A dish not yet cold enough

Just over a year ago, our hometown clinic advised (as I'd feared they would) that we quit our IVF cycles and switch over to donor sperm & Clomid IUIs.

So then they sent us to a shrink to make sure we were okay with donor sperm, and the shrink pointed out that, if we wanted to do one more cycle someplace else, we should just go ahead and do it, so we went to Cornell, and, well. (Actually, if you've started reading recently, it all did get hairy for a while in November and December.)

I'll be back in Ohindinois in late June. For a variety of reasons, I don't have an OB there, and I'm really going to need one. Monday I called our old clinic looking for a referral to the giant OB/GYN practice next door (they share the ultrasound suite: yes, bitter IVF stimmers sit next to giant pregnant bellies in the waiting area!). Today I got a call back from Dr. Brash himself.

There exists an alternate universe in which I crowed immediately, "Remember how you didn't want us to fuck up your stats? Well, we went to doctors a lot more famous than you, bucko, and it worked when they tried!"

Fortunately for everyone, I don't live in that universe. Instead I live in a universe where I can spend an evening's surfing careening from Cloth Diapering 101 to Fetuses and Newborn Infants at the Threshhold of Viability: A Framework for Practice^*. We're not there yet, folks. I know.

In fact, I was so indirect that it took several minutes for Dr. Brash to realize that I was looking for a referral because I was, well, pregnant. I finally 'fessed up to Cornell. He asked about their protocol and homed in on the endometrial coculture: "We used to do coculture here, with monkey cells. We got quite good results in cases of IVF failure. But we had to shut down the program. You know, everyone who gets vaccines is exposed to those cells. It's really not such a big deal."

Cornell's protocol was structured completely differently from Dr. Brash's: they tried to get the first best eggs, instead of the most. But, c'mon folks, the labwork rocked: 100% fertilization, instead of 25%? (I did manage to point out that last stat during the conversation.) Mostly, though, I was struck by the phrase "IVF failure." It burned, even now, to know that that was how he saw me—and confirmed the gut feeling I'd had that I shouldn't cycle again at a clinic that thought I shouldn't.

IVF is a procedure that, at very, very, very good clinics, only succeeds half the time. Two failed cycles earned me that label—me and at least 25% of the patients at any program. Even though no one knows why cycles fail. And no one knows why they succeed either. Perhaps our odds were worse than I can imagine, even at the fancy^** clinic; perhaps we just got lucky. Perhaps we were simply unlucky at our first clinic, and there was no point to the undercurrents of reciprocal blame ("Bad doctor!" "No, bad patient!") in today's conversation. We'll never know.

Dr. Brash also counted up how many embryos it had taken us to get this singleton pregnancy (13), and I hated him for it. But not so much that I told him how much less my Cornell endometrial biopsy hurt than the one with him (that man is vain about his hands!), 'cause I only live in that universe in my dreams.

In the end, he offered a cogent discussion of his colleagues down the hall. I trust him on that sort of thing; God knows I heard enough from him about hospital politics during such tender moments as post-transfer immobilization. (And I'm paranoid enough to want to deliver at the hospital that they'd Medivac me to anyway if anything went seriously wrong.)

^* Remember the spotting a little while ago? Last week Dr. Pippi-Poisson found a small cervical polyp, which she snipped off. I think I've had a couple of Braxton-Hicks contractions, which freaked the hell out of me, but basically all is well.

^** It's tax time again, so I have the numbers at hand: the one cycle at Cornell cost—including travel expenses, which isn't entirely fair, I suppose—as much as two cycles with Dr. Brash.

Comments

[bj]

Hey Emma:

It's so great that this pregnancy worked. And you know, you posted, before your beta, saying that it was the right decision to work with Cornell. So you're not falling into the success failure of post hoc evaluation (i.e. it worked, so of course I"m happier).

Since I'm an academic, and so are you, can I quibble about your statistics? It's not true that a 50% failure rate overall means that 25% of people have 2 cycles that don't work. That calc would assume that everyone did 2 cycles, and the likelihood of success on the 2nd was uninfluenced by success on the 1st. Both assumptions are unlikely to be true.

Those conditional probabilities will get you every time.

Congratulations! I'm so looking forward to normal normal normal reports from you. You know, your life might get sickeningly boring soon -- a research mentor, a good job, a baby. Maybe you'll be able to title your blog "don't hate me 'cause my life is perfect. " I'm teasing (I know your husband has a life threatening illness, and as pointed out in laughter and forgetting, nobody's life is perfect from the inside, and lots of them might look enviable from the outside) -- but isn't it nice to imagine being in that position.

bj

[Emma Jane]

Ah, but if the results are positively correlated (and it would be a sick sick world if independence failed any other way), then that will only push up the probability of consecutive failures... as would going to a less good clinic. Also, women who succeed the first time are pretty likely to try again -- they believe it works, and few people want just one kid! (Should normality ever entail around here, that might be the central drama oh, 18 months from now or so. Of course, I've been too chicken to find out if they have any of Beaker's sperm left on ice.)

One of the things we really liked about Dr. Data was that he was quite open about the correlation issue, and what happened if one looked only at those with no success so far, and quoted us different (lower, but not super-low) odds than Cornell's, overall, for my age. Plus, Cornell has done enough cycles that their personal data collection is really substantial.

I really don't know what I think, in the end. I see so many women getting sent out for more testing, after cycles fail. Getting protocols renovated. Changing clinics. Hating their bodies and their life choices. Really, really suffering with the decision on whether to keep going -- as we did. Is there a skill issue? Do the doctors know what they're doing? Dr. Brash gets an awful lot of women pregnant, an awful lot of the younger ones with twins. Is he better than I give him credit for? Aggressive in filtering his patients? Aggressive in treatment, in ways that work well with many patients? Or lucky, except with me?

Would I feel any clearer if I had access to both clinics' raw data and could do my own Bayesian analysis? Data being data, and my knowledge of practical statistics being sucky, quite possibly not. Sigh.

[boxing octopus]

those braxton-hicks are freaky, aren't they? i had my first one the other day and it was like my belly turned into a watermelon. not painful, just strange.

has your baby started acting like an octopus yet? sometimes i wonder how many limbs my critter's got.