But who can retrieve hope out of a 10 foot deep pit toilet? Who, you ask?
Me, that's who.
January is almost over. I'm fairly sure I'll survive the rest of it. I have almost finished the things I absolutely have to finish. I am still standing; I have most of my wits; and I feel strong: albeit a little smeared by the shit of circumstance.
Ah, let me back up a bit.
We had our follow up appointment with Dr. Cotter. I always have a sinking feeling anticipating these appointments, and it didn't help that I had to drive across the city in winter weather. I felt crazier trying to figure out the parking machine at the clinic than I ever felt while taking any fertility drugs. I narrowly restrained myself from cursing a blue streak at it and the bystanders behind me for the insult of existing and making demands on my stressed mind.
That was my mood going in, but I was quite prepared thanks to the detailed charts and notes I kept during my Clomid cycles, and the fact that I blogged about the matter and received some helpful comments.
Dr. Cotter chose, uncharacteristically, to open with a positive: "You ovulated several times!" (with reference to the first three Clomid cycles). She followed this with "We received some new information from the latest semen analysis." I allowed myself to briefly fantasize that this new information was good, even though I knew it wasn't.
Mr. Turtle's last SA (September 2016) showed a drop in numbers from 17 million (2013) to 1 million. That moves him from the "moderate" male factor infertility category to "severe."
Dr. Cotter was quick to add that "men's sperm counts go up and down like the temperature in [Western prairie-steppe city that has huge temperature fluctuations due to the Chinook phenomenon]. "Men can go from zero to millions in a few days," she elaborated, and said that this was true for men of all ages, including men in their 20s.
"With those sort of numbers," she continued, we would usually go to IVF, but we know you didn't produce any eggs on [very high dose of follicle stimulating hormone]. And you were three years younger then, so....[pause]."
"It does seem unlikely that we'd get a better result now," I mutter at Dr. Cotter and the indifferent universe.
"So the question is...." [pause to lean forward and make intense eye contact] "How aggressive do you want to go?"
There is another pause while some part of me registers that the last time I heard about aggressive treatment, it had to do with my dad's esophageal cancer. Also that at the moment I feel not very aggressive at all, but maybe this is one of those times that you fake it till you make it.
"Would you consider donor egg? Would you consider donor sperm?"
I stare at Mr. Turtle. "It's not off the table. But we haven't talked about it lately." Mr. Turtle adds, "Yes, we'd definitely have to have more conversations about that." He then steered the conversation back to his SA and recurrent lymphedema as a possible reason for it. Mr. Turtle has Crohn's disease and is immuno-compromised because of the drugs he takes to manage it. Anytime he is fighting an infection, he gets a lot of swelling in the genital area which increases body heat, probably killing sperm or causing them to not develop properly. We talked about how at the time we conceived AJ, Mr. Turtle had been doing lymphatic massage for drainage. He didn't think that at the time it made any difference, but maybe it had? Also his perception was that he was in worse health overall at that time than at present - but still managed to conceive a child, which is interesting. Dr. Cotter looked up his medical records on her computer, corroborating what he was saying with what his other doctors had observed.
Her recommendation after this discussion was to repeat the sperm analysis twice more, to see if there are any changes or if the low numbers seen in September continue. In between the analyses, Mr. Turtle can try what he can to reduce the lymphedema. He also has follow up with other doctors to get more opinions. So that's all good.
After we talked about that, I felt like I should bring the conversation back to my issues, although for a change, I was (sort of) the receiver of good news. I asked:
Assuming Mr. Turtle's sperm counts improve, would Dr. Cotter suggest trying Clomid again or look at something different?
Dr. Cotter reiterated that she feels Clomid is the logical treatment, because I did ovulate on it, it has been used for a many decades, and because "we know that Clomid at low doses works for women at the end of their reproductive lives." She seems quite positive on this point. She also implied that considering the one anovulatory cycle, she might increase the dose. She also talked about Femara/Letrazole as a possibility, but noted that it works in "a very different way" and she could not judge if it would be better than Clomid or not.
I asked if there was an advantage to going off Clomid for a while before trying it again, and she said yes, you need to take a break every four cycles. If we do try Clomid again, I will want to ask more questions, such as the short luteal phase on the ovulatory cycles and in what circumstances she would consider additional things such as a trigger shot/progesterone supplementation. But that conversation can wait till we know more about what's going on with the sperm and if improvement is possible.
I asked if there were any risks to taking DHEA over an extended period of time, and she said not that we know of, and agreed to give me a prescription for it for another few months. It shouldn't do any harm and it might do some good.
And then because I felt I should, I asked what were the options for donor egg should we choose to go that route.
Most of the donor egg information I already knewfrom asking the same questions three years ago. Two options: fresh cycle with an (unpaid) egg donor, 38 or younger. Since we don't want to recruit a donor this isn't likely an option for us. Option 2, we can buy frozen eggs in batches of 6 from a US egg bank. The cost is $10 000 plus $1000 shipping cost, plus the cost of the IVF cycle. The donor eggs would need ICSI and assisted hatching as the freezing process makes the eggshells tough. (She actually said eggshells). As Dr. Cotter was talking, I couldn't help thinking of all the things that could go wrong during this process. Another wrinkle: Dr. Cotter said the egg banks might refuse to sell eggs to a couple with a low sperm count, because they would worry about it affecting their pregnancy rates and that's how they market themselves.
And what about donor sperm? Dr. Cotter had floated the idea of donor sperm with Clomid and/or an IUI as an option.
Dr. Cotter told us that "donor sperm is expensive" although the numbers she gave were in the hundreds of dollars, not thousands which is less expensive than eggs, at least. She then went off on a tangent about how sperm costs more or less depending on the race of the donor: Caucasian sperm is the cheapest, and Black/Hispanic sperm goes up in price with Asian sperm being the most expensive. Asians have low sperm counts and sperm donation is not a cultural norm. "There is literally one Asian donor in Canada and he is in high demand." I don't know why she thought all these details were necessary since we are obviously white and not likely to seek out a different race donor but what do I know. She told us how sperm and eggs are flown all over the world and that is normal. At the end of this informative disclosure all I could manage was "It's an interesting world you work in." "Oh yes, very interesting,"Dr. Cotter said breezily, as though she had quite enjoyed discussing professional business with us. Maybe this is her way of testing if people are really serious about "aggressive" treatment.
It's an interesting word, aggressive. A google search of "aggressive treatment" brings up this definition : "Aggressive care describes a particular approach to a life-threatening illness or condition. A patient receiving aggressive care will receive the benefit of every medication, technology, tool and trick that doctors can devise to treat his or her illness." "Aggressive" usually (to me) has a negative meaning, such as a person who wants to pick a fight and threatens with words or actions.
But in the context of illness, aggression sounds kind of positive: Imagine soldiers of medicine fearlessly fighting the enemy disease! If you are aggressive, you must really be doing something. No more talk, all action! It seems cowardly to say, well shucks, maybe I don't feel like being aggressive. It rather reminds me of times in my life (mostly as a child) when well-meaning people kept telling me to be more assertive, maybe even more aggressive, with the stated or unstated implication being, if I didn't, the aggressive people were going to win or get all the good stuff. By the time I was in my 20s, I felt I had proven that I could have a good life without being aggressive, i.e. something I wasn't. But the notion they planted still lingers in my thoughts: if I'm not aggressive, I'm not really serious about what I want, and I won't get it.
The thing is, at least with regards to infertility, I see aggression as illogical. Aggression implies an opponent. But who or what is my opponent here? My own body. So aggression means two things: I'm fighting my own body, or, I'm asking doctors to fight my body (while I passively watch? how is that a thing?). Neither possibility makes a whole lot of sense to me. Maybe the key piece here is self-image: I see myself/body as fundamentally good and beautiful. My body is not so much my property (I didn't ask for it and I don't get to keep it) as a sacred trust. To harm it or hate it feels deeply wrong and always has. In so far as "aggression" means harm or hatred, I can't go there. At all.
But you might say, it's just a word. Why not focus on the treatment options, not the words. Well, because I think words actually do mean something. Words tell us truths about how we and others think, if we listen attentively. The words we use are not coincidental or accidental. They have histories. The histories tell the story of real things and real people. Real bodies. When Dr. Cotter calls DE/sperm IVF "aggressive treatment," she's telling a real story with real world consequences.
And whether I have another child or not, all my life I'll be telling my story. More than that, I'll be telling my child(ren) their story. What kind of a story do I want to tell?
That's where my thoughts are at. Not whether I can conceive naturally or whether DE IVF or some other treatment will "work." Those are valid questions, but I won't be able to answer them until I try, and when I get the answer, it may well be too late to do something differently, and thus the answer itself will be useless. So truthfully, none of those questions or their hypothetical answers will actually determine our course. The one that will is, What kind of a story do I...do we....want to tell?
So back to retrieving hope.
I'm actually feeling quite good. January is almost done. The days are getting longer. My daughter is beautiful and my husband walks with me on this path. We don't have to go back to The Fertility Clinic for another four months (after the second SA) and I'm quite happy about that. We can cycle unassisted. Or not. But we probably will. We can talk about DE IVF and the other options Dr. Cotter floated. Talk is good.
Basically, I'm not being aggressive. And I feel just fine about that.