Thursday, 20 March 2014

Sometimes you have to roll a hard six...

While I still have moments of subspecialty resentment toward REIs, there are also times when I wouldn't want to have their job. In addition to being repetitive and redundant, I imagine it must also seem intellectually frustrating. One can apply the most sound rationale based on evidence supported data as well as his or her own personal experience and still experience a disappointing outcome. An RE may also witness cases where patients go against his or her recommendations and manage to conceive spontaneously or with less likely to succeed treatments. In such a situation, it must seem personally satisfying to know that your patient reached her goal; but I can imagine that professionally, it may go beyond bruising one's ego and may even shake one's confidence. Additionally, an REI is only as good as the team around him or her. My RE described the importance of the skills in the embryology lab. One can be effective in creating optimal protocols for oocyte retrieval, but may have low success rates if the lab is poor; while another RE may be lazy during a stimming cycle, but if the talent in the lab is able to work magic with limited gametes, he or she may be credited for their achievements.

I wonder if I have become one of my RE's more irksome cases. He initially suspected that I may have a septum based on my office ultrasound, but personally reviewed the films from my hystosalpingogram (HSG) and noted if there was one present, it was unlikely to be signifiant.  I saw the live fluoroscopy during my procedure and mentioned the possibility of a septum to the radiologist, but we both concurred that it looked like a normal cavity. One month later, I attended a conference where a renowned REI reported that an HSG has about a 37% false negative rate for diagnosing a cavity defect, and he advocates performing a hysteroscopy prior to starting IVF. Around that time, we received Husband's post Clomid semen analysis. As there was only minimal improvement, my RE was abrupt with his recommendation; IVF with ICSI is our best option for getting pregnant. We could try IUI for 2-3 cycles at most. While we were digesting that news, I didn't get around to ask about re-evaluating my cavity, because we somehow managed to conceive spontaneously the next month.

My RE admitted that he wasn't surprised by our seemingly miraculous pregnancy, even though it contradicted his previous prognosis. He also described that it may have been a fluke, and while those words may sound harsh, I appreciated his candor. I'm glad he didn't dismiss us, 'well, it looks like you're fertile after all! Go be fruitful and multiply!' In the end, he was accurate about IVF and ICSI being our best option, and now it seems that it may not even work. Those of you who are long time followers know the rest of the details. After miscarrying, a sonohystogram revealed that I did have a septum present. When we started IVF, I raised the issue of PGD as I wanted to avoid a miscarriage due to a chromosomal abnormality, which is exactly what happened after a hasty day 3 transfer. A transfer of an allegedly perfect blastocyst failed to implant. I know I'm not one of the most challenging nor unfortunate patients in my RE's practice, but I sometimes wonder if he, Misery and New Girl ever speculate, 'of course this would happen to Jane -look at what she does!' On the obstetrics side, many of my colleagues have described that they perceive any patients who are medical providers to have an inherent higher risk.

At the end of my WTF appointment, my RE offered to do a baseline scan in the event that we wanted to pursue FET#2. New Girl led me into an exam room, "so you're going to go ahead with this transfer?" she asked. "Well...I'm still not sure.."I admitted. "What does your instinct tell you?" she inquired. "Forget what [the shared first name between Husband and my RE] says. It's your body, you're the one who has to go through this." My first instinct was to ask to whom she was referring, but that missed her point; what was my gut telling me to do?

Well, my intuition senses that we will need to do a second cycle. I also fear that it may yield very similar results as last time. A relatively small number that make it to the blastocyst stage. Maybe PGD testing will find that none are normal. Or maybe we would transfer a normal embryo and it still wouldn't implant. It is also possible that I could achieve a pregnancy with a euploid embryo and still have an early miscarriage. There is also the potential that we could have a completely unsuccessful second cycle, transfer the remaining fro-yo from IVF#1 and have it result in a successful pregnancy and baby. If that were to happen, I would be pissed. Thrilled and happy, of course, but still pissed. It just seems that whatever decision we make is really just a throw of dice.

So, if there really isn't any method to this madness, I decided against applying any rational thought to this selection. Here is how we elected to proceed with FET#2.

Could I still swim in our championship meet?
I know I'm not enough of an accomplished swimmer to make this such a priority, but I enjoy this meet so much, and I am on the fast girls 35 and older relay team. Additionally, as my coach takes this meet so seriously, coming up with an excuse on why I couldn't swim would be harder than thinking up a reason for being out of work. Not a problem, according to New Girl, as she asked me when I wanted to do my transfer. Whoa. I actually have some input into the timetable? Now, that is mind blowing.

Potential fresh cycle conflicts
After recommending an agonist protocol instituted in the luteal phase, my RE and I started looking at the calendar to determine day 21 of my cycle. I couldn't resist mocking him for counting each individual day rather than counting ahead three weeks and subtracting one day. "I'm really bad at math..." he explained. Such a flaw earned adoration from Husband "That's exactly the type of mad scientist you want... someone who can solve complex equations, but is stumped by basic times tables..." Anyway, I am digressing... If my day 21 progesterone level confirmed ovulation had occurred, then I would start the lupron. There are only two problems with that scenario. Firstly, it requires my ovaries to cooperate. Post D+C, it took just over two weeks to have a withdrawal bleed and then I didn't have an LH surge until day 21. Who knows what they would do after being suppressed for a month. Additionally, the timing of my blood draw comes close to when I'll be in Memphis for a few days. Oh, that is just too much temptation for the mischievous Si and Am (my ovaries have officially been named after the evil Siamese cats from Lady and the Tramp). If there is an opportunity for inconvenience; they will find it. "We could just keep you on lupron for another day or so," my RE theorised. Nope. If we are doing a second fresh cycle, we compromise nothing.

The Orange Light
“Gatsby believed in the green light, the orgiastic future that year by year recedes before us. It eluded us then, but that's no matter--tomorrow we will run faster, stretch out our arms farther.... And one fine morning-- So we beat on, boats against the current, borne back ceaselessly into the past.”

In the end, it was the little orange light on my dashboard that would serve as our beacon. I waited a few days before confessing to Husband, as I was hoping it would spontaneously resolve. While we were recapping the WTF assessment and my RE's recommendation, I introduced the potential game-changer. "So, I noticed this morning that my check engine light was on..." Technically, that was not a lie. I noticed this morning that the light had been on for four days. I'm pretty sure Husband knows me well enough to add at least more three days on the time I was reporting. The look on his face was a mixture of anguish and disgust, and I could tell he was trying to determine what is the maximum value we would justify paying to repair my 11 year old Jetta with 142,000 miles. "So, I guess we'll go ahead with the FET" he replied.

The next morning I called my clinic to inform them of our intention, while Husband took my car to a mechanics shop that investigates your check engine light for free. Sigh. Infertility has made us chavs. He stopped by my office later that morning with a peculiar smirk on his face. "You didn't tighten the gas cap tight enough that last time you fueled. The pressure in the tank decreases and sets off the check engine light..."

Our die had already been cast.
We are proceeding with FET#2.


  1. Best of luck. :) And yes I do the gas cap thing too.

  2. Sometimes you just have go by choosing the path of least resistance. You have plenty of time for a fresh cycle. An FET only takes a month or so of your time.

  3. Best of luck to you! I find it really interesting that 37% of HSG's have a false negative. Would you say HSG is more or less accurate than an Laparoscopy? I ask because I had both, the Lap said one tube was blocked yet the HSG showed everything clear? I struggled with what to believe on that. We did conceive on 50mg of Clomid (although it ended in miscarriage) so I guess at least one tube is open.

    1. Hi Amie,
      I added a clarification, HSG has a 37% false negative rate for uterine cavity defects, not tubal conclusions. HSG is recommended as first line assessment when there is no suspicion for tubal factors. Laparoscopy with chromotubation is preferred when endometriosis or pelvic adhesions are suspected, as it allows for direct visualization of the tube as well as opportunity to treat endo implants or adhesions.

    2. Thank you so much for answering! Whew ok so then I will go with the HSG results. Best of luck to you with the upcoming FET. I have been reading along following your journey.

  4. Great post! Hopefully your check engine light was a sign from the universe that your fro-yo is your take home baby. Wishing you the best this cycle!

  5. Haha! Glad it was only the gas gap silly.

    SO happy to hear you're moving forward with FET #2. You make a good point on a fresh cycle having no guarantees either, and it makes a lot of sense to use all of your life lines on hand first before going through all of that. Glad you'll be able to schedule everything accordingly so you can do your meet and the FET both too!

  6. I have to laugh a little at the gas cap thing. Totally something that would happen to me. I have had quite a few expensive repairs on my Passat so seeing the check engine light would definitely make me nervous.
    Glad you made a decision and are moving forward with the FET. I've got everything crossed you won't need another fresh cycle.

  7. I'm glad the orange light turned out to be easy to fix.
    And I'll keep my fingers crossed for the FET!

  8. It's amazing that weighing all the options and possible outcomes doesn't always lead to a clear decision and we still end up with a throw of the dice. I am really hoping that FET#2 is the lucky one for you!

  9. Sometimes, I feel the same type of stress dealing with my car acting up, as I do when I try to manage all of the visits to the RE for testing. I am so happy you came up with a plan.

  10. Ok, I totally thought I had commented on this already. But I have to admit that I'm going to disappoint...I had to look it up to realize it was a BSG reference. M would probably have gotten it right off!!

  11. Funny how little things like a check engine light can help make such a big decision. I'm glad it was only your gas cap and not something more serious (or expensive).