Published January 12, 2014 | By Greg Hodgson-Fopp
So, this is part 2 of my best attempt to describe the surrogacy process in as simple a way as possible. You should probably read part 1: “Before the Magic Happened” ahead of this if you’re new here.
This part describes the most scientifically intensive part of the process, and also consequently the most anxiety-inducing part. There are a lot of resources on the internet that talk about the IVF 2-week wait, and I now understand why this is something so many people need to write about. It’s basically the hit-or-miss throw of a very long, very emotionally laden process. It’s where the biggest joys and biggest let-downs occur. It’s also probably the part people understand the least, as it bears no resemblance to what happens in a traditional pregnancy.
Transvaginal Aspirations
The process starts with egg aspiration. We talked in part one about synchronizing the menstrual cycles of our egg donor and Natasha, our surrogate, so that their, ahem, ladygarden seasons were roughly in alignment with each other. Ideally, they should be about 5 days apart. The Egg Donor will be ready first.
For the last month, the Egg Donor has been having injected hormones and hormones taken as pills, which cause her to “Super-Ovulate”. Rather than the normal one egg per month with ovaries taking turns that would occur throughout her natural life, this month her ovaries have been kicked into higher gear and will be producing a whole bunch of eggs.
We were told to expect anywhere between 10 and 20 mature, usable eggs. That doesn’t mean that she produces 10-20, generally she produces more, but only the mature and fully ready ones are able to be used.
During the course of the month leading up to the aspiration, our Egg Donor made multiple visits to the fertility clinic, and they used an ultrasound to examine her follicles to see which ones are maturing and growing eggs. It’s important for an egg donor to have lovely follicles that show up easily on ultrasound and are accessible.
Actually, our second choice for Egg Donor was rejected primarily because her follicles weren’t big or visible enough on the ultrasound. So I guess it’s just another something to keep in mind. Some girls just have bigger follicles than others, I guess.
The actual process kicks off about 36 hours before the retrieval process, when the fertility clinic begins the last stage of “ovulation induction” which triggers the final maturation process. This is done with drugs that mimic the hormones naturally produced by the pituitary gland, and tells the ovaries to ripen and release their eggs.
The Egg Donor then comes into the clinic for the procedure and is put under. They are generally asleep the whole time this is going on. The actual technique involves a really, really long needle (seriously, it looks like it’s about half a meter long) which is inserted into an ultrasound probe, and then guided by ultrasound to the follicles of the ovaries. Think ‘acupuncture needle’ and you wouldn’t be too far wrong.
For obvious reasons this is known as “Transvaginal Aspirations” which I personally think is a great name for anything. I can definitely imagine a German Rock band with that name.
Dr. Ringler identified the mature follicles by massively amplifying the ultrasound picture. When this needle pierces the follicle, a gentle suction is applied and the fluid contents of the follicle, including the egg are retrieved into a vial, which is then palmed off immediately to the lab. The whole process takes about 15 minutes, and the Egg Donor generally only needs a couple of aspirin to recover fully within the day.
Once the eggs are safe in their new glass houses, there is a very short window of opportunity for fertilization. Approximately 2 hours. Which is why we kind of needed to make sure all important decisions were made in advance.
Phone-calls in the night
In our case, the stress started before the Aspiration day. When they examined our Egg Donor on the day before, Dr. Ringler was unsure about the number and quality of the follicles. He asked us to consider what we might like to do if we only got a small number of eggs this time.
This sent Matt and I into a bit of a spin, because it sounded like he was advising us to change our plans. We had always decided we were in this together, and we would divide whatever number of eggs that we got equally, and implant equally. That way (as has now turned out) if we got two babies, it’d definitely be one each and done.
But when our Doctor sent us a message saying “Please consider what you’d like me to do if I am unable to get enough eggs to do both of you.” Well, it sounded like he was asking us to decide who would go first.
I decided this needed clarifying and so I called Dr. Ringler up in the middle of our night once the time-zones allowed me to do so, and we went over his expectations and our plans. It turns out, he was quite happy to go ahead with both fathers even if the number of resulting embryos was quite small. It might have meant that only one of us could be a father this time if, say, all of Matt’s eggs were successful and all of mine weren’t. But I think we were already quite happy with that possibility. So that’s what we went with.
It’s been our mantra from the start – Do everything equally, and let nature decide who is going first.
We started with 12 candidates
So, we arrived at the day of aspiration, and thankfully in the last 24 hours before aspiration, a number of mediocre mature follicles had actually matured fully. The Doctor and our cheerleader egg donor were able to aspirate 12 eggs. For some reason, when I picture our egg donor, I keep picturing Hayden Panettiere - who played the Cheerleader in Heroes. I’m happy with that image, it’ll do.
As it happens, all of my straight male friends seem very happy with her image, too. Note to self for future reference, who not to invite to our babies 18th if they’re girls.
My friends at work seem to think the next part of the process simply involves a big bucket and some gentle stirring, perhaps with a wooden spoon, and people standing around cheering individual wrigglers on. They have been referring to it as the “swishy swoshy” bit for months.
But it’s actually a whole lot more scientific than that. Our 12 eggs were inseminated with a method that involves gently piercing the outer skin of the egg with a super fine needle, and then actively picking up one sperm and shooting it down the needle and into it’s goal. How they picked that one sperm from the 470 million I left them with, I have no idea. Luck, I guess. When our children are a bit older, I shall remind them that they started life with a 1-in-470 million chance lottery win.
With this injection based fertilization there is no competition, there’s no risk of dual insemination, and this method has a higher rate of success (65-75%), so my reading confirms.
Also, Matt and I had horrible visions of sperm ‘fighting it out’ in the race to the goal. I mean, the stakes are pretty high, so there’s every reason for the little fella’s to slug it out. Only one winner, and the rest consigned to the drains of history. It wasn’t really a helpful image.
And then there were 9
24 hours after the fertilization happened, the embryos were checked. Of the 12, only 9 had successfully fertilized. That’s pretty much exactly the statistical average for this method based on my extensive google-powered research, so we should consider that a success. We then started the 5 day wait between Egg Aspiration and Implantation.
On day 2, the embryos are at a stage called the 8-cell stage and their progress is again checked. At this point, they don’t even vaguely resemble anything but slightly advanced amoebas. It is expected that at this stage, a proportion of the fertilized eggs will not have progressed to the next stage. In our case, one embryo did not advance to the 8-cell stage, but was still just 2 cells at day 2.
And then there were 8
There really isn’t much to tell about the process at this stage. The little candidates for implantation are proceeding with the natural state of affairs in little dishes inside small bio-safes which are humidity, temperature and atmosphere controlled. The right amount of oxygen in the air, the right amount of moisture, the right comfiness of the petri-dish, a few pillows (not too soft, not too hard), maybe some light refreshments provided, I guess. The doctors leave them alone at this stage to quietly go about their business of cell division and growth.
For Matt and I, this was not a quiet time. There were no light refreshments and climate controlled atmospheres. We were pretty much not sleeping, not eating properly, bickering about small things, and frankly utterly unable to focus on our normal lives.
For me, it was a particularly stressful few weeks at work, and the addition of knowing that we were in the Knock-Out-Round of our baby making was pretty much putting me over the edge from my calm, reasonable and unflappable self and dangerously close to going Postal at co-workers for things I’d normally handle with effortless grace. We got by, I think, mostly because we were in separate countries at the time. Matt had to be in Australia (again, for a far from stress-free rollout of software) so we were a half world apart.
In LA, little bundles of mini-me in petri dishes were being made, while the fathers concerned were respectively in Switzerland and Australia. Talk about long-distance fertilization. We’ll be able to gleefully tell these poor children that their parents totally phoned in the procreation process.
I know they were in safe hands, but the science is still so far from 100%, and the internet full of people whose stories did not go well, that we were pretty much bundles of nerves the whole time.
And then there were 4
I know Matt and I were deeply regretful that we couldn’t be there on the day of the implantation, to be with Natasha. It was just a case of bad timing for both our work commitments, and trying to work out that fine compromise line between dedication to employment to keep the income safe, and dedication to a process happening a 14-hour flight away. In the end, Natasha went to her appointment with her mother, which I’m very glad for, as having such a supportive family makes me reassured that there are people there looking out for her well-being.
So, on day 5 of the process, a Saturday, I sat home and basically kept hitting refresh on my email waiting for updates from either Natasha or the clinic itself. Giving up waiting for emails, I rang them a couple of times, but when they work on a Saturday, their reception staff aren’t in, so I kept leaving voice-mail.
I can’t fault the clinic, they did exactly what our instructions said. We were later given a copy of the scans from the microscopes, which showed the final 2 candidates that Dr. Ringler had selected as the most viable. This photograph is sort of like the first family shot, now that we know that both implants were successful. We shall definitely roll it out at prospective birthday parties, that’s for sure.
And 2 were left
The process of implantation starts with grading. While they are growing, the embryos are monitored closely and given grades. Some clinics use a three-grade system. Such as “5AA” or “4AB” to rate different parts of the little mini-me. One grade is for baby, one is for the placenta, and one for the sack of embryonic stem cells they’re floating in. Our clinic uses a slightly more common system of just giving them the number to represent their overall prospective chances.
By then, of course, I’d over-educated myself to death in what a 5-day blastocyst (lovely term) should look like. The larger of the two was pretty much text book perfect, I could tell that. I actually considered submitting the photo for the textbooks to use in future editions. But I was mildly concerned about the viability of the smaller one. Natasha told me that they’d shown her the implants before whisking them into the catheter, which she found oddly rewarding.
In subsequent follow-up emails, the clinic informed us that the four embryos that were left with from the 12 original eggs all scored 4.5 out of 5, except for one ‘super star’ which scored 5 out of 5. That’d be the text-book perfect one then.
Though initially we felt gutted to get down to just 4 embryos from 12 eggs, a bit of research tells me this is a pretty good result. The statistics say that only 1 in 6 embryos makes it to an implantable quality. As it stands we got close to 50% of our fertilized embryos at implantable (or freezable) quality.
I was happy that we had two frozen, because we intended all along to have two children. So knowing that we had a couple of spares for 2-3 years time was very pleasing to me. It gave us the chance to think about that, and factor that in. To know that if we wanted to repeat the process, we could do so with the same genetic materials.
For our implant, the ‘super-star’ embryo and one of 4.5 embryos was implanted. The process involves pretty much exactly what you would expect. A long, thin, plastic tube, an ultrasound for traffic control and guidance, and a little bit of a push and the embryos are gently dropped off at the end of the line where they’re expected to make themselves comfortable. Dr. Ringler reported that he was very happy with the quality of the embryos and the implantation process itself. Natasha was safely heading home straight afterwards, and we actually heard from her (texting from the car) long before the medical staff at the clinic had had the time to sit down and write up their emails to us.
And then we began the most harrowing part of the process altogether – the wait to see if we’re pregnant or not.
This is known as the “IVF 2 week wait” and any research at all will show it’s the most stress-filled part of the whole process. And that’s what I’ll save for the next post.
