Plus 16 is the loneliest number...

Hours before the ultrasound that revealed the doomed fate of our embryo, our office was visited by another area REI. A few years ago he did a lunch time inservice to share the latest updates in the field of infertility, and to discuss how bread and butter Ob/Gyns and REIs can improve the referral and transfer processes for patients. He left us with his email contact, and I consulted him on several patients, including a particular "patient" who was actually myself. I considered revealing that I was pregnant after my first IVF cycle and was awaiting my viability scan, but I never had quiet moment alone with him and secondly, I knew better than to tempt fate like that.

During his previous visit, he delivered a power point presentation and distributed hand-outs; this time he was not as prepared. He discussed using the Anti Mullerean Hormone (AMH) level as the novel new way of measuring ovarian reserve; as my colleagues and I exchanged glances acknowledging that we've all been ordering AMH tests since he informed us about it three years ago. That was it. He then asked if we had any questions. When no one else raised his or her hand, I decided I wouldn't pass on an opportunity to pick an RE's brain. I went wild with my questions. What factors determine a choice of protocol? (experience from prior stimulation is the best guide) How about endometrial injury prior to a FET? (gaining more support in the literature, his group is reserving for recurrent implantation failure) Thoughts on 'mini-IVF'? (a gimmick) What is your percentage of day 3 versus day 5 transfers? (25%-75% based on the fact that day 5 embryos are likely to be of a higher quality, but if a day 3 transfer results in a pregnancy, it's not more likely to be chromosomally abnormal than a successful day 5 transfer) He then introduced the concept of Pre-implantation Genetic Diagnosis (PGD) and its utility in allowing for more single embryo transfers and higher pregnancy rates.

Some of our medical assistants, who were learning about this technology for the first time, were fascinated. "Wow! So you wouldn't have to do any screening or an amnio?" "Can you find out right away if you're having a boy or girl?" "That's so cool!" I was screaming inside my head; "THIS ONLY HAPPENS IF YOU HAVE ENOUGH EMBRYOS TO TEST!!!" All the promises of PGD are taken off the table when you get this call from your RE: [in the voice of Bill Lumbergh from Office Space]
"Hey Jane... what's happening... yeah... you see, your embryos kind of suck... I'm gonna need you to come in and transfer your embryos today...Yeah...if we could just go ahead and transfer your embryos today, that'd be great...or maybe it won't be...mmmkay?"

I knew it would take a little longer for my pathology results to come back due to the holidays, but I overheard one of my colleagues taking about abnormal results on a patient who had her D+C just about the same time as me. Since the products were sent to a hospital within our shared computer system, I asked my Lead Physician to access them for me. "It was abnormal +16" she wrote in her text message. (Husband and I decided that we did not want to know what the prospective gender would have been) Trisomy 16. The most common trisomy that occurs in more that 1% of all human pregnancies. An abnormality that is not compatible with life.

My first reaction was one of relief. "It's sort of good news!" I described to Husband. We have an answer; a explanation for our loss. It would have been disheartening if we had learned that the embryo was euploid and may have been a healthy baby. We would be left asking 'why?' and may never would have known the reason. I feel fortunate that the demise was discovered so early and did not progress any further. Yet, it's still another loss, another opportunity denied.

Thus, I feel a bit annoyed, although I acknowledge that it would be much more frustrating if we didn't have an identified cause. This was the situation I wanted to avoid by doing GPD. This is why I shared with my RE that "it seems a bit daft" to speculate about the best looking embryos and merely hope for the best. There was a reason why I would have preferred to do a day 5 transfer (two other bloggers had chromosomal abnormalities confirmed after a miscarriage with a day 3 transfer). I sensed there was a measure of desperation with the recommendation to transfer on day 3. I was right to be so guarded and so cautious. I saw the writing on the wall from the moment my RE projected the retrieval would only yield 6-8 mature eggs. All my instincts were correct, I just failed with the execution.

There is nothing to be gained by wasting time looking over my shoulder. A few hours after my transfer, my RE called to query if we wanted to biopsy my remaining embyros for PGD testing. Husband and I took a few minutes to conference and decided against it. The embryologist and my RE had managed to convince us that our transferred embryos were decent and that we had a reasonable chance to produce a pregnancy. Husband joked that if we spent the extra five grand to test those embryos, it would guarantee the success of this transfer. As I didn't have much confidence in those embies, I didn't want to spend the extra money only to learn two days later that none progressed to day 5. We were both mentally preparing that we would need to do a second fresh cycle and PGD testing for those embryos didn't seem like a good investment at that time. Additionally, selection of a euploid blastocyst would not guarantee implantation nor eliminate the possibility of a miscarriage. I need to keep reminding myself of that fact.

These results do provide reassurance as I look ahead. I've had two miscarriages. One (I believe) was attributed to a uterine septum, the most common uterine abnormality to contribute to a miscarriage, and the other due to trisomy 16, the most common chromosomal abnormality. Additionally, if this embryo were euploid, I would have higher doubts about whether or not our fro-yos were normal. The embryology lab estimates that ten eggs are required to yield 1 euploid embryo. If you factor a two-third fertilisation rate, you'll have six to seven embryos. Only half of those will advance to become blastocysts (approximately three) and only half of the day 5 embryos will be normal (thus leaving you with one or two useable embryos). The implantation rate with a euploid embryos is about 75%. We only had eight eggs, five fertilised, two were transferred and two of the remaining three became blastocysts. My RE reported that the embryologist noted that one looks "really good" and the other was just good enough to freeze. So is one of those two a normal embryo? Husband and I are speculating that we might want to place our bet with the sub par one...