scratchings, PESA): $5,500 Blood Tests: around $10,000 Intralipids: $4,500 Vitamins: around $20,000 Therapy: $10,500 and counting (not covered by insurance, but much needed by the time I fell pregnant; in fact, I wish we’d done it sooner—more on that in Chapter 6)

Don’t let my costs discourage you. Your costs may be wildly different in either direction. You may live in a country or state that subsidizes IVF attempts or covers a certain number of cycles entirely—aren’t you lucky! Most are not as fortunate to have that allotment. Regardless, it’s difficult to be as realistic as one should be during a process predicated largely on hope. You can only prepare for the worst and hope for the best. The whole point of following the advice in this book is to minimize the probability of “the worst” happening and maximize the possibility of getting it right the first time.

Personal Implications and Some Things to Prepare For Despite warnings and wisdoms from the handful of close friends I knew were going through IVF, I was blindsided by the numerous impacts. For the first few months, my husband and I were living in a cloud of disbelief. As reality hit, the cracks started to show, and new cracks continued to form in ourselves and in our day-to-day dynamic as a couple. Then the dam broke. IVF is like a torrent of water—emotional quicksand— and it will nearly drown you no matter what you do. But you still try to stop it. Exhausting as it is, you find the strength. Hope against hope, you

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fight for it, surprising yourself along the way. After you are successful, holding that little love in your arms, you can rebuild and start anew. And that is what you need to keep telling yourself.

SEX First and foremost, there was an impact on our sex life. There is nothing less sexy than sex that becomes a perfunctory requirement. If this is not a big thing for you, as it becomes secondary for many couples during the quest for a baby, skip to the next section. I raise the topic of sex first because for me, this was a big deal. I loved the amount and quality of sex we had before we started on IVF. It was daily (at least once) and it was good. Sometimes it was just a morning quickie before work. Often it was hot shower sex. Then IVF changed everything. Instead, it was now in the evenings, longer and more purposeful. A gradual decline commenced after our first doctor visit, wherein we were told we had to abstain from sex for four days before another sperm sample, then another four days for the IUI sample, then . . . you get the idea. The memory of our doctor’s laugh still haunts me as I think back to him watching the horror pervade our faces when he told us for the first time that we couldn’t have sex for five days before the transfer. Five whole days was unfathomable. Hindsight makes me think he must have pitied us for what was to come. As it turned out, we weren’t waiting with bated breath until that fifth day came. By the time my husband gave the sample, he was flat-out stressed. Stressed by IVF. Stressed by the pressure of giving samples. Stressed we weren’t as intimate as usual. So that much-awaited fifth night was no showstopper. Our regular rhythm took a hit, to say the least. (It did not bounce back like a rubber band the way I’d hoped, and pregnancy only made it worse. However, after our little guy came, we got back into a rhythm that affirmed we still had the amazing chemistry I was once so scared we had lost.)

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Then the drugs hit me. If it was the one time, the one cycle, it would have been tenable. I felt haughty thinking of how a dear friend, who only had to undergo one cycle, lamented her plight. “What a wuss, to be traumatized by one cycle,” I thought. Well, by the time my third started, my monthly cycles were pretty horrific. Headaches, sleep issues, and constant moodiness are not the breeding grounds for spontaneous sex and multiple orgasms. In Chapter 11, we will talk about how to build this back, but it was a tough and unwelcome shift in our intimacy that was only exacerbated by everything else at play.

THE WORK VERSUS TOTAL FOCUS DILEMMA Work/life balance . . . what is that? Not everyone has the luxury of taking off work to do IVF. Perhaps more importantly, not everyone wants to. With all the worries and stressors of IVF, the welcome distraction of work can be a godsend. Plus, IVF is barely affordable in its own right, let alone when you subtract one income from a two-income household. Still, it does become a tricky question for many women going through IVF. Do you work during the process, or do you take time off to reduce stress and maximize your chances of shorter-term success? Or, after so many failures, do you stop work for a time to eliminate all stress? It will surely cross your mind at some point, and if you don’t bring it up when it does, you may become a tad resentful. (I did.) Leaving work was not even a consideration until we had nine months of IVF under our belts. At that point, we knew something was just not working, and the stress of work was substantial. For ages, I kept thinking that the stress of having less money would be more significant than any stress brought on by work. That is, of course, until we ran into friends who had been on the same trajectory as us. After not seeing results, the one thing they changed was work. She had stopped working to focus on getting pregnant—and she did. I had heard this story a few times before, and several times after. Do not discount it.

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This opened up a can of worms in my household. I never wanted to be a woman who didn’t work, who had no career, who made her children her life and had nothing outside of her home, who had to explain her spending proclivities to a single-earner spouse. So, the idea of walking away from my job to have a baby was a tough pill to swallow. How could I possibly step out of my career during these pivotal wealthbuilding years? We had two children—and ourselves!—to invest in and care for. On the flip side, I wasn’t sure how much more I could take. My unshakable confidence was in tatters and my (healthy) arrogance and joie de vivre had waned to near nonexistent. I was tired. Weary. Worn. When I finally managed to bring myself to verbalize the thought— and feeling more than slightly angry that my husband hadn’t “offered” it, given all I was going through—my husband was extremely supportive of my taking time off. (It’s true, men can’t read minds!) But I was afraid. I was afraid I wouldn’t get another job in the volatile market. In my industry (or any industry, for that matter) not many employers will hire someone who is already pregnant or someone in their late thirties with nearly two years missing from their CV. It may not be impossible, but it certainly isn’t the norm. In the end, after another horrific miscarriage, I decided to tell my boss I was going to stop working. I told him everything—the IVF, the miscarriages, the desperate quest to have a baby. Like a small ray of sunshine on a very dreary day, he told me to take the time I needed and come back part-time until I was ready to do more. I cannot tell you how fundamentally that helped reshape the stress conversation. He will never know how he single-handedly changed my path with his generosity and understanding. With that change in narrative—the stress gone, the question removed, and a new option given to me—I went back to work after two weeks, and that next cycle I got pregnant. (And my boss supported me the whole way through, now referring to my son as a happily finished “company project.”)

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YOUR SUPPORT GROUP Your support group cannot be one person, and it cannot be solely derived from the internet. I honestly did not give thought to a support group of any kind until my third transfer failed. Even then, the support group was not a concept even faintly familiar to my solitary mindset. But you can’t “do it all” without paying a price. You will need some roadside assistance on this route. My husband was my main support. Frankly, if you are in a partnership, your partner should be that main support for you. As hard as IVF is on the woman, it is difficult for the man, too—albeit in a different way. This is not always easy to comprehend day after day, needle after needle, retrieval after transfer, but it’s true. You knew getting into this process that it was heavily skewed to be entirely unfair to you, the woman. Pout in the corner and get over it. You two need each other. There is a tendency in most couples for one person to lean in to the other and the other to seek solitude at times of extreme stress. It was only at our (thankfully happy) end that I realized I should have leaned on my husband a lot more than I did. Closeness and communication will save your relationship during IVF. It helps to prevent thoughts of resentment and offers a safe harbor. It is certainly not possible to intuit how your partner feels and where you stand with each other every minute of every day, but you should both always be aware that your relationship is more important than the baby you want so badly. You must take care of each other and put in place a few recurring methods of bringing that to the forefront. You can try regular counseling, weekly touchpoints wherein you pointedly sit down and ask the other how they are doing (i.e., “checking in” with each other), plan biweekly dinners, and so on. It doesn’t have to take hours—it could be as little as twenty minutes—but it does need to be about prioritizing the other person and truly hearing each other, openly and honestly. Find something that works for you and make it a habit now, before it’s truly needed.

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While it’s important to maintain that closeness with your partner, there should still be a balance. Don’t shut the world out and hide in each other. Don’t put yourselves in a little boat and drift out to IVF sea; it exacerbates every ripple that occurs on the ocean of your love. My husband and I had been so social. We went out to and hosted dinners all the time and generally enjoyed engaging in society. Then IVF stole our spark. I shut down. He shut down. After each transfer, I didn’t want to see anyone until I knew if I was pregnant. Then not until I was at twelve weeks. After a miscarriage, it was at least a week before I wanted to speak to anyone at all. By the time we finally got pregnant and were past the danger zone, he was ready to move forward—and I resented him for leaving our cocoon before I was on the same page. It took me a while to recover. Be cognizant. In the end you may wind up with that love child, but with a partnership in tatters—that does not a happy family make. Partners aside, it’s always best to diversify. Complaining to your significant other is different from complaining to your friend. When you leave a dinner or lunch with your bestie, you both go back to your own private spaces and different worlds. When you have words with your spouse, the resulting dynamic usually lingers in the home, feeding easily into the next round of discord, and you both get little reprieve. Pick one or two people who are “your people.” Perhaps it’s your oldest friend, or your colleague who just went through IVF—but make sure at least one of them has gone through this process themselves. Maybe someone who is just an acquaintance becomes your IVF BFF. Maybe that person you connected with so deeply on an online forum becomes your WhatsApp buddy and your angel. Find them. Keep them close. Whoever you choose, make sure it’s someone you can be frank with. You don’t want to start every conversation with niceties, having to ask about work and kids. You just want to tell her your beta hCG is dropping and you are having another miscarriage. You want to tell her how depressed you are. You want to ask how many eggs she transferred last time. You want to know if she almost gave up and why she didn’t. You want to tell her

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that your husband is an utter moron for leaving you home in bed after a transfer, with a migraine, while he went out for tacos with people who barely register on your radar screen as nominally important. Find your people. They are essential to your mental well-being. The internet is one possible resource. It can be a rabbit hole, but a useful rabbit hole, nonetheless. Google is a great research tool, but also an addictively easy window into misinformation. There are some awesome sites and responsive IVF warriors out there to commiserate with and exchange upbeat support. However, online support groups have a tendency toward misguided information and false hopes, which are far more devastating in the long run. So, approach with caution. In-person support groups, on the other hand, can be a treasure trove. Ask your IVF clinic if they know of or are affiliated with any groups in your area. Compassion and a selfless ear go a long, long way on this lonely, lonely road. By this time, you may have decided that IVF is for you. All you can see is a chubby little face looking up at you and smiling in the not-toodistant future—and you will get there come hell or high water. You’ve asked and answered at least some of the major preliminary questions. You’ve addressed finances. You understand the effects IVF may have on your career or relationships. You have even armed yourself with a support group and new hobby. You are up for the challenge of fighting the good fight. As you continue through these chapters, keep going back to check yourself on all of these fundamentals; your choices may require some fine-tuning along the way. Now let’s get started!

RECAP 1. Familiarize yourself with ART. 2. Understand the array of decisions before you. 3. Assess the potential costs and your financial strategy.

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4. Get comfortable with the personal implications and have a rough notion of how to deal with them. 5. Carve out time with your partner to check in with each other and make it a habit. 6. Gather your people.

FURTHER ESSENTIAL READING 1. A comprehensive, holistic view of IVF from a renowned expert: Sher, Geoffrey, et al. In Vitro Fertilization: The A.R.T. of Making Babies (Assisted Reproductive Technology). New York: Skyhorse, 2013. 2. Looking at the natural side of how to maximize your fertility: David, Sami S., and Jill Blakeway. Making Babies: A Proven 3-Month Program for Maximum Fertility. New York: Little, Brown, 2009. 3. For a little humor and a little male perspective: Sedaka, Marc. What He Can Expect When She’s Not Expecting: How to Support Your Wife, Save Your Marriage, and Conquer Infertility! New York: Skyhorse, 2011. 4. Older, interesting read that explores the commerce of reproductive medicine as opposed to the science or personal implications: Spar, Debora L. “The Baby Business: How Markets Are Changing the Future of Birth.” Harvard Business School Press. 2006. 5. Society for Assisted Reproductive Technology: www.sart.org

CHAPTER

2:

The Chicken or the Egg?

You told me to go back to the beginning . . . so I have. —Inigo Montoya, The Princess Bride

I

t’s that age-old question—which came first? For our intents and purposes, the egg came first. In IVF, the egg always comes first. The quality of the egg will make or break a cycle. Let me save you time, money, and heartache: Your eggs can make all the difference. Commit yourself to that. Accept that your eggs are the foundation of the whole IVF process. Period. The uniting of an egg and a sperm, bearing twenty-three chromosomes each, should result in a forty-six-chromosome embryo. That’s forty-six chromosomes or bust, ladies. Fewer than that and we have

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aneuploidy on our hands, resulting in implantation failure, miscarriage, or birth defects. Approximately 90 percent of embryo chromosomal abnormalities (known as aneuploidy) derive from the egg rather than the sperm, thus resulting in an embryo that will be incompetent, if it even fertilizes at all. According to fertility expert Dr. Geoffrey Sher, “The most important variable that influences IVF outcome is ‘embryo competence.’ This is largely (but not exclusively) a function of the egg’s (rather than the fertilizing sperm’s) chromosomal integrity.”1 More than 70 percent of IVF failures and miscarriages are due to embryo aneuploidy.2 Nearly 90 percent of the embryos produced by women over forty-two are aneuploid.3 I know all of that sounds rather unsettling. But what if I told you that you can stop chromosomal abnormality in its tracks in about three months? That’s the time it takes for that little follicle you were born with to mature, and there are lots of ways you can make the most of that time by prepping your body for success. Three months might seem like ages to wait for something you wanted yesterday. That is, of course, until a year of IVF has gone by and you’re still no further upstream than where you started. Trust me, it’s worth it to start now and take back control of your fertility. Are you starting to feel better?

If I Could Turn Back Time . . . Unlike Cher, we age. What happens to our eggs as we get older, and what can we do to prevent “egg aging”? It was once considered a well-known fact that a woman is born with all the eggs she will ever have, and about half are lost by birth. While this may not be the whole story (which we will discuss in chapter 8), egg aging is definitely a thing. As puberty hits and menstruation begins, a bunch of follicles compete, but just one matures every month in order to produce a viable egg for the purposes of conception. It is commonly assumed that as we age, our egg quality declines. Statistically, the number of chromosomally abnormal eggs increases as we age, but why?

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Contrary to archaically held opinion, egg quality does not suddenly drop off a cliff the moment you hit thirty-five. As we age, our ability to optimize our ovarian environment degrades; it’s not dead, but it needs a little external help. The final stages of maturation of the follicle begin to take place approximately three months before ovulation. During this final period of meiosis (wherein the egg, once a single cell, has divided and divided . . . ) is when most chromosomal abnormalities will occur— and as such, this period is where we can influence the ultimate quality of our eggs. As with anything stuck in a long production line, meiosis is prone to errors. As the cells divide, an egg should end up with one copy of each chromosome for a total of twenty-three. That’s the woman’s half of what she brings to the table. If anything goes wrong in this process, we have chromosomal abnormalities. These increase significantly with age, primarily due to the decreasing ability to stave off oxidative stress in the reproductive system. The fabulous news? We actually have considerable control over lessening the effects of this aging process. Essentially, we need to recharge our egg’s batteries (the mitochondria) and create an environment with less oxidative stress (the imbalance between free radicals and antioxidants). As a woman ages, her body has a lower ability to combat the oxidative stresses that damage the mitochondria essential to healthy egg maturation. Without properly functioning mitochondria, your eggs are more likely to end up with chromosomal abnormalities. This is especially important in those three months before ovulation wherein the follicle is maturing, and it must be addressed through diet, supplements, and an entire clear-out of toxins from your household and lifestyle. This period before ovulation is also when high doses of fertility drugs can negatively affect egg quality, because they have taken over your natural hormone production capacity and shoved it into overdrive. So how do we kick off the next three months? Change your mindset and I’ll lend you my hindsight. Please do not be one of those people who jumps straight into IVF without preparing their body and their

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mind. The cost associated with that misstep is not just financial; it takes a tremendous toll on one’s health. This is all quite simple, but not necessarily easy.

The Lay of Your Land Would you go into a deal or negotiation without knowing your counterpart? No. You would conduct the required due diligence on the company, their balance sheets, and any personal aspects of the players involved. You would research and study, turning over every rock in the middle of a desert in order to succeed. You would fill your bag of tricks with enough information to turn the tables, should they turn on you. As the leader of a country, would you go into battle and invade enemy territory without knowing the terrain’s pitfalls and weak points? Clearly not. Why should IVF be any different from these other scenarios? Why would you go into it unprepared, not having primed your mind and body for success? You need to know the lay of your land. Remember, it’s not as simple as injections and retrievals and then comes a baby. There is no magic solution. You need to do the work to make IVF work for you. Thankfully, so much of it is within your control. Your wonderful doctor likely will not tell you that. In my experience, there were no holistic IVF clinics that really walked me through a personalized journey. To them, it is all about the results they can publish! They will not encourage you to read and research. They will not apply a personalized approach to this “deal” or “battle” you’re about to charge into. They have their tried and tested ways, and generally a deviation from their “norm” happens cycles down the line, when all else has failed. What they will do is prescribe an effective protocol to stimulate follicle growth in order to retrieve as many eggs as they can to produce viable embryos. But they will not tell you that the very drugs you take to multiply your eggs also have the potential to degrade them in the process. This is why it is vital to mitigate those risks by taking responsibility over every single factor within your control.

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What can you do to take charge? Whether you have a host of issues or none at all, you must tick every box you can to sway things in your favor. No egg is perfect. And if it’s your partner with the issue, overcompensate where you can. So, impatient or not, you first need to get those eggs into the best shape possible. Can you try IVF in the interim? Of course. I did, several times . . . unsuccessfully. First and foremost, you need to know your body. Know your cycle. What day of your cycle do you ovulate? Do you ovulate? What is your cervical fluid like throughout the month? For the many of us whose cycles don’t run like clockwork, there are ways to keep track of things down-under with apps, journals, basal temperature recording, and so on. To each their own. I used acupuncture for years and it kept my cycle regular. I knew when I ovulated according to my cervical mucus and ovulation pain, confirmed by my period arriving about fourteen days later. If you truly have no sense of your cycles and general reproductive health, Toni Weschler wrote a great book called Taking Charge of Your Fertility that runs through how to map your own body. Then you can lean on science to disclose the rest.

Blood Tests Blood is the starting point to quickly and painlessly get a baseline of what you’re working with. In Dubai, where we did IVF, blood tests can largely be ordered personally—directly from the lab, with no doctor needed. I acknowledge that in many countries this is either too expensive or not allowed. In this case, an initial consultation with your GP or gynecologist/urologist should suffice to get you started. Below are the most important blood tests to help you pinpoint what needs to be addressed. I am not adding indicative ranges for the simple reason that, as with many factors along your IVF journey, it just depends on your unique situation. Some tests will vary depending on where you are in your cycle, others on your age, and still others by medical factors. Labs have their own ranges. Doctors have their own

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interpretations. Read through your results with your fertility specialist or endocrinologist—or both! (I’m partial to second and third opinions.) But if, like me, you wind up initially doing most of this on your own, there are plenty of online resources to which you can refer. While I will list only tests that merit strong consideration, a few are more important than others. The big ones to keep your eyes on are AFC, AMH, Estradiol, FSH, food intolerance testing, LAD, LH, progesterone, and TSH. These are the most crucial tests, but as everyone is different, make sure you lay out what your known issues are and rule out all that you possibly can right from the start. 17-OHP: This test screens for adult onset congenital adrenal hyperplasia when PCOS is suspected but not confirmed. AFC: Done by ultrasound alongside your AMH, this test will paint a pretty picture of your ovarian reserve. High AFC will indicate a good response to IVF. AMH: Whether you have the ovaries of a twenty-five-year-old or a forty-five-year-old, you need to address egg quantity, as it may affect your protocol. Super high levels of AMH may indicate PCOS. Go get that AMH test and check your reserve so you know what you’re dealing with. The AFC and AMH should be interpreted together during the follicular period. ANA: Screens for autoimmune disorders by detecting the presence of antinuclear antibodies (produced by the immune system) that attack components of the patient’s own cells. Cytokine ratio (Th1, Th2): High levels of Th1- or Th2-type immune cells are associated with reduced egg quality, implantation failure, and miscarriage. Estradiol: Done alongside FSH, this test establishes a baseline of ovarian reserve. “Free” T3/T4: These hormones are related to thyroid function. Thyroid imbalance with affect your menstrual cycle and overall fertility as a result.

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FSH: This test measures the hormone that stimulates the growth and maturation of the ovarian follicle. As with most things, we want balance. A low result may indicate PCOS, while high levels can indicate low egg reserve and may be an indicator of poor pregnancy outcome. It is important to know where you stand. This test is usually done on CD3. HLA-DQ Alpha testing: Determines which DQ Alpha markers your cells carry. Both you and your partner should be tested. When similar markers are carried, there is an increased chance that the embryo may carry identical markers to the mother, resulting in an increased rate of implantation failure and/or miscarriage. This can be due to an increased immune response that may become more aggressive with each successive attempt. Inflammation/Dietary testing: I can’t stress this enough. Find out what foods you may be allergic to, but more importantly, what your intolerances are. Keep in mind, allergies and intolerances are two very different things. Food intolerances cause inflammation, which is the breeding ground of disease, and it wrecks your chances of conception. Excess inflammation causes imbalance in the body that is heavily associated with implantation failure and miscarriage. Inflammation will also disrupt hormones and endometrial lining, and it can potentially increase NK cells in the womb. Inhibin B: Low levels of this protein have been associated with a poor response to gonadotropins. Insulin resistance: An insulin resistance test to diagnose PCOS is usually done by direct infusion of glucose or insulin, fasting glucose levels, or insulin sensitivity tests. Karyotype analysis: This is a genetic test that is used to determine if either parent is presenting with any chromosomal abnormalities that could be causing repeated implantation or pregnancy failures. If any test has to be skipped, this would be the one—but if you have been experiencing infertility issues for some time, it does rule out a variety of issues that could dictate a very different IVF protocol.

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LAC and ACL: Lupus anticoagulant testing looks at how long the blood takes to clot. Anticardiolipin antibodies will show a predisposition for blood clots. These are often tested if there is a history of recurrent miscarriage and if an autoimmune disorder is indicated. Leukocyte Antibody Detection (LAD): This will test for the antibodies that a woman must produce in order to prevent her body from attacking the embryo. The father’s blood should also be tested. It measures the levels of blocking antibodies in the prospective mother’s blood against samples of white cells from the prospective father. Low levels of blocking antibodies are associated with higher rates of miscarriage and implantation failure. The treatment options are limited and include a white blood cell transfusion (from your partner or a donor) to help maintain a pregnancy. LH: This is the hormone responsible for triggering ovulation. Again, we want balance: not too low, not too high. This test is usually done on CD3. MTHFR gene mutation: These mutations severely affect 1 in 4 people and mildly affect 1 in 2 people. Those with certain mutations have a 40 to 60 percent decreased ability to produce methylfolate.4 These mutations not only inhibit the absorption of folic acid (so you must ensure your vitamins contain folate), but are generally bad for hormone levels and detoxification. One particular mutation also contributes to elevated homocysteine levels, resulting in recurrent pregnancy loss, preeclampsia infertility, Down syndrome, and other problems. PRL: High prolactin levels can affect ovulation and indicate fertility issues in general. Progesterone: This test measures ovarian function and is usually done a week before menstruation to assess for ovulation. Thrombophilia: Thrombophilia (known as “sticky blood conditions”) can be inherited or acquired. They can cause problems in maintaining an adequate blood supply to the uterine lining and to the growing placenta, which results in increased rates of implantation failure and miscarriage.

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TSH: Elevated levels of thyroid stimulating hormones can be directly correlated to recurring implantation failure and early pregnancy loss. If TSH levels are too high, this can also indicate hypothyroidism. Vitamin D: This test isn’t conclusive, but higher levels of vitamin D have been linked with higher pregnancy rates and prevention of miscarriage. Vitamin D is also key for women with PCOS. Studies have shown women with PCOS who were deficient in vitamin D were 40 percent less likely to get pregnant.5 When tests reveal an autoimmune function disorder, there are several measures your doctor may use to mitigate or treat the situation, including but not limited to intralipids or IVIg infusions, corticosteroids, Clexane, progesterone, Metformin, vitamins, antibiotics, and Lymphocyte Immune Therapy (LIT).

The Not-So-Nice Tests There a few additional tests that are more invasive and involved than blood work but are, in some cases, necessary. Natural Killer Cells: Also known as NK cells, they are a type of lymphocyte that keep tumors and viruses away. You need them. But you don’t need them to attack your frail fetus. Uterine NK cells are meant to protect the developing fetus. However, if there is any inflammation or infection in the area, the seas of uterine NK cells part and the NK cells from the bloodstream attack, resulting in recurring failures in implantation and pregnancy. This test assesses your reaction. Unfortunately, it’s not a blood test; it’s a biopsy, which is invasive but not painful. Do not bother doing what I did and self-order this as a blood test in a lab (I ordered the wrong kind of expensive NK test). Having said that, you can also take an NK Cell Cytoxicity assay (a blood test) before rushing off to biopsy. If you have endometriosis, PCOS, or any autoimmune disease which causes inflammation, NK cells can be of particular concern. Treatments range from natural remedies to steroids to intralipids. I wound up doing intralipids without the biopsy for no other reason

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than intralipids were not invasive and I have PCOS. In desperation, I figured it couldn’t hurt, and it didn’t. On the cycles wherein I used intralipids, I did conceive. HyCoSy (Hysterosalpingo-Contrast Sonography): What is going on with your fallopian tubes? This screening test involves contrast being injected into the uterus in order to see if it flows freely through your tubes. Blocked tubes are a common cause of infertility. It also examines the uterus, endometrial cavity, and pelvis. This test is often done as part of the investigative process, usually after your period has finished and before you ovulate again. This test is often deemed less important if you have previously given birth. Hysteroscopy: This is basically an inspection of your uterus. It will identify adhesions, polyps, and any abnormalities that might be preventing implantation or affecting your chances of a successful pregnancy, while allowing for simultaneous treatment in some cases. This may be slightly painful and may require general anesthesia, depending on the specific purpose of the hysteroscopy. Right before my first successful implantation, I had a hysteroscopy, which identified and removed scarring on part of my uterus (from previous C-sections, though scarring can also be caused by previous D&Cs and terminations). My doctor actually gave me a video of my hysteroscopy that showed the adhesions being burned away. Laparoscopy: A diagnostic procedure now largely reserved for actual corrective surgery of scars, endometriosis, tubal issues, or other abnormalities. The aforementioned diagnostic procedures are used to assess issues and often result in the choice of IVF over corrective surgery. Once these tests are done, you will have a first-pass understanding of the lay of your land. You will know what your issues are (or could be) and how to tackle them head-on. Alongside the other advice given in this chapter, basic knowledge of your health will drastically optimize your chances of success because you can personalize your journey. Some infertility challenges will require a change in drug protocols and a

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host of other factors. Don’t waste precious time on cycle after cycle. Get your baseline. Know where you stand. Are the tests expensive? Yes. And so are multiple cycles of IVF.

Categories of Female Issues That Contribute to Infertility You’ve taken your tests. Now you need to take a look at your own physiology and rule out, or create an attack plan for, the following: • PCOS is a very common cause of female infertility wherein a woman produces more androgens (male hormones) than normal, often resulting in ovulation issues. One in 10 women suffer from PCOS.6 One study found that more than onethird of women diagnosed with PCOS had seen three or more doctors over two years to arrive at that diagnosis.7 For me, diagnosis took about fifteen years! I was told long ago that one of my ovaries may be “slightly polycystic” and no doctor had said much differently in the ensuing years. When I was thirty-seven, my fertility doctor laughed at this and officially diagnosed me with PCOS. Note that dietary changes can vastly improve PCOS. • Endometriosis occurs when cells normally inside the uterus are found outside the uterus, often causing adhesions and obstructions. Endometriosis can cause a host of complications for ovulation and implantation. It can also wreak havoc on your emotions, hormones, and sex life. As with PCOS, dietary changes can also vastly improve endometriosis. • POI is a condition in which a woman’s ovaries have basically stopped producing hormones and eggs before age forty. • Uterine fibroids can change the shape of the uterus or position of the cervix, can cause blockages in the fallopian tubes, and can prevent blood flow to the uterus, all of which affect implantation.

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• Autoimmune disorders like Hashimoto’s, thyroiditis, lupus, alopecia areata, vitiligo, multiple sclerosis, pernicious anemia, and celiac disease involve inflammation and cause the body to attack cells it would otherwise leave in peace. A fertility specialist will be able to address these unwelcome stumbling blocks through various ART procedures and drug protocols that are personalized for you. However, you will already be miles and miles ahead of the game if you take action now to address your lifestyle, diet, and supplemental needs.

Egg-Friendly Foods What foods make your eggs strong and your body the perfect producer and incubator? Do you really need to cut out carbs? Is a high-protein diet best? To address egg quality, you must address diet and nutrients first and foremost. The ideal diet is jam-packed with protein. I repeat: Jam. Packed. Low sugar, low carb, no processed foods. Full of proteins. Everything you put in your mouth should be building those eggs. This is not about your pleasure or “life balance.” It is not remotely enjoyable. It is about getting that elusive BFP. Consider it a short-term sacrifice for a life-changing gift. First things first: Make sure everything in your grocery cart is organic. Everything. Pesticides hit us from every angle. Hormones from nonorganic meats and dairy are toxic and entirely throw off your own hormonal balance. Get every toxin out of your body. There is no denying that organic foods are more expensive. However, using this as an excuse is a short-sighted and penny-wise but pound-foolish trap when it comes to IVF. Just keep the end goal in mind and hit it with all you have for (hopefully) as short a time as possible. Sugar. Do I have to say it? Don’t. Just don’t. Honey and naturally occurring fruit sugars are fine in moderation, but processed sugar is a

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hormone-disrupting drag. It can affect insulin levels, weight gain, and immunity. A 2018 study found that even a single soda every day can have a negative effect on fertility.8 And those “healthy” juices are just sugar-loaded traps. Is it worth it? The short answer is no. Dried fruit, sports drinks, pasta sauces, cereals, salad dressings, nondairy milk, crackers, gummy vitamins, protein powders, energy bars, jam . . . these are just some of the unsuspecting places where sugar lurks. To build your eggs, you want to choose an organic diet high in omega-3 and omega-6 fatty acids, protein, and antioxidants. Zita West wrote a great book on this called The IVF Diet. Read it. Sticking to fruits, vegetables, lean meats, fish low in mercury, and unprocessed foods will cover all your bases. Spinach, broccoli, flaxseed, pumpkin seeds, walnuts, full-fat foods, lentils, beans, oats, organic chicken . . . this is what you stick to, coupled with at least two liters of water per day. Given my (previously unknown) food intolerances, I also avoided gluten, eggs, dairy, wheat, and yeast. There are also many foods that help to boost levels of serotonin (the feel-good hormone) by providing the amino acid (tryptophan) required to produce it. Walnuts, bananas, tomatoes, cheese, eggs, seafood—when taken with the right complex carbs to ensure proper processing by the body, these will all do the trick.9 Serotonin will help lower anxiety and depression, something to be aware of as you progress down this path.

Inflammation and Food I would never have thought that inflammation was a potential culprit in my fertility struggles. I felt fine. I ate well; I exercised. Inflammation, food intolerances—those were other people’s problems. The thing about inflammation is not only that it is largely silent, but that most of us subject our bodies to foods and products that may cause low levels of inflammation on a daily basis. Until you have reason to dig deeper (such as your fertility struggle), you often have zero idea that your body has been affected.

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After a horrific failed transfer that resulted in the worst bleed I had ever experienced, I gleaned a vital pearl of wisdom while madly messaging a fellow IVF warrior for support. She told me that food intolerances—not food allergies, but food intolerances—are the breeding ground for inflammation. Who knew? Inflammation is essentially the immune system signaling that there is a need within the body to heal or defend. When you are intolerant to a food, it causes inflammation in the body, and this inflammation not only contributes to disease (there is endless reading to be done on this!), but more pertinently (at this juncture) affects implantation, hormones, and the ability to stay pregnant. Sugars, trans fats, certain vegetable and seed oils, refined carbs, alcohol, and processed meat are common inflammation-inducing foods.10 After learning about this from my friend, I left my office and hightailed it over to a nearby lab for an overpriced blood test to see for myself. (In Dubai, where I did my treatments, labs are different than in the US. You can walk in and, for better or worse, order just about any test and be left to your own devices on their interpretation.) When the results came back, I was a fair bit surprised. Very few intolerances came up, except for my main staples! Egg whites (I eat about four eggs a day, more than a few times a week), gluten, dairy of all types (No more Greek yogurt with honey and milled flax! No cheese!), oats . . . I nearly cried. What the hell else was this “path of growth” going to take from me? It had wrecked my energy, my emotional balance, my sex life, and now it was taking my unpasteurized brie truffé? I drove myself to the local organic shop and sadly purchased every yeast-free, egg-free, taste-free thing I could find. Lentil pasta, black rice, lean meats, and an over-consumption of nuts and seeds were my new normal. Sighing as I passed the heavenly-smelling bread section, I entirely gave myself over to the process. I was thankful I lived in a city with amazing Lebanese food at every turn and discovered the endless joy of grilled meats and unearthly amounts of hummus. Although it was painful, the dietary changes paid off. Within days,

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my constitution was regular and honey-colored. I had more energy and less water retention. I ate copious amounts of high-fat nuts, seeds, avocados, and lean meats but did not put on a pound. Overall, I felt leaner, more balanced, and less “inflamed.” I followed this diet without one cheat day for just under three months before I did my successful egg retrieval (and to be clear— “successful” has a name, and his name is Axl). I remained on it through the transfer and up to ten weeks gestation. At ten weeks I went back to eggs and yogurt to ensure a proper pregnancy diet but largely tried to stay gluten-free. I personally felt that the nutrients in a wider variety of food was better for the little guy growing inside of me than avoiding a bit of potential inflammation caused by dairy. Please only stop your IVFboosting diet after ten to twelve weeks, when you’re off to the races and comfortably nearing that second trimester. That being said, I do intend to go back to a stricter keto-type regimen right after breastfeeding.

Caffeine “They” say to stay away from caffeine. Caffeine is linked to implantation failure and miscarriages. For once, “they” are right. Newer studies have come out to say that under 200mg per day is fine.11 If your small cup of brewed Starbucks (containing 250mg of caffeine) is so essential to your life, what can I say? I say, stay away! It’s not impossible. I did it, and I was a four-coffees-a-day gal for almost twenty years. Stay away from caffeine. Give your body a break and a chance to reboot. A Danish study found that drinking five or more cups of coffee per day decreased chances of successful IVF by up to 50 percent.12 Who is to say where that tipping point is for you? And remember, caffeine is not limited to coffee. We are talking chocolate, teas, sugary soft drinks—anything else that has caffeine is off the table, too. Fortunately, many of the things you need to stay away from are crossovers from other food groups (alcohol, sugar, processed foods and cookies, and so on), so your elimination list shouldn’t be endless.

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At first, I drank coffee every cycle. I cut back but did not stop entirely. The transfer in which I finally conceived and did not miscarry was the only one wherein I drank not a drop of coffee for three months preceding retrieval and until ten weeks gestation. Thereafter, I had one tall Starbucks a day (one-quarter brewed, three-quarters hot water). Yes, it was tough. Yes, it made work harder and the days longer. I fell asleep every night well before 9 p.m. until about fourteen weeks gestation. But I also got and stayed pregnant. With my previous births, I drank coffee from day one through the last, but IVF pregnancies are different. Never, ever forget this.

Alcohol A very wise acupuncturist who had treated me for seven years for irregular periods kept telling me not to drink. Not even my beloved red wine. Not even a little. Her specialty was acupuncture for IVF, and she was famous where we lived. Over 90 percent of her clients conceived. She had done IVF herself and knew every doctor in our city, every protocol, and every wives’ tale versus what would actually help. Still, I ignored her for nine months. How could a glass of red wine a day hurt? Didn’t “blue zone” centenarians imbibe daily? Even my doctor (and my friend’s doctor, and that woman on that forum site . . . ) said it was fine. As it turned out, for me, wine was not fine. For starters, sugar kills your eggs. And it’s a main culprit in alcohol. Whether it’s wine or spirits, they all alter your hormones and affect egg and lining quality. Some studies suggest wine may be helpful for women with PCOS thanks to the effects of resveratrol on insulin levels,13 and other studies conclude there are no discernible effects on fertility if consumption is kept at a minimum.14 For this woman with PCOS, neither was the case. Again, it took me nine months to glean a little clarity. Nine desperate months. But finally, I decided to give up the last of my (arguable) vices, and both my husband and I cut out all alcohol. Two

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months later, we harvested the first set of eggs that yielded the first successful implantation. Unfortunately, it miscarried before we heard the heartbeat. I had been too impatient to wait the full three months (I was scared to stop IVF; afraid if I rested a month I would go crazy just waiting, wasting time, feeling I was not actively trying; and even more afraid that if I did stop I wouldn’t start again), but I knew the diet helped and I knew we were onto something. The next transfer was a success. Many people stop drinking full stop when trying to get pregnant for fear of drinking once conception has occurred. When on the IVF path, this is a solid choice from the start, given that alcohol will affect the egg and sperm health you so desperately need to be top-tier. However, for the record, I find nothing wrong with a small glass (5 ounces) of red wine a few times a week during established pregnancy (after twelve weeks). Maybe I lived in Spain for too many years, where a little red wine during pregnancy is hardly glanced at. While there are numerous studies to support this, there are equivalent studies that condemn alcohol consumption in its entirety. This remains a very personal choice. Regardless, during the egg-growing months and until you harvest, alcohol of any kind is a no-no. Then feel free to enjoy a glass of your personal favorite before transfer and after—within reason—if you choose. The effects of stress are far worse than an earthy glass of Vega Sicila Único 2004.

Vitamins For the love of Joe, take your vitamins. I had us both on a regimen that would bring a man to tears (it did mine). I go through this in greater detail in Chapter 4, but I cannot emphasize enough the necessity and the difference it made. Don’t read the stupid one-off article that says vitamins do nothing. Yes, fresh food is your first point of attack, but do not discredit supplements. For eggs, they will help support the energy required to stave off abnormalities.

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As we age, our bodies simply slow down and become less efficient at warding off disease and toxins. A stressful lifestyle also depletes our much-needed nutrients. Because of these factors, the antioxidant environment required for optimal egg maturation is compromised. Supplementation rich with vitamins, minerals, and macronutrients will repair and regenerate your body in order to take on the additional physical stresses of IVF. Your body obviously needs a little external help to make this baby happen or you wouldn’t be reading this book. Supplements will be an integral contributor to that success.

Phthalates, Toxins, and Basically All Your Cosmetic and Beauty Products Read the ingredients on everything in your home. Can you pronounce half of them? If not, toss it. Phthalates, bisphenols (like BPA), toxins, anything with flame retardants (PFRs)15—they are all endocrine disruptors and they will all affect egg quality and implantation. Not to mention, they will impede sperm quality and quantity. The good news is that these toxins don’t stay in your system for very long, so the faster you discard them, the better. These endocrine disrupters essentially mimic estrogen. Excessive estrogen fuels infertility; contributes to a higher risk of cancer, heart attack, and stroke; leads to increased depression in women; and, if that wasn’t bad enough, causes oxidative stress on your fragile eggs. Oxidative stress occurs when a cell produces more free radicals than it can handle. The body will then require additional antioxidants to stave off this state. Oxidative stress is a direct contributor to age-related decline in egg quality and the ever-elusive “unexplained infertility.” From a very practical standpoint, you want to eliminate all plastics (water bottles, microwave-safe Tupperware, plastic bags, even containers labeled with a 7 in the recycling icon); highly processed foods (yes, that means fast food and, shockingly, microwave popcorn—my go-to

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low-calorie filler); and all perfumes, cosmetics, air fresheners, scented candles, and cleaning products containing phthalates. In general, you’ll want to swap to phthalate-, BPA-, and paraben-free items. Also be aware of glyphosate (found in pesticides) and triclosan (found in deodorants, first aid creams, toothpaste, antibacterial soap, and mouthwash). Go to ewg.org to find out which brands use triclosan. In her amazing book It Starts with the Egg,16 Rebecca Fett lists ten other toxins to be aware of: Dioxin (choose low-fat foods and avoid butter) Atrazine (use organic foods and filter your water) Perchlorate (mitigated through iodine) Lead and arsenic (use a water filter) Mercury (watch your fish intake) Perfluorinated chemicals (use stainless steel pans or those labeled as being free of PFOA and PTFE) • Pesticides (buy organic) • Glycol ethers (found in cleaning products) • Quaternary ammonium compounds (used in disinfectants) • • • • • •

There are thousands of products with these toxins, so do your homework and read all your labels. Even products labeled natural or organic should be researched and given a second look-over. Not all plastics are created equal, especially against heat. Opt for glass and stainless steel where you can. If we look at the trends, phthalates and bisphenols are being banned in countries around the world to varying degrees. Certainly, consumers are more aware of the negative effects on fertility and overall health, and companies are responding accordingly. In one week, I replaced my entire skin care and hair care regimens. I changed my entire meal plan. I banned plastic from my sight. (I also did this for my husband, or “did this to him,” if you ask his opinion.) Just over three months later, IVF finally worked for me.

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Exercise I will keep this section shorter than your workout. If you were running marathons before IVF, great—keep running, within reason. If you were not running marathons before, don’t start now. Exercise should be moderate and low impact. Get your blood flowing a bit every day, even if it’s just twenty minutes. It’s good not only for your BMI, but also for your stress levels (which take a real beating during IVF). A walk, a swim, or some yoga are all great ways to stay in shape. I highly recommend and adore Tracy Anderson’s workouts, which you can stream right from her website. An avid disciple beforehand, I started on her pregnancy series the second I hit ten weeks. That woman keeps your arms and butt tight like no other. I also bought a rowing machine for good measure. More than my vanity, exercise helped my mind. Every day I turned on a video or dragged myself to the gym—or did any form of exercise—I felt like I had accomplished something. It got my blood flowing. I felt empowered. As long as I was focusing on the rhythm of the movements, or picturing how my exercise would help me bounce back after delivery, that meant I wasn’t focusing on transfers or miscarriages. I was motivated by positive progress, and it was just what I needed. In terms of mental health, exercise causes the body to release endorphins (hello, serotonin!), which elevates the mood and clears the cobwebs of the mind. This makes a tough breeding ground for stress and depression. Highly stressed women are up to 40 percent less likely to conceive.17 So, try to find an hour for that burst of energy. It doesn’t have to be at the gym, or even a full-on workout every day. A thorough house organizing, a shopping spree at your favorite “guilty pleasure” store (or the grocery store), a walk through the park with the dog and your tunes, or a jaunt around your office yelling at people you don’t like will do just fine. Do something outdoors for a little added vitamin D— of course, ensuring your sunscreen is IVF-friendly!

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Bear in mind that after retrieval, leading up to transfers, at the twoweek wait mark, and up to twelve weeks gestation (when you get that BFP, and you will!), you will be required to take it easy. And you’ll want to. IVF is grueling on the mind, body, soul, and spirit. Listen to your body. Don’t push it too hard, but do push it just a little.

Three Months Approximately ninety days, 2,160 hours, or 7,776,000 seconds. That is all it takes to turn your ship around. Change is not always enjoyable, but it is often necessary. Commit yourself to your child before he or she is even conceived. That little follicle growing inside of you needs all the help it can get. You have this well in hand!

RECAP 1. Go to the doctor or lab with your blood test checklist. 2. Make a shopping list for toxin-free groceries, personal care products, and vitamins. 3. Take your vitamins! 4. Rid your body and household of toxins. 5. Get on an exercise schedule of some kind and shake it up between the rowing machine and the grocery store. 6. Remember that IVF pregnancies are different from natural pregnancies. Approach it this way and give yourself the best shot possible.

FURTHER ESSENTIAL READING 1. Awesome book on all things egg: Fett, Rebecca. It Starts with the Egg: How the Science of Egg Quality Can Help You Get Pregnant Naturally, Prevent Miscarriage, and Improve Your Odds in IVF. 2nd ed. New York: Franklin Fox, 2019.

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2. Thoroughly excellent book all-around, but specifically check out Chapter 13 for egg-related advice: Katkin, Elizabeth. Conceivability: What I Learned Exploring the Frontiers of Fertility. New York: Simon and Schuster, 2018. 3. Immunology tests explained: www.infertilitylab.com/immunological-testing 4. Excellent resource for those with PCOS: www.smartfertilitychoices.com 5. Read more about your nutritional requirements: West, Zita. The IVF Diet: The Plan to Support IVF Treatment and Help Couples Conceive. London: Vermilion, 2016.  

CHAPTER

3:

Great White Whales (Sperm)

A foolish consistency is the hobgoblin of little minds. —Ralph Waldo Emerson

M

en, let’s shake things up a bit and give you a brand-new to-do list. This section is written specifically to you and for you. By all means be thorough and read the whole book, but at a minimum, read these next few pages while you’re on the throne. So, your little swimmers aren’t swimming. You have defragmented sperm. The count is so low the lab technician had to search that puny dish for five minutes. Some of those guys had two heads and were dancing in the wrong direction.

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On average, over the past ten years, sperm count and quality have been in significant global decline.1 One study found a 52.4 percent decline in sperm concentration and a 59.3 percent decline in total sperm count in western men from Europe, New Zealand, North America, and Australia.2 This can be attributed to any number of factors, from the proliferation of STDs to the usage of gender-bending plastics for just about everything. Gender-bending chemicals are essentially manmade chemicals that mimic estrogen, cause estrogenic activity in the body, and negatively affect hormone balance. It can greatly affect your fertility, specifically your sperm count and quality. If you aren’t too worried about this for yourself, consider that unborn baby boys are at risk of developing cancer or infertility in later life due to exposure to these chemicals in utero.3 However you slice it, there is an undoubted link between male (and female) fertility issues and environmental chemicals. Regard plastics as you would smoking and excessive drinking— completely off limits to you before, during, and after trying to conceive. Unhealthy lifestyle choices, poor diet, and lack of general awareness around the poisons of plastics affect those fragile little sperm far more than we have previously allowed for. (More on these lifestyle factors later in this chapter.) According to the National Institutes of Health, “Males are found to be solely responsible for 20–30 percent of infertility cases and contribute to 50 percent of cases overall.”4 However, this number does not accurately represent all regions of the world, nor can we believe these are completely accurate statistics around male fertility. After all, it’s not often the man running to the specialist to shoot his little guys into a cup and be poked and prodded. Data on male infertility is usually captured alongside the female infertility inquisition. What we do know is that male sperm count and motility have declined significantly over the last fifty years and continue to do so.5 However, with the statistics being somewhat uncertain and open to interpretation due to the myriad of variables involved, it’s absolutely crucial that you take the time to do

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your homework and have your tests done. You need a high-resolution picture of exactly where your fertility issues lie, and this chapter will help you get started. While about 90 percent of any anomalies with the embryo are attributed to the egg, there is no question that healthy sperm play a vital role in fertilization. Thanks to the advent of technological and medical advances within the ART world, we now have the perfect tool to combat moderate to severe male factor issues: ICSI, in which the “chosen one”—your single most viable little swimmer—will be injected straight into a (hopefully well-prepared) egg. And voilà! Baby time. The thing about ICSI is that while it absolutely guarantees that the sperm penetrates the egg (because the embryologist does this), it does not guarantee fertilization. Essentially, it circumvents motility and penetration issues, but the sperm still has to be in tip-top shape before its emergence into the world. The embryologist will assess the sperm under a microscope, literally assessing via sight. Imagine the technical expertise required in this selection! The embryologist will look at head and tail dimensions, shape, movement, and overall appearance. And then it’s down to the egg and the sperm. Everything is riding not only on the embryologist’s selection, but also on the fact that both the egg and sperm are chromosomally normal, compatible, and ready to procreate. The egg is held by a lovely tweezer-like tool while a single sperm is collected from a petri dish by a delicate, hollow needle. It is then inserted through the shell of the egg and into the cytoplasm. As with all things too good to be true, there are a few concerns over ICSI that get lost in the gray area of what would (or could) ever take its place. Should we favor natural selection (i.e., the random selection of sperm)? If we don’t do PGS testing, are we wasting time placing back untested embryos? If ICSI—essentially the ability to help the sperm penetrate the egg, which in many cases it is assumed unable to do on its own—was not on the IVF menu of options, it stands to reason that IVF would simply not work for many people. So, for better or worse, ICSI

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is usually your best bet when doing IVF—especially where male factor is a concern. Unfortunately, other than by testing the embryo, none of the sperm selection processes can accurately predict the presence or absence of chromosomal abnormalities. While birth defects and other abnormalities have been largely dismissed (we are talking 15 million per millimeter of semen. There are mild (5–14 million per mm), moderate (1–5 million per mm), and severe (