The miracle makers

There is a team of physicians, nurses and staff members at UF Health dedicated to one goal — helping people become parents in the face of all obstacles. In this issue of The POST, we follow one couple’s journey to becoming a family through fertility treatment at UF Health Reproductive Medicine – Springhill.

By Morgan Sherburne     Photos by Jesse S. Jones

Jesica Cox, Brad Cox and their son Bryson, four months old. Jesica and Brad used in vitro fertilization to concieve their son, Bryson.

Bryson seems like an exceptionally happy baby.

He wakes up from a nap with a smile and without protest. He sleeps 10 hours a night and, until recently, has been napping regularly during the day, although on this particular day, he sleeps without stirring until his mom decides to wake him.

At 3 months old, Bryson is equal to or ahead of all of the development markers. He can stiffen his legs and stand when his dad, Brad Cox, holds him with his hands cupped around the baby’s rib cage. If it weren’t for that pesky balance issue, Bryson would be ready to stand on his own.

“He’s my IVF baby,” says his mother, Jesica Cox, of Lake City. “I know it’s bad to label them like that, but I’m proud that he is, because that’s how we got him.”

Each day, at UF Health Reproductive Medicine – Springhill, nurses and doctors help people become parents.

Sometimes, that’s through in vitro fertilization, in which an egg and sperm are joined outside the body, then implanted into a woman’s womb — which is the way Bryson was conceived.

The doctors and nurses begin the day with a huddle to discuss the day’s patients, combing through a stack of folders with health histories and needs.

Jesica Cox, Brad Cox and their son Bryson, four months old. Jesica and Brad used in vitro fertilization to concieve their son, Bryson.

Jesica and Brad used in vitro fertilization to concieve Bryson.

“We’re thinking baby thoughts,” says Alice Rhoton-Vlasak, M.D., a physician and associate professor in the College of Medicine department of obstetrics and gynecology. “We’re looking for the best treatment options to help people build families, although we may not always be successful. Our goal is to help them on the fertility journey.”

The Springhill facility, which opened in 2013, houses UF Health’s reproductive endocrinology and infertility services. The team includes embryologists, lab technicians, clerical staff, nurses and nurse coordinators Sue DeGennaro, R.N., and Melinda Bestland, R.N. The team’s physicians are Rhoton-Vlasak, R. Stan Williams, M.D., chair of obstetrics and gynecology, and Gregory Christman, M.D., director of the division of reproductive endocrinology and infertility.

Jesica Cox, Brad Cox and their son Bryson, four months old. Jesica and Brad used in vitro fertilization to concieve their son, Bryson.

Who’s taking photos of me?

DeGennaro and Bestland help guide patients through treatment. Not every patient receives IVF, which is typically reserved for individuals in whom all other fertility treatments have failed, or may not even be options. Other fertility services include egg donation, ovulation induction, intrauterine insemination, fertility-promoting surgery and fertility preservation, most commonly for patients with cancer.

“I was a surgical nurse for 15 years prior to this job, but I’ve been with this department for another 15 years and have done the full array of nursing,” DeGennaro said. “This job gives a lot of empowerment to really use your full skill range because you really are a patient advocate.”

Jesica, 32, has known for nearly a decade that a severe case of endometriosis would not allow her to become pregnant naturally.

In endometriosis, tissue that normally lines the inside of the uterus grows outside of it. Outside the uterus, the tissue can curl around other internal organs, most often involving the ovaries, bowel and the inside of the pelvis.

The tissue behaves just as it would if it were still in the uterus. It breaks down and bleeds along with the typical menstrual cycle. But, trapped inside of the body, the thickened tissue has no place to exit. It can form fibrous cysts along the ovaries and fallopian tubes, which is what it did to Jesica’s reproductive organs.

That meant each serious relationship after she learned of her potential fertility problems involved a conversation about the future. That resulted in ending one relationship.

•••

Infertility cover storyThen Jesica met Brad.

Just a few weeks into the relationship, Jesica built up the courage to tell him about her fertility issues.

“What I was hearing from her was that the doctor said she had to do a specific thing to have kids, not that she couldn’t have kids,” Brad says. “She said, ‘Yeah, but we’d have to do this, we’d have to do that, and it’s not guaranteed, and it’s not easy.’ And I said, ‘So what? It’s not a no.’”

That’s when Jesica knew Brad was the person she would marry.

Later, when the couple was ready to start a family, Jesica’s doctor evaluated whether endometrial tissue had blocked her fallopian tubes. If eggs become fertilized, they make a several-day journey down the fallopian tubes and implant in the walls of the uterus. Her tubes were completely closed off.

After Jesica’s test results, the Coxes began treatment at UF Health. Because of the damage from her endometriosis, IVF was the couple’s only choice.

In IVF, a woman gives herself hormone injections to increase the number of eggs her ovaries produce each month. The eggs are retrieved and then fertilized with the father’s sperm outside of the womb. If the eggs become fertilized and begin to divide, the fertilized eggs, now called embryos, are placed back into the woman’s womb. Then, the parents have to wait two weeks to see whether the embryos have implanted in the mother’s womb, the start of a pregnancy. Each time a patient goes through this process is called a cycle.

While the Coxes were readying for their rounds of IVF, the infertility and reproductive endocrinology team reviewed their case to determine the best plan of care for Jesica.

“It’s a team approach,” Rhoton-Vlasak said. “It’s really a team approach because every provider is involved in a separate aspect of the cycles of every patient.”

The nurses schedule visits, teach patients about how to administer medications to spur hormone production, help create schedules for the patients and help run the operating room at Springhill. In the operating room, women undergo egg retrievals and embryo transfers under ultrasound guidance. The physicians track patients’ treatment cycles to determine when eggs should be taken and to determine the best time to place the embryos back in the uterus.

“Everything we do is based on how a woman’s body is responding to the treatment,” Rhoton-Vlasak says. “You have to do it when the body is in the right state. You can’t schedule it in advance like you can an elective surgical procedure.”

•••

It just takes one.

Jesica Cox, Brad Cox and their son Bryson, four months old. Jesica and Brad used in vitro fertilization to concieve their son, Bryson.

One fertilized egg could turn into an embryo, and finally, a baby. That’s what Sue DeGennaro, the infertility nurse, told Jesica and Brad each time they became anxious about their chances.

In December 2013, Jesica’s fallopian tubes were removed, leaving her ovaries, in order to avoid further complications. After recovering from that surgery, she began the month-long process of fertility injections to coax her ovaries into producing more eggs than their typical one per month.

Jesica produced five eggs, all of which were fertilized. After five days, Jesica and Brad had only one viable embryo, which Rhoton transferred to Jesica. Then, the
wait began.

“Those two weeks are horrible,” Jesica says.

At the end of the two weeks, Jesica went in for a blood test. They were to learn whether they were pregnant by 5 p.m. Then, they planned to text and call family and friends to tell them of the hopefully happy news.

“I had people texting me, saying ‘Have you found out yet?’ Then I got the phone call,” Jesica says. “It didn’t take.”

The couple considered taking time off to recover from their disappointment, but Rhoton-Vlasak encouraged them to jump right back into trying.

So the Coxes started the process again, and when a nurse checked Jesica’s ovaries, she found Jesica only had two underdeveloped follicles. The suggestion
was to put off the process for another cycle.

“I cried all the way home, from Gainesville to Lake City,” Jesica says.

After discussing the situation, Jesica and Brad decided to continue the treatment anyway. They had done a month of fertility injections. And, as the nurse reminded them, it does only take one.

This time around, the phone call brought much better news: Jesica was pregnant.

The Coxes were quick to realize that the fact that Jesica was pregnant did not end their worrying.

Jesica started bleeding three days after they found out she was pregnant, and didn’t stop for six weeks. The nurses assured her the bleeding was normal, and she and Brad were able to see Bryson’s heartbeat at 8 weeks, when he was still the size of a sesame seed. Even so, she dreaded even going to the bathroom, fearing she would see more blood.

When Jesica was nearly 20 weeks pregnant — just before she was scheduled
to learn her baby’s gender — she began bleeding again. She drove herself to the hospital, where staff thought she
was miscarrying.

After several minutes during which her nurses thought she would need a blood transfusion, they found the baby’s heartbeat. He was healthy. A condition called placenta previa, in which the placenta partially covers the cervix, was causing the bleeding. Although the placenta was nearly completely covering her cervix, it moved within days. The bleeding halted again.

The nurses at UF Health Reproductive Medicine – Springhill are more than just infertility nurses.

They are coaches and listeners. They answer panicked questions from pregnant patients who had a tough road to pregnancy. Although the clinic also offers clinical psychologists and counselors for patients whose attempts at becoming pregnant aren’t successful, the nurses are often the first people the patients think to contact.

“We do what I call almost a verbal massage to our patients who are struggling emotionally,” DeGennaro says. “Many of our patients are already in need of that emotional piece of this, because they’re struggling to become pregnant for more than a year on average, if not more so.”

But the payoff is good, Bestland says. “It’s nice to follow your patients from start to finish,” Bestland says. “I enjoy working with people who are essentially well. It’s happy, most of the time. There’s a good outcome a lot of the time. It’s nice, too, when the patients come back to show you their babies.”

It’s a job that has no regular business hours. When a woman’s body is ready to ovulate, the team must be ready to help her.

“Everything we do revolves around follicle size and ovulation,” Rhoton-Vlasak says. “Just like having babies, you have to be there 365 days a year. Fertility is exactly the same.”

“We’re open 7 days a week,” Bestland says.

“People ovulate 365 days a year. We’re open 365 days a year,” Rhoton-Vlasak adds.

Jesica was induced Feb. 25, on Bryson’s due date. She labored for two days.

In the early morning of Feb. 27, over a period of six hours, Bobbie Patterson, Jesica’s mom, watched the heart monitor flutter and fail. She and the nurses turned the monitor away from Jesica so she wouldn’t focus on it.

Jesica told them she thought something was wrong. The doctor scheduled a Cesarean section.

When Bryson was born, his umbilical cord was knotted and wrapped around his neck twice.

“If I had delivered him normally, he would have died,” Jesica says.

“The nurse said he was a little miracle boy,” Bobbie says.

From the beginning, the Coxes wanted to be as open as possible about their fertility journey.

Once they started the process, Jesica and Brad started hearing from many people undergoing the same fertility issues. Jesica met a childhood acquaintance in the waiting room of the UF Health fertility practice.
Family members told them their daughter
had been conceived through IVF. In all, six people contacted Jesica to tell her of their IVF experiences.

“The more we got into this, the more I realized there are more people who go through it that I never even knew,” Jesica says. “It opened a door.”

“People don’t talk about it,” Brad adds. “We got some information about blogs where people talk about their experience, but it’s not somebody you know, or someone you’re ever going to see. We’ve even talked about starting a blog or some sort of support group where people actually meet and talk about it. It would be a lot more therapeutic.”

For right now, the Coxes are happy to get to know their new little boy, who Brad swears was born smiling.

“Thirty minutes after he was born, it was just the three of us in there,” Brad says. “I told him, ‘You gotta smile for the camera,’ and just when I went to snap the thing, he turned and smiled.”

The UF Health team approach

The team at UF Health Shands

The UF Health Reproductive Medicine team discusses the day’s patients.

Behind the scenes of infertility treatment at UF Health Reproductive Medicine – Springhill, there is a careful choreography.

After assessing each patient’s particular problem, the physicians decide which treatment each patient needs. In some cases, that treatment is IVF, the technique for which UF Health’s reproductive endocrinology team is most well known.

“We consistently have excellent pregnancy rates, and are known for our individual patient care,” says R. Stan Williams, M.D., the Harry Prystowsky professor of reproductive medicine and chair of obstetrics and gynecology.

Gregory Christman, M.D., the J. Wayne Reitz chair of reproductive biology and the director of the division of reproductive endocrinology and infertility, says UF’s infertility program tackles tough cases in which patients have been previously unsuccessful in undergoing IVF.

“We take on the difficult cases that other people won’t take on,” Christman said.

If the physicians determine a patient needs IVF, she undergoes treatment to stimulate her ovaries to produce more eggs than she typically would. When these eggs are retrieved, the physician hands them off to either Joseph Kramer, Ph.D., director of the in vitro fertilization lab at the clinic, or embryologist Larissa Ali through a window in the wall of the clinic’s operating room. The window passes into the IVF lab.

The IVF lab is designed to optimize conditions for growing embryos, including controlling for light and temperature.

“We try to best mimic the surroundings of the womb,” Kramer says.

Between the third and fifth day after fertilization, the physicians transfer the healthiest embryo back into the patient.

If the patient has a positive outcome, they stay with the program for about eight weeks and then graduate to their regular obstetrician-gynecologist. If the patient does not become pregnant, the program has a clinical health psychologist on hand to help.

Collectively, Williams, Christman and Alice Rhoton-Vlasak, M.D., have 60 years of experience with IVF and infertility treatment.

Williams has been with UF since 1988, the year the clinic’s first IVF babies — a set of twins — were born.

Other nurses and assistants have likewise been with the program for decades. Sue DeGennaro, R.N., an infertility nurse specialist, has been in the obstetrics and gynecology department for 15 years. Melinda Bestland, R.N., a nurse for 29 years, has worked the gamut of obstetrics and gynecology, including neonatal intensive care and labor and delivery.

“Not in every clinic do the nurses meet up with every single individual patient as part of their care,” Rhoton-Vlasak says. “But here, they do.”

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