IVF drugs, types, brands, methods, syringes, pens, etc., etc., etc.

Heather has been way mellow this week.  Pleasant, warm, affectionate, and laid-back.  Does anyone know if birth control has such a side effect?  Or any way I can keep her on it?

There is absolutely zero else going on.  We were both delighted to finish up with the antibiotics and attendant queasiness yesterday, and this afternoon we heard that the AMH results were in.  ("They look good," said the nurse.  "Um, yeah, did you fax them?"  Of course they look good; every test looks freaking magical and Heather's no more pregnant than she was during the first hundred tests.  Fax the goddamn thing.)

The theory, I suppose, is that someone in Nashville will call us this week to set a drug schedule for Heather.  Now that it's getting close, I keep going back to my notes from the IVF class last month to see what's coming.  AND I found out, in doing so, that I was totally wrong about what all this stuff is.  So I'm going to review.  (Teaching is the best way to learn, right?)

Lupron

Lupron is central to the ovarian-suppression phase and is designed to drain your reproductive hormones.  According to my notes, the Lupron will come in a little bottle and will look dangerously empty.  It won't look like there's enough for the whole cycle, but allegedly there is.  So says Nurse Jennifer.  You inject 10 units every morning with an orange-capped insulin needle.  It can be injected anywhere you can pinch the skin, but the stomach is often least painful (so long as-- and I was vague about this before-- you don't insert it along the longitudinal line of the navel).  You poke it in at a 90-degree angle; my notes say that 45 is too shallow.  Not sure why. 
Side effects are due to low estrogen levels.  The most common are headaches and, just before you begin FSH, nighttime hot flashes.

FSH (Follical Stimulating Hormone)

FSH is the beginning of the ovarian-stimulation phase.  Right around Day 27 of the cycle, you have a "suppression check"-- something that the Nashville people take very seriously.  It's a super-long appointment, we're told.  They check estrogen  (technically estradiol or E2) levels, do a pelvic ultrasound, and do a test run of embryo transfer where they use the catheter to "map the cervix" and figure out which things twist which way.  I guess so they don't poke your innards too hard during the real thing.  Once they see how all that plays out (the E2 level should be below 50), they kick off the FSH.  What's ridiculous is that the Lupron has been suppressing your FSH all this time, so after the suppression check they wean you off the Lupron while jacking you back up with the FSH.

FSH is definitely supposed to be injected into the belly.  The average dose is 300IU.  There are a few different ways of administering it.  We picked Follistim because Nurse Jennifer said that was what PGD manager Amy would want-- and we were grateful because the four options they gave us were confusing as fuck.

1) Bravelle: This one scared me most.  It's a powder that you mix with sodium chloride, and there's a whole long thing about the "q-cap," which goes on top of the syringe...  All of which is to say that my eyes began to glaze over at, say, step three out of what the Bravelle website describes in eighteen.  (You can take a look at their website for the FIVE videos it takes to explain this, along with the PDF instruction sheet.)  Per my notes, Bravelle is a pain in the ass, but cheaper than the pens at about $50 for 74IU.  

2) Menopur: Also a powder; uses the exact same process as above.  It's not clear to me what's different about the two, as they're made by the same company.  According to the Menopur folks, it is "the most widely used and extensively studied reproductive hormone, proven to be both safe and effective."  Not claimed about Bravelle.  Both Menopur and Bravelle contain a combination of FSH and LH (luteinizing hormone), but in different concentrations-- Menopur has a higher level of LH.  Our doctors didn't give us any sign that one is better than the other, and from a casual Googling it looks like a lot of doctors put women on a combination of the two, or switch depending on what's effective.

Also, both are made with hormones extracted from urine of postmenopausal women.  Neat!

3) Gonal: This is a pen application, like Follistim.   It comes with little needles in cartridges that look like the Keurig K-Cups.  The pen portion has a little dial at the end opposite the needle, and you twist it to select dosage.  When you pull back on the plunger, it locks the dose in.  The pen will also warn you when there's not enough in it.  This one, you hold in your fist like a murder weapon, then push the needle all the way in at a 90-degree angle.  

4) Follistim: Also a pen.  The drug comes in little cartridges that you place inside the pen-- like you would replace ink-- on top of a springy plunger.  You twist the two halves (see below) together to close it.  One nice bonus is that you can cap it for portability.  The best thing we learned about it was that, if, when you spin the dial, you go too far, turning the dial in reverse will cause the whole thing to squirt.  I got it in the face during our training session and there was much merriment.  So, anyway, just keep turning it in the same direction till you get back to the appropriate dose.

During FSH treatment, you have to be all cautious-like because it has caused your ovaries to swell grotesquely (okay, maybe not that much, but still enough that there are creepy warnings).  If the FSH gets you too excited, you can get into OHSS (Ovarian Hyper-Stimulation Syndrome), which means that the standard side effects of stimulation are severe enough to cause illness.  Bloating, headaches, and worse.  Even without reaching the level of OHSS, during your time on FSH you're not supposed to have any alcohol, lift anything over 10lbs., make any kind of twisting motion-- vacuuming, for example-- or exercise beyond light walking.  Heather's kind of upset about the vacuuming part, actually.

FSH also seems to mean a lot of doctor's visits.  From my notes, it looks like you have to get testing done on days five, seven, and ten of the FSH process.  On the third visit, the doctor will most likely assign you to employ another drug, hCG (Ovidrel), to trigger final cell division.  I'm very excited for this one because Ovidrel comes in pre-filled syringes.  One in each side of the belly, then you're done with that, FSH, and Lupron.  In the next day or two, you go through egg retrieval.

Progesterone in Oil

This starts right after embryo transfer to keep hormones pumping while the placenta develops.  I am not kidding when I say that my notes state that it "maintains uterine integrity."  Much to Heather's chagrin, the drug is drawn up into the syringe with a giant pink needle; when you're ready to inject, you take that one off and replace it with a skinny gray one.  You do this around dinnertime, injecting the drug in the ass, in the northern hemisphere of either cheek.

Even without the big pink needle, the progesterone shot seems like a painful one.  There are really detailed suggestions for avoiding pain, like warming the vial beforehand in your bra (I am so prepared for this) so that the oil will disperse more easily.  Using a heating pad on that area afterwards helps, too.  Some people recommend icing beforehand, but the nurse pointed out that a cold muscle and cold oil were just going to result in a chilly oily bubble on your back, so you should go for warmth instead.  Baths are good, too.  

Another suggestion was to press your finger hard into the skin for several seconds.  Use the divots as insertion sites.  The nerves, they say, will be "distracted."  The deeper you insert the needle, the better.

Ickily, they allow vaginal inserts of progesterone after a few weeks, but they're messy and most people stick with the needles.  Haha.  Also it makes me think of Suzanne Somers and her hormone creams.