Checkmate

I have previously described that navigating infertility treatments is like playing chess. Although, I confess I'm just using a literary reference; I don't actually know how to play chess. I can't remember the names of the pieces beyond their descriptions of the 'little horsey' or the 'castle thing' and I'm so confused about how they can move. I am aware that chess is the ultimate game of strategy, where a player must anticipate his or her opponent's response and plan two or three moves ahead as he or she contemplates each turn. A skilled player is one who can appropriately react to the opponent's challenges and revise tactics as the game is played.

Prior to starting any infertility treatments, I had read some intriguing articles advocating for endometrial injury prior to an embryo transfer. Additionally, I had one patient who had experienced secondary infertility after the age of forty. As she had pre-term deliveries with both prior pregnancies, her RE strongly insisted on single embryo transfers. Her first two attempts were unsuccessful, so she had an endometrial biopsy prior to the transfer of her final embryo, which resulted in a BFP and successful pregnancy. I also worked with a patient who was pursuing a donor egg IVF cycle at an out of state clinic. She failed two cycles with her own eggs, which were judged to be of low quality. She had selected a proven donor, but her RE still wanted her to go through an endometrial biopsy. A transfer of two embryos resulted in healthy twin boys. I recall one blogger mentioned that her RE will perform a biopsy for a patient with two or more failed transfers. Why wait for someone to fail multiple times? I thought to myself. As this is a relatively easy and inexpensive intervention with data demonstrating that it increases success, why not employ it?

As I had intended to do PGD testing with my first cycle, I was also conspiring to have an endometrial scratch prior to transfer. Of course, I hadn't anticipated the need for a day 3 transfer and the resulting pregnancy. Although I wasn't surprised when I learned that the pregnancy was non-viable and later learned that it was due to a trisomy, this information challenged my thoughts on pursuing an endometrial biopsy. I didn't bring it up when my RE suggested waiting for one normal cycle before prepping for the FET. I figured that the D+C accounted for endometrial injury, but as it took over seven weeks for AF to return, I wondered if it offered any benefit by the time we transferred The Chosen One. As I had such little faith in our clean out the freezer transfer, I never gave any thought to aggravating my endometrium. I was really ready to move on to another fresh cycle and didn't want to invoke any additional delays.

I admit that I've become a bit superstitious; I didn't allow myself to make any plans for a transfer until I received my PGD results. I tried to prepare myself that all six could be abnormal. However, by the time my RE called with the news that we had four euploid embies, I was on CD3. AF arrived on a late Saturday afternoon, before I had an opportunity to coordinate a biopsy. My RE had offered that he wouldn't send my endometrial sampling to pathology in order to reduce the costs, but I have other resources at my disposal. There aren't many perks to working in Ob/Gyn while you're infertile yourself, but one of them is that I can walk down the hall and ask a colleague to rough up my endometrium. Saving a few hundred dollars is merely a drop in the bucket compared to our total costs, but as I've mentioned before; infertility has made us chavs. This time I didn't mind the delay. It gave me time to grieve over the loss of my cat, Angus and start the process of welcoming a new kitty into our family. It also offered me more time to evaluate my long term strategery.

When we transferred The Chosen One, Husband did some research and found statistics that demonstrated transferring a high quality embryo in a woman of my age yields a 60% success rate. Data from the XYZ Fertility Centre cites a 75% pregnancy rate when a known euploid embryo is employed. According to the math, we gained a confidence interval of 15%. I can understand why my RE repeatedly conferred the lack of cost effectiveness.  Yet while I can appreciate the facts, the peace of mind afforded by our CCS testing is priceless, even if it only increased our chances by 15%. Not to be a glass three-quarters empty person, but a 25% failure rate seems high with an established euploid embryo. It's hard to quantify the advantage of an endometrial biopsy, but some studies have conferred higher implantation rates.

I want to approach my next transfer with the fortitude that I have done everything in my power to increase the potential for success, while simultaneously preparing myself that it still may not work.  If it yields a BFN and represents my third consecutive failure, I'll consider re-evaluation of my uterine cavity. My RE wanted me to do another sonohystogram prior to my first IVF cycle, and I argued that it wasn't necessary as I had a hysteroscopy 8 months ago. Reluctantly, I agreed to it, and not surprising, it was normal. In my future scenario, I would probably advocate going right to a hysteroscopy prior to another single embryo transfer.

In addition, I would consider The Endometrial Function Test, as years ago, I attended a lecture from Dr Kliman and I appreciated his methodology. My RE noted the data from his test doesn't seem to be reproducible (I doubt the pun was intended) but reported that his colleague will sometimes utilise it for difficult cases. If that one doesn't deliver, then I'll proceed with a final transfer of both remaining embryos. If we end up with twins, so be it; although I'm starting to believe that we're too infertile to be concerned about twins. This also presumes we don't encounter any lost embryos during the thawing process. While I realise how fortunate we are to have the number of embryos that we achieved; at times it still feels like it's not enough.

Where would we go from there?  At least for the present, that would represent our end point. It's mostly a logical decision. I can't imagine we would exceed our current yield with a third cycle. Even if we got a decent production,  I wouldn't want to be back at the XYZ transfer suite with my RE and the hottie embryologist trying to convince me that 'the fifth euploid embryo is the charm!' I also recognise that we wouldn't gain any advantage with donor gametes. I recall reading that CCRM recommends moving toward a gestational carrier if there are three or more failures with good embryos. Not only is the GC price tag hard to swallow, I would struggle to accept that option without having a conclusive answer on why my own uterus is ineffective. Prior to my second stimulation cycle, I had two colleagues ask if I had considered adoption, which is an infertility journey milestone in itself. There is a lot to say regarding that topic, but it the interest of brevity; it would be much more of an acceptable option if we were ten years younger. Not that we'd be provisionally rejected because of our age, although I think we'd be seen as unsuitable candidates as Husband is not yet a US Citizen, I used to work at an abortion clinic and we are atheists. After spending three years navigating through the maze of infertility treatments only to find there is no way out, I just don't think we would have the stamina to endure the uphill battle of adoption.

Enough. No Más. I'll go back on birth control, preferable one that will induce amenorrhea. There is a surprising sense of calm that comes with having an identified end point, although I acknowledge that I am writing from the perspective of someone who feels slightly hopeful at this point in time. I doubt that I'll feel as calm if we turn up empty after a somewhat decent first cycle and a kick ass second IVF cycle. At least we would be able to say that we did all we could, and now we would be moving on. Wow. What would I do with all this energy that would not be devoted to all things procreation and infertility related? Maybe I'd find the time to write the great American novel.