Tuesday 1 July 2014


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.


  1. It's good to have a plan (I sure feel better with one). But for now I'm putting a lot of hope into those four embryos!

  2. I also am pretty confident in those euploid embryos...but I know what it's like to have to worry about the endgame. We haven't yet decided how many donor cycles we'll do (hopefully just one!!) but I don't know that adoption is in the cards for us either. I'm hoping that neither one of us has to really deal with this scenario.

  3. My doctor recommended the Endometrial Function Test, but I can't seem to get on board with it... I'm probably just being difficult. : ) I'm really, REALLY hoping that you're about to take Infertility's queen with the next transfer!

  4. In many ways, I feel ready to give up now. I'm done being consumed by infertility--even though I'm just really getting started. I think you have a great shot with those four embryos, and I'm feeling confident it'll work for you (because that's all it takes, right? a stranger's confidence?). However, I do hope you'll write a novel either way.

  5. You really are doing everything you can! I had the same feelings and thoughts with my last cycle at CCRM. I did everything I could... Everything... And somehow knowing that, going into that last cycle, made it more "well within my soul" post transfer. XOXO

  6. My RE was not convinced that endometrial scratching is beneficial. He thinks there needs to be more studies. However, we insisted we wanted to try it so he agreed to do it since he said it wouldn't hurt anything. I was the 2nd patient he had done it on and both resulted in pregnancies. I really believe that it had a lot to do with finally getting implantation. But, maybe it was just pure luck. Who knows. I read good things about it and figured it couldn't hurt to add it to the arsenal of things we were throwing at our last cycle.
    I feel really good about these embryos for you. 4 healthy embryos. This has to be your time. Next time I head up to the Bay Area I expect to be bringing you a baby gift ;)

  7. Yes! Yes, you would write the next great American novel using this blog! However, I'd prefer it if you had a baby first, of course, because that's what you want and I want that for you. I can so relate to this post. Trying to be hopeful and optimistic, but also feeling relieved that there is an end in sight regardless of the outcome. I had an endometrial biopsy before IVF. It was required by my insurance before I could proceed as part of my "turning 40" testing. The RE mentioned that it may help get me pregnant. Honestly, I think it's all about the eggs.

    1. By the way, I loved "no mas"! When I worked at daycare center years ago, there was the most adorable Mexican baby named Natalia. She was so cute when she danced and we'd constantly ask her to dance for us. As she became more verbal, she'd yell at us and say "no mas"!

  8. I’ve followed your story for awhile never commenting but I’m rooting for you and wanted to share my story with you. Earlier this year I did my 3rd, 4th, and 5th IVF cycle to bank for PGD. IVF #1 (last year) resulted in an early miscarriage. IVF #2 we yielded 3 embryos to test for PGD. All of them were abnormal. In cycle 3-5 we yielded 13 embryos total. 11 out of 13 were normal to my shock after a miscarriage and all abnormal for round one of PGD. I then did a fresh transfer of 2 perfect PGD embryos and it was a negative result. I put 2 more in (FET) and now i am almost nine weeks pregnant with a single pregnancy. Very early still but the furthest I’ve gotten. So 4 perfect PGD embryos and only one “took”. I’m not telling you this as a negative…more as a positive. No one wants to do more rounds of IVF…but now you know you can get normals. That’s the hardest part in my opinion! If you end up using your 4 normals don’t give up on yourself! Hardest months of my life 3 IVFs back to back. But I truly believe that cycling back to back even helped me yield more embryos. I know what you mean by saying 4 doesn’t seem like a lot. But as hard as it maybe to try…you could possible get more next round (if needed). Hopefully those one or more of those represent your take home baby. Good luck to you.