Unhappy cramper

I've started feeling strange abdominal cramps. I'm worried that something is going wrong. Obsessing about my uterus was a useful distraction, at least, from the horrible movie Paul and I went to see tonight. (Not even the delectably pockmarked Jet Li could save it, and I normally like the hitting.)

For the record, I refuse to believe it has anything to do with helping Paul move lumber yesterday. I keep chanting to myself, "Slave women gave birth in the fields and kept on working." I, cream puff that I am, need not worry about overexertion.

Aside from the sore breasts I've had since I began the progesterone suppositories, I had my first symptom of pregnancy tonight at the movie. Paul unwrapped a chocolate bar and the smell of it was so intense I had to get him to re-wrap it. It felt like an assault. It didn't make me feel sick, but, wow, sensory overload from a whiff of chocolate. Since then, I have noticed that everything smells like cigarettes. Some women get a lush new rack. Some women get lovely skin. I get a full pack of Camels crammed right up my nose. Thanks.

If something is wrong, there is, of course, nothing to be done. Third beta is tomorrow.

Fat lady, you're wanted onstage.

The news isn't good. My third beta rose from 226 on Wednesday to...269 today.

Dismal, dismal, dismal.

I've been asked to return on Monday for yet another beta. The nurse presented three possibilities:

1. a failing pregnancy;
   
2. an ectopic pregnancy; or
   
3. a meaningless statistical blip in an otherwise healthy pregnancy.

I sure would like to believe it's the latter, but I don't think that's a realistic hope. To say I am sad doesn't really cover it.

That Hallmark moment

My beta went up, so theoretically I'm still pregnant. And shocked to the core.

It increased from 269 on Friday to 713 on Monday — that's a 63% two-day rise.

Now the Internet, blessed fertility oracle that it is, tells me that's adequate, although certainly not ideal. (And getting medical advice from the Internet has proven so far to be a great idea.) But after our two-day stall last week, I refuse to get too excited.

Seems like I've been refusing to get too excited for weeks now. I was quietly smug after the first beta, cautiously optimistic after the second, and solidly grounded in determined pessimism by the third.

Goddamn it, I completely missed that Hallmark rush of elation. You know, the one where I present Paul with, I don't know, a tiny pair of booties and he looks bewildered for a minute, then breaks into a smile whose brightness rivals the sun. And then he lays his hand lovingly against my still-flat belly (not that it's flat to begin with, but this is my fantasy), and speaks in a hushed tone of wonder and says...

I have lost my mind entirely. See, I told you this whole thing fucks you up good. To be fair, we're not exactly Hallmark people to begin with.

I'm scheduled for a scan early Friday morning to see what's going on. By then my hCG levels should have risen, if they're going to, to about 1,200 — that's right around the discriminatory level for seeing a sac with transvaginal ultrasound. First we want to see a sac in the right place. Then, though I don't really dare to hope, we want it to be the right size.

Until then, I will be working very hard to will a comely little sac into existence.

Relatively good, absolutely bad

The good news is that we saw a gestational sac via ultrasound today. The bad news is that it's much smaller than it should be at this point. (It should be at 10 mm by now, and mine is only 5.)

So the good news is only relatively good: it just means that we can pretty much rule out an ectopic. Indeed, the doctor stirred the ultrasound wand enough to check out my tubes and ovaries, and they appear to be normal, with no fluid masses.

The bad news, however, remains absolutely bad. This is not a viable pregnancy. I asked my doctor if the sac could somehow catch up to where it needed to be. Because he is a kind man, he gave the appearance of considering it, but finally had to say, "I would be shocked."

This is what we expected to hear after the appalling lag last week in my hCG levels. But expecting bad news doesn't make it any easier to take when it's delivered at last; it just makes it easier not to look like you've been kicked in the gut.

Denial is a lovely name for a girl

This is the worst mindfuck I've ever had. I know my pregnancy isn't viable. I've seen the evidence myself on ultrasound. I've left no electronic stone unturned on my Internet quest for a single piece of research that could prove the ultrasound wrong. I've found nothing. I know it's over.

So why did I dream last night that we had a baby girl whose name was Lucy?

The best of three bad choices

A miracle did not occur. We were not surprised.

Today's ultrasound showed that the gestational sac had grown, but it was still about a week behind where it needed to be, with no yolk sac, no fetal pole, and obviously no heartbeat. If you don't have most of those things at 6 weeks 5 days, you're just not going to get them.

It confirmed what we already knew. I felt a dull sadness, a background version of the more turbulent feelings I've been having for about two weeks now.

My doctor offered three options.

I could wait to miscarry naturally. As far as I was concerned, this wasn't an option. On the one hand, you know beyond a doubt that the pregnancy is really and truly over. On the other, that could take weeks, and could happen in the supermarket checkout line. At this point, haven't we gone through enough without imposing more uncertainty on ourselves?

I could have a D&C. I briefly considered this, but decided I'd like to avoid that if possible. I worried about the pain of the procedure, and I worried that I'd have to wait for an appointment. I wanted it over.

I could take misoprostol, a drug that induces miscarriage. (It's usually used in conjunction with mifepristone, but in IVF patients the other drug is unnecessary.) It's taken vaginally, and it causes your cervix to soften and dilate; the ensuing contractions usually empty your uterus of the products of conception.

I decided on the misoprostol because it will cause a predictable miscarriage that I can endure at home, properly medicated, without surprises. I'll be inserting the tablets tomorrow, after which I intend to spend the weekend feeling hideously, operatically sorry for myself.

Bloodless coup

I took the misoprostol yesterday as directed. I put it in around 8 AM and sat down to wait for my uterus to explode.

And waited.

And pretty much wasted the entire day just waiting to feel something. Finally around 5 PM I started feeling some gentle cramping. Because I thought the festivities were beginning in earnest, I girded my loins with the thickest maxi-pad I could find, dosed myself with Tylenol 3, and stationed myself on the sofa.

And waited.

Now I grudgingly concede that my vagina and what eventually issued forth are not of interest to everyone. Skip the next part unless you really want to know.

At long last the cramping grew stronger. At around 10 PM I began to pass some gelatinous fragments of grayish-looking tissue. There was never a lot of it, and very little bleeding. In fact, there was no red blood; I had only occasional scant dark brown spotting.

I found this disconcerting, as I'd expected to be floundering in a pool of my own blood by now. (First time in my life I actually hoped to see blood.) But I cheered up a bit once I decided I would probably wake up in the middle of the night having soaked through the sheet, lying in a pool of my own gore. I went to sleep with high hopes.

And woke up this morning lying in nothing more than a lighly spotted maxi pad.

Shit.

The dark spotting has continued, but I still haven't seen a single drop of red blood, and since last night I've passed no more of the grayish matter.

I hope I'm wrong, but I'm not convinced it's over yet.

I liked it so much I did it again.

I went back today to get my blood hCG levels checked after Thursday's dose of misoprostol. My doctor saw me in the waiting room and took me aside to ask me how it had gone. When I told him that it was mostly unproductive, he furrowed his brow and suggested an ultrasound. Why not? It had been days since I'd been romanced by a cold piece of medical equipment. A girl could start to feel neglected.

Sure enough, half of the sac was still there. He said I would probably pass that on my own if I was willing to wait, but he didn't seem surprised when I said I was eager to get it over with.

The weeks without a resolution have been excruciating. From the day of my second beta test, I've worried; from the day of my third I've known this wasn't a viable pregnancy. At this point, I'm in favor of anything that will hasten the end of this discouraging cycle.

On the way home, I stopped and picked up three large Symphony bars, a giant bag of potato chips, and a fifth of vodka. (A girl needs her medicine.) When I got home I inserted the tablets as before and sat down to wait for my insides to fall out.

I didn't have long to wait. This time it took effect more quickly. Within three or four hours I was having some fairly strong cramps. Now I'm having some spotting, some bright red blood instead of the dark sludgy stuff of last time. I have taken to the sofa and I will not budge until it's over, or until I need more chocolate, whichever comes first.

I can't even do this right

I don't believe it worked.

I bled some during the night, but not enough to convince me this is over yet.

I have yet another hCG test scheduled for Friday...my eighth, I believe. I am thinking of having a convenient grommet installed in the crook of my elbow for easy withdrawal.

Third time's the charm

I went in today for more bloodwork to confirm that the second dose of misoprostol worked. I had my doubts, as I'd finally had some bleeding, but not as much as you'd expect from a real live miscarriage. (I'd sort of expected to wake up the next morning with HELTER SKELTER painted on the wall in blood.) As I waited to be taken back for the blood draw, my doctor breezed past the waiting room, saw me, wheeled back cartoon-style, and took me aside to ask me how it had gone.

I told him what had happened, and what hadn't, and he seemed nonplussed. I had no ultrasound scheduled, but before I knew it, there I was, naked from the waist down and impaled on a probe. (Hello to you, too.)

What we saw was not encouraging. The remains of the sac were still there, the same size they'd been on Monday. "Want me to just get it out?" he asked.

"God, yes," I said.

A harrowing description of my cervix being wrenched open follows. You've been warned.

I gave my blood for the hCG test, took a couple of Vioxx, and waited for them to take effect. I asked for a sheet because I was cold. "I'm not cold," said the doctor. "Are you cold?" he asked the nurse. "No," she answered. "In fact, it's kind of warm in here."

"See, the thing is," I pointed out reasonably, "you're wearing pants." A sheet was produced with alacrity.

Shortly thereafter, the doctor and nurse collected their tool kit and got down to business. Speculum: check. Cervix swabbed with iodine: check. Panic attack held valiantly at bay: check.

"Okay, first I need to see where your cervix goes," the doctor told me. "Everywhere I do," I answered. Oh, how we all did laugh. Discuss among yourselves this question: why must I try so hard to be entertaining?

"Now I'm going to attach a grasper to your cervix to open it up," he said, and I was instructed to cough. It took him three tries to get a firm grip on my recalcitrant cervix.

"Grasper," I said, when I'd caught my breath.

"Yeah," he said. "It sounds less threatening than tenaculum."

And then things stopped being funny. I was given a local anaesthetic — lidocaine, I believe — and he waited a moment for it to take effect. Then the nurse, a real sweetheart, came to stand beside me, held my hand tightly, and said, "This is going to hurt, for only about 30 seconds."

It did.

Finally the doctor said, "That's got it." He and his nurse were quick, efficient, and as gentle as they could be under the circumstances. And they did a first-rate job of not letting me see any of the implements used or the so-called products of conception. (I know I would have looked. I don't think it would have bothered me, but I can't really know.)

My uterus continued to cramp for several minutes, so I lay quietly on the table under my hard-won sheet. The nurse brought some water, which I didn't want but drank. Another nurse came to check on me in a few minutes, and assured me that I could stay as long as I needed to. In about 15 minutes I was on my way home.

I guess I can't complain. It's not like I had a co-pay or anything.

You reproduce — I'm bitter.

If all goes according to my diabolical plan and my hCG level drops as expected, it should return to 0 around the end of this month. If I ovulate two weeks later, I should get my period sometime in mid-May. This means I could possibly do another IVF cycle in June.

I feel myself getting hopeful for the first time in weeks. And then I think, Wait. So far nothing's gone according to plan. Why in the world would it start now?

It's hard enough to come to terms with the loss of potential. (I don't even really think of it as the loss of a child — I'm not sure I'd dared to think in those terms.) What's almost as difficult is resigning myself to the loss of hope.

I don't mean I think it's hopeless for us to attempt IVF again, or that our hopes of becoming parents are forever dashed. Nothing that melodramatic or final. I mean that I don't think I can approach another pregnancy, or even another IVF cycle, with the same optimism I felt before.

The day I had my first beta test, I talked to my friend T. on the phone. T. has two gorgeous children, the result of two effortless conceptions and two uneventful pregnancies. I suppose I was pretty low-key about it, because she asked, "Aren't you excited?"

I told her, "Until I see that the second number doubles, I'll be hopeful, but cautious."

She said, "I can't imagine that. As soon as I saw those two pink lines I was choosing names and decorating the nursery."

It seems that infertility changes your whole frame of reference. Losing a pregnancy shifts it just as drastically. I didn't have that luxury, that heedless joy, in my first pregnancy. How cautious will I feel during the next one?

Still pregnant

After three attempts to end this once and for all, I am still pregnant. Only today, 8 weeks and 3 days after my egg retrieval, was I finally diagnosed with an ectopic.

The doctor's office called and said the pathologist found no chorionic villi in the tissue removed during my D&C. We weren't sure whether I'd passed it during my earlier miscarriages (and how strange is it to make that plural?), or whether it was a more ominous sign, so I went in for bloodwork to make sure my hCG levels had decreased as expected.

Well, they hadn't. In fact, they'd risen — a pretty clear indication of an ectopic pregnancy. Why didn't we know this earlier? I blame society.

No, wait. I blame the pseudosac.

Apparently, in 10 to 20% of ectopic pregnancies, a pseudosac is formed in the uterus, mimicking the appearance of a real gestational sac. I don't know why a pseudosac sometimes develops. Who the hell does it think it's fooling?

In my case, the sac we saw on ultrasound looked like an early intrauterine pregnancy — just one that was far behind where it should have been in size.

As to why this wasn't detected sooner, I can only assume it can be hard to tell the difference. Either you can wait for the development of a yolk sac and a fetal pole to be sure it's a true sac, or an ultrasound can show the characteristic double ring (known as the double decidual sign).

My doctor pored over the ultrasound films and determined that it looked like a real live sac. Because I was eager to move on, we didn't spend any more time waiting for a yolk sac to develop. We concluded it was simply a non-viable uterine pregnancy, and acted accordingly.

What can I say? Mistakes were made.

I've had attentive followup care; otherwise the situation could have become dangerous. I have some mild symptoms (cramps, bleeding), but I would have ignored them because they're also what you'd expect after a D&C.

I go in tomorrow for a shot of methotrexate, which should arrest the growth of the pregnancy, allowing my body to resorb or jettison the remaining tissue. After working so hard to achieve a pregnancy, I never imagined I'd be working just as hard to end one.

CAUTION: CHEMOTHERAPY!

After a quick detour for still more bloodwork, I went in today for the aforementioned methotrexate injection. Now, methotrexate works by interfering with rapidly growing and dividing cells — i.e., an embryo. Or a tumor.

That's right. Methotrexate is used to treat cancer. The pharmacy gives you the medicine in this big lightproof bag with fluorescent stickers all over it: "CAUTION: CHEMOTHERAPY!" and "DO NOT HANDLE WITHOUT PROTECTIVE CLOTHING." It makes you want to use tongs and gloves just to carry the bag back up to the nurse (who then dons a disposable gown, gloves, and fetching plastic cap, of course).

It seems like a scary drug, but apparently it's very successful in treating unruptured ectopic pregnancies. About one patient in 20 will still require surgery, but I have no intention of being among those ruptured few.

The injection itself was uneventful. I was given a stern talking-to about the absolute necessity of follow-up bloodwork on a weekly basis, and a long list of things I must not do:

1. Drink. Methotrexate screws up your liver, so just when you need it most, alcohol is forbidden.

2. Consume dark, leafy green vegetables. Folic acid impairs the efficacy of the methotrexate.

3. Drink orange juice. OJ is heavily fortified with folic acid, so see above.

4. Have marital relations. I must not be jostled, lest we free the embryonic beast within.

5. Spend time in the sun. Methotrexate makes you susceptible to really bad sunburn.

6. Be far away from a phone. I guess that's in case the creepy little thing ruptures and I need to dial 911 to bellow, "THAR SHE BLOWS!"

She used to seem so sane

I spent a lot of last night convinced — for no good reason — that I was going to die. I wasn't really prepared for the horrible cramping the methotrexate would cause, and I was sure it was a precursor to the "sharp, stabbing pain" all the Web sites promise upon a rupture.

My anxiety level wasn't exactly flatlining to begin with. My doctor called this morning to check in, and I think I must have sounded suspicious when he identified himself, because he hastened to assure me that he didn't have any bad news.

"You can't really blame me for being afraid another shoe's going to drop," I told him. Last night when I was panicking about the pain, I realized that I really have come to expect bad things to happen. I've been on the freaky side of the odds the whole way, really, and it's hard to believe anything will change. One patient in 20 will still need surgery after the methotrexate; with my track record, I wouldn't bet against it. I've already packed my goddamn toothbrush.

I asked him how long we'd have to wait after the resolution of the ectopic to do another cycle, if we'd need to wait longer to recover. "You mean for your sanity?" he asked, not getting it.

Sanity? Long gone. I'd have thought he'd know that; surely I'm crazy even to be considering another cycle. Last night was iron-clad proof that I've lost it entirely.

I sat quietly in the kitchen while Paul made dinner, not helping because I was sure I'd felt light-headed. I told him I hoped I didn't progress into dizziness, then wondered anxiously whether light-headedness and dizziness were the same thing.

I obsessed aloud for a full 10 minutes about where the tips of my shoulder are — one symptom of a ruptured tube is "pain in the shoulder tips," but how could I know whether I had it if I couldn't figure out what the hell a shoulder tip was? Paul's wise approach: "Are your shoulders hurting at all?"

"No," I admitted sulkily.

"Then you probably don't have to worry about shoulder tip pain."

Damn him.

It took me a very long time to go to sleep because I was afraid I wouldn't wake up, that my tube would rupture in the night and I'd bleed to death without being awakened by the pain. I cried for a little while as Paul snored beside me, thinking about how sad it would be for him to find me lying lifeless in our bed.

How embarrassing when I woke up the next morning not dead after all.

Sunday, bloody Sunday

Every time I go to the bathroom, it's like I'm visiting my own murder scene.

I am shocked to be bleeding this much. I started bleeding after my D&C more than a week ago and haven't stopped since. It wasn't clear where the D&C bleeding stopped (if it ever did) and where the ectopic bleeding started (if it has). There's certainly been a qualitative change in the bleeding, though.

I am totally fascinated by the torrential downpour landing on my maxi-pads. If you're not — and who could blame you? — don't read any further, okay?

See, at first the bleeding was just this thin bright red stream. It looked almost like Kool-Aid, cheerful and watery. When I'd crouch over the toilet, curling over to watch it leak out, it would just flow and flow like urine.

But in the last couple of days I've been producing these awe-inspiring clots. Today I passed one the size of a quarter. The blood has gotten darker, a little more serious-looking, and rather viscous. I'd swear there's mucus in there; when I wipe with toilet paper there are these impressive pink and gooey strings.

I can't wait to see what's next.

The downward spiral

This morning's hCG level seems to have plummeted from 4,583 to an astonishing 317.

Can this be right?

I'd thought it should take approximately as long to come down as it did to go up. I found an interesting note here, though:

After successful tx of ectopic, serum hCG decreases in two-phase distribution (initial half-life 5-9h; secondary half-life 22-32h)

If this is true, today's number makes a lot more sense than I initially thought.

No major change on the pain front: Still hurts like a motherfucker. I'm experiencing general abdominal cramping, with special bonus throbbing on my lower right side. The nurse assured me this is expected as the pregnancy detaches from the tube. Don't let anyone tell you Tylenol 3 will do the trick, though; hold out for the Percocets. This really hurts. And I assure you I am no piker when it comes to pain tolerance.

I'm also sprinting to the bathroom every half-hour or so, but yielding only these ridiculous little trickles. I unbuckled my belt for that? I'm told that the increased urinary urgency is a result of blood in the peritoneum — I guess that's not supposed to sound as alarming as it does, because the nurse didn't seem concerned.

The bleeding appears to have stopped for the moment. Since this morning I've had only scant spotting, quite a change from yesterday. Overall, I appear to be holding my own, except for the minor matter of abdominal agony, inadequate pain relief, and the complete denial I seem to be luxuriating in.

This too shall pass

All hail my Fallopian tubes. I passed it at last.

The pain was bad throughout the afternoon. I called the doctor's office to ask for some sort of medication. All they could prescribe without an order in writing were those damned Tylenol 3s. (Thanks for the war on drugs, Ronald Reagan. Fucker.) The codeine didn't help much, but I was gobbling them hungrily, for want of any other relief.

By evening, I was spending a lot of time in the kind of pain that made me see stars. The cramping was intermittent but strong. When a cramp came on I was reduced to taking fast, deep breaths to try to work through it. The breathing didn't help but it was the only thing I could think of to do.

I lay in bed most of the time because I felt light-headed whenever I stood. Sometimes I'd walk to the bathroom, sit on the toilet, and then sink to my knees and crawl back to the bed to avoid fainting.

At one point I became convinced that only a hot bath would soothe the cramps. I ran a tub full of hot water and sat in it for about half an hour, until I was well and truly boiled. The hot water did help relieve the pain for a while. When I got out, though, I was light-headed again, so I lay down on the bathroom floor to rest for a while.

Just in case you're planning ahead, a word of advice: Never do this unless your bathroom has been cleaned within, say, the last week.

Another word of advice: If you're easily squicked, read no further. Really.

When I finally managed to stand up, I realized I'd been bleeding all over the bath mat. I also realized that the mass that had been in my right tube wasn't there any more, because I felt it slither down my vagina. I had the presence of mind (and the requisite twisted interest) to cup my hands between my thighs to catch it.

Now, I should make some excuse for my deep fascination with this. All along I've felt like a human science experiment. My body's reaction to the stims, my weird pregnancy symptoms, my apparent inability to miscarry when told to — I've found all of these things mysterious and interesting. Since my narcissism is apparently infinite, maybe it's no surprise that I wanted to inspect the yield this time, too.

And inspect it I did. It was about the size of a walnut, and composed of three distinct parts. Part of it was a giant blood clot. Another part looked like ground meat. The third part looked like whitish tissue.

I wonder which part was which. I couldn't tell. I imagine it had gone through some unpleasant compacting as it got squeezed through the chute. There was nothing there that looked remotely like baby, but then I didn't expect that at such an early stage. It was pretty much what I did expect: a gelatinous blob of rejected tissue.

After inspection, I deposited it unsentimentally into the toilet and gave it the royal flush, with my most intense feeling being relief.

Now, you know, there are women who save the remains of a miscarried child and bury them in the garden. There are women who can't save the remains and agonize because of it. There are women who memorialize their never-to-be babies, who name them, who think of them as angels who simply never had the chance to live on Earth.

I didn't. I don't. This wasn't a baby, a child, or an angel. It was an agglomeration of cells that grew in the wrong place, and that might have killed me had it grown much more. Forgive me if I don't seem, well, maternal.

What I am is tired. I'm feeling exhausted from the pain, relieved that it's over, and strangely peaceful at last.

Note to self: clean floor before dying.

Have you ever honestly thought you were going to die?

The early hours of the morning found me on the bathroom floor again, the floor which needs a good wash now more than ever. I lay there naked on a towel, thinking, I wish I'd made a will.

After I passed the big clump of tissue last night, it seemed that the worst was over. I limped into the den and arranged myself very carefully on the sofa, aching and enervated but feeling rather triumphant. I couldn't stop talking, making poor Paul listen to Blood-soaked Tales of Horror from the Master Bathroom, rendered in glorious verbal Technicolor. I guess I was giddy. I know I was proud of myself for making it through.

When we went to bed, I dutifully took two Tylenol 3s, thinking it would send me into a dreamless sleep of exhaustion. Not two hours later, though, I was back on the bathroom floor, planning my many bequests.

I didn't know whether there was still more tissue that my tube was trying to jettison, or whether it was just trying to shrink back to its normal size, or whether it was spraying a hot jet of blood through my abdominal cavity like a garden sprinkler. Maybe it was all of the above.

Three hot baths and three blood-spattered towels later, I'd finally concluded that it was time to go to the hospital. I'd spent the last several hours arguing with myself. I knew surgery at that point was probably unnecessary, as expelling the mass earlier surely removed the possibility of a tubal rupture. But I was also pretty sure that if I went in, it was fairly likely I'd still be put under and sliced up.

But, see, they'd give me really good pain drugs.

At that point, that's all I wanted: really good pain drugs. Okay, and someone else to be in charge of deciding what to do with me. Someone else in charge of taking care of me, because clearly I was doing a piss-poor job of it, lying naked and whimpering on the filthy bathroom floor.

So I took my last hot bath of the morning. I tried to get dressed quietly, but I woke Paul up in the process. He had to wake up sometime, because I'd decided it was time to call the hospital.

I did, and eventually spoke to the doctor on call. He listened very patiently to my whimpering, and offered the reassurance I needed: "I don't think you're in any imminent danger, and I don't think it's an emergency. You should probably be seen, so you can come in now to the ER, or you can wait until your doctor's office opens and see them then, whichever you prefer. But you're not in any immediate danger."

Paul was already awake and showered and revving the engine out in the garage, poor guy, ready to whisk me away to safety. I decided I'd wait until my doctor's office opened, only an hour from then, so he came back inside and stood by the bed holding my hand while I lay there panting.

I'm pretty sure I've never looked lovelier.

My doctor called in about half an hour, having been notified by the doctor on call. Just imagine it, if you will: "Dude, your patient's having a real, for-true crazy-person four-alarm meltdown." To his credit, my doctor was, as ever, attentive and reassuring. Despite all evidence to the contrary, he succeeded in convincing me that the worst was over, that I just needed to lie still, take enough Tylenol 3 to fell an ox, and rest. I'd spend most of the day feeling like I'd been hit by a truck, he warned, but it would get better.

It did, some. I slept most of the day. When I wasn't sleeping, I was lying in bed feeling like I'd been worked over by Turkish prison guards. But the worst did truly seem to be over.

Again.

Enough already

This morning I left a message for the nurse, just a progress report to let them know how I was doing: slight fever, very painful abdomen, burning when I urinate. I guess those are alarming symptoms, because the nurse called back shortly thereafter and asked that I go in that afternoon. Paul drove, and I kept up a monotonous whine as he hit every bump in the road.

I'm lovable these days.

Now, this particular nurse is very good at her job. She did not say, "My God, which rock did you crawl out from under?" She didn't even say, "You don't look so good." She said, "I'm glad we asked you to come in, because you don't look like you feel very well." May I introduce Sherlock Holmes, R.N.? Wonder what tipped her off. My unwashed hair? My red-rimmed eyes? My hollow, crazed look? The fact that I needed to be flanked on either side as I lurched down the hall to the exam room, unable to straighten up?

I then had a short visit with the doctor, who looked me over briefly, examined my nails and my skin tone, and opined that I'd had some internal hemorrhaging, but that it had stopped. Then he gently prodded my belly to see just how tender it was.

I surprised myself by bursting into tears on the table.

I mean, it hurt, but not that much.

I've simply had enough. I've been hurting for days, feeling entirely abused by the universe. I'd been completely unprepared for the pain, and don't feel that I was properly medicated for it. This was just one more indignity, one more poke, one more vigorous jack-booted kick while I was down, and I lost it for a minute.

That's what it's like. Physically, I'm holding my own; though sore and tired, I'm definitely on the mend. Emotionally, I am 100% tender, well-marbled belly. Enough with the goddamn poking.

Dear doctor, Knock it off. Anxiously, me

At the doctor's office today, I was marveling aloud at the size of the blob of tissue I'd expelled. My doctor said, with just a little too much eagerness, "Yeah, if we'd left it alone you probably would have had a rupture. It sounds like you were pretty close."

Um. Yeah. Thanks. Listen, next time could you say something, you know, reassuring?

Do you think maybe I've given an incorrect impression of how well I'm handling this?

No sex, please. We're infertile.

So when you're trying to have a baby you have sex all the time, right? It may be joyless, mechanical, and obligatory, but at least it's frequent, right?

I haven't had sex in two months.

The last time was a few days before egg retrieval. My abdomen felt swollen and fragile and I wasn't especially interested at first, but somehow it seemed like the thing to do. And it actually was; it was gentle, friendly, and sweet, a good way to be nice to my body when I wasn't treating it particularly kindly otherwise.

After transfer, I was instructed to observe pelvic rest (no penetration, no orgasm) until after the pregnancy test. Foolishly, we didn't seize the opportunity immediately once we had a positive. And only a couple of days later we learned that the pregnancy wasn't viable — a situation not exactly conducive to moonlight and roses.

So then I was going to miscarry. And then I didn't. And then there was the ectopic. And now I'm benched again until my hCG bottoms out.

The funny thing is, I don't miss the reality of it. My poor battered pelvis has been through enough. I don't even want to do it by myself — I know, I was surprised, too. I've had not a single stirring of desire in the last several weeks. I miss the idea of it, but my interest at this point is only vague and theoretical.

Which is a crying damn shame. It all used to work so well.

Three's a crowd

Got word today that yet another friend — the third — is expecting a baby in mid-November.

No wonder none of my friends were available to commiserate as I went through IVF #1. They were all busy conceiving children of their own!

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.

Day 6: Team player, my ass

This morning's scan wasn't promising. I've cried all day, leaking tears since I left the hospital. I even cried through acupuncture. The tears ran into my ears, and when I tried to wipe them I dislodged several needles protruding from my cartilage. (The acupuncturist was very kind, offered some thoughts about loss and unfairness. I hate to say it, because it's not like me to neglect such a ripe opportunity for gleeful mockery, but it was not creepy in the slightest.)

The scan showed that my right ovary isn't really rising to the challenge, and while I have several teeny follicles on my left, I also have a single malevolent giant that will probably require us to cancel the cycle.

The suppression drugs (Lupron, in my case) are supposed to keep your ovaries from developing a dominant follicle. What you really want is a bunch of them all the same size, developing at the same rate: a clutch of team players. When one leader decides to upstage the rest, it can keep the others from growing. It can cause also ovulation before retrieval — poof, no eggs, no cycle, no refund.

Because my clinic uses a team approach, I don't see the same doctor each time. The doctor I saw this time was one I hadn't met before. She was very emphatic about the likelihood that we'd cancel, but said they'd discuss it at the team meeting later that day.

I was somewhat relieved this afternoon to hear that my regular doctor wasn't necessarily convinced that cancellation was necessary. (I say "somewhat" because I wonder whether even unhappy certainty would be better than just not knowing. The anxiety is relentless.) He suggested that I continue the drugs and return on Friday to see what's going on.

If we have to cancel, we could still convert to IUI, but given that our problem is fertilization, I don't think that buys us anything. Good money after bad; on this Paul and I agree. By waiting until Friday to make a decision, the only thing we have to lose is a couple of days' worth of injectibles.

Oh, and my sanity. But that's okay, because I'm not really using it for much anyway.

Day 8: Whatever gets you through the night

The relaxing and effective ways in which I am coping with the likelihood of a cancelled cycle:

• Hyperventilating
• Wrenching my shoulders up into a twisted shrug only Chang and Eng Bunker could love
• Producing oceanic tides of stomach acid
• Standing up, sitting down. Standing up, sitting down. Standing up, sitting down to gauge the relative jolt sent through my ovaries by the shock.

Mission: aborted

Today started badly and got steadily worse.  I was up at 6 to wait by the phone.  I knew the doctor's office didn't open until at least 8, but I guess I wanted ample time to work myself into a high enough dudgeon. 

The first call was around 9, from the doctor who'd instructed me to trigger yesterday.  She apologized for the timing mistake, but reported that my doctor's opinion was that we'd be better off converting this cycle to an IUI after all.

My usual doctor called later after he got out of the operating room, and reiterated that opinion.  He said, "If I'd seen the ultrasound yesterday, I would have given you that advice then."  On Friday I'd had one follicle larger than all the rest, but by Sunday, he said, a second had jumped out.  "Three eggs, max," he said, "but more likely two" if we went to retrieval.

It was an extremely difficult conversation.  When I'm upset I shut down — these long silences occur while I try to think of something to say that sounds sufficiently sane and controlled, with no sputtering or swear words or inarticulate squawking.

I finally asked him what accounted for the discrepancy in his opinion today and the other doctor's comments yesterday.  He said he didn't think there was one, claiming the other doctor had agreed with our desire to go to retrieval as a gesture of respect for our autonomy.

Here's where I actually did start squawking.  We don't need a doctor to validate our fragile feelings of independence, for crying out loud; we need a doctor to give an informed medical opinion. 

"We're not allowed to be directional," he reminded me. 

"Please," I sputtered, hoping my eye-roll was audible.  I get very impatient with this statement, which he's trotted out on a couple of occasions.  Pop quiz, kids!  Who knows more about assisted reproduction: my doctor or, well, me?

Generally speaking, my doctor (yes, he has a name, and yes, I do know it) seems to tend toward optimism.  But his predictions about this cycle's potential for success were so grim that they frightened and convinced me.  An IUI it is.  Practically speaking, that means another $185 down the tubes with nothing to show for it — with our fertilization history we might as well write it off before it even happens.

As we wrapped up the conversation, he said that if we thought we'd be happier at another clinic, he'd write us a referral.  I don't even know how to think about this, and will worry away at it later when I'm bored by the usual topics.  For now I'm feeling sufficiently pathetic to leave it alone for the moment, thank you very much.

Now let us never speak of it again.

As we sat in the waiting room today before the IUI, my doctor lured us into a conference room, apologized for the clusterfuck that this cycle had become, and told me the IUI was on the house. He also gave us meds from the sample closet for our next round of IVF, free of charge.

I don't know what to make of this. I hope I said something grateful.

The upshot of this cycle is that it cost us only time and sanity. Because I am crass, I can admit that the failure seems to sting slightly less when the insult of losing money is removed.

It occurred to me to refuse, to say they should give them to someone who really can't afford the medication — I'm not exactly sure why I didn't, because I don't truly think we deserve any special compensation. I don't think my poor response to the protocol could have been predicted or averted.

Mostly I think I just didn't want to have to discuss it any further. I am worn the fuck out.

Paul, who yielded a sample this morning without turning a hair, joked with me while we waited, and sat steadfastly next to me while the IUI was done. ("Um, hey, sit near my head, not at the other end, okay?") The procedure itself was easier than it's been in the past. Veteran that I am, I instructed the nurse to bend the catheter "like a hockey stick," and it slid in easily once the speculum was wrenched open.

So it's done. I'm considering this cycle finished — I don't believe it can work. I've felt lighter all day, relieved that the stress I've been under is over. We won't go through another cycle until October at the earliest. See you in the penalty box.

Pollyanna is a fickle bitch.

On the spur of the moment, Paul and I went to the coast this weekend. It did me enormous good to get out of the house, to stop reading esoteric medical abstracts, and to focus on something other than my very busy pelvis. (Unless I am entirely mistaken, that's the sequel to The Very Hungry Caterpillar.)

As far as symptoms go, I am feeling utterly normal, aside from tender breasts and tiredness, which I've had for a couple of weeks now. I did feel intensely flushed right around 9 PM over the past few nights, but I'm assuming it's the hormones surging happily.

Things look good. So why am I intent on preparing for the worst? When I was packing my overnight bag. I considered taking the Tylenol 3 and a supply of maxi-pads, just in case I miscarried over the weekend. I realized at the last minute how morbid I was being, and gave myself a stern exasperated talking-to.

What's wrong with me? As excited as I am, I can't stop acknowledging that it could all go horribly awry any minute now. I've let myself feel joy, but I still can't seem to squelch the random surges of pessimism. I did my level best to smother them in a pile of dismembered lobster carcasses. Didn't work, but you can't blame a girl for trying.

I guess we spoke too soon.

This morning's ultrasound was grim.

The doctor who did the scan inserted the wand, looked around for a moment, and said, "What is she, about six weeks?"

As soon as she said that, I knew the news wasn't good. I'm 7w5d today.

The rather dippy doctor who was assisting shocked me by turning on the sound so we could hear the heartbeat. "I love hearing that," she said brightly. Note to doctor: I could tell the news was bad just by looking at the screen — so don't get my hopes up by making me listen.

Although the embryo is more or less appropriately sized, and although we have a strong heartbeat of 140 beats per minute, the gestational sac is far smaller than it should be, measuring at about 5w2d.

My usual doctor came in and looked at the scan with us for a few minutes. Then I got dressed and we waited for the bad news. It is easier to discuss such things while wearing pants.

"We both know that's not what we wanted to see today," he began. He said that although he'd seen cases where a small sac resolved itself successfully, he said it could also mean an impending loss. Though he said he's seen a worse case than mine turn out all right, he was not especially encouraging.

When the sac isn't large enough, the embryo doesn't have enough room to develop properly. The embryo gets compressed. Depending on whose statistics you believe, between 80 and 96% of pregnancies with such discrepancies between sac and embryo will fail.

Someone has to be in that 4-20% of successes, and I've been on the surprising side of the odds many times. But I have a feeling that this time I'm going to be in the unhappy majority.

The only thing to do, of course, is to wait. My doctor said he'd be happy to do additional scans as frequently as I liked; his recommendation was that I return two weeks from now. I didn't ask whether I was likely to miscarry before then, but I'm assuming that if it's going to happen, it'll probably happen before then.

Outnumbered

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%.

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.

Just so goddamned sad

Paul and I talked this morning while standing in the dark in the upstairs hallway. He said, "If this doesn't work out, I guess we'll want a long break."

I don't, at least not at the moment. I tried to explain how gladhearted I'd felt before Monday, how truly glad, and how wrenching it feels to be so close. How I'd known I wanted it, but hadn't really understood how much until now, when it seems to be slipping away. How I couldn't stand the thought of losing this pregnancy only to face more waiting, more months of standing still, delay in regaining the ground we're currently losing.

I know Paul's sad, too, and he might indeed need some time to regroup if this pregnancy fails. He'd just begun to get comfortable with the idea that it was actually going to work, shyly venturing ideas for what we could do to prepare or names he might like. I surprised him in his office this morning sifting through journal abstracts — same as I'd done yesterday. He wants to believe as much as I do that everything will turn out all right in the end.

I want to believe, but I can't claim I do. I've been drinking oceans of water in the absurd hope that somehow the gestational sac will plump up swiftly. It's the only thing I can think of to do, but even as I drown myself I know it's ridiculous.

This evening I felt some low-grade cramping. It didn't last long, and it was nothing even remotely like the cramps I'd felt when I'd taken Cytotec. But I thought, "This is how it'll begin."

Then, because my powers of denial are magnificent indeed, I thought, "Well, maybe it's just the sac expanding."

I'm just so goddamned sad.

Don't bet the farm

I talked to my doctor on the phone today. After Monday's ultrasound, I was too stunned to ask any questions, so I was glad for the opportunity to get some answers.

Sure wish he'd had some.

His predictions weren't as grim as my reading had led me to believe — he said he'd guess our chances were in the neighborhood of 50/50. "If I had to put money on it," he said, "I'd guess it'd turn out okay."

But I'm pretty sure he's not exactly packing his bags for Vegas. What I don't know is whether he's talking entirely out of his ass, or whether he's basing his opinion on specific aspects of my case and his own experience. He and his staff have always tried to give me the best possible care, but I'm not convinced this is within his field of expertise. I am not especially reassured.

I asked what causes early oligohydramnios. Unknown.

I asked whether I should be concerned about it in future pregnancies. Unknown.

I asked when we could expect a resolution. If I'm to miscarry, will it be sooner or later? If I'm not, when will we be able to breathe easily? He couldn't offer any idea about how swiftly I might miscarry. His opinion was that if I make it to 12 weeks, he'd feel comfortable (with some hemming and hawing) releasing me to a regular OB/GYN. But he also said he'd recommend various kinds of prenatal testing, which we otherwise wouldn't have considered based on my age.

He tried to be encouraging about our future prospects. "We did get you pregnant both times..." he said, in reference to this cycle and the previous one. (I waspishly reminded him of our numerous prior unsuccessful IUIs. I am not particularly receptive right now to encouragement.) From a clinical standpoint, I suppose it is good news that I can get pregnant, but that information is of little comfort in the absence of a live birth.

Running the diagnostics

I can't really say whether I'm feeling any different, because I'm paying attention to my body in an entirely new way now. Before Monday, I'd been experiencing the occasional cramp, thinking casually, "Oh. That's normal." Now, I feel my stomach knotting with every twinge, wondering if this is how it'll begin.

My breasts are still quite tender, more so, I think, than earlier in the week. I'm as tired, if not more so, but it's hard to tie that to anything concrete — it could well be my response to stress. Finally, over the last several days I'd been experiencing quite a lot of dampness, but today it seems to have vanished.

All of these things could be normal, or could be ominous. I don't know what, if anything, is changing.

No blood as yet. The embryo could have stopped developing at any time without causing bleeding, of course, but without blood at least I feel there could be a chance.

An infinitesimal one, to be sure.

Heart: beaten

No heartbeat.

As soon as the doctor inserted the wand and located the sac onscreen, I knew we'd lost this one. I wasn't looking for a heartbeat, so that's not what I noticed. What I noticed was the lack of room inside the gestational sac — it was even more crowded than it was a week ago. There just wasn't enough room for the embryo to grow.

The doctor searched for the heartbeat for a few minutes. She brought in a colleague to confirm her findings. No heartbeat.

I surprised myself by my response, or lack thereof. When I'd imagined this happening (and I had, playing it over and over in my head as if I could rehearse my way into acceptance), I'd wondered whether I would gasp, or cry, or squeeze Paul's hand until I broke his fingers. No: I lay on the table feeling enormously detached, as though I were a disinterested onlooker just watching this all happen.

I didn't cry at all. The most emotional I got was when I felt a crazy urge to complain: "You didn't give us a picture this time!"

I got dressed and the doctor took us into the consultation room. I've always liked this doctor before; she's the head of the department and inspires great confidence with her friendly manner. This time she was all business — still kind, but absolutely grave as she outlined our options. I'd heard this before, but I let her explain.

A natural miscarriage could happen that day, she said, or it could take up to a month — there was simply no way to predict. This wasn't an option for me. The thought of going about my business as normal and waiting to expel the pregnancy that was already over...no.

I could take misoprostol again. This option at least had the virtue of predictability, but I would still have to endure the ordeal of cramping, bleeding, and passing massive amounts of tissue. I was too scared to do that. Waiting for the ectopic to resolve last time frightened me enough that I wasn't going to volunteer to sit at home and bleed.

If I chose a D&C, it would be more involved than the one I had before; since I'd had no Cytotec to dilate my cervix, I'd have to go to the hospital for the procedure and undergo some kind of major anaesthetic. I asked how long I'd have to wait for a D&C to be scheduled. The doctor said I didn't have to choose immediately, but I could get it done the same day once I'd decided.

Well, that was that, as far as Paul and I were concerned. We asked to be scheduled that day.

I think we surprised the doctor, who seemed more used to counseling people who'd been surprised by such sad news. For better or worse, we'd expected it, and had already spent some time talking about our options. The sooner my body could begin to heal, the sooner my heart could. Theoretically.

The wait of the world

Once we'd learned the embryo no longer had a heartbeat, we asked for an immediate appointment for a D&C. The nurse who was making the arrangements consulted her schedule, then pointed out that my usual doctor happened to be in the OR that day, so he'd be the one to do the operation. I thanked her for her help, and resisted the urge to say, "I don't care who does it — just get it out of me."

I guess I was feeling a lot less detached than I'd felt in the exam room.

In order to have it performed that day, I'd have to be an "add-on": they'd see me in the OR after the rest of the day's scheduled cases had been completed. They couldn't say when, but would call when they were ready for me.

It was a long wait. A long, hopeless, foodless, drinkless wait.

It didn't make sense to drive home, so Paul and I wandered aimlessly downtown. We walked down by the lake for a while, watching the ducks and trying to process what lay ahead. We went to the bookstore to buy a distraction or two, where I couldn't help mocking the nice young man who earnestly wished us a nice day. We sat in a Starbucks for hours, having nabbed two comfortable armchairs. Paul drank chai and read while I cadged the occasional ice cube and cried discreetly. (In case you ever need this information, Starbucks' unbleached napkins are hard on a delicate nostril.)

Our chairs looked through a large plate glass window onto a busy pedestrian mall. Most of the busy pedestrians in question had babies, strollers, toddlers, preschoolers, or some combination thereof. Many of them, it seemed, were visibly pregnant. They all looked entirely carefree, seen through my personal bloodshot lens. I tried not to stare. I also tried not to be noticed as I cried. Hard to avoid when everyone in the coffee shop is trying to glare you out of the comfy chair you've been monopolizing for two hours.

It all made for a monumentally wretched day — the wait, the lack of privacy, the sadness I felt I couldn't politely show. And the worst was yet to come. As I told the nice young man at the bookstore, "Why, this day just keeps getting better and better!"

Completion

When the hospital called around 4 o'clock, we headed over. As soon as I got off the elevator on the surgical floor, I panicked. My heart started pounding and I realized I was sweating. No, no, no, I thought, I shouldn't be here. It's not too late to go home. It's not too late to get out of this.

I don't know what I'd expected, but when I saw the alcove where I was supposed to undress and wait, everything in me rebelled. This was a hospital, where people have operations. Surgery. Major medical interventions. This couldn't be right. I shouldn't be here.

Oh.

Wait.

I kept feeling this rising tide of panic, which I tried to beat back by reminding myself that nothing I could do would save the pregnancy, which was already over.

As Paul parked the car, I got settled in my alcove, changing into a gown and slipper-socks, getting my blood drawn, and generally trying to stave off a system-wide freakout. Every doctor and nurse who stopped by had a kind word, making me cry all over again each time. Every gentle pat on the knee. It's the kindness that gets me — as long as everyone is matter-of-fact I can hold myself together.

My usual doctor stopped by and asked if it was okay if someone else did the operation — he'd been in the OR since early that morning. "I don't care if the parking lot attendant does it," I answered, "as long as it gets done," and managed a bleat that passed for laughter.

Now a brief digression while I ponder this question: Why do I need to entertain my doctors? And why am I so intent on seeming impervious to every dreadful thing that's happened? And how scarily robotic does that make me seem? Truth be known, one of the main reasons I trust my usual doctor is that he seems only occasionally nonplussed by my primary personal coping mechanism: breathtakingly inappropriate humor.

We had a short discussion about the current score. One ectopic, one miscarriage. I'm 0 for 2! Maybe next time we can go for the hat trick. We talked briefly about the possibility of doing another IUI with injectibles rather than a full-blown IVF, but agreed to come back to that in a couple of weeks. I wasn't entirely equipped to be making major decisions just at that moment.

Then the anaesthesiologist came in. After a cursory inspection, I was relieved to conclude that he didn't look like a junkie. We had an awkward moment when he asked me if I was here for "completion." I didn't know what he meant. "Are you pregnant?" he asked. And I didn't know what to answer. Yes, there's an embryo inside of me. No, it's not alive. Completion. Indeed.

Finally, around 7 PM, I was wheeled into the operating room. An oxygen mask was fitted over my nose and mouth. The anaesthetic was introduced into my IV. Next thing I knew, I was awake, unspeakably groggy, smelling smoke.

Burned toast. The nurses give toast to patients emerging from the anaesthetic, a kind and merciful act considering that I hadn't eaten all day. When I felt well enough, I ate some toast (buttered, white, delicious) and drank a little water. Correction: Since they wouldn't let me leave until I'd proven I could urinate normally, I drank a lot of water.

At one point the nurse asked me if I was in any pain. "A bit of cramping," I answered, expecting to be given a couple of punk-ass Tylenols. To my surprise, I got a scrumptious hit of morphine right to the IV. I was shocked by how quickly it took effect; within five seconds I was feeling just fine, thank you. So I didn't win the jackpot — at least there was a nice little consolation prize.

Once I'd made it to the bathroom and demonstrated my urinary prowess, we were cleared to go home. I dressed, keeping on the funky disposable underpants I'd been diapered in while still unconscious, and Paul drove us back home. Two Tylenol with codeine, for forgetfulness, and I was out like a light.

Foul discharge

The last week has been grim.

After the D&C Monday night, I slept hard with an assist from my faithful henchpill, Tylenol with codeine. I took it easy the next day, hunkering down in a soft nightgown with a couple of shockingly crappy novels. I was bleeding, but not in any alarming amount, and while I felt sore all over it didn't seem unwarranted.

On Wednesday and Thursday I couldn't seem to do anything. Even unloading the dishwasher was a chore too daunting to face. I moped around the house looking tragic while Paul quietly and efficiently kept us fed and clothed.

Friday I started hurting. It felt like a bad period of mine: the bloating, the intestinal mutiny, the widespread abdominal inflammation that made me curl up in bed like a comma. And, hey, throw in some unusually persistent lower back pain just for kicks. Paul pestered me so skillfully that I finally phoned the doctor on call, who basically told me to suck it up, take more drugs, and ignore it unless I had a fever or "foul discharge." Neither of the above, so I simply continued my systematic abuse of narcotics.

I felt physically lousy, but emotionally I thought I was holding my own. Emotionally, I'd pretty much been okay — surprisingly, suspiciously okay. That came to a screeching halt on Sunday. I don't know if it was the chronic discomfort that finally wore me down or the hormone crash I'd been expecting, but since then I've been in an implacably evil mood. In fact, it's fair to say that pretty much every word that's come out of my mouth has been angry, sharp, and bitter.

I'm not a nice person to live with right now. Mostly I've managed to spare Paul the worst of my vitriol, mostly, though there was an unpleasant and uncharacteristic contretemps today over a missing tortilla. Although I try not to take it out on Paul, who's been nothing but kind, patient, and helpful, I'm furious at the world and the anger just keeps oozing out, a foul discharge in its own right.

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."

Oh.

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.

Three eggs, scrambled, runny

Nine eggs retrieved. Two eggs fertilized.

Of the nine, three were immature. Immature eggs can't fertilize, so they didn't even bother with ICSI on those. It's normal to have a couple of immature eggs in every clutch.

One was ICSI'd but didn't fertilize — this, too, is normal. ICSI only guarantees that the sperm gets inside the egg, not that it will perform brilliantly once it's there.

Three were of substandard quality. In fact, they were of abysmal quality. Total crap eggs, completely worthless.

See, an egg is surrounded by a membrane designed to allow a single sperm to penetrate it, the zona pellucida. This membrane is also what keeps the squishy contents of an egg inside — without it, the cytoplasm and nucleus just ooze into a useless mess. Some women have a tough zona; ICSI solves that problem. But my three bad eggs had a fragile zona that disintegrated as soon as they were manhandled.

Poof.

With two fertilized, we're already better off than we were at this point during IVF #1, so I suppose I shouldn't complain. And yet I feel like we've hit a wall, as if we've learned nothing from the past two disappointing cycles.

On second thought, I suppose we have learned something — that at 32 I have a worrisome egg quality issue — but it's not the kind of knowledge I hoped for.

I guess it's all relative.

"Hi, Julie. Can you give me a call back?" said my doctor on the answering machine. "It's not bad news — in fact, it's relatively good news — so I'd like to talk to you in the next eight hours or so."

Relatively good news. Now, normally when I think of good news, I think of things like a big tax refund, or a relative's cancer going into remission, or an out-of-work friend getting the great new job she'd hoped for.

Relatively good news would be, you know, breaking even on taxes, or that the chemotherapy isn't making Grandma sick, or that at least the friend is getting unemployment payments.

The kind of things that make you say, "Well, at least..."

So last night's "Well, at least..." was this: Well, at least we have one decent-looking embryo.

Despite the chipper message he'd left, when I finally talked to my doctor, the news overall wasn't good. That is, perhaps, an understatement, since I am, after all, characterizing a conversation that included the phrase, "donor eggs." The general drift was that my egg quality is poor enough that future attempts at IVF might not be worth it, considering the odds.

I asked a lot of disorganized questions and took very poor notes. Here's what I took from the conversation:

If your egg quality is made worse by a particular drug protocol, that can be manipulated a bit. And if your egg quality is decent at the outset but your embryos degrade, there are games you can play with the culture medium. But if you're seeing intrinsically bad eggs across a couple of cycles, there doesn't seem to be a lot they can do.

It's not normal for a 32-year-old to have a pelvis full of rusty scrap metal. I do try to be original.

Beyond the egg quality/donor egg issue, about which I will obsess at great length in the future, there was the news that one of our embryos is looking good. Yesterday it was a 4-A — 4 cells, grade-A quality, right where they want to see it. That was the good news. The other, however, looks like embryonic shit.

Must take after its mother.

But if the ugly one hasn't arrested by then, we'll transfer it anyway. Who knows? The good one might implant. And the mangled one could still turn into...the evil twin.

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.

A "maybe" is worse than a "no."

Here is something I did not know: an unequivocal negative is easier than an ambiguous positive.

To women who've never had a positive pregnancy test, that will seem like the rankest heresy. In unison: "At least you know you can get pregnant."

Now let's try it in a round, to the tune of "Row, Row, Row Your Boat."

Great! Next let's break it down old skool-stylee.

Wait, that last was a really bad idea.

The truth is that I do have the knowledge that I can get pregnant, but it's not the comfort you might think it is, because I also have the knowledge that I can lose it. I can be happy, the happiest I've been in my life — and that happiness can be yanked away unceremoniously in the space of thirty seconds.

(Perhaps it's crass of me to mention money, but I must point out that it particularly stings when you spend $11,000 getting happy...and they still charge you a co-pay when that happiness is shattered. My most recent D&C cost me more than a live birth would have. But I'm not bitter.)

It's oddly soothing to know that's not at stake this time. This time, I can go on a valedictory vodka bender, cry until I look like Marty Feldman, and know it's over. Then, somehow, I'll just manage to scrape myself off the floor to pursue plan B.

Home for the holidays, my ass

If you're not an infertile person, you may not be aware that the holidays are often painful for those of us who are. And I don't mean the wrenching sight of your freshly-scrubbed children in fuzzy red pajamas painstakingly writing their poorly-spelled letters to Santa (although there's that). I don't mean the agony of ringing in yet another sparkly new year no closer to having children in my home (although there's that, too).

No, I'm speaking only of the grinding inconvenience of it all.

If you have no children, it is settled: you will be the one who travels for the holidays. You will pack your bags, ship your gifts, farm out your pets, and assume the not inconsiderable expense of heading home for the holidays, arriving gaily on someone else's doorstep brimming with merriment. Why? "Because it's easier for you."

In a sense, this is true. Logistically speaking, I suppose it is easier for me. I don't have two car seats to wrestle, five sets of mittens to tame, or one cranky two-year-old to forcibly restrain upon takeoff and landing.

And yet there is nothing especially easy about spending every winter holiday for the last 14 years in transit. There has been a single exception, and that was the Christmas Paul's mother died. Not really a warm and festive carnival of lights, that one. We weren't exactly ho-ho-hoing ourselves stupid that year.

I sputter with the injustice of it, the unexamined assumption that it's okay for me to be inconvenienced because I have no children. Insult to injury, if you ask me. (You did. You came here on purpose. Hey! Finally, someone to roast a turkey for!)

And if it's inconvenient for fertile people to travel at holidays because they've achieved their heart's desire, pour me a big steaming cup of that inconvenience, please. Make it a goddamn double.

I make a better moron than a hero

From my doctor, via e-mail:

As always, nice seeing you two yesterday...I just wish the circumstances were better. I am in awe of the resilience you folks have exhibited.

My response:

Some days I feel heroic. Other days I just feel stupid.

Today is one of those other days.

I talked to a friend about our situation and told her we might try stimulated IUIs as we vacillate about whether to do another IVF. "Is an IUI really expensive?" she asked.

"Nah," I said, "not in the grand scheme of things." I was thinking in terms of an IVF cycle, which would cost us upwards of $15,000 at Cornell, to say nothing of the money we've already spent.

But when I told her how much a stimulated IUI actually costs, her jaw dropped. "What sounds like not a lot to you," she said, lips pursed, "sounds like an awful lot to me."

Once again I was reminded of how dramatically my frame of reference has changed, and of how foolish and almost reckless this pursuit sometimes seems, even to me.

The money is really the least of it (and I know how fortunate I am to be able to say that). What embarrasses me most acutely are thoughts of the wasted time, the misplaced emotional energy, and the utter self-absorption of the last year.

Sometimes I feel heroic to have kept up the struggle in the face of such discouraging results. Like there's some intrinsic merit in pursuing a cherished goal with no thought to personal hardship.

But other times I feel like a total chump. One year, thousands of dollars, two pregnancies, and nothing to show for it all. All such a sad goddamn waste.

I loved that cat

My cat died this morning.

He'd been ill since November. When he began displaying some uncharacteristic behavior (hiding, occasionally growling, failing to hop up onto my lap at every opportunity), we took him to the local vet, who diagnosed him with hyperthyroidism — easily treatable. So we treated him.

Unfortunately, about two weeks into the medication, he became extremely lethargic and light-sensitive, eventually losing his ability to stand, eat, or control his bladder. We suspected a brain tumor. We thought it was the end. (This dovetailed nicely with the failure and aftermath of IVF #3.)

In a last-ditch effort to save our cat, the vet took him off his thyroid medication and put him on a potent combination of antibiotics and steroids. His recovery was swift and startling. Within a day he was like a new cat — slightly weaker than he'd been, perhaps, but affectionate and friendly and ambulatory once again.

We took him to a specialist who dabbles in neurology, who said she was certain he didn't have a tumor. She believed his condition was a reaction to the thyroid medication. So we took him off the drugs and scheduled radioactive iodine treatment for him.

You can't know how relieved we were.

We took him to the thyroid hospital three hours away and left him there to board over the holidays while we were at my parents' house. I called to check on him daily — he was doing fine, I was told every time. When we returned, we went straight from the airport back to the thyroid hospital without even stopping at home — we were so eager to have him back. When we got him home, he trilled happily and walked around, sniffing and remapping all his favorite spots.

But then later that night, he became mopey. He seemed to want to hide.

His decline continued all through last week. Repeated visits to the vet revealed that his bloodwork was normal, except for a slightly low thyroid value. Thinking that was the problem — radiation thyroiditis, a reaction to the procedure he'd had — we supplemented his thyroid hormones and waited for him to improve.

He didn't.

More steroids, antibiotics, then subcutaneous fluids, then, when he stopped eating, syringe-feeding. Nothing helped. He couldn't walk very well. He spent most of his time with his nose pressed into any dark corner. He didn't seem to know we were there.

We took him back to the hospital yesterday so that he could be put on IV nourishment while we talked to yet another doctor. But when we went to pick him up this morning for his appointment with the specialist, he'd become unconscious.

The only thing to do was to pat him while the vet slid the needle into his vein. The liquid that was injected was bright pink. And then the cat's heart stopped.

You should know, by the way, that this wasn't just any cat. He was the cat of my soul. I've had other pets, and will again, but he was the one. He loved me extraordinarily, like I loved him.

He used to lie obligingly across my belly during my period, tireless in his service as a comforting live hot water bottle. When I lay sobbing after my last D&C, he brought me all his toys, lining them up carefully beside the bed in an effort to cheer me up. (It just made me cry more.) Paul and I used to joke that he could help us herd our children once they began to crawl, like a responsible sheepdog nipping at the heels of its flock.

Well, not now.

How crazy does this sound? I wanted my children to know him. He was a fine cat, friendly and faithful, and I will miss him horribly.

Day 9: I knew it was too easy

This morning's appointment went great. I was the first patient seen, and the two doctors on duty were total sweethearts, patting me and making much of my admirable work thus far. "Excellent stim," said one, squeezing my shoulder. She said she thought we'd likely trigger Tuesday night, with either four or five mature follicles in play. I left with a warm glow and a pleasantly purposeful feel in my pelvic region.

But then, splashing ice cold sulfuric acid all over my lovely glow, she called later with my estradiol level. It's gone from 641 on Friday — respectable and encouraging — to 490 today.

You may not know this if you haven't run the gauntlet of infertility treatment, but your estradiol level (E2) is supposed to increase until ovulation, at which point it'll go down and progesterone will begin to rise. A drop in the E2 level likely means that my uppity ovaries are ovulating, long before they have been given official leave to do so.

I don't know what else it could mean; the doctor said something vague about a couple of follicles possibly having petered out. I was too stunned by the news to ask many questions. I'll be back in the office tomorrow morning for more bloodwork. The progesterone numbers should tell us one way or the other. I am preparing for disappointment once again.

Worst sex ever

Last night my husband and I had what might be the worst sex we've ever had.

Now let's get this straight from the start: I am crazy about Paul. He makes me feel understood, which is a rare talent. He's kind and not at all shy about showing affection. He's brilliant — the smartest person I know, and I am not a gentle judge — and has a sly sense of humor that often catches me by surprise, much to my delight. I am grateful every day that he loves me. ("But why?" I've asked him. "You're nice," he answers. So demonstrative language isn't his strong suit. Big deal.)

But we've known each other for about eight years now. When we were first together, we couldn't keep our hands off each other (to say nothing of our mouths). Now, well, we're used to each other, and while the sex we do have is warm and exciting in a still-waters-run-deep kind of way, it's not as frequent nor as intense.

It is easy to blame infertility.

First you have the treatments, which are stressful and sometimes painful, hardly conducive to lust. Then, in my case, you have the aftermath — a month at a time when my body has been healing from some insult or other. Finally, if you're delusional enough to feel there's a chance you might conceive during the rare months when you're not in treatment, you'll be doing it under duress: sex on a schedule without even the spur of hope that fertile couples feel when they see that clear and stretchy mucus.

I am going somewhere with this.

In case I did ovulate over the weekend, it seemed like we should cover our bases, no matter how futile a pursuit. So I left off my impenetrable Polarfleece pajamas, took a deep breath, and gingerly crept across the mattress to where Paul lay.

I have to confess it was awful.

Sad and freaked out to begin with, I felt no desire whatsoever. I felt entirely goal-oriented. (This can be an exciting approach to sex, but it does tend to dampen the mood when you bite your tongue to keep from asking, "Are you close? How 'bout now? Okay, now?") My body didn't respond to any of the usual suave blandishments — anyone who tells you that high estrogen levels increase your natural lubricity has never visited the Mojave that is my vagina these days.

But to accomplish the goal, the well-placed deposit of a copious spermy payload, I willingly played along. What else could I do but pretend to enjoy it? The goal was indeed accomplished, with heroic effort and no small relief.

I lay awake for a long time afterward. Not only did my body feel misused, not only did I feel angry and sad about the likely failure of this cycle, but I also felt small and dishonest to boot.

I'll make it up to us both sometime, once I stop believing this fiasco has eradicated all sexual feeling once and for all.

Day 10: Great, more bad sex

"You know, everything that can go wrong with you does," my doctor just said on the phone.

That's right, friends: I ovulated.

My estrogen had increased slightly, but what was really telling was my progesterone level, which was at 4.5.  Anything above 1 is apparently a reliable indicator of ovulation.

As soon as I heard his voice on the phone I knew it couldn't be good news.  His recommendation was that we have sex tonight and hope that I can "pull a rabbit out of my hat" as I've done before.  (You know, "pull a miracle out of thin air."  Or perhaps, in my current mood of misplaced rage, "pull the poor blameless UPS delivery man's spine out through his rectum.")

I asked my doctor if he would recommend a different course of action on a future cycle — closer monitoring, a change in protocol, anything.  He said he'd want to check my progesterone throughout the cycle, which isn't normally done at my clinic, but didn't offer any other thoughts about how we could keep this from occurring again.  "It's just one of those things," he said.

One of those $2,000-in-drugs, crush-my-hopes-up-but-good things.

There's no point in even bothering to do an IUI at this point.  We're not likely to have more than one egg in play for this cycle, even if Paul's rather immotile sperm can get to it.  I can't even talk about how disgusted and angry I am, at my body and at the world.