The IF-RPL Stages of Grief

Although the Kuber-Ross model describing the five stages of grief often experienced while facing a terminal illness has been applied to other situations, I've noted that I seem to be going though a unique five stage approach following my second miscarriage.

Frustration
This emotion seems to have replaced denial and anger. I think I did a pretty good job of repressing any expectations of optimism, so much so that the news that the pregnancy wasn't viable wasn't even a surprise to me. I prevented myself from feeling any sadness at the time, but the sadness creeps up on me at times if I think about where the pregnancy could be at any given time. This is when I transition to frustration. I'm ready to be done with procreating. I'm ready to be finished with the frequent visits to my RE's office and the accompanying lies and excuses. I want to end the secrecy. I'm tired of feeling as if our lives are on hold.

Although this is petty, I really wanted my last pregnancy to work as it would have granted Husband fatherhood before his 40th birthday. Waiting two more months feels like two more years at our age. Even more petty, my friend in Maryland is lapping me -she's pregnant with her second while trying to conceive in the same time period as us. I'm starting to prepare myself that Myrtle will be pregnant again soon. Although this could be the least of my worries, I resent that I could have to share the spotlight if we were to be pregnant at the same time. I'd have to endure hearing about her uncomplicated, perfect pregnancy while I'll be a high risk mess. I never thought I'd feel this way, but infertility and pregnancy loss makes you bitter and spiteful.

Perhaps anger could also be replaced by regret, which is sort of a subcategory under frustration. I regret that we didn't start trying to conceive sooner, I regret that we didn't start IVF sooner. I regret wasting time regretting about the past when I should be focusing on the present and the future. I'm so fortunate that we have our embryo insurance, but at the same time, it's frustrating to think about going through another two week wait and ensuing uncertainty. I'm also preparing myself that we shouldn't expect our FET to work, just because our first transfer resulted in a pregnancy, which could mean waiting even longer for our next transfer. I feel like I don't even want to know the numbers of any positive beta results. Beta numbers mean nothing to me. I once joked that I won't accept that we're having a baby until my hands are behind my knees and I'm hearing someone instruct me to push. Now that's sounding much more realistic.

Consumption
As we drove separately to the visit that discovered our embryo's arrested development, Husband arrived home before me and had a glass of wine ready for my entrance. While I didn't feel the need to drink, I just appreciated that I could. Fortunately, the eating part of this phase was short lived, but it included a shameful trip through the Burger King drive through. I turned into a dead-end street and parked in the cul-de-sac and devoured the oh-so satisfying while yet so horrifying fast food. I then tossed the rubbish and took my car in for interior cleaning to cover up the crime. Until I had my D+C, I felt that it didn't matter if I ate healthily. Once my uterus was reset, I restarted my good eating habits.

Research
I have yet another two week wait until the results from our products are received. I figure a chromosomal abnormality is just too straight forward to be our answer, so I'm preparing to learn that our embryo was euploid. Fortunately, I've not have any recent patients with RPL, so I was overdue for a refresher.  Seemingly, ever article seems to start with a discussion on how difficult it is to study and analyze RPL. Even women with RPL may have different explanations for each loss and two individual women with RPL may have separate etiologies. Making matters more complicated, the expert groups (American College of Obstetrics and Gynecology and American Society of Reproductive Medicine) lack consensus on what defines recurrent loss and what type of evaluation should be performed.

Statistically speaking, 15% of pregnant women will have a spontaneous loss, but just 2% of pregnant women with have two consecutive losses. This is actually slightly lower than the observed frequency alone (0.15)(0.15) = 0.0225 or 2.25% which does allow for mere bad luck to be a plausible explanation. However that mathematical model doesn't account for the inherently higher risk due to my age. Accordingly, my miscarriage risk with a future pregnancy is now 24-29% as I have two losses recorded.

Interestingly, I uncovered some information I hadn't read previously. A uterine septum is the congenital anomaly associated with the poorest reproductive outcome and it is the most common uterine abnormality to cause RPL. Although some women with a septate uterus can carry a full term healthy pregnancy, (with a higher occurrence of malpresentation) it is proposed that decreased blood supply to the septum may lead to poor implantation and the miscarriage rate may be as high as 60 percent. My RE felt that he couldn't conclusively attribute my first miscarriage to my septum, especially as mine was relatively small, but I intuitively felt that it was to blame. Now, I have some data to validate my instincts.

Some other information to consider is that there is an increased risk of miscarriage in the setting of abnormal sperm morphology (defined as fewer than 4% normal forms -Husband only had 1% normal on his complete semen analysis). Although I felt confident that my level of exercise and activity wouldn't cause a miscarriage, I kept quiet about what I was doing as I feared I would be judged negatively, given my history. Now I have it in writing that exercise does not increase the rate of a sporadic or repeated loss. Regarding celiac disease, more evidence is indicating that even subclinical disease may contribute to recurrent pregnancy loss and treatment in the form of a gluten free diet seems curative. However, as it is the end effects of gluten enteropathy that may create a poor reproductive environment and not the gluten itself,  a gluten free diet would not offer benefit in the absence of celiac disease.

The other controversy in the field or RPL research is the role of thrombophilia evaluation and treatment in the setting of first trimester losses. Recent recommendations suggest limited testing to Anticardiolipin antibodies and lupus anticoagulant (uterine cavity and thyroid testing are also suggested as part of an initial RPL work up. Karotyping of both partners should also be considered, although the yield is small, the findings of an imbalanced translocation could represent a game changing plan requiring PGD) My RE and I had discussed that there seems to be a low pre-test probability of performing hyper coagulable testing with early losses, but I'm reconsidering as I experienced an episode of aura a few days after I learned the pregnancy was non-viable. I had been instructed to continue all my meds so that I wouldn't pass my products spontaneously, and I honestly can't remember if I took my estradiol that morning. However, all forms of exogenous estrogens are contraindicated in women who experience aura (with or without migraine) as that combination produces a higher risk of stoke. Thus I wonder if the supplemental estradiol contributed to an increased hyper coagulable state, which may have played a role. I know such a theory cannot be determined with testing for inherited thrombophilias, but I'm still curious to see my panel.

Planning
As I anticipated, my RE wants me to wait to have one normal cycle before proceeding with a FET, so if AF cooperates, we're looking at February. He's proposing that we do a natural cycle transfer as it seems that I have more than just blood pressure problems with exogenous estrogen. (on a side note, I'm so bummed that I won't be able to take HRT when I go though menopause!) Although the concept of a 'natural cycle frozen embryo transfer' sounds like an oxymoron, I like the idea of using fewer drugs. However, I'm reluctant to rely on my unpredictable ovaries and my borderline uterine lining. I'll be gutted if we miss the timing and have to wait another month, but more so I fear wasting our good blastocyst if everything isn't perfect. Other options to consider include using transdermal or intravaginal estrogen to avoid the liver's first pass effects, and/or anticoagulating. Fuck me, why does this seem so complicated?

The other part of my plan is that I am going to trial going gluten free in the month of January to see how I feel with it. In the past few years, I've had some patients describe how (even in the absence of celiac disease) they went gluten free and it seemingly changed their lives and they feel so much healthier and happier. My inner skeptic questioned if it was merely a placebo effect, but over time I came to accept that if you think you feel better, who cares about the validity of the variable, if you're feeling better -good for you! A few bloggers have also reached out to me with their gluten free success stories. As I used to eat cereal two, sometimes three, meals a day, I am pretty sure that I do not have any form of gluten intolerance, so I know that the data does not indicate that there would be any benefit. However, it's a relatively easy intervention and I figure what do I have to lose? (maybe a few pounds!) We cleared out our pantry and made a donation to the food bank whilst discovering the gluten free section in the store. Additionally, as we found a gluten free beer, Husband is willing to do this with me.

Embracing
This is essentially the same as the Acceptance phase, but I thought 'embracing' implied a more positive connotation. It's the process of appreciating the things you can do in your non-pregnant state. After running a half marathon in the middle of August, my training went on hiatus while we spent our weekends preparing for the in-laws arrival. I resumed my routine in October, but shortly had to taper my activity level as I reached the end of my stimming phase. I was back in the pool on the 6th day after my transfer, but I was still feeling a little delicate from the effects of my retrieval, so I moved myself to a slower lane. However, once the temperatures dipped below freezing, I decided against swimming in an outdoor pool. I skipped a month of Cross-fit during this time, and my Thursday evening tennis group stopped meeting just before Thanksgiving. Once I learned that we were non-viable, I ceased all activity.  Although exercise cannot disrupt a healthy pregnancy, I feared that it could potentially cause me to spontaneously passing my products, and I didn't want to take that risk.  Funny how your perspective can change. I went running a few days after my D+C, and discovered just how much my fitness had declined.

Once again, I've become a cautionary tale to be careful about what you wish. When it was originally proposed that we would do a freeze all cycle, I liked the idea of being able to recover from the stimming and retrieval and get myself back into shape for my transfer and possible pregnancy. Wish granted. I signed up for three 10Ks in January and a half marathon in February. I ran 5 miles on Christmas morning, just to prove to myself how committed I was. Husband and I re-enlisted in Cross-Fit. As the yoga classes have been temporarily suspended from the Cross-Fit schedule, I picked up a few DVDs to do at home. I joined another session of Thursday night tennis. After taking almost six weeks off, I'm looking forward to getting back in the pool.

Perhaps my objective is to keep myself so busy that the time passes quickly, but I welcome a break from all the medications, blood draws and ultrasounds. It's been a struggle to keep up with my workload as I've been running out of the office so much, so I'll try to get ahead in anticipation for my FET preparation.  Mostly, I appreciate this time as I feel protected from disappointment. While I'm anxious to move forward with our next steps, I'm also fearful.