Yesterday, Kyle and I had our follow-up appointment with our reproductive endocrinologist (RE), and it ended up being really reassuring but at the same time not reassuring at all.
The first thing we talked about was the most recent miscarriage, which honestly came as a surprise to everyone. That blastocyst had been perfect from day one and was still perfect when they transferred it. It was classified as 4AA, meaning that it was getting ready to hatch and that the cells had divided to look like a textbook blastocyst on day 5 after fertilization. Both the inner cell mass (that’s the fetus) and the epithelium (the cells that become the amniotic sac and placenta) were well organized and looked good. The transfer went “beautifully,” and when I got my pregnancy test bloodwork back about ten days later, the numbers were almost double what they’d expect them to be at that point. They increased at the exact rate they were supposed to, so everything looked really good. I thought that maybe this would be the one.
The only thing that didn’t look good was my progesterone number. Progesterone basically helps a pregnancy to stay in place–it tells your immune system, “look, we actually want this foreign body in us, so DON’T ATTACK IT.” It helps the uterine lining, or endometrium, which is thickened with estrogen, to stay intact and healthy. For the first several weeks of pregnancy, the ovaries produce enough progesterone to keep the pregnancy in place; after that, the placenta takes over.
In a frozen embryo transfer, your ovaries are basically turned off (the absolute polar opposite of an IVF cycle, and my god is it refreshing), so you have to take supplementary progesterone. This can happen in a number of ways, but the two most common are intramuscular injections and suppositories. You can either take an ENORMOUS needle and shove it into your buttcheek every day (sometimes twice a day for kicks!) or you can shove a bunch of goop where the sun don’t shine twice a day, every day.
Isn’t infertility a blast?
(so. much. fun.)
Without getting into too many details, I chose the latter because while I’m a-okay with most needles, I do have a limit (and also because either Kyle or Kat would have to give me the injections, and bless them, but no). It had its drawbacks (which I will not go into here), but those paled in comparison to how little I wanted an enormous needle in my buttcheek.
(Maui gets me)
So fast forward again. When I got my bloodwork back, the nurse told me that while my HCG numbers (HCG is human chorionic gonadotropin, the hormone produced exclusively during pregnancy… or testicular cancer, which I most assuredly do not have) were really great, my progesterone was extremely low. It was above a 5, which is the cutoff for a viable pregnancy, but it was still much lower than they wanted to see. They scheduled me for an earlier ultrasound, just to make sure that things were still growing, and long story short, we never made it to that ultrasound.
Logically, I put two and two together. My progesterone was low; I’d lost the pregnancy; therefore, I’d lost the pregnancy because my progesterone was low. I was taking so many progesterone supplements at that point that I guessed the problem must have been with absorption, and the culprit for that, I figured, was the ridiculous volume of estrogen I was gulping down every day (6 mg, for those playing along at home). Too much estrogen can overwhelm the progesterone in your system, so that just made sense to me. Maybe my body just got a taste of estrogen and decided to go full ham, churning out the stuff at staggering speeds and volumes. My progesterone never stood a chance.
Well. This is why I’m not a reproductive endocrinologist.
(that and all the math)
My doctor looked back at my numbers and explained that my estrogen levels had been, like everything else in this swing-and-a-miss pregnancy, “beautiful.” My progesterone levels had seemed low because I was opting for the suppository route, which delivered progesterone directly to my uterus. Levels would have stayed pretty low in my system until the placenta kicked into gear because I was basically bypassing the bloodstream. If I hadn’t been getting enough progesterone, I would have experienced breakthrough bleeding, and I didn’t, not until the miscarriage itself.
(I’ll spare the gruesome details and just remark that it looked like The Shining)
So that itself was reassuring: I didn’t do anything wrong. Different progesterone supplements wouldn’t have changed the outcome; like the last two miscarriages, this one had likely been the result of something going wonky with the chromosomes when Kyle’s DNA and my DNA merged and split. We weren’t able to save the fetal matter, so there’s no way to know for certain what the problem was, but chromosomal problems are kind of impossible to prevent anyway, so it wouldn’t have mattered much.
In that vein, we talked about chromosomal boogaloo, and my doctor basically said that while it’s usually an egg health issue, there’s no way to test for egg health before fertilization. You basically have to fertilize as many eggs as possible, freeze them, and then do what’s called a preimplantation genetic screening, or PGS. PGS basically makes sure that the embryos are chromosomally healthy (and can determine the genders of any embryos, which makes it pretty controversial), that there aren’t too many or too few chromosomes (a condition called aneuploidy). The embryos are refrozen after PGS takes place and can be transferred at leisure.
SO. What does all of that mean for the future of me getting knocked up?
FIRST. We’re going forward with another frozen cycle ASAP. Initially, I’d thought, “well gee, I’d like to wait a couple of months and just give my body some time to chill,” but whether because I’m not feeling hopeful or because I’m tired or whatever, I just want to get this frozen cycle over with. If it works out, awesome, I’ll have a due date sometime in December or January. If it doesn’t, we can move on. The last frozen blastocyst is of a 3AB quality… not picture perfect, but I’d rather have a fetus that grows than one that’s textbook perfect as a blastocyst.
SECOND. If this doesn’t work, I’m going ahead with another IVF cycle, though I don’t know when that would take place. I talked to my doctor about making sure I’m not overmedicated this time like I was last time (I am NOT doing the OHSS boogie again, that was miserable), and with any luck, we should have found the right medication cocktail to produce a lot of healthy eggs. Those will be fertilized with ICSI (intracyatoplasmic sperm injection, basically they’re going to actually inject the sperm into the egg to make sure the poor lamb doesn’t get lost), and then we’ll freeze them to do PGS.
Which, why haven’t we been doing that all along? Well, because it costs $2500 minimum, but usually closer to $3000-3500; and while I’d love to say I’m rich enough to throw that much money at anything whatsoever, I’m not. We’re not. We’re going to be saving many pennies for either PGS or, if this frozen cycle works, upgrading our baby stuff (our stroller is very sad, and we’ll need new carseats and a new car).
(pictured: not me)
Initially, my plan was to just do back-to-back-to-back IVF cycles, get as many embryos as I could, and then test them all in one fell swoop; BUT apparently our insurance requires that we use all frozen embryos before doing another IVF cycle. That’s entirely fair, and I just hope that any future individual cycles produce enough embryos for testing.
(this all makes me sound like a mad scientist. I’m not… a scientist, that is)
So that’s the path forward. Emotionally, I’m… I don’t honestly know. Guarded, I suppose. I feel like I just want to move on, keep going. I’m not planning anything, and I’m trying to avoid getting my hopes up even a little bit. We’ll see what happens, I suppose.
3 thoughts on “Looking Forward”
I kind of think that fertility clinics should not be allowed to tell patients that their embryos look perfect, you know? I think it sets us up for so much heartache. We are in our sixth and final round of donor egg IVF, and we started out with 13 average to excellent grated blastocysts. So you’d think that it would have worked by now as we’ve gone through 7 embryos, right? I had a miscarriage on the 4th cycle and the whole nine weeks that I was pregnant I had a hard time believing it was real, and really wonder if my immune system is just giving a giant fuck you to any new thing put into my uterus. I did however learn that my TSH was tripling every time I got onto estrogen, and hypothyroidism triples the chance of miscarriage so finally now at cycle six I have it down below 2.0 where it needs to be and I’m also taking 5 days of prednisone to keep my immune system from treating it like a foreign invasion. We also ended up doing an endometrial receptivity assay which showed my implantation window is typically a day after they’ve been doing the transfers, sell or transfer on April 14th will be after taking 6 days rather than 5 days of progesterone shots.
Wishing you the best in your next transfer!
That’s been my biggest lesson throughout this particular cycle: blastocyst grade means so much less than I think a lot of us want it to. Even my husband was blindsided by this loss because of how textbook that blastocyst was, but nada still.
That is wild that your TSH was going all wonky because of the estrogen. What prompted your doctor to test for that?
Thanks, and good luck to you too!
My doctor didn’t test my thyroid at all, but it’s standard at many fertility doctors because a TSH above 2.0 can affect both fertility and miscarriage rates. I learned that after doing research on my own and through my naturopath, so after my miscarriage we tested it and saw that it was around 7 and have been working since August to get it down. Sadly a lot of REs don’t check thyroid for their patience and it’s so important. From what I understand if you have even a touch of hypothyroidism, if you get pregnant or are otherwise taking pregnancy hormones you should you should have your thyroid monitored monthly.