Sunday, 28 September 2014

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.


  1. I'm too tired for statistics at this point, but is the difference between 75% and 88% even significant, given the small numbers?
    Either way, I can relate to your feelings about being desperate for answers yet apparently unable to find any evidence. It just sucks.

    1. It was not statistically significant (p = .182) The Contol group included infertile patients who were either a first or second time implantation success. There was a lot of drop off in the study, which the authors don't explain. 22 of 25 control patients, were found to have a receptive endometrium, 11 did a transfer and 9 became pregnant. (81.8%). It's hard to grasp that or make comparisons, given the much lower number, but in the RIF group, even with a receptive endometrium, the pregnancy rate was on 51.7%. It's an interesting trend.

  2. Human beings have the lowest implantation rates in all of the mammalian class. Implantation failure is indeed the final frontier of IVF. But, I think your previous pregnancies would suggest that your lining is appropriately in phase when transfer (or ovulation) is correctly timed. I think you were on to something with your concerns about your endometrium growing too thick. Two weeks of continued estrogen supplementation when a lining has already met the standard for transfer thickness seems excessive. I hope you insist on more monitoring before initiating progesterone injections. It's baffling how little anyone really knows. I suppose that's a reality you already deal with everyday in medicine. But, hearing a highly paid expert say "I don't know why" is always unsettling even if it's a reasonable response.

  3. I feel like I totally get what you're saying... If anything, ANYTHING at all could possibly help... Then why not go for it?! But, if that something else doesn't give you the result you want... Then what? I'm really interested to hear what you ended up deciding. This study sounds really interesting.

  4. Hi Jane! I dont usually comment on your blog but I have been following you for quite a while and more than deeply appreciate your writing. I dont know if you follow the blog "Searching for Our Stork" but I've become quite close with the person who writes this blog as we discovered we live in the same city (in France). She has done the biopsy/test of which you speak several times, after having multiple failed transfers with no implantation at all (7 or 8 I believe, all of which were blasts although not genetically tested). After much suspense, her second biopsy appears to have revealed her implantation window (requiring two additional days of progesterone priming?) and as of last Friday, she has gone ahead with another FET according to this new protocol. I am really crossing my fingers for her that this was the missing piece of the puzzle. I am also hoping that your next FET will work as well! Although we live abroad, and her test was done in Spain, you might be interested in following her blog to see how things work out or exchaning with her about the biopsy, etc... Sending you lots of hope whatever you decide to do.

  5. Oh the what ifs? I was always drawn to the natural supplements (I had a fridge and cupboard full of them!) and when they were still not working, I gave in and tried accupuncture. Although I did not like the lady who did the accupuncture, I have to admit that I really did feel different when I left. Maybe she really had aligned something that wad off kilter in my body's energy? The next cycle, I got pregnant so who knows?

    I totally get the feeling of wanting to try something that may increase your chances. I've never regretted trying anything while TTC, even the things that didn't work...

  6. uggg. I hate the big decisions that come with infertility. We have battled for YEARS wheter we pay the extra 5k+ to test our remaining embryos. They all say it doesn't increase success but after 2 miscarriages via IVF, I don't want to go through implanting ones that don't stand a chance. I hate that we have to make these type of decisions ALL the time and that it's a gamble, not a promise.

  7. I probably would have done this test if it was something I had known about. I was willing to try anything and everything. Mostly for regret management because I honestly didn't think anything was going to work. I'll be interested to see if you decide to do it and what the results are.
    It's funny you mention that Seinfeld episode. I feel like I reference that episode a lot when I I am on a roll of bad decisions (or just bad luck). I start thinking I should do exactly the opposite of what my instinct tells me to do. I don't think I have actually tested the theory out, though.

  8. I can totally understand wanting to do ALL THE TESTING because you want to find that one thing that's the answer, that's been wrong or missing the whole time. I was like that with CoQ10 and DHEA for egg quality, thinking that I just had to take these pills and I'd be that person to get spontaneously pregnant. Didn't happen for me, and yet it seems to have worked for others. I don't know what to tell you about the testing other than that, if you're going to have constant doubts if you don't do it, it might be worth the peace of mind.

  9. Sounds like you are being very thoughtful about the pros and cons of this. I'll be interested in reading what you decide, although it sounds like you may have already made that decision.

  10. For personal reasons I'm very interested in this study as well. While the results were not significant I do understand not wantitng to have any regrets and doing everything possible to ensure success. I may shoot my RE an email asking for his thoughts on this test. I feel his response will probably be similar to what you think yours will say - he'll do it if I want but with the inconclusive results he doesn't necessarily recommend it. Interesting - thanks for sharing and keep us posted.

  11. What a conundrum. I'm sorry he didn't respond before you had your plan set with Dr. STIUTK. It's so hard to know what the best plan is, until it works! I find it interesting that this test is available, and I would be inclined to do it simply to have the most information possible going into your FET. But then, if it delays you till after the New Year.....? I don't know. I am wishing you the best of luck no matter which route you decide to take and am crossing my fingers that it is The One that will work!