While I was in cycle limbo, I decided that it would be prudent with regroup with my RE. As I was sitting across from his desk, I was shocked at the size of my chart. Prior to infertility, I can only think of four occasions when I had to access health care for non-routine services. The binding was frayed and there wasn't much space left under the wire clips. I feared my file would soon be established as 'Jane Allen: Part 1 of 2'.
A bit to my surprise, my RE began discussing RPL testing after acknowledging the aneuploidy on my path results. Although unlikely, there still could be more than one contributing factor. I was curious to hear his approach. He identified five categories. Uterine anatomic abnormalities, general endocrine (thyroid disorders, hyperprolactinemia and diabetes) hypercoagulable (spontaneous and inherited) and genetic factors (referring to the products and the parents). I specifically asked about what hypercoagulable labs he requests, as there is a lot of controversy in this area. He listed lupus anticoagulant, anti-phospholipid antibodies and Factor V Leiden deficiency. As I feel I have an explanation for both my losses, and don't have any other symptoms or family history to suggest another confounding mechanism, I didn't think much of the testing seemed necessary. I did agree to do a karyotype for myself and Husband. Although the yield is low, if a balanced translocation is found (i.e. pig and elephant DNA won't splice) we would forgo transferring our existing blasts, and do a fresh cycle where would need to do PGD testing.
Preparation for FET
We again revisited the process of a natural versus a medicated preparation. As I have blood pressure issues with exogenous estrogen, it would seem beneficial to do a natural cycle FET. However, my RE described that it requires much more frequent monitoring and is very unpredictable. "I know you are really busy..." he commented. I quickly recalled how arduous it was travel back and forth to my RE's office every other day during my stimulation and I knew what a drain it would be if I were to be monitored daily. "We wouldn't have any advance notice of your transfer date..." he mentioned. In ten plus years, I have never once called out sick. There have only been three occasions where I needed to cancel patients at the last minute. Once when I had a delayed flight, once for my first miscarriage and most recently when I needed to do my day 3 desperation transfer. "A natural cycle is ideal for patients who ovulate consistently" he offered. Well, that's not exactly me. Left to their own chagrin, my ovies can ovulate anywhere from day 12 to day 19. I finally received a 'high fertility' reading on day 20, but as I've received both false positive and false negative readings with this monitor, I'll be waiting for AF to determine if this is real.
I quickly rationalised that the stress and strain of making twice daily visits to my RE's office could not only affect my blood pressure and general sanity, but could also suppress ovulation. The other option would be to use Femara and a trigger shot to coordinate ovulation, thus taking some pressure off my ovaries. However, when we were using this approach during my IUI treatments, I'm pretty sure my ovaries went rogue and prematurely ovulated on their own for at least one cycle. Simply stated, those girls cannot be trusted. They're like the Siamese cats from Lady and the Tramp. Husband often asks the question 'what is your time worth?' The other concerning factor with a natural or modified medicated cycle is that we could miss the window, conditions may not be optimal and we would need to cancel the transfer. Thus costing ninety minutes of driving time daily, consuming my 'why I need to leave the office' excuse, as well as the tangible fees for the visits and labs. Oh, and much frustration and disappointment.
My RE glanced at the report before reviewing that one looks really good and one is not so good. "It just met the criteria for freezing." He commented, just before he recommended thawing and transferring both. Recalling my meltdown over the possibility of multiples from my day 3 transfer, he quickly added, "it's not the same risk for twins as if we were transferring two high quality blasts." I indicated that I understood, yet it's still not a risk I'm willing to take. I know a lot of embryologist reflect that they've seen a lot of beautiful babies born from ugly embryos, after a short lived pregnancy with a aneuploid embryo, I'm not too keen to transfer a subpar embryo and possibly endure more devistation.
I asked this question, even though I already knew the answer. If we were to encounter a BFN after a single transfer with our good embryo, he would recommend doing a second fresh cycle rather than cleaning out the freezer. "Of course he would..." Husband sarcastically commented as he made a cha-ching! sound. "Not necessarily" I countered, pointing out that he could also be accused of wasting our time and money if he advised a single transfer of a poor quality embryo. Additionally, I had received a break-down of our IVF expenses earlier in the day. At least from what I could determine, my RE was only billing for my ultrasounds, retrieval and transfer. The other charges were divided between the lab, anesthesia, embryology, and facility fees. Talk about it takes a village. Prior to my own experience with infertility, I held the impression that the 15 grand per fresh cycle went right into the RE's back pocket. I'm not denying that REI is a lucrative subspecialty, but I feel that I have a little more perspective.
My RE followed his answer by adding that he'd work on adjusting my protocol to try to get better quality eggs. I felt satisfied that he was acknowledging disappointment with my cycle, although he didn't specifically use such words. Prior to the start of my stimulation, he seemed upbeat about our prospects. "I never promise anyone a baby..." his voice trailed off, but it left me with the impression that I had a better than an average shot. Now he seemed much more subdued, seemingly accepting that the odds were longer. I disclosed that I started to prepare for second cycle after he projected my retrieval would only yield 6-8 mature eggs. "I think that's accurate." he replied. "It's not a matter of thinking positively or negatively, but being realistic." I truly appreciated those words. I often found myself defending my cautious position to Co-worker and my Lead Physician, who were encouraging me to be more hopeful. I always planned that if I ever heard my RE make such a suggestion, I would counter; 'if you have a patient with a failed transfer, would you ever attribute it to her not exhibiting enough positive thinking?'
I often leave my RE's office with the feeling that I'm asking for directions as I'm navigating through the land of uncertainty. I may know where I'm going, but I still feel lost. The possibility of having a baby seems more tangible, yet seemingly still so far out of reach.