Help! I need somebody!

And, not just anybody.  I need a doctor who will treat my thyroid.  Who knew it could possibly be this hard?  But, I’m getting ahead of myself.

I waited with a fair amount of restless impatience on Wednesday for my latest round of beta results.  And, not just beta and progesterone, either.  I was pretty annoyed on Monday when I discovered my first beta draw didn’t also include a TSH check.  It’s been a standard part of my workup with every other (negative) beta for the past 6 months, so why they left it off this time is beyond me.  So, when my blood was drawn at 7:30am I requested that a TSH be added.  I got minimal push back from the nurse, but I’m used to fighting.  Anyway, blood exited the veins, and I was told I’d hear something by 11am.  At noon I hadn’t heard a thing so I gave in and called.

That phone conversation is hard to paraphrase, so let’s just do this Shakespeare-style.

Me: Yes, I’m calling for my blood work results from this morning.

Nurse: Uh, yea.  Still pregnant.  When do you want your ultrasound next week?  Wednesday, Thursday, or Friday?

Me: Wait, what?  What was the value?  What was the TSH?  How’s the Progesterone?

Her: Um, I gotta open your chart back up. Gimme a second. [Gum smack, gum smack.]  HCG was 256.  That’s fine.  When do you want your ultrasound and who is your OB?

Me: [Doing the math on the fly] But, that didn’t quite double from my 139 on Monday.  Are we really not doing another beta?  I won’t get anything else until over a week from now?  What about the other values?

Her: I don’t know what to tell you.  Everything’s fine, so there is no reason to retest.  You can see the rest of your results in the portal later today.  I already closed your chart again.  Call your OB.

Me: I don’t have one!

Her: Well, that’s silly.  Get one.  We will release you at 8 weeks and won’t help you from that point on.

Me: But I’m barely 4 weeks!  I’m not calling one.  Not yet.  I’ve had to cancel three OB appointments before due to miscarriage.  I’m not doing it again.

Her: Well, I don’t know what to tell you.  How about next Thursday for your ultrasound?  7:30?

Me: [In tears] Wait what?

Her: We’ll see you next Thursday, October 24 at 7:30am.  Call an OB!

After I was hung up on I sent an email to my boss saying I suddenly didn’t feel good and would be going home for the rest of the day.  I stayed home in my pajamas crying for the next 36 hours.  The Mr. and I spent an additional 90 minutes screaming at one another last night about how many more miscarriages we can possibly handle.  He said things like, “I just don’t have the energy to watch you miscarry 9 more times with 9 more perfect embryos!”  I heard things like, “Why did I marry this barren shrew who keeps killing my children?”  It was good times.

Equally good was what I found when I logged in to my patient portal teary eyed on Wednesday night.  Yes, the HCG went from 139 to 256.  Perfect is doubling in 48 hours or less.  Mine was on pace to double at 54 hours.  Not remotely terrible or doom and gloom depression-worthy, but that’s still the emotion it evoked.  After 4 years and 3 prior losses anything less that absolute perfection generates worry.  I’ve been full of worry ever since.

But, it turns out, the beta was just the tip of the worry iceberg.  My amazing progesterone on Monday of over 40?  Yup, dropped to a pathetic 19 despite daily Crinone suppositories and PIO injections.  Oh, and that TSH they had no intention of running?  Yea, about that…

Co-sponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association, 2012’s “Clinical Practice Guidelines for Hypothyroidism in Adults” recommends the following course of action for pregnant women with elevated TPOAbs or Hashimoto’s:

When a woman with hypothyroidism becomes pregnant, the dosage of L-thyroxine should be increased as soon as possible to ensure that serum TSH is <2.5 mIU/L and that serum total T4 is in the normal reference range for pregnancy. Moreover, when a patient with a positive TPOAb test becomes pregnant, serum TSH should be measured as soon as possible and if >2.5 mIU/L, T4 treatment should be initiated. Serum TSH and total T4 measurements should be monitored every 4 weeks during the first half of pregnancy and at least once between 26 and 32 weeks gestation to ensure that the requirement for L-thyroxine has not changed. [Emphasis mine]

When I started this cycle, my thyroid was well controlled on my usual Synthroid dose.  On 9/18 my TSH was a beautiful 0.49.  My redraw on Wednesday?  5.69?!?!?!

On Thursday morning, I wrote my endocrinologist asking what to do.  On Thursday afternoon they left a message on my work voice mail (good thing I skipped work given my hysterical I’m gonna miscarry again crying fit, right?) saying they couldn’t go on what I told them, but needed to have my RE fax lab results to them.  My RE closes at noon on Thursday.  Last night at midnight I wrote a hysterical email to my RE’s nurse basically saying, “Why isn’t anyone paying attention to me?  Why won’t you help me?” (Yes, it was about that eloquent.)  This morning she wrote back saying calm down, we’ve faxed your results.  Later this morning a message arrived from my endo’s nurse saying, “We don’t treat pregnant patients, you will need to talk to your OB.  Who are you seeing?”  I wrote back with the same damn, “I don’t have an OB and I don’t plan on having one!” I gave my RE’s nurse on Wednesday.  And, that was that.

So, basically, by 2 this afternoon, I was left with the following:

  • RE won’t treat my thyroid since I have a thyroid-specializing endocrinologist.
  • Endocrinologist won’t treat my thyroid because I’m pregnant and that’s an OBs job.
  • OB won’t treat my thyroid because, well, I don’t have one.  But, even if I did, my experience has been that OBs won’t see patients this early anyway, so what good would it even do to have one?
  • Oh, and my rural PCP (who isn’t even in the office on Fridays) thinks any TSH under 10 is hunky dory.

Whee!!!

I escaped home from work and started making phone calls again, desperate to get some sense of resolution before the weekend (my 30th birthday weekend!) began.  It went something like this:

  1. Accept I must call a fucking OB at all of 4w4d pregnant.  Hyperventilate.  Explain situation.  Sound like a crazed woman.  God bless the patient receptionist who listened and cared.  Unfortunately, listening and caring doesn’t solve the fact that I’m not their patient, they’ve never seen me before, they don’t have my blood work, and it’s far too early to book an OB appointment with them.  She encouraged me to push my endo a little harder, but, after I told her I was seeing the thyroid center attached to the same teaching hospital their practice is attached to, she acknowledged they tend to not want to treat pregnant women for fear of liability.  Good thing I haven’t had about 5 conversations with my thyroid doc in the past 18 months saying I was specifically there so that they’d manage my care through pregnancy, eh?  Anyway, sweetheart scheduled me in as a new GYN patient (NOT an OB patient) for next Thursday.  Yes, the same day as my ultrasound.  But, at least since it’s a GYN appointment I won’t have to cancel it if I find out that morning I’m miscarrying, right?  Always looking on the fucking bright side.  That’s me alright!
  2. Try and call endo and get an answer that isn’t simply “Talk to your OB.”  Dial.  Press 0 to speak to a member of the staff.   Silence.  Dial back, press 0, silence.  Dial back, press 1 “if you’re a physician or a physician’s representative” (what the fuck do I care at this point?), receive error message that the extension is not available so try another extension.  Cry.  Give up.
  3. Call RE’s nursing line.  Get “Why don’t you have an OB?” heartless bitch nurse on the line.  Simply ask for the slightly less bitchy nurse I sent my emotional breakdown of a portal message to last night to call me back when she has a chance.  Hang up.  Cry.
  4. 30 seconds later, slightly less bitchy nurse returns my call.  She says, “Honey how are you?”  I cry.  And, then cry some more.  She orders me a prescription for 150mcg to replace my 112mcg of Synthroid.  She assures me there is nothing I can do (or that they are really willing to do) between now and next Thursday.  She tells me to always feel comfortable asking for her directly.  As I whimper out a, “Sorry I’m being so unhinged and irrational,” she responds back, “Honey, you have every reason to be irrational right now.  You’ve been burned enough times before and you won’t feel alright until you are holding this baby.  What else can I do to help make this better?”  I just start sobbing even harder.
  5. I call and set up an appointment with an infertility counselor.  Yea, you guessed it, it’s scheduled for next Thursday…
  6. Endo calls back.  He’s ordered a prescription for 137mcg and apologizes for the inconvenience.  He just, “Doesn’t like the confusion of handling pregnant women since usually OBs want to make those calls.”

So, I’ve gone from self-medicating by cutting my pills in half, to shortly having an arsenal of Synthroid prescriptions in different doses in my bedside table.  Not quite sure what the pharmacy is going to make of me, but that’s a call I’ll make for another day.  I can’t handle more phone battles right now.

But, let’s look on the fucking bright side, right:

  • I theoretically have an OB/GYN again for the first time in a while.  (Talk to me about whether this is a bright side when I have to face sitting in that waiting room again on Thursday.)
  • I will shortly have a full party array of Synthroid in all it’s beautiful colors.
  • My RE’s nurse has once again underlined that gold star next to my name denoting, “This chick is batshit crazy, handle with care!”
  • I managed to stop thinking about miscarrying for nearly an entire day since my focus instead was directed toward my thyroid.
  • It’s Friday.
  • I always wanted to have kids by 30, so at least I’ll be able to say I was technically pregnant on my 30th birthday this Sunday.  Close enough, right?

PUPO

Quote of the weekend from the mister: “There’s nothing like trying to make small talk while another man stares at your wife’s cooch.”  That, in a nutshell, was the story of my transfer.

Chick socks

Transfer day socks

We were told to arrive to the clinic at 10 sharp on Saturday morning.  We swung by the farmer’s market, lined up for our Saturday morning chocolate croissants before our town’s magical baking couple even arrived to set up their tent, and were on the road in time to make our appointment with plenty of time to spare.  I even had enough time to leisurely pick out my transfer day socks.  As I Tweeted out the pic of me and my socks in the town gazebo I captioned, “Transfer day socks. ‘Cause eggs and the chicks that produce them rock!”

45 minutes in to the drive we zipped around a blind curve only to find a police cruiser parked sideways across both lanes of traffic.  The friendly local cop sauntered up at the leisurely pace one expects of small town America and said, “Oh, yea, we’ve got a car in a ditch.  Road’ll be closed til the tow truck gets it out.”  Honestly, I’m surprised they didn’t want to search our car right then and there given the sheer sweat-producing panic that news elicited.  I definitely looked like someone hiding something.  We declined to wait and I iPhoned us off-road and through planned community after planned community until we arrived just a few minutes after our scheduled appointment.  Crisis averted.

Upon arrival to the clinic’s waiting room, I was informed that transfers actually take place in their spa facility next door.  Let’s play spot the newbie!  I rolled my eyes and somehow staved off the desire to mumble a chorus of, “You could have fucking told us this before this moment!”  We drove around to the spa entrance, I entered this unfamiliar new territory, and waited.  For a clinic that prides itself on trying to offer a relaxing atmosphere and support positive self-thought, the unanticipated facility change, the constant barrage of “Are you doing acupuncture today?” (No, I’ve paid more than enough for this already, thank you!), and the gaggle of women discussing unruly 1 year-olds just inside my earshot was none too relaxing.  Little did we know the best was yet to come.

We entered the waiting room around 10:05.  We were finally taken back to our room at 11:00.  The doctor came in at 11:30.  Good thing my husband told his boss he had to miss that very important 9am meeting.  Grumble.

Turns out the reason for the delay was the entire clinic was experiencing a wireless networking outage.  4 years (1 hour and 30 minutes) of waiting to do our very first embryo transfer, and the clinic was unable to print any pictures of my embies because of a wireless issue.  Seriously, FML.  It’s odd how much that little fact bothered me.  I’ve anticipated my first transfer for ages.  I’d walk in to the familiar surroundings of my clinic (fail), be presented with pictures of my gorgeous embies (fail), and be in and out calmly and quickly.  Yea, not so much.

When the doctor finally entered the room I was thrilled to see it was my favorite doctor.  He did my latest D&C and I remembered liking him then.  I like him even more now.  He spoke to me of science and medicine, not mantras and yoga.  His professional demeanor did help calm me, even if things ultimately got a little weird.

An embryo transfer is really not much more than a slightly more invasive and prolonged pap smear.  You scoot to the end of the table, a speculum goes in your vagina, the cervix is cleaned with the same medium the embryos have been growing in (aka “Embryo Gatorade”), a small catheter is threaded into your uterus, a syringe containing the embryo is threaded through the catheter, an ultrasound probe is inserted to visualize the uterine cavity, and, when the ultrasound shows that the catheter is in exactly the best spot for (hopefully) future implantation, the plunger is pushed and the embryo’s deposited.  Easy peasy.

Thing is, though, they don’t bring the embryo-containing syringe into the transfer room until the very last moment.  They want you to be waiting on the embryo and not the other way around.  Though it surely didn’t feel like it at the time, a thirty-year-old woman is more capable of waiting than a fragile 5-day old blastocyst.  What this meant in reality was I was sitting there for what felt like an eternity, legs spread wide open, husband at my head and doctor holding the empty catheter in my hooch, waiting for the embryologist to appear.  So, we made small talk.  Awkward, awkward small talk.  I about jumped up and kissed my husband when he broke yet another unbearable silence with a well-timed question about the clinic’s embryo freezing procedures.  Anything to break the silence.  Well, almost anything I guess.  When the transfer was actually happening the doc wiggled the catheter and pointed to the ultrasound screen saying to me, “That’s me waving high from inside you!”  Uh, wha?  As I saw the quick explosion of fluid and embryo flood the ultrasound screen he added, “And now you’re pregnant!”

We transferred one grade 4AA blastocyst – the highest quality blastocyst possible.  We had at least one other 4AA blastocyst waiting as well.  The clinic offered us the choice of transferring one or two blasts, so they had grading ready to go on the two best embryos on the day of my transfer.  The grading of the remaining embryos will post to my patient portal sometime in the next week.  We also found out on Saturday that I had an additional 7 expanding blasts that would be frozen, with the possibility more would reach expanding blast stage by Monday (today, 7 days post retrieval).  I called for the final report this morning.  This cycle has been a dream:

  • 23 eggs retrieved
  • 19 eggs mature
  • 16 eggs fertilized
  • 16 embryos still growing on day 3
  • Of the 16 embryos:
    • 1 blastocyst transferred
    • 9 blastocysts frozen
    • 6 discarded (failed to become blastocysts)

Those numbers are pretty much beyond my wildest dreams.

Because I’m a fiend I’ve been peeing on everything in sight since Saturday.  My official blood test is next Monday, October 14, but I’ve been taking daily home pregnancy tests as well just for giggles.  The shot I administered last Saturday to trigger the final maturation of my follicles in preparation for egg retrieval is essentially a straight dose of the same hormone picked up by home pregnancy tests.  This means if I hope to get convincing news either way with a home test, that I’ve got to follow the tests from positive (from the shot) to negative (from the shot being gone) to, hopefully, positive again (from a pregnancy).  This morning’s test was the first stark white negative.  If a line reappears in the coming days there will be immediate cause for hope.  The earliest I’d expect to see a true honest-to-goodness positive is late this week, but that news surely won’t quash my desire to pee on my hands in a Dixie cup each morning when I wake from now until next Monday.

For now, though, I’m officially PUPO – Pregnant Until Proven Otherwise.  As the doc said after my transfer, it’s time to party like a pregnant lady!

Unimaginative update

I just don’t have it in me to be witty. I worked until 10pm last night (the joys of keeping college student hours, I tell you!), and then had another monitoring appointment this morning. Up at 5, road by 6, work by 8:30. I’m beat.

I thought I owed ya’ll an update, though. My ovaries are cooking nicely. We’ve got half a dozen eggs in waiting. Less than I’d hoped for, but more than required. I’ve learned that any hurdle cleared is reason for celebration. So, I’m celebrating.

And, because I’m me and IF is the biggest mindfuck in the world, I’m also fretting. Fretting about the steroids the clinic nonchalantly has me on. Angry at the nurse who got snippy with me for asking to switch to a different steroid. (“You’re either doing this or nothing! You’ll just have to live with the risks!”) I’m disappointed that, despite the high doses of hormones, the cramps and twinges in my sides, and the PCOS diagnosis I carry, that my body’s only popping 6 (potential) eggs. I’m frustrated that my questions about the size differences between the right and left follicles were dismissed, and am worried that my hidey-go-seek right ovary and it’s two large (16mm and 17mm) follicles is going to mess with the well-behaving left ovary that is currently so jam-packed with follicles she could only measure the four biggest (9mm, 10mm, 11mm, and 13mm). I’m anxious about the timing of this all as more and more “You positively can’t miss this!” events start popping up on my and Mr. But IF’s work calendars in the next 2 weeks. Overall, I’m just wishing the days away, hoping for them to fly by and bring me my answers (whatever they are). And, then, I’m angry at wanting life to blur by. I’m mad that instead of cherishing precious moments with a little one, I’m wishing away the last gasp moments of my 20s.

In other words, I’m in the midst of IVF. I’m up, down, and all around. I’m exactly the same as anyone else that has ridden this roller coaster. I’m ready for the ride to end.

Nap time

You know that totally put together, strength of a million mighty women post I published last week.  Yea, I’m a liar.

Well, sort of.  I do think the foundation of that post holds true.  In my heart of hearts I did feel a switch flip and bring a sudden awareness, a silent peace that if I’m never a mother, I’ll make it work.  I’ll find new dreams, live in ways I’d never planned, learn to live on.  That part was true (or as true as any untested predictions we apply to our lives can be).

The lie?  It’s not bravery or strength or courage that’s propelling me, it’s exhaustion.  Granted, it was more lie of omission rather than outright “fooled you!”, but still a lie.

I’m just so tired.  The past four years of my life have been a haze of doctor’s appointments, surgeries, arguments with insurance companies, strained conversations with friends and family, shots, pills, sleepless worry-filled nights, physical therapy, counseling sessions, support groups, MRIs, X-rays, blood draws, IV infusions, driving to appointments, keeping family, friends, and strangers abreast of those appointments, fundraising, waiting to get pregnant, waiting for a new diagnosis, fighting for a new diagnosis, waiting to miscarry, waiting to pick up the pieces and try again.  And, as if that wasn’t exhausting enough I had to watch my husband and my IF friends in the computer live the same struggles and walk the same paths.  Again, and again, and again.  I’m just so very tired.

I would guess that for every minute I spend with a doctor, I spend another 20 minutes on the phone with the doctor’s office, on the phone with my insurance company, on the phone with the mail-order pharmacy, standing in line at the traditional pharmacy, going through outpatient intake to get my blood drawn again, writing out checks for co-pays and co-insurance, and filling out the same medical history form over and over and over again (number of pregnancies: 3, number of live births: 0).  I’m running out of steam.  Actually, I ran out of steam a long time ago.

Last Friday I went back to the lab for yet another blood draw.  We needed to decide whether it was time to give up on my body doing what it’s supposed to do and start a course of Provera to bring on menstruation, or whether we should let it do it’s thing and hope (har har har) for a miraculous naturally conceived pregnancy.  Tuesday’s tests were inconclusive, so I was ordered a repeat course on Friday to see whether levels were going up, down, or staying stagnant.  I hauled my bottom out of bed bright and early, went to the lab, sat through another round of “dumb things fertile phlebotomists say,” and waited.  My clinic never called with the results.  When I called back Saturday, I got an answering service.  On Monday I called at 7AM and started screaming bloody murder.

“Oh, the hospital never sent them.  You’ll have to figure this out with the hospital.”

Two hours, 5 phone calls, 2 times being hung up on, and a whole lot of lost work for my employer later, I got the (now 3-day old) results.  Body as stubborn as ever.  No change whatsoever.  Start Provera.  What’s another 3 day delay, right?

Last night I started spotting.  I started planning out our cycle, mentally scheduling the appointments, checking that I’d be in town and available around the potential retrieval and transfer dates.  I was excited.  This morning the spotting is gone and there are no signs that my period has any intention of starting any time soon.  What’s another two weeks of waiting, right?

I’ve been getting bills from my rheumatologist for a while now because they refused to collect my co-pay on the day of my appointment.  The invoice provides no way to pay by credit card (something I always do because of our flexible savings accounts through work) so I have to call.  Well, I’ve tried to call.  Apparently they are closed on Thursdays and Fridays, leave early on Tuesday, and take lunch every day from noon to 2pm.  After calling today and receiving a brusque, “This is the answering service, the office is on lunch break until 2 <you idiot!>” I lost it.  What’s another hour of waiting to pay a bill for a useless office visit that delayed my chances at trying to conceive for 4 months for no good reason, right?

I’m tired of this being the best that is out there.  I’m tired for my friends (first and foremost among them dear C) who have had to fight tooth and nail for quality of care that makes mine look like the gold standard.  I’m tired of being treated like I don’t matter by “professionals” that don’t know what they are doing, don’t respect the weight of their influence on our lives, and don’t do any more than the bare minimum (at best).

So, that peace and zen?  It’s just a scam.  In reality, I’m just ready for this journey to end.  I’m ready for nap time.

I’m risky business

So, I almost lost bowel control in my endocrinologist’s office last Thursday.  After honestly venting my frustration with how poorly I felt my visit to the rheumatologist was handled last spring, my endo displayed sympathy and a dry wit I hadn’t really realized was there before.

I’ve had a grand total of one visit with this PA since moving north (my initial consult was with the actual MD and left me feeling lackluster and sad that I’d left some excellent quality of care behind in Delaware).  That one visit was good but less-than informative.  He listened without criticism when I complained of back pain and skin rashes (those same recurring ailments that have driven me to various doctors for years), and he even agreed to followup on them with some bloodwork.  That bloodwork found an unusually high titer of ANA which triggered the referral out to rheumatology (and commenced the giant wastage of timeage that was that adventure).  So, yea, when viewed through the usual lens I apply to my physicians (“Did he insult me?” “Did she say something I know to be outright medically untrue?” “Did they send me home with a sterile collection jar and say good luck?”), he was pretty amazing.

But, back to the shitting a brick mid-checkup.  After recounting my time with rheumatology he responded, “That’s so frustrating, isn’t it?  Rheumatologists, man, sometimes I don’t even know what language they are speaking!”

(My eyes began bugging out of my head here.)

So then, he turned from the computer, looked me straight in the eyes, and asked:

What resources have you been able to find to tell you more about your conditions and explain why this has all been so difficult to diagnose and pinpoint?

Breath taken away.  As was my ability to speak, form coherent sentences, and (nearly) keep my shit in place.

You see, I’ve practically made doctor’s-appointment-going a full time job for the past 4 years.  Never once has a doctor asked if I was educating myself.  Never once have I been told of the importance of doing my own homework.  Never once have I not been laughed at for admitting that I’d done tons of reading and research on my conditions.  It seems I now have to amend all those sentences.

This man actually wants me to be proactive, stay informed, and engage in a conversation with him as we work through my medical issues.  As I engaged in my usual dismissive answering behavior (“Yes, I did have that rash, but it went away.  I don’t think it is tied to the seasons, but I guess I don’t know, it could be…”), he actually scolded me a teensy bit.  “No,” he said, “these autoimmune conditions can be funky.  Would you believe I get a flare-up of Raynaud’s every three years like clockwork?  Never any other time, just every three years.  I know countless doctors who would laugh me out of their offices, but I’ve lived it so I know it can happen.  Just keep an eye on those rashes, ok?”

Bestill my beating heart.  I think I’m about to dump Mr. But IF for this 6’4″ older male doctor.

When we got to talking about my future plans – the IVFs, the possibility of more pregnancies, my desire to have his office on my side in those early days of pregnancy when my thyroid is so very prone to wreaking havoc – he offered me more advice.

“You’ll be seeing a perinatologist, right?”

I stared blankly for a while before I managed a, “I’ve always been told I’m not a potential high risk pregnancy.  Is that wrong?”

“Yes,” he answered, “I think you’ve been through more than enough.  I want to make sure you get all the monitoring you think you need.  If you have any trouble, give us a call.”

Now, maybe its odd to be so thoroughly thrilled to be informed I’m “high risk” before I even manage to conceive, but I left happy.  Someone’s taking me seriously for once, and I’m holding firm to that.  (And, let’s face it, after 4 years and 3 miscarriages I’ll gladly take all the extra monitoring they can throw at me if I ever manage to get and stay pregnant again.)

I’m off to see the endo

Can we all just take a deep breath and celebrate the fact that I’ve managed to get it up to post three days in a row?  Huzzah!

I have my regular 6-month check up with my endocrinologist this afternoon.  I’m feeling odd about it.  For the first time in the 3.5 years since my Hashimoto’s diagnosis I’m walking into an endo appointment without a list of questions nine miles long.  Part of me wants to celebrate the fact that that clearly must mean things are finally as they should be and that managing my thyroid disease has become that mythical “not a big deal” all my now-fired doctors once promised.  Thing is, though, that’s not the cause.  The cause is primarily that I’ve gotten so good at managing my own care by now that I really only need the doc to write my scripts these days.  And, of course, there’s the fact that I’ve already had my “I’m-on-the-brink-of-starting-IVF-please-help-me-manage-my-thyroid-through-it” appointment.  It was over a year ago, two doctors ago, and 300 miles away.  Ah, memories.  Nothing like repeatedly gearing up for a whole lot of going nowhere over, and over, and over again!

The one thing I am certain of is there is no way I’m getting delayed.  The fallout from my last endo check was tremendous.  It was this practice that first noted my elevated ANAs last winter, and insisted on my having a thorough going over by a rheumatologist before returning to treatment.  Good right?  Not really.  The earliest this practice would get me in with their sister rheumatology group was 3 months away.  I found another clinic that would only make me wait 5 weeks.  I went seeking answers, and left with a “who the hell knows?”  We’re not doing that again.  I don’t care what they find, we’re sure as hell moving forward this time.

Well, it’s about that time.  An hour up to the doctor, surely an hour wait (they are always insanely over-booked), a 10-minute visit, and then an hour drive home.  The glamour of my life I tell you!

Do or do not. There is no try.

Yes, my reproductive endocrinologist quoted Yoda this morning.  So, yea, that happened.

Today was my post-op appointment/WTF appointment/IVF consult.  (Clearly, when you’re driving an hour each way, it’s good to make sure you can cram as much as humanly possible into one trip.)  The visit started nicely enough.  We were escorted back to the comfy couches in what I’ve titled the “Den of Solitude.”  The name’s part a dig at the obscenely dark wall color, and part remembrance of the long-lonesome wait we had there for my D&C that came a day too late.  Awesome room, awesome memories.

The doc reaffirmed that surgery went fabulously, that my suspicious right tube looked “wonderful,” and that I was young.  We discussed my visit with the reproductive immunologist during my last failed pregnancy and went over that specialists’ recommendations.  I said, “he suggested Lovenox, which we added to the last two cycles, and Prednisone, which we didn’t.”  What I didn’t say was, “The Prednisone which the NP said we couldn’t do we didn’t add.”  So, guess what?  6 months after I first sent an email inquiring about Prednisone, I was told, “Why don’t we just try some Prednisone and TI or IUI?  It works for a lot of my immune patients!”  Head, wall, again.

The mister (likely seeing dollar signs flowing through his head) seemed into that (insurance-covered) option, I said, “No.”  We were exactly in this place 15 months ago.  We walked into our IVF consult, we got our calendar, we paid our down-payment.  We left with a plan.  A plan that got derailed by a money hungry clinic, an asinine insurance system, and a interstate move.  I wasn’t leaving this second IVF consult with another aborted IVF plan.  I simply said, “We need to move on.  We need to try something different.  We need to know that there is an end in sight and our lives might one day be back to normal.  This is the step we need to take before I have no stamina left to keep trying.”

The answer?  “As Yoda says, ‘Do or do not.  There is no try.'”

Basically, the next 15 minutes were filled with yoga recommendations, self-help book suggestions, mantra repetition, and the soft-eyes of my close-talking RE glaring uncomfortably into mine.  I’m not a feeler, I’m an analyzer.  I rarely talk emotions, but regularly talk statistics, clinical studies, and journal articles.  There is no more certain way to bring on my rage than to turn my quest for medical insight into a “how do you center yourself?” discussion.  I grinned, I bared, I pinched the skin between my thumb and pointer finger so tight that I can still see the redness 7 hours later.  But, ladies and gentlemen, we have a plan.  (One that I’ll surely relay in fuller course in the next several days.)

See, here’s the thing with conversations that go like this.  I truly do understand the medicine behind relaxing and minimizing the worry.  As someone with both endocrine and autoimmune disorders I get how putting your body under unnecessary stress triggers a cascading waterfall of nasty, hormone- (and thus fertility) impacting issues.  Back in the days before we moved and when we still lived in civilization, I did acupuncture, I hosted a support group, I sought counseling.  I’ve drunk the Kool-Aid when it comes to believing that reducing one’s stress is a can’t hurt, might help accompaniment to traditional infertility treatments.  (And, lest you misunderstand, this is a far, far cry from saying that believe that “Just Relaxing” will cure my infertility.  That, my friends, is just a steaming pile of bullshit.)  It’s exactly this belief in the power of minimizing freak-outs that fuels my hatred for Doc Yoda’s attitude this morning.  You know what stresses me the fuck out?  Knowing I get about 10 minutes with my doctor once every 12 months and having to spend all of it answering questions about my yoga practices.  So, congratulations doc, you just added so much more stress to my life.  A+ effort and all that.

I treated the rest of the appointment like a junkie hoping they’ll get a discount if they listen to their dealer talk about their new pitbull.  Doc’s got the stuff I need, be a good girl and let the doc talk.  I left with my scripts for steroids, stims, estrogen and progesterone support, intralipids, and Lovenox.  Oh, and a healthy dose of stress.

As we were preparing to leave the consult room, Mr. But IF asked a few more questions about the lap findings.  Basically, our third/fourth/fifth utterances of “are you sure my tubes are fine and there wasn’t an endo annexation of my bowel occurring?”  Yes, tubes fine, no, minimal endo.  I replied, “That’s a relief.  I expected worse due to how it looked last time and how many quality of life-impacting symptoms I’ve been dealing with.”

“Are you alive?” he asked.

“Err, yea.”

“Then the quality of what you do with that life is totally up to you.  Only you can improve that.”

[Blank stare.]

“Have you read about the man with no arms and legs?” he queried.

“Uh, no?”

“You should.  If he can find joy, so too can you.”

I left my comments regarding my mother’s joyless chemo unspoken.  I got my drugs.  I got my probing.  I got the fuck out.

My parting gift?  A giant middle finger from my body.  I knew it was too good to be true when he said we could start stims as early as tonight if I appeared to be baseline.  The ultrasound showed a giant follicle/cyst on my right ovary, and bloodwork revealed a mildly elevated P4 and LH.  I could have ovulated (and left a corpus luteum cyst behind), I could be about to ovulate (and be witnessing the final growth of the follie), or I could just have a rock star lazy non-functional cyst hanging around.  Either way, I’m neither ready to start IVF nor ready to take Provera.  Bloodwork on Friday to check what’s up.  More waiting!  Huzzah!

I wonder if I can “use the force” to get this cycle going?  Probably not seeing as I fully inhabit the dark side…

Electives

I actually used to like electives. You know, the classes no one could make you take? The ones where you got to explore in an academic setting the bits and pieces that made you you.  My senior year of high school was divine.  In addition to my usual butt-load of advanced placement (AP) courses, I indulged in taking both band and chorus.  As drum major, band was my first love, but hanging out in the choir room with my primarily chorus kid friends and high school musical co-stars was a lot more exciting than, say, physics.  Intro to Acting, the Philosophy of War and Peace, Film and History, Race in the Age of Empire – I spent my high school, college, and two graduate school careers embracing that word “elective.”

In the past several years, however, “elective” has been redefined.  No longer the fun extras in my life, my health conditions and physical needs are now viewed in various ways as “elective.”  This became clear to me again yesterday as I sat through my (predictably underwhelming) pre-operative consult with the fertility clinic.  After reviewing my medical history, current medications, past experiences with anesthesia, and all the other bells and whistles, the NP began her pre-scripted laparoscopy/hysteroscopy speech.  I learned of all the many ways I could die, be rendered permanently sterile, or be reliant on a colostomy bag for the rest of my life as a result of the surgery I’ll have again on August 20.  I was asked to give my consent to undergo removal of my tubes should the surgeon deem it necessary, and was advised that a hysterectomy would be performed should that option be medically necessary to save my life.  Yet, none of that discussion was unanticipated.  Yes, it made my heart race, but I sucked it up and, with a fair amount of been-here-done-this-before positive thinking I nodded in agreement.  Until the following was uttered: “And, you understand that this procedure is entirely elective.  This procedure is not necessary for any reason other than potentially improving fertility.”  No, that one startled me.

Don’t get me wrong, I completely understand that I will not die tomorrow if I do not have this lap.  Endometriosis has not caused my heart to be one beat removed from its last, and in the world of “will I die in an hour if you don’t operate?” my procedure is about as elective as they come.  But, I do take offense at the sentiment that this procedure is only being performed in the hopes of improving my fertility.  Honestly, my hopes of that ever happening sailed off into the sunset a looong time to go.  Like, after the first lap that didn’t result in immediate fecundity.  The knowledge that we are moving to the very expensive and very not covered by insurance land of IVF following this thankfully-is-covered-by-insurance laparoscopy definitely impacted our decision to move forward now, but by no means am I only doing this lap to improve the likelihood of a positive IVF outcome.  I’m doing it for a whole host of other “trivial” reasons, such as the following:

  • To be able to have a bowel movement more than once every few weeks;
  • To minimize or even eliminate the extreme leg, back, and pelvic pain I feel EVERY SINGLE DAY;
  • To make it possible for me to actually work and function for the first three days of my menstrual cycle, rather than be tied to a bathroom variously vomiting, thinking about vomiting, changing my super/overnight pad/tampon every half hour, or washing another pair of underwear, jeans, and sheets that bore the brunt of my latest pad/tampon mishap;
  • To decrease the fistfuls of Advil I have for breakfast, lunch, and dinner when my period arrives;
  • To shorten my 10 day periods to a lovely 5 or 6;
  • To enable me to have sex with my husband without being immediately engulfed in tears from the searing pain of penetration; and,
  • To, you know, remove the fucking abnormal growths that are slowly destroying my body and my quality of life.

So, no kindly nurse, I do NOT understand that this procedure is only being done to improve fertility.  In my mind, it’s being done to make my life worth living.  Thanks for advocating for the health and happiness of your patients, by the way.  It’s not like those of us with endo are facing a very difficult climb to get respect from insurers, employers, and society at large.

At least this time around I know up front that my surgery will be covered by my insurance.  Last time I was living in a state with no statewide insurance mandate for the coverage of infertility diagnosis and treatment, so, as I mentally and physically prepared for the impact the surgery would have on me, I also had to financially prepare for the impact it might have on my pocketbook.  In a state without insurance mandates, my “elective” exploratory laparoscopy in 2012 was, as the insurance call center rep informed me, “on equal medical footing with a breast augmentation.”  And, she continued, “We don’t cover breast augmentations!”  It was an odd experience to wake up ecstatic to hear that abnormal cells were growing on my ovaries, tubes, and pelvic wall, and had fused my bowel to my abdomen.  I was thrilled to be ill because it meant the surgery would be paid for by my insurance, not by depleting our savings.  So, things could surely be worse with this second at-bat at this having a hole cut in my stomach thing.

I thought electives were, you know, supposed to be elective?  Something you chose, something optional, something to be assessed, debated, and voted on.  How, then, is my infertility elective?  At what point did I chose to be infertile?  When did I decide to allow endometrial tissue flourish outside of my uterus?  And, if this is something I “turned on,” how the fuck do I turn it off?

If you’re looking for an update…

… you’re not going to get one.

Had my beta drawn at the local lab at 7:45am this morning.  Drawn by a phlebotomist-in-training.  A phlebotomist-in-training that was being trained by “I’ll be your surro!” gal.  I was introduced as a frequent flier, and also used to teach vampire-in-training what to do with used sharps containers.  It was a laugh a minute.  “I’ll be your surro” was genuinely sad when I told her I most likely wouldn’t be seeing her again until October at the earliest.  She pouted as she asked, “But why?”  I was feeling vindictive, so replied, “If you have $15K you want to give me for our next attempt I’ll come back sooner!”  She stopped talking then.  The silence was beautiful.

On Monday, the night before beta #1, I was so anxious I couldn’t sleep.  I had such trouble sleeping that I overslept and didn’t get to the lab until about 8am.  Then I got stuck behind poor little old confused woman that had come a week early for her pre-op and was jamming up the works at outpatient admitting.  Blood didn’t leave my veins until 9am.  I got the call from the clinic with my beta of 38 at 11:15.

Having gone much earlier this time around, I was hopeful for an earlier call.  I waited.  A computer went down at work and I couldn’t fix the connectivity issue.  I cried like a baby.  (If our IT doesn’t stop fucking around with network I swear they will receive the full brunt of my next Lupron crazy attack.)  Then, after submitting  ticket that basically said, “Stop fucking with our network!” I resumed my waiting.

One nice thing about working at the same university as Mr. But IF is that we generally have lunch together.  Today was no different.  When noon rolled around, we met at our usual spot, and I had my phone and list of WTF questions for the nurse on the table and at the ready.  I was sure she would call just as I took that first juicy bite of my apple.  But, I’m no n00b.  Even after the father and his prospective student daughter sat down right the fuck next to us I knew I’d still gladly shout over the din in the cafe to ask questions about my progesterone levels, inquire about cycle package costs, ask when to start my birth control, and demand a consult to discuss future protocols rather than just continuing to do them on the fly.  It’s then when I realized something.  Something that was about to turn Mr. But IF into a stammering pile of bright red German anger.

It’s Thursday.  The clinic closes early on Thursday.  In fact, the clinic closed 10 minutes ago.

Guess I’m not getting my beta results after all.  Given the one line pee stick I got this morning, I decided to celebrate being royally fucked over yet again with a giant cup of coffee.  I might follow it up tonight with a giant pint (pints?) of beer.  I have no hope, I’m just sad that Mr. But IF did.  And, just upset that he’s upset.  I lost all faith in humanity and the kindness of infertility clinics long ago.  Against better judgement, he seems to have retained some.  I hate being right all the time.

Total fucking breakdowns have their perks

So a (not so) funny thing happened at this morning’s monitoring appointment.  But, since I’ve largely been AWOL lately, let me back up.

We’re in the midst of a Gonal-F injectables IUI cycle.  This, of course, comes on the heels of our most recent failed Gonal-F timed intercourse cycle.  And, in the midst of our decision that we’re finishing out the year with treatments — IUI and then one IVF — and then we’re calling it quits for good with the whole TTC ballgame.  So, to say the pressure is on a little is a bit of an understatement.  After responding decently on low doses of Gonal last cycle (2 follies created in response to 7 days of 75IU and 4 days of 112.5IU), this cycle has been a total mindfuck.  I’ve done 5 days of 75IU and 5 days of 150IU and still have no lead follie(s).  My estrogen is going up and down like a yo-yo and my LH is being predictably unpredictable.

Just to make life more exciting, it seems I’ve suddenly developed strong side effects to either one or both of my current meds (Gonal and Lupron) that I didn’t really have last time around.  Last cycle I had a bit of a headache, this cycle I want to carve my brain out with a mellon baller just to get the pain in my head to quiet for a moment.  Last cycle I felt a wee bit emotional, this cycle I literally go from calm to catastrophe in a matter of seconds.  On Friday, I had what I presume to be my first ever panic attack.  I couldn’t get the lid off of my sharps container, I threw it across the room, and started crying and convulsing uncontrollably.  As I felt my mind leave my body and began to watch myself from outside the hysteria, Mr. But IF dutifully packed me into the car as we started our long drive down to the in-laws for the holiday weekend.  Slowly, everything went numb.  I couldn’t feel my lips, it felt like a million tiny needles were ballet dancing across my skin, I couldn’t catch my breath no matter the effort I put into breathing, and the tears kept flowing.  It was terrifying.  Totally fucking debilitating.  And, the entire time, I was powerless to stop it or to stop the growing panic setting in for dear Mr. But IF.  A little over an hour into our drive I caught my breath, found a teensy bit of mental clarity, and Mr. But IF bought me ice cream.  And, like that, it was over.  But I’ve been clinging to the edge of a cliff ever since.  Not ever the best place to be, but even worse when you have no idea what you’ll find at the bottom.

And, in a nutshell, this was the baggage I brought to my monitoring appointment this morning.  So, when my least favorite NP walked in I braced myself and suppressed the inner grimace that was fighting to come to the fore.  As she went about aggressively probing around in an attempt to find my right ovary, the grimace surfaced.  I’ve had hundreds of trans-vaginal ultrasounds over the years, but never once have I felt as much pain as I felt today.  She pushed, she pulled, she twisted, she angled… she even took the wand out and tried to find it abdominally.  Nothing doing.  So, at the end of it all when I was informed I had two 11mm follies (barely worth measuring) on the left and a completely missing right ovary to show for 10 dutiful days of injecting myself with psychosis-inducing crap, I lost it.  And, by that I mean I totally fucking went bat-shit crazy.

As I’ve explained before, I have issues with my clinic.  Actually, I’ve had issues with both of my clinics.  My first RE – a one-man-show sort of practice – redefines the word arrogance and had an office staff that was so totally inept that they ultimately caused me to leave the clinic in a blaze of curse-laden voicemail messages, canceling my first planned IVF and accepting a job 2 states away in the process.  As awful as that sounds, I’ve been finding myself missing that very same clinic as I’ve endured the trials and tribulations of my new mega-practice.  I had come to view my old RE as your local neighborhood Hallmark franchise.  Yea, they are over-priced, but you keep going back for the nostalgia (I always got a Hallmark Christmas ornament growing up) and the desire to support the familiar group of little old ladies that work there.  The new practice?  It’s Wal-Mart.  Equal measure “Always low prices,” “Why can I never find someone to help me?,” and “I totally know I’m going to leave here wishing I’d gone somewhere else.”

As I commenced the world’s finest showing of shit flipping this morning, I let all my frustrations out.  What started with a simple, “So when do we actually cancel this pointless cycle?  I’m sick of wasting my time and my meds on this train wreck!” became (a likely much less coherent version of) the following:

I’m totally done with your practice and the revolving door of NPs I’m constantly subjected to.  I’m sick of none of you knowing shit about me, ever explaining a damn thing to me, and constantly asking inane questions and offering demoralizing, uninformed, trite advice.  I’m convinced that none of you have ever once looked at my chart and, as long as I keep paying, you’ll keep running me through this conveyor belt until I loose my mind, give up, or die.  And, I don’t even think you care which one of those comes first.

Did I mention I threw a tantrum?  Cause, yea, I did.  And, lest you think that my assertive, often emotional blog voice is the same as my often reserved but skeptical and analytical feet-in-the-stirrups voice, I should probably say I never act like this with my doctors.  I often don’t trust them, but I do acknowledge how totally dependent on them I am for my care and treat them with a level of professionalism and calmness that, quite frankly, they don’t often deserve.  All this is a very long way of saying that what transpired this morning was abnormal.  Really, really out of character.

As my rant continued my formerly least favorite NP transformed before my eyes.  This woman I’ve quietly hated for months due to her rushed and nonchalant approach to my situation, suddenly changed.  I swear her face softened, her voice lost its usual sharp edge, and she physically relaxed as she stopped her mad rush to get out the door and onto probing number 20 of the day.  She turned back around and sat on the stool to talk to me.  And, even more importantly, she started to listen to me.

Through the tears I recalled my history for what felt like the hundredth time.  But this time, she started to hear it.  She opened my chart and started going through it – commenting on what tests I’d done there, what tests I’d done with my old doctor and asking questions about prior diagnostic procedures and the paths that led me to all my diagnoses.  Somewhere along the line I told her that both my emotional stability and my fears of a resurgence of my mild endo were playing into our decision to be done come 2014.  I explained what I’d been thinking but barely able to express even to my husband in the past months.  Namely, that my hallmark endometriosis symptoms (chronic constipation, pain, heavy bleeding, intense menstrual cramps, etc.) appear to be coming back and that has me terrified.  I told her what I remembered from my post-op report with my old RE, the one who had excised my endo in February of 2012, and explained that surely the records the old clinic had sent to them contained more detail than my recovery-room, drug-addled mind could ever recall.  She went into my historical records, found the post-op report, and started to read.  Despite the gigantic three-ring binder I maintain that comprises the whole of my medical history for the past 4 years, I’d never seen the surgical report.  I wasn’t remotely prepared for what came next.

She read it aloud.  I recall phrases like, “right fibria obliterated,” “right ovary encapsulated in adhesions with evidence of torsion,” “cul-de-sac decimated,” “extensive scarring,” “retroverted uterus,” and “bowel affixed to left pelvic side wall.”  I wish I had requested a copy of the report, but I was in the midst of having my world turned upside down.  I still don’t feel like I know which way is up.  You see, my old RE, the same RE I’d been sorely missing these past many months, had simply told me my endo was “quite mild” and posed no cause for concern moving forward.  Following my lap we happily did two clomid cycles (1 BFN and 1 chemical) and it was only our declining patience and his refusal to do injects without IVF that actually prompted us to move down the IVF path this time last year.  He didn’t recommend IVF, he basically said Clomid may work, but if we cared more about getting pregnant quicker than getting pregnant cheaper then IVF would be a good option.  After all, my endo was “so mild,” my tubes “completely clear,” and my prognosis “nothing but positive,” that there was no medical cause for concern.

The report I had read to me this morning – a full 17 months after the surgery that generated it – doesn’t even exist in the same universe as those unfounded, optimistic platitudes I had lobed at me back then.  The NPs jaw started to drop as she formed the words to read them aloud.  When she was done she turned to me and said, “Honey, your entire right tube and ovary are completely shot.  I’m not surprised I couldn’t find your ovary this morning.  I’m afraid your adhesions are back.”  She continued with, “Knowing this, your pregnancy in December was so unlikely.  You must have ovulated on the left and had one stubborn embryo.”  And, finally, she said, “I’m so very, very sorry.  You are right.  Someone should have caught this; someone should have read this before now.  Had we seen this we never would have pursued the treatments we’ve been pursuing.  You need another lap.  And you need IVF.”

In an odd way, it all was kind of comforting.  This is a dance I’ve become so familiar with over the years.  I report my concerns to my doctors, they dismiss me with the lowest common denominator answer, I do my best dutiful patient act and follow their orders, I become increasingly miserable, I reach my breaking point (physically, mentally, or both), I push the issue, and I finally start getting answers.  This is my Hashi’s diagnosis all over again.  Hell, this is the path that led to my initial lap all over again.  In late 2011 I terminated a suspected ectopic, in early 2012 we were blindsided by the news that both of my tubes were blocked.  At my consult after that failed HSG the doctor suggested that it was likely a “false positive” initiated by cramping or “casual debris” and merely suggested another HSG (this time under sedation).  I went home and pondered my options, discovered my aunt had endo (thanks for telling me earlier!), went back to the office, demanded a lap, and found I indeed had (supposedly mild) endo.  Present problem, languish with problem, be ignored, reach breaking point, demand more than simplest answer, find validation in being right, and welcome in new anger and disgust at the fact that you’ve been left languishing for so long.  Rinse.  Repeat.  It’s odd when joy becomes a prevailing emotion in response to repeated discoveries that yet another part of you is broken.

Mr. But IF is furious and quite possibly planning a murderous rampage down to our former home state to “chat” with our former  RE.  It will likely involve a baseball bat, or hammer, or maybe one of my bruiser cousins.  (And, to any law enforcement types reading this, please consult the definition for hyperbole.)  I, on the other hand, feel more hope than I have in a long time.  I’m angry, but I’m angry and armed with answers.  And those answers are more empowering than even Mr. But IF can fully appreciate.  Today someone gave me a window into my fucked up body and acknowledged my pain, confirmed what I thought to be idle worry, and validated our path moving forward.  My anger stems from the fact that, yet again, it was a totally uncharacteristic, unprofessional meltdown of epic proportions that initiated these revelations.  But, as far as the other elements of the story, I’m oddly zen in this moment about it all.  Talk to me in an hour.

So, what’s the plan?  We’ll continue this mindfuck of a doomed IUI cycle because, after the shit these meds have put me through, I’m totally not willing to pull the plug just yet.  I go for another (fifth) follie check Saturday morning.  We’ve scheduled my next laparoscopy for August 20, and we’ll commence our first IVF as soon as I’m recovered from the surgery.  And, with the toll my work has been putting on me lately, I’m almost happy for the lap.  It’ll be a vacation that even my boss can’t talk me out of taking (which has happened to every other vacation day I’ve tried to plan this summer so far).  And, my amazing mother-in-law will come up for the surgery since the hubs will have to work and be unable to drive me to and from.  I really am amazingly blessed in some ways.

The even bigger picture plan moving forward is that I’m going to stop accepting half-assedness (hell, quarter-assedness) on the part of my new clinic.  Every visit I have moving forward will specifically be with my formerly hated, now much respected NP from this morning.  (Apparently, I should have magically known all along that I could “simply” request an NP by name each time I appeared at reception if I wanted to have the same one every time!)  I also have been assured that the doc is always at my disposal whenever/however I need him, and that if anyone ever gives me a hard time or doesn’t treat me with the patience I need and deserve I’m to report it to my new BFF NP.  Fences aren’t totally mended (I mean they did totally fucking practice medical negligence for the past 8 months!), but for once I actually feel like we are moving in a positive direction.  You have no idea how good it felt to hear the NP say to me, “We dropped the ball.  I’m so very sorry for this and you have every right to be furious.  I know it makes none of this feel any better, but I think sometimes we detach ourselves from all that is going on with our patients as a coping mechanism.  I know I do.  It’s hard to remember sometimes when you are doing 20 or 30 or 50 monitoring appointments in a given day, that this appointment is your only appointment and you need us to be there for you 100%.”  The latter part of that paraphrasing does go a long way toward making the “we fucked up” part of the statement a lot more palatable.

Or, maybe the Gonal’s made me soft?  I mean, it’s certainly been adding fluff to my mid-section, so why not my heart as well?