Everything I need to know I learned on codeine

I've been correponding with my friend H., who's been in on our diabolical scheme from the beginning, and a very helpful sounding board throughout. She's a veteran of several painful episodes of her own, and had this to say about my ectopic adventure:

"Pain is an interesting bedfellow. It teaches you things...but I'm not sure what you learn is actually worth it."

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Infertility for dummies

I was thinking today about what H. said to me about pain, and it occurred to me that I've learned a lot so far. Courtesy of my inner Pollyanna, here's a partial list — I think each phase teaches me something, though I'm not sure it's worth it.

1. Take as many drugs as you can legally acquire.

Pharmaceuticals are your colorful gelcapped friends. There is simply no reason to be undermedicated if you're going through painful procedures or pregnancy loss. If they offer you Tylenol 3, fill the prescription and take it, frequently. If they offer you something stronger, thank your lucky stars and take it, frequently. If they offer you horse tranquilizers, feel free to take them, frequently. Believe me: you will be glad for any help you can get.

If, on the other hand, they offer you nothing, grab your doctor by the lapels of his immaculate white lab coat and ask. In fact, insist. You might end up not needing pain medication, and you don't have to take it, but you should have it readily available just in case. If worse comes to worst, you can slip it to your nosy sister-in-law should she ask too many questions.

2. People who love you will say stupid, stupid shit.

No matter how dear they are, how sympathetic, how supportive, the people you love are going to say something sooner or later that's so breathtakingly stupid it'll make you want to scream. They love you and they want to make you feel better — and they honestly won't be able to help pissing you off.

They need to say something, because they truly hope to comfort you in a difficult time. But because they may not have dealt with infertility or loss themselves, they don't know what not to say. Either way, consider cutting them some slack. They do love you, stupid shit aside.

You have a couple of choices as to how you handle this: you can suck it up, or you can educate them. I personally chose to respond with a sickly smile, as I could see they truly did mean well, and crammed all my rage into a tiny ball, way down deep inside. (This approach may not work for those of you who are, you know, sane.)

3. There is not a limited amount of fertility in the world.

I can personally guarantee that while you're going through treatments, there will be at least one of your friends who gets pregnant with no trouble at all. In my case, it's three so far. Most days, I'm tempted to feel bitter (no shock, since we have already established that I am a petty, stunted person who should be shunted off immediately to work among the lepers for a much-needed lesson in generosity). Other days, the tiny rind of magnanimity in my soul surfaces and I think, Good for them. They're as happy as I'd be.

On these rare occasions, I'm able to remember that one person's pregnancy doesn't count against some great cosmic total: their extravagant fertility doesn't reduce mine. If nothing else, an acute appreciation of schadenfreude gets me over the hump: I may wish I had their ovaries, but I certainly don't envy the rest of their lives.

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A little knowledge is a dangerous thing

It hit me hard this week: I'm back at square one, no closer to having kids than I was before.

Even a garden-variety miscarriage might have brought some weird solace; for a few days I was able to console myself by chanting, "At least you know you can get pregnant. At least you know you can get pregnant."

Well, I don't really know that, do I?

(At the moment I refuse to seethe about the righteous indignation some infertile women can summon. "I've never even had a positive! At least you know you can get pregnant!" "Yes, and I also know how devastating it is to lose it — I hope you never learn." Wait. I guess I don't refuse after all.)

From our first cycle, I know I can make eggs, though not as many as those loathesome perfect cyclers who bubble up dozens without turning a hair. I know we made a pretty embryo.

But I also know that we only made the one, possibly due to a male factor that our several semen analyses didn't detect. And I know that the single pretty embryo we did make lodged itself firmly in my Fallopian tube, revealing the greater possibility of another ectopic in the future and the possibility of tubal damage. And as a special bonus, I learned that there's an implacable endometrioma perched on my ovary, taking up space and suppressing egg production, possibly requiring a laparoscopy before our next cycle.

I knew if our first cycle was unsuccessful, at least we'd learn from it. I didn't expect to be so goddamned discouraged by that knowledge. What we learned is that there are numerous plausible reasons for our infertility, instead of the single simple explanation I'd hoped to discover — in short, we're more mysteriously fucked than we thought.

I don't want to dwell on last cycle — if I must, I'd rather be reflecting on our new knowledge as a tool to improve our future chances. I intend to have achieved this remarkable feat by the time I have my next consultation, when we'll plan our next onslaught.

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Kindly old aunt, my ass

I find I sternly disapprove of the attempts to make this whole process seem warm and fuzzy. Take a look at any Internet message board where infertility is being discussed: You don't develop follicles; they're follies. You don't transfer embryos; they're embies. You don't bleed like a hemophiliac once every 28 days; you get a visit from your kindly old Aunt Flo.

If anything, mine's closer to being like Paul's evil grandmother. She was a crazy old bat who survived all her children by dint of pure meanness. In her declining years one of her grandchildren found her on the stairs, viciously kicking the shit out of her black leather handbag. "Uh, Grandmother...why are you kicking your handbag?" asked the grandchild. She paused, shook her head muzzily, and said, "Oh. I thought it was the cat."

That's my period.

So why do we (and by we I mean, well, they) feel the urge to make something cute out of infertility?

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After the embryo attains a CRL of 5 mm, the probability of subsequent loss falls to 7.2%. The loss rate drops rapidly thereafter to 3.3% for embryos with a CRL of 6 mm to 10 mm and to 0.5% for embryos with a CRL of 10 mm or more (i.e., 5 weeks postovulation or 7 weeks after the last menstrual period). That 3.3%? That's us.

Only 1.9% of pregnancies have small gestational sacs in relation to crown-rump length.

According to that same study, 80% of pregnancies fail when the difference between MSD (mean sac diameter) and crown-rump length (CRL) is less than 5 mm.

Another study with a smaller sample, however, found a more ominous failure rate: 94%.

Pregnant women have a lot of magical talismans they like to invoke against the potential for loss. One of them is the mythical 5% — "Once you've seen the heartbeat, your chances for miscarriage drop to 5%." There are a lot of things wrong with that statement, primarily the assumption that any statistic pertains to any individual. I am most painfully aware that even if you assume that magic number is accurate, somebody still has to be in that 5%.

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Fluid dynamics

The March of Dimes has this to say about oligohydramnios, the condition of having too little amniotic fluid (and thus too small a gestational sac):

The most important known cause of oligohydramnios early in pregnancy is birth defects in the baby (often involving the kidneys or other parts of the urinary tract) and ruptured membranes. The effect of oligohydramnios on the baby depends on the cause, the stage of pregnancy in which the problem occurs, and how little fluid there is.

In the first half of pregnancy, too little amniotic fluid is associated with birth defects of the lungs and limbs and increases the risk of miscarriage, preterm birth and stillbirth. [...] The causes of oligohydramnios are not completely understood. The majority of pregnant women who develop the condition have no identifiable risk factors.

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All of a sudden I get it.

I had a minor epiphany as I waited for the D&C. Though I knew this pregnancy was over, I would have given anything to change the situation if I could. I felt frantic, terrified, and absolutely desperate.

And then I thought, "Maybe this is how women who are having an abortion feel."


Women with an unwanted pregnancy probably feel just as trapped and scared as I did. I felt utterly violated by this procedure I was about to undergo — and I imagine that women who don't want to be pregnant feel every bit as violated by the presence of a heartbeat inside them.

I've always been pro-choice in theory, though I've never had to put that to the test. When my college roommate had an abortion, I saw that while the procedure itself was difficult for her, the decision to do it was not. As for me, I'd always been sure I'd have an abortion if I ended up pregnant at an inopportune time; if I ever imagined it, I saw myself resolute and implacable as I slung myself into the stirrups.

I never really thought of the emotional aspects of it — how many women who undergo abortions must be propelled by panic and desperation.

But as I sat in my cubicle, fighting off waves of anxiety, it occurred to me: Two sides, same coin. As much as I longed for my pregnancy to continue, they long for theirs to end. As destroyed as I felt, they'd be just as devastated if they didn't have the option to terminate.

I think I truly understood for the first time how important that option is. For the first time, I felt real empathy for anyone in that position. What a strange time for me to be feeling the power of sisterhood, though at least it kept me from feeling the full horror of my own situation.

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Something to look forward to

Fun fact: Women with diminished ovarian reserve who do manage, through some fluke of nature or science, to get pregnant at all...

...are at higher risk for miscarriage.

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Mighty, mighty

One aspect of the two-week wait after IVF drives women particularly crazy: the progesterone.

Most women are subjected to the nightly pleasure of a stab in the ass with a 1.5" 22 gauge needle. (For those of you unfamiliar with the gentle art of injection, that's roughly the length and diameter of a #2 pencil.) I, on the other hand, get off easy, with only the lowly progesterone suppository.

Our British friends call it a pessary, but that reminds me too much of a cassowary — the thought of shoving a large, flightless bird all up in my business makes me feel a little bit faint. I mean, would you look at the bony helmet on that thing?

So after that zoological digression, we'll stick with suppository. When I began my first IVF, I was worried about the progesterone injections; a friend had told me they were agonizing. Imagine my relief when the nurse told me I'd be inserting suppositories thrice daily instead. (And imagine, if you're feeling stout-hearted, the strangeness of being relieved by hearing the words, "suppository," "vagina," and "three times a day" in quick succession.)

Anyway, back to my original point, which I momentarily mislaid. Progesterone will make you crazy.

Its side effects mimic exactly those of early pregnancy — tender breasts, occasional nausea, slight uterine cramping — but also those of an impending period — bloating, depression, insatiable cravings for carbohydrates. But wait! There's more! At no extra charge, we'll throw in crippling constipation. Now how much would you pay?

At any point after embryo transfer, any physical sensation can easily be attributed to progesterone. You can think you're pregnant when you're not even close. Or you can think your period is imminent when you won't get another one for almost a year. In short, you're screwed; you can't count on a single one of your body's cues to tell you truly what's going on within.

In my case, the progesterone side effects swooped in overnight. I woke this morning with enormous breasts. Now, I am normally on the shapely side, which is a delicate way of saying I'm a brick...house. I am indeed mighty, mighty, but I do not dare to let it all hang out lest I destroy small villages with the devastating pendulum action of my breasts.

Today they are even bigger. Behold the majestic ProgesteRackTM! Look upon my breasts, ye mighty, and despair!

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Plan B: Make someone else do the thinking

I normally do pretty well during the two-week wait after any event intended to induce pregnancy, from the low-tech option of doing it like Amazon tree frogs on up to the high-tech maneuvers of IVF. Or I have so far, because I've always known what plan B was.

Ah, but this time is different.

Here are our options, as I see them, if my two embryos have killed each other in a bitter uterine gang war:

  • Another cycle of IVF at a top-tier clinic
  • A few cycles of stimulated IUIs
  • Adoption
  • Donor eggs
  • Bellowing "Stop the insanity!" and giving up on the idea of having a family

It all looks so good, I don't even know where to begin!

On the way to the hospital to have the embryos transferred, Paul and I had a long talk. You have never seen a man turn so pale so fast as when I said to him, "Living without children is not an option for me." To be fair, it's not the kind of discussion you ever imagine you'll have when you're first planning a life together. In principle, we'd agreed that we wanted children, but we'd never before confronted the possibility that we might not be able to have the kind with his peasanty-looking nose and my ineffable charm.

He has the usual reservations about adoption — How could I be sure I'd love the kid unconditionally? — but recognizes, from his experience with his own family, that shared blood is no guarantee of love to begin with. He worries that he'll look at an adopted child and always think, I wish we'd had one of our own. What he doesn't know is whether that's a show-stopper, or whether it would assume the same level of importance as the wish that we'd had a kid with, say, red hair or a flair for music.

These things are, alas, unknowable. The one argument I could make — and it's not really an argument — is that we often find our stance on theoretical issues changing once we confront the reality of a thing. Once the theoretical becomes the actual, the specific, the concrete, our thinking changes to embrace it.

I finally put it to him like this: I do not share his discomfort with any of the options. At this point, the goal (a squirmy, pissed-off toddler refusing to put on her shoes) is more important to me than how we finally get there. Therefore, he gets to pick. He needs to consider our options, decide which makes him the closest to comfortable, and choose how our family will come about.

Poor guy is still catatonic from the shock. I have stood him in the corner and have been using him as a coat rack.

So while I remain entirely agitated over the absence of a contingency plan, I am trying to lie low and let Paul do some thinking. Behind the scenes I am, of course, busily wishing, plotting, and scheming...

...and trying very hard to make these forlorn little embryos feel at home.

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