Genetic Counselor

We met with the genetic counselor today about CCS (Comprehensive Chromosomal Screening).  Our plan is to use CCS with IVF #2 to help us find that one good embryo that will stick, grow and become our child. 

We have a bit of time before this all takes place but I want to get it all down now so I don't forget it.

Test results are given as follows:

Normal
Abnormal
No Diagnosis

Normal means that the embryo has all 23 pairs of chromosomes, or Euploid.  These are the only embryos that would be transferred.

Abnormal means that the embryo has a missing or extra chromosome somewhere, or Aneuploidy.  Monosomy or trisomy of either chromosome pair or sex chromosome (Trisomy 21, Monosomy 13, Monosomy X, XXY, etc).

No Diagnosis means that either the embryo had begun to arrest at the time of biopsy, some kind of error occurred, or the DNA of that embryo had already begun to break down at the time of biopsy.

A 35 year old (me) can be expected to have 40-50% of her embryos test abnormal.  Just giving me a heads up on that one.

We need to decide how many embryos we need at retrieval to make the cost of this test worthwhile.  If we only get 2 blasts, for example, we would go ahead and transfer those two rather than do CCS.  The decision becomes more difficult if, say, we have 3 or 4 blasts.  What should our cut off be?

We asked that the sex of the embryo (XX or XY) not be given in the results unless the embryo had an abnormality of the sex chromosomes.  My fear was that the embryologist would call and ask, "Do you want a girl or a boy, a girl and a boy, twin girls?"  I was reassured that, as a policy, they do not reveal the sex chromosomes of the normal embryos.  Normal embryos are just "Normal."



On a side note:  Why do some scientists and doctors refer to XX or XY as the gender of the embryo rather than the sex of the embryo?  We said sex, she said gender.  In my academic discipline, gender is an identity formed over time, one not determined by sex chromosomes.   Gender is social and cultural.  I cringe anytime I hear "gender of the embryo." 

Ovarian Age Revisited

The morning before my hysteroscopy and d&c, the IVF nurse called with my day 3 AMH results.

The level was at 1.5.

A few months ago I wrote a post titled Ovarian Age after listening to a Creating A Family podcast on predicting IVF success.  The guest RE discussed factors that determine IVF protocols, predict IVF success and provide a patient's "Ovarian Age".  He gave an example of establishing Ovarian Age using one factor, AMH (AMH seems to be the preferred diagnostic for determining ovarian reserve).   An AMH level of 1 would be expected for a 40 year old woman, whereas an AMH level of 1.5 would be expected for someone who is 34.  At the time I heard this, my last and only AMH test had come back at 1.1.  So naturally after two IVF miscarriages and an AMH matching someone older than my chronological age, I latched on to the idea that my ovaries were 40 years old, freaked out and wrote the post.

There were comments to that post that reminded me that AMH is just a number, just as FSH is just a number (Yes, that is true when these tests are taken individually).  But my antral follicle count (not just a number, btw; you can't make more eggs than you have) was on the low side, I'd had three early miscarriages and my RE continued to express concern about egg quality, so...

So. What does my current AMH of 1.5 mean?   I know, probably nothing.  According to the guest RE, it is more consistent with my age than it was last year.  My FSH is under 9, my antral follicle count this cycle was in the average range and my AMH is 1.5.  Maybe they are all just numbers that fluctuate slightly or maybe my odds are better with these values than they were last year.   I have learned since writing the original post that a 35 year old with an AMH of 1 still has a better chance (on paper) of achieving pregnancy than a 40 year old with an AMH of 1.  Age is still the biggest predictor of success with one's own eggs.

But really, the most important thing I have learned in the last year of IVF treatments is this: Just as I should not let these numbers discourage me or affect my attitude about a particular cycle when they are not great, I should not put too much emphasis on the results when they seem normal.  If it is just a number when it is bad, it is also just a number when it is good.   They are always just numbers.  I will let my RE worry about what they mean for my cycles.

Also, thank you to all of you who set me straight about the Antagonist protocol.  Alex, Erika, Fran and KMP, all of whom have different diagnoses and who had success with this protocol.

Hank

Hank is what F and I named the retained pregnancy tissue hanging out in my uterus (We've learned that you need a sense of humor to survive infertility.  The more macabre the better).

The night before the hysteroscopy and d&c, we said our goodbyes to Hank.  It was probably light cramping from the SIS, but I imagined Hank protesting against the walls of my uterus as we talked of his ablation.

My 44 days of miscarriage bleeding and/or spotting?  Hank.

Painful ovulation symptoms with spotting?  Hank.

What I thought was a period, a HEAVY period, only fifteen days after miscarriage spotting stopped?  Nope, Hank

Hank, you bastard. 

A Hitch in the Get-Along

This week has not gone, this cycle is no longer going, as planned.  My vagina has a hospital smell.   Let me explain.

F and I traveled to the RE this week for the Sonohysterogram (SIS) and IVF review teaching.  I came prepared with my list of questions about my new protocol: 1)  How/why was the Antagonist Protocol chosen this time?  2)  Do you think we will get more eggs with this protocol?  3)  Egg quality was a concern after repeat miscarriages with embryos from last cycle.  Has this protocol yielded eggs of higher quality for other patients?  4)  Is my Day 3 E2 level of 23 a concern?  Too low?

I didn't get a chance to ask any of my questions.

We settled into the exam room for the SIS.  The saline went in.  But my uterus did not expand with the black, pear shaped, negative space.  Instead, it formed a crescent shaped space, and a large grey mass appeared.  Perhaps a polyp, most likely retained tissue from the most recent miscarriage.

And IVF canceled.  Okay, not canceled, DELAYED.

We did not review IVF teaching.  We did not go over the IVF calendar.  We did not order IVF meds.

Instead we scheduled a hysteroscopy and d&c (or ablation) at the hospital for the next day.  Thankfully, for the very next day, and with my RE as the surgeon.

We got lucky with this last minute opening.   It was either that day or wait until next month.  Which would push IVF back two months...

I have waited so long already.

________________

The hysteroscopy and ablation went well.  The tissue was in fact leftover from the miscarriage.  The RE sent it off to pathology and I am recovering at home with minimal discomfort.

I did get a chance to talk to the IVF nurse making my calendar before the surgery.  I will finish the current pack of birth control pills and start a new pack to prepare for IVF after that.   I should be able to start stims around September 28. 

In the end, IVF #2 will only be delayed by a month.  Not so bad.

Antagonist

I just got the call from the nurse working on my IVF calendar.  Things are happening very quickly!  This is due to a protocol without Lupron suppression.  The nurse started giving me dates--start doxycycline tonight, stims on September 1, possible retrieval on the 10th-12th--and I kept thinking, "How is that enough time for Lupron??" 

The answer was, "You will not be taking Lupron with this protocol."  We will discuss the details of the calendar and the protocol on Thursday, when I go in for my SIS and IVF review teaching.

I guess that means I am on an Antagonist Protocol for IVF #2.  Antagonist protocols are often used for patients with low ovarian reserve, or low responders who do not need Lupron suppression.  I clearly don't know much about protocols.

So I have mixed feelings.  Excited that this cycle will move quickly, that I will be starting stims in just a little over a week!  Yet, unsure about this new protocol and what it means for my diagnosis.  Have they been telling me all along that I am a poor responder, that I have low reserve and I just didn't hear them?  Regardless, in a month from now we will be waiting for the results of the chromosome screening.  It is probably best not to think much about that now.  I'll have plenty of time to stress over that later.



P.S.  If you have been prescribed the Antagonist Protocol for IVF, please let me know in the comments by sharing your experiences and successes, if you don't mind.

August ICLW

A special Hello! post for ICLW visitors.


Who I am:  Jill.  A mid-thirties, unexplained infertile, married to F.  That is usually as personal as I get.  I will tell you though, since it is ICLW, that I have recently begun the Couch to 5k running program.  I'm a swimmer and a bicycle commuter and a walker and an off and on yoga poser, NOT a runner.  I truly despise running.  My arches are too high, I have a weird form, I don't like exercising in public and most of all, running is so hard!  Yet despite my fear and hatred of running and shin splints and running shoes, I recently developed the odd urge to go for a triathlon if I am not pregnant next summer.  You know, "to do something for myself," as they say.  So today, while moving my body in a way I really hope resembled jogging, but mostly just wincing in pain from shin splints and stiff hip flexers, I wondered if it was a bad idea to begin my introduction to (the agony of) running at the same time as I prepare my body for IVF.  Of course I will have to slow down as my ovaries enlarge, but is this a bad idea now?  Why is running so painful and does it get better?  P.S.  I am on week 4.

Where I am in treatment:  I am currently on birth control pills in preparation for IVF #2, after IVF #1 and FET #1 both resulted in early miscarriages. We will have CCS done on our blastocysts this round in hopes of finding a good embryo that will grow to be our baby.

My current emotional challenges in dealing with infertility:  Other than trying to stay positive for IVF #2?  Pregnant friends and mother-in-law woes.  I am really having a hard time dealing with the news of a good friend's pregnancy.  I've been trying to write a post about it for a while now.

Recent posts on this blog that reflect what has been on my infertile mind lately:  Infertility Resumes and Ovarian Age

IF Blogs I am reading right now:  Womb For Improvement, The Infertility Voice, Everyone Else But Me, Fertility Lab Insider, My Bum Ovaries, Creating A Family

Happy ICLW and thanks for visiting!

Cycle Day 3

This first period after miscarriage is  H E A V Y.  Wowsa.  Where is all this blood coming from?  I feel like I've been bleeding all summer.  I haven't soaked pads since I was a teenager.  I haven't leaked during the night and stained my sheets since college. 

Everything looked normal on the baseline scan today, though.

Lining measures 4.4
My right ovary had 8 resting follicles.  My left ovary was mostly obscured by my intestine (lefty always seems to hide).  The RE counted at least 3 with only a partial view.  In total, I should have more than 11, which is what I had for IVF #1.  That's hopeful.

Blood results include:

FSH: 8.99 (past values include 7.08 and 9.3)
E2: 23 (this seems low?)
TSH: 1.69
T4: 1.21

Popped my first birth control pill this evening and I should get my protocol and calendar this week!

Oh, and my Hcg did finally drop to zero.

Cycle Day What?!

ONE.  Yes, one.  My uterus just went, "Ta Da!"

(Cycle day one will actually be tomorrow due to the evening arrival of flow.  The spotting started last night and continued through most of the day.  I was getting worried that it wasn't going to turn into anything, that not enough time had passed since the end of the miscarriage bleed and that I couldn't possibly have anything to shed for a period to count, but lo and behold, there is red flow!)  

So it seems that 15 days after the last bit of spotting (from 44 days of bleeding, mind you) ended, I am at the beginning of a new cycle.  Once my beta finally dropped to negative, my system must have jumped into gear.  And brought on wicked PMS.  Rage.  Depression.  Self-doubt.  Ugly cries.  Ugly laughs.  That was my weekend.

It has been two months since the actual miscarriage happened.  Cycle Day One, like the last one after my first IVF miscarriage, is bittersweet with relief and sadness.  Mostly what I feel is closure.  I also feel ambivalent about starting IVF all over again.   I feel overwhelmed already.  When I think about how difficult IVF can be, a little voice in my head whispers,  "Just quit."

But tomorrow I will call to schedule a day 3 workup, fill my prescription of BCP, wait for my calendar, plan trips.

We'll be doing CCS with this retrieval which adds another layer of worry, money woe, timing and thought.  

There is so much to do to prepare.  I realize this will take the rest of the year. 

Deep Breath.  Ok, let's do this.

Weekend Trip

I've been looking forward to this fun weekend trip to celebrate my friend's fortieth birthday for most of the summer.  For me, it would not just be a celebration of a friend's milestone birthday, but also an official farewell to a pretty shitty summer.  However, I was getting worried that the never-ending miscarriage bleeding was going to put a damper on my swimming pool experience.  Thankfully, it did not.

Mostly.

Saturday morning we went for a long bike ride, returned to the house to change into swimsuits and jump in the pool.  I went to the bathroom, wiped and saw faintly pink tinged mucous on the toilet paper.  Shit.  I told myself it was probably just the increased mucous that can show up after a m/c and that the bicycle seat probably just put pressure on my cervix or something.  It was not a return of bleeding.  Please.

After swimming and sun, the spotting turned to dark brown.  We went out to dinner and the cramping started.  With bloating.  Really bloated.  Like the worst kind of PMS bloating.  I thought my period was about to start.  But it is too early for a new cycle.  The bleeding only stopped a week ago.  Any bleeding now would still be considered miscarriage bleeding.  And I would be crushed.

More brown mucous the next morning and then nothing.  Still nothing.

I told you I have been taking my BBT every few days to track this cycle.  Before I left, my temperature was low.  And now, this morning, my temperature was elevated.  Could I have ovulated this weekend?  Was the spotting and cramping just an uncomfortable ovulation? 

Could a new cycle really arrive in two weeks?  I hope so.

Post-Miscarriage Beta #4

At least I think it is #4.  It has taken so long and there have been so many I am losing count.

My hcg levels came back yesterday at 6.8.  And quite possibly as the best news I have received all summer.   Not quite zero (anything under 5), but close enough to give me a break from blood draws until cycle day 3 (In addition to baseline tests, they will run a beta hcg at this time just to be thorough).

I also got the okay to start birth control pills with this next cycle in preparation for IVF #2.  I am as ecstatic as one can be in my situation.   Cycle day 3 will be a big day--baseline testing and scans, SIS, possibly an updated mock transfer, as well as birth control pill popping.

As crazy as it sounds for someone who has only just stopped bleeding after 44 days, I hope AF arrives quickly.  The nurse said my next cycle could be anywhere from 2 weeks away to who knows when and the bleeding could be really light to really heavy.  Unpredictable, basically.

With my last miscarriage cycle, my BBT showed a temperature spike and elevated temperatures for my usual 14-15 days, so I am hoping to catch the temperature rise this time as well so that I may have a better idea of when to expect AF and what my IVF calendar will look like.

---

This is what a beta level of 6.8 looks like (in photograph) on a FRER hpt.  You might need to enlarge the image by clicking on it to really discern the second line.  It is there, I promise!

For me, this may also translate to a lesson on testing too early.   FRER tests are really sensitive!   They need to add a warning to the instructions:  Testing too early may detect chemical pregnancy!  FRER will break your heart.