The Second Opinion

While I was in research mode after my latest FET, I contacted two other REIs in the area. One has visited our office a few times, and I have corresponded with him via email regarding some of my patients, as well as my personal situation. The other was Co-worker's RE, as we also have a few mutual patients. I was hoping that I could take some of their suggestions into my WTF appointment, but neither wrote back to me. Not even with an, "I'm sorry you're going though this, but you'll have to schedule a formal consultation." I shared with my colleagues how disappointed I was with their failure to respond. It makes you realise just how lonely and isolating infertility is when you receive this type of treatment from your infertility specialist associates.

The next day, after slagging them both off to my colleagues, I received a message from Co-worker's RE. He apologised for the delay and expressed his empathy for my frustrating situation. Very little information is available about Recurrent Implantation Failure (RIF). The issue is either the embryo or the endometrium. Even with a euploid embryo, his observation is that the implantation rate is only 50%. Mere chance does explain our failures. He then introduced a new test that identifies the window of implantation from an endometrial biopsy. If my endometrium is found to be out of phase, I could pursue another single transfer after correction. If the endometrium is in sync, then we should consider transferring two embies. "Being responsible to limit twins is respectable, but I think you need to be more aggressive."

They say you shouldn't ask a question, if you don't want to hear the answer. I wanted a second opinion, just not after I had already established a plan. I needed some information on this new test, so I typed the name into The Google, which led me to the company's website. 'Recurrent Implantation Failure? We can help!' Okay...I'm intrigued. The test involves performing an endometrial biopsy 7 days past the LH surge in a natural cycle, or 5 days after starting progesterone in a medicated cycle. Apparently, 20% of women with RIF are found to have a displaced implantation window. The results will either indicate that the endometrium is receptive, and the transfer should occur at that time, or it will reveal that the lining is not receptive and the analysis will offer a recommendation on when the transfer should take place.

So, this was another test to assess endometrial capacity. We had dismissed two other testing methods for lack of reproducibility and ambiguous implications. However, this one could offer feedback on my endometrium, which seemed pertinent given our plans to alter my estrogen priming. Suddenly my head was spinning. I had to do this test! If my next transfer resulted in my fourth consecutive BFN, I'd be filled with regret. This could provide a possible answer for my failures as well as increase my chances for success! I can't risk wasting another embryo, not mention the cost of an FET. What did I have to lose? Besides the cost of the test, (~$1,000) there would be a loss of time. I could have the test done in October, but my RE is away in November and my parents are visiting in December, so I wouldn't be able to transfer until the new year. Although, there is the hypothetical loss that I could just proceed with my planned transfer, have it work, and possibly be done with this process without making things more complicated.

I read through the research article that was posted on this company's website. In the clinical trial, they evaluated 85 participants with RIF and 25 control patients. A receptive endometrium was found in nearly 75% of the RIFers and 88% of the control group. 29 RIF patients with a receptive endometrium went through a transfer and the pregnancy rate was 51.7%. A non-receptive endometrium was seen in 22 RIF participants, but only EIGHT went through a personalised transfer based on the recommendations from their analysis. Four became pregnant, yielding a 50% pregnancy rate. The author concluded that due to the low number of patients, these results should be considered preliminary.

I had become swept off my feet. The lonely and desperate infertile who was seduced by the latest theory promising answers and results. Yet, what if this was the one? I started stewing about how much I resent being in this position and needing to make these difficult decisions. "Just talk to Dr. Somebody that I Used to Know about it." advised Husband, who was keen to shut me up so that he could go to sleep. I already knew what we would say about it. Limited studies, lack of reproducibility, ambigious findings...Yet he'd be willing to go along with it if I felt so compelled. I reviewed the data and crunched the numbers again. 85 women entered this study and only 4 (less than 5%) benefited from the intended intervention. (15 women who had a receptive endometrium also became pregnant, so the pregnancy rate for the trial was 22%)

It feels like a rational decision, but there is something else contributing to the lingering doubts. At times, it just seems like every decision I make turns out to be the wrong one. A bit reminiscent of the episode of Seinfeld where George observes that every instinct he has is wrong, so Jerry deduces that the opposite must be correct. I shared with Husband that if we proceed with our transfer as planned, and it works, then our formula must have been right. "Yet, if it doesn't work, it doesn't mean that it was wrong" he quipped, displaying remarkable wisdom in his half asleep state. That is precisely what is so fucked up about this process.