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The question was asked on the last post, “What is the difference between PIO and 17-p?” so I thought I’d do my non-scientific/non-medical-background best to answer. I’m not a doctor, I’m just a woman who’s been to this circus a few times and I’ve figured a couple of things out.

When you go through infertility treatment cycles that use a suppression method, essentially what you are doing is overriding your body’s natural production of hormones necessary to create and maintain a pregnancy. This allows the doctor to control those hormones more precisely. The downside is that, if you are fortunate enough to have an embryo implant, you still have to provide the hormone support until the pregnancy is advanced enough to take over. That’s where the progesterone in oil injections come in. They maintain the higher progesterone levels needed (increased progesterone is what prevents you from having a period. In a “normal” month, if you did not conceive, the progesterone levels that increased to help build the endometrial lining starts to drop and that decrease is what triggers your uterus to expel the unneeded lining and start the cycle all over again). PIO injections are continued until the placenta is established enough to produce progesterone on it’s own. That’s usually close to the end of the first trimester. Every doctor seems to have their own timetable for when to stop PIO injections.

17 Alpha-Hydroxyprogesterone Caproate or 17-p as it’s known to it’s friends, is used in high-risk pregnancies when there is a risk of preterm delivery. It is given as an intramuscular injection, like PIO, usually starting around gestational week 16 and continuing until week 36 or delivery (although I think I’m only doing it until 34 weeks since 36-37 weeks WILL be delivery for me). According to a study conducted from 1999 to 2002 by the National Institute of Health, the 17-P relaxes the smooth muscle, blocks the action of oxytocin, and inhibits the formation of gap junctions. Now, if you’re like me, that went in one ear and out the other. What Dr. T explained to me is that women in the study displayed better cervical competency, with improved length of the cervix and a significant reduction in the rate of preterm delivery (although in the very high risk cohort of the study, the rate of preterm delivery still remained high at 36.3%, indicating that more research into the causes of preterm delivery are needed. I agree!).

The shots are essentially the same as the PIO injections used from just before an IVF/FET transfer to sometime around the end of the first trimester. It is a compounded suspension of progesterone in an oil base injected into the glutes. We had a home healthcare nurse come over to teach Shannon how to give the shots. There were a few minor differences in this shot and how we were taught to give the PIO injections (basically, wipe the area, hold the skin tight, inject and withdraw, massage).

First, he was taught a technique called z-tracking. After locating the area for the injection and cleaning it with alcohol, he takes the palm of his non-injecting hand and pushes the fat layer out of the way. Ever done one of your injections and had a bead of PIO ooze back out after withdrawing the needle? This method prevents that. You shove the subcutaneous fat to the side, inject the medication, withdraw the needle and “close the door” by releasing the fat.

Second, the nurse told him that after he removes the air from the syringe to make sure he’s drawn up the correct dosage, to then draw back a small bubble of air. This bubble will move to the back of the syringe (the plunger end) when the 17-p is being injected and it will ensure that all of the oil is pushed from the needle while still in the muscle (apparently that will help with the itching and stinging as the oil can be irritating to the skin and surface layers) and the air is not harmful in either the muscle or the fat layer as it will simply be absorbed.

Third, the 17-p injection is given over a 60 second period. I will tell you right now, that is a REALLY long time to have that needle in your hip. I’m not happy about it at all, but that is the technique used in the study and that’s the technique that is being taught for the highest success rate. It’s a 1cc injection, so that’s veeeeery slow.

Fourth, the nurse said DO NOT RUB, MASSAGE, ICE OR HEAT. I’m supposed to just walk around after the injection to help work it in. The injection site was sore to the touch for a few hours afterwards, to the point that leaning back in a chair was uncomfortable, but once that passed, it was fine.

Fifth, the 17-p is administered once a week instead of once a day. Thank goodness! I’m not sure I could take a 60 second injection every day. I’ve only done one so far. We’ll see how it goes over the next 18 weeks. If anyone is interested in actually reading the New England Journal of Medicine article on this study, I’ll be happy to scan it and send it along, or you might be able to find it at NEJM.ORG. The study is called “Prevention of Recurrent Preterm Deliver by 17 Alpha-hydroxyprogesterone Caproate” and the volume information is N Engl J Med 2003; 348:2379-85.

Hope that answers the question! Basically, one helps you stay pregnant in those early days and the other helps keep you pregnant later of if you’ve had problems with that before. Since our best guess of what happened to Lennox is that my cervix softened enough to allow bacteria to come into contact with the sack and infect the placenta, leading to the membrane rupture (we don’t know for certain because we hadn’t gotten to a point where anyone thought to start checking my cervix) anything that keeps my cervix long and tightly closed is a good thing.

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First, I’m having a terrible time remembering the word “methotrexate.” I don’t know why my brain just doesn’t want to put those sounds in that order.

With an eye towards future blog visitors, a quick background. On December 20, at 6 weeks pregnant, I had a miscarriage. After three weeks, my hcg levels stalled out indicating that my body had not rid itself entirely of what is referred to as “products of conception.” On January 14, I received an injection of methotrexate to give my body a shove in the right direction.

Methotrexate is most commonly used to treat some neoplastic diseases (cancers), psoriasis and rheumatoid arthritis. It works by interfering with the growth of new cells. It is an antimetabolite and a folic acid antagonist. It is also commonly used to treat ectopic pregnancies, although the FDA has not approved it for this purpose. For obvious reasons, it is a category X drug, meaning it should not be taken if you are pregnant, think you might be pregnant, or might become pregnant.

It is given as an intramuscular injection in the hip. Based on my experience with progesterone in oil, this injection was much less painful. That’s probably due to the thick consistency of the PIO, which requires more time to inject. Following the injection, I did feel a slight burning sensation for about 30-40 minutes. It felt like a bad bee sting.

Side effects at the dosage used for treatment of an ectopic pregnancy (and, I assume, for miscarriage) are uncommon according to the information sheet the clinic gave me. They can include vomiting, diarrhea, mouth ulcers, and liver problems. Prior to being given methotrexate, a metabolic panel should be done to make sure your liver is functioning well as methotrexate is metabolized by the liver. That also generally means no alcohol. I’m also going to take a break from my metformin. It probably isn’t necessary, but metformin is also metabolized by the liver (I have to have a metabolic panel every three months because of it) and I don’t see any reason to make my liver work any harder than it has to. But, I’m not a doctor, so don’t take my paranoia as medical advice.

Because folic acid interferes with methotrexate, stop taking any pre-natal vitamins while undergoing treatment. We asked about avoiding folic acid-rich foods but the PA who gave my injection wasn’t the most knowledgeable. Just to be on the safe side, I plan to avoid store-bought orange juice, store-bought breads, and dark green leafy vegetables until this passes. Better safe than sorry and while I love my almost daily serving of kale, I’ll gladly give it up if it ensures that this works.

The protocol going forward is a beta every 3-7 days (I picked 3 for the first one. After all, who doesn’t enjoy starting their Saturday with a blood draw?) until we get to less than 5. If I don’t show “progress” I may need a repeat injection.

Ok. That’s the more technical stuff. So, how does taking methotrexate make me feel? Right now, it’s been about 2.5 hours. I’m really tired and have that uncomfortable-in-my-own-skin feeling, but I woke up at 3:45 this morning and never went back to sleep, so I doubt it’s the drug causing it. My stomach feels “off.” Not really nauseous or even upset, just something I’m aware of. I was particularly anxious about all of this this morning, so it could be from that. The injection site no longer stings and isn’t sore to the touch. Hopefully, that will be the case from here on out. I’d like to not have to update this with more side effects, but if any rear their ugly heads, I’ll write ’em down for posterity’s sake.

Live side effect monitor:
1. Gross metallic taste in my mouth. Pretty sure that’s from the mtx.
2. stomach is mildly upset. lower digestive system is a bit more upset…rather like when I first started taking metformin.

That’s all I’ve got. I’m going to let myself spend the day on the sofa, surfing for fun, searching for a job, and working on getting a huge stack of cds imported into iTunes. I figure I’ve earned that.

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I don’t think this was around last year when I was compulsively calculating due dates after a procedure. Maybe it was and I missed it, I don’t know, but anyway here’s a fantastic due date calculator for the ART set.

August 21, 2009.

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I just happened to notice two visitors found this blog by searching for “stillborn birth announcements.” And since I’m already in the sharing things I wish I didn’t know about mode…

I went around and around about sending out announcements. After all, pretty much anyone I would send them to already knew what had happened. My family has a good communication network. But, I finally realized that Lennox and Zoe deserved that formal recognition.

But…there aren’t many examples to work with. Oh, sure, you can find tons of annoucements for babies who came home. Bazillions of them in just about any style you can imagine. Ones for twins…slightly fewer, but only slightly. Ones for babies who died or were stillborn? A small handful. Ones for babies who lived three days or three weeks? Yeah, not so many. I don’t have the link here at work, but when I get home I’ll update this with the link to the website I did find. I started with their examples and went from there. Update card examples

After many, many rewrites, we came up with something that we felt truly expressed our situation. We started with the idea that you can’t understand beauty, joy, happiness, anything fully unless you have it’s opposite to compare to. Yin and Yang, balance in everything.

“To know perfect joy, you must sometimes experience the deepest sorrow.

Allison and Shannon sadly announce the early arrival and passing of our children, Lennox and Zoe. They were here for far too short a time, but they taught us to feel perfect joy and their absence fills us with the deepest sorrow.

Zoe Harper Simpson 1 pound 10.4 ounces January 3, 2008 – January 24, 2008

Lennox Maximilian Simpson 1 pound 13.2 ounces January 3, 2008 – January 5, 2008”

We also included a separate slip of paper with information about their memorial fund.

I don’t know if that helps those two people who came here, I hope so. I’m sorry you have to do that particular search. I hope you do send out announcements though. It will be incredibly painful. Each envelope you seal, address and stamp will be like another papercut-sharp reminder, but every single one, every person who receives that announcement is another person who remembers with you.

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