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Once medical and legal clearance has been achieved, you will agree an approximate date for the first embryo creation and transfer with the clinic. If you are attempting a fresh embryo transfer then the menstrual cycles of the intended mother and the surrogate will need to be aligned. If you are attempting a frozen transfer then there is no need to align the cycles; the intended parents can arrange for the embryo creation to take place at a time convenient for them, and the embryos will be frozen and subsequently thawed for the purposes of transfer.
The intended mother will need to take fertility drugs in the weeks leading up to the egg retrieval. The purpose of these drugs will be to stimulate the production of eggs to maximise the chance of successful embryo creation. The drugs will be prescribed by the clinic in the United States, but you will need to source them in the UK, unless you intend to be in the US for the whole process. We ran in to some practical difficulties: (i) the US clinic prescribed one drug that was not available in the UK; (ii) the UK pharmacies supplied us the drugs but did not give us the needles to inject them; we had to source these elsewhere; and (iii) the UK pharmacies did not show us how to take the drugs, and one in particular was quite complex (see below). We recommend that you plan ahead and ensure you have ample time to iron out any similar problems.
In total we did two cycles. The drugs we were given to take on both cycles were:
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Synarel, a nasal spray, taken from day 1 for approximately three weeks. Initially one spray in each nostril four times a day, then reduced to one spray to one nostril four times a day
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Menopur, 75 units, taken once a day by injection. This was the trickiest drug to take, because it required mixing two liquids in a sealed glass vial, the breaking the glass vial without spilling the liquid, or contaminating it with shards, taking the liquid into a syringe and then injecting it into a bottle of powder, then taking up the combined mixture into a syringe and injecting it. This takes practice. Taken from day 13 for about 11 days.
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Gonal F, 150 units, taken by injection. This comes in the form of an injection pen with several shots pre-loaded (typically six). Each time it is used we had to change the needle, which was straightforward. Taken from day 13 for about 11 days.
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HCG – 10,000 units, mixed with 1 cc of water and injected by intramuscular injection. Taken once, on day 23, to trigger ovulation.
On the second cycle we were given an additional drug to take from day 12, Ganirilex, which guards against premature ovulation.
In addition to the injections, Lucy had to attend a clinic to have ultrasounds (monitoring follicular development) and blood work and vaginal cultures taken on days 10, 16 and 18, and thereafter as directed by the clinic (essentially daily until the decision was taken to trigger ovulation).
We stayed in the UK for much of this process, flying to the US only on day 17.
One challenge we had was finding clinics in the UK which could support us with the bloods, cultures and ultrasounds, and provide the results the same day, which is important for the clinic in the US to be able to adjust medication as required and to be able to confirm when we should start taking certain drugs. On our second cycle (a fresh transfer) we ended up taking drugs before we were medically cleared to do so (our clinic had failed to send us ultrasound pictures and had closed for the weekend), so as not to risk falling out of alignment with Jennifer. Clearly, that was not ideal, although we got away with it and the US clinic subsequently confirmed we would have been medically cleared to proceed to the next stage had the results been available on time. We would advise that you plan appointments ahead as far as possible, book them in early in the morning and ensure that the clinic can provide same day results. There will be times when you will have to be persistent.
Each person reacts to fertility drugs differently. We found the daily multiple injections a chore (and a bruising experience) but Lucy did not feel particularly unwell during this phase. More stressful was the experience of co-ordinating the various blood tests and ultrasounds.
Once we were in the US it was just a case of being monitored every day until we were ready to trigger ovulation. On our first cycle we were instructed to take the HCG on the evening of day 23, and egg retrieval took place on day 24. The second cycle ran to similar timing.
The egg retrieval was a quick and painless procedure under general anaesthetic. It took place in the morning and Lucy was discharged within about an hour of the procedure.
While Lucy was undergoing the procedure John provided his sperm through a more conventional process that requires no further explanation...
The embryos were then created through a procedure known as ICSI, in which a single sperm is injected directly into the centre of the egg. This increases the prospect of fertilisation. On our first cycle we had 10 mature eggs inseminated, and on the second, nine. In each case all were successfully fertilised. ICSI is a relatively new procedure and is a little more expensive than conventional IVF, in which the gametes are mixed together in a test tube and nature is allowed to take its course. You should ask your clinician to advise on the relative merits of ICSI vs conventional IVF. We also paid for the embryos to be subject to genetic testing, a process by which doctors check whether the embryos have any evident chromosomal abnormalities and also confirm the sex of the embryos.
The embryos were the cultivated in the lab, and we were given updates on day 3, day 5 and day 6.
On our first cycle Jennifer experienced a minor bleed shortly before the proposed transfer date, so the cycle had to be abandoned and we were told that any resultant embryos would be frozen. At day 3, nine of our embryos were developing well and one was a little behind. At day 6, six of our embryos had reached blastocyst stage (approximately 200 cells) and were frozen. We left the US very happy, thinking that our work was done.
About a week later, we received a call from the clinic with the results of the genetic testing. We were told that of the six embryos that had been frozen, only one of them (a boy) was genetically normal. The rest had an incorrect number of chromosones or other noticeable chromosomal deficiencies. This was, at the time, devastating news and probably the lowest moment for us in the process. Looking back, we just hadn't been prepared for the possibility of such a result, nor were we well-counselled as to what it meant. We feared that there was a problem with us, that we would struggle to make healthy embryos. We knew we would have to go through another cycle to produce more if we were to have twins (or even if not, to have a higher prospect of success). We would advise you to have a full discussion with your clinician about the pros and cons of genetic testing. We certainly would not recommend against it (the embryos with the chromosomal abnormalities are unlikely to have produced healthy babies, significantly decreasing our prospects of success), but we would urge you to be prepared for the results and fully understand what they mean.
Happily, on our second cycle our nine embryos developed well, and by day 5, six of the embryos were at the blastocyst stage. After genetic testing, five of those were found to be normal (four female, one male) and two (one female and the male) were selected for transfer the next day, the other three being frozen. On day 6, one more embryo made it to the blastocyst stage (sex unknown) and was frozen.
The contrasting results of the two cycles (one healthy embryo in the first cycle, from ten fertilised eggs, six in the second, from nine) underlines the element of fortune in the process and the importance both of persistence and of not losing heart over any setback.
Jennifer flew in on day 5 after embryo creation, ahead of the transfer scheduled for the next day. We met for the first time and had coffee together, before she drove on to Connecticut to get settled in.
In the meantime, Lucy had been experiencing the after-effects of the retrieval, which included bloating and some abdominal discomfort. For Lucy, this was the most unpleasant part of the process, and was worse on the second cycle, although manageable on both occasions.