ALTAMONT The door to Keegan Prue and Olivia Cohen-Prues nursery, on the second floor of their Altamont home next to their master bedroom, is open.

It was closed for a while last year, after their first effort at in vitro fertilization ended in miscarriage right around Thanksgiving, about eight weeks into Cohen-Prues pregnancy.

A lot of people just close that door, and have it be like a symbol of the sadness, said Cohen-Prues husband, Keegan Prue, 32, who works for the State University of New York Charter Schools Institute.

After our first miscarriage, we had closed the door. It had become that sad door, he said.

Right before they tried IVF a second time, earlier this year, the couple made a conscious decision to change the energy, to open the door and move forward.

Your parents came and painted the walls, Olivia Cohen-Prue, 34, a paralegal, reminds her husband. We began to get furniture and to finish the room, little by little. The babys room is now about 75 percent complete, she said.

The door was also closed for about a day, Cohen-Prue said, after she miscarried for the second time, this time at 12 weeks, in the beginning of May.

The couple is now preparing for their third round of IVF.

The nursery walls are painted a pale blue and decorated with framed illustrations from a childrens book, a map of the United States, and a vintage railway travel poster featuring a bold illustration of a train. In the center of the room is an oval Scandinavian convertible crib they found secondhand that they explained is meant to grow with the child, going from crib to toddler bed and beyond.

The nursery is almost ready now for the child they are sure will come someday, one way or another.

If this third IVF cycle doesnt work, they have decided to stop trying for their own biological child and focus on adopting. They have already spoken to private agencies, where they would apply to adopt a baby; they are sure they would also be happy to become parents that way.

Either way, said Prue, even if the third cycle should work, they might still like to bring a second or third child into their family through adoption.

Having a crib and a carseat are requirements for adoptive parents hoping to get the call about an available baby, Cohen-Prue said.

What we recommend to people, Prue said, is to research what the choices are and figure out whats right for them. Some people say, If I cant have my own child, I dont want to do it, and then thats the right choice for them.

Along with the open door, the couple explained, they also decided to be open about telling people about their struggles. They had learned that about one in eight couples deal with infertility. Maybe hearing about the difficulties they had had would make someone else feel less alone, they decided. He wrote a letter to the Enterprise editor, published this week.

Its such a common experience, but people dont talk about it enough, said Prue.

He and Cohen-Prue also want people to know about a change that will come when the New York State budget enacted this year goes into effect on Jan. 1, 2020. From that time, Large Group insurance plans serving companies with 100 or more employees will be required to cover up to three cycles of IVF.

In addition, insurers in all commercial markets will be required to cover medically necessary fertility preservation medical treatments for people facing infertility caused by a medical intervention such as radiation, medication, or surgery. Presumably, this could cover banking sperm or freezing eggs.

Not everyone will be helped by this new requirement, said Prue. People who will not be helped include those at smaller companies and those at companies with more than 1,000 employees, as well as gay male couples. Gay male couples wont be helped because surrogacy remains illegal in New York State. Prue called the change in the law not perfect, but a step forward.

He and his wife both have good health insurance, Prue said, adding, I give both our workplaces a lot of credit for being so supportive and saying, Whatever you need, in terms of time off for doctors appointments and things.

The couple have friends whose insurance does not cover fertility treatments, who have paid $30,000 or $40,000 out of pocket for multiple IVF cycles, Prue said, and there are many people without insurance for whom IVF would not be an option, because of the cost.

The new law gives people one more option for trying to fulfill this most basic function, he said, and he and his wife want to raise awareness so more people know there is hope out there.

He has heard people undergoing fertility treatment compare it to The Hunger Games, Prue said with a knowing laugh, because there are so many steps at which the weakest eggs and embryos can be winnowed away.

The couple started seeing a fertility doctor after about a year of trying on their own. I was 31 when we got married. I wasnt old, but I knew time wasnt on our side, said Cohen-Prue.

After doing testing, the doctor told them that Cohen-Prues egg reserve was low. The doctor explained, she recalled, that if a woman has a lower egg reserve, the eggs are also not good quality.

When I first found out, she said, Your eggs arent what they should be for your age, its like a knife in your gut.

When she says that, her husband quietly reaches out a hand to touch hers.

Unlike men, who continue to produce sperm throughout their lives, a woman is born with all the egg-containing follicles in her ovaries that she will ever have. According to the American Society for Reproductive Medicine, at birth a female has about a million follicles. By the time she reaches puberty, that number will have dropped to about 300,000. Of the follicles remaining at puberty, only about 300 will be ovulated during the reproductive years, with most deteriorating and being reabsorbed by the body and effectively lost. As the number of eggs diminishes, so does the average quality.

A womans best reproductive years are in her 20s. Fertility gradually declines in the 30s, particularly after age 35, according to the society. As a woman gets older, more and more of her eggs have either too few or too many chromosomes.

That means that, if fertilization occurs, the embryo also will have too many or too few chromosomes. Most people are familiar with Down syndrome, a condition that results when the embryo has an extra chromosome 21. Most embryos with too many or too few chromosomes do not result in pregnancy at all or result in miscarriage. This helps explain the lower chance of pregnancy and higher chance of miscarriage in older women.

A complete IVF cycle starts with hyperstimulation of the womans ovaries, so that she will produce a large number of eggs; this stage can be skipped, as the couple did in their second cycle, if there are frozen embryos left over from an earlier cycle.

The womans uterus is prepared for weeks by giving her estrogen to create a lining that is as thick as possible, to increase the chances that an embryo will implant there and grow. In addition, in the days leading up to the transfer, she takes shots of the hormone progesterone, meant to protect and maintain pregnancy.

Throughout this process, Cohen-Prue said, youre kind of an emotional basket case, full of anticipation, drugs known for their ability to produce rapid mood swings, and, leading up to the egg retrieval, eggs.

You actually have a bunch of eggs, you look pregnant, and feel awful, she said.

Egg retrieval following hyperstimulation might yield anywhere from about 2 to 40 eggs, Prue explained. This is followed by a process of combining the mature eggs with sperm and waiting to see if they fertilize and begin to develop.

The healthiest-looking embryo is then selected for transfer with a catheter through the womans cervix, into her uterus, in hopes that it will implant there. It is possible, the couple said, to do genetic testing of the embryos to discover which might have chromosomal abnormalities likely to produce miscarriage, but they did not do that testing before their earlier tries.

Cohen-Prue spent the days before and after last Thanksgiving in painful and unproductive contractions after being prescribed misoprostol. She was to take the drug to induce a miscarriage, since there was no heartbeat; her pregnancy was over at eight weeks. Because of the holiday, the clinic was unable to schedule a dilation-and-curettage surgery to scrape the uterus until about a week later, she said.

She wasnt burned by it, she said, adding, I was like, Lets get back on it. The silver lining was, the doctors were like, Well, we know you can get pregnant.

The couple started again with estrogen in January and did another transfer at the end of February, using an embryo they had frozen from the first round. At the nine-week ultrasound they saw a little embryo moving around, Prue recalled. We saw the arms, Cohen-Prue said, raising her hands near her face and waving her fingers.

At that point, their close friends and family knew. We were more cautiously optimistic than the first time, Prue said.

If all went well at the 12-week ultrasound, they planned to announce it more generally.

Twelve weeks is such a marker, said Prue.

Almost right away, Prue said, the ultrasound technician had been saying, I dont see a heartbeat; I dont see blood flow.

The baby had died the week before, Cohen-Prue said.

That was the worst day, she continued. You go from going to the doctor in the morning, to your world falling apart. She got an appointment for a dilation-and-curettage that same night, and, while waiting for it, told her husband, We have to talk to an adoption agency. I cant go through this again.

Fetal testing after Olivia Cohen-Prues second miscarriage showed Down syndrome. Her fertility doctor said that the presence of a chromosomal abnormality was a relief, since it would provide a potential reason for the miscarriage, and chromosomal testing of an embryo could be done next time, prior to transfer, to lessen the chance of a miscarriage.

We had a concrete reason this happened, Prue said.

They have had their embryos tested now, and have two chromosomally normal ones. One is from their recent egg retrieval, done in August, and the other the last remaining embryo from their earlier efforts.

The couple did look into private adoption and met with some really helpful adoptive parents from Adoptive Families of the Capital Region, Prue said, but decided after a three-month break to try IVF once more.

Weve heard of people whove done 10 rounds of IVF, 14 rounds, he said.

His wife added, You have to know your own limits, I think.

At about the end of October, they will transfer the more recent embryo, Prue said, because freezing embryos twice is thought to decrease the chance of implantation a tiny bit.

What are they doing, meanwhile, to keep calm?

Were no longer having conversations around, What if we dont have children? What if we dont become parents? said Prue. They take walks in the evening around Altamont, see close friends and go on little trips, and cook and bake their favorite foods.

Theyll find out by mid-November if they are at the beginning of a pregnancy.

If it doesnt work this time, they plan to start doing the paperwork for adoption by the end of the year.

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Keeping the door open to welcome a baby - The Altamont Enterprise

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