When the LP and I first started trying to have a child, I thought I did everything right and though I knew there could be hiccups, I never expected to be hoping for pregnancy number 10 to have 2 living children. How did this happen?
If you ask Western Medicine, the answer up until the current donor-egg miscarriage has been “old eggs” because:
- I’m of “advanced maternal age” – meaning over 35;
- The repeat pregnancy loss (RPL) panel of tests revealed no clotting or immune disorders recognized by Western Medicine as being correlated with recurrent pregnancy loss;
- The karyotype testing done on me and the LP produced normal results;
- The worries I had that my immune system is getting progressively more “activated” and “distressed” over the time since we began our most recent run of 6 pregnancy losses since early 2013 were not substantiated and it was not fathomable that I could be reacting to my body’s own hormones.
Yesterday, that changed.
Yesterday, the LP and I had a very lengthy telephone conference with our current RE. He reviewed in detail my loss history (again – in case we missed anything before and because my prior clinic’s records were less detailed than one would like in this regard) and then he went over possible reasons why our first donor-egg IVF cycle (a natural frozen-embryo transfer) ended this way. Then he reviewed the option to do possible further testing (for natural killer or NKa cells and for T-helper cells) and the possible experimental treatment options for diagnosed and sub-clinical immune conditions that could cause a pregnancy loss pattern. He told us what we already know:
- My case is hard to diagnose because I do not have clear markers of a condition Western Medicine currently has a reliable means of testing and accurately diagnosing;
- My loss history is quite varied, but the more recent losses are similar regardless of whether they involve my own eggs or the egg (we’ve only transferred one) from a young, proven, healthy donor;
- The chance of this embryo having had chromosomal abnormalities and that being the cause of this loss is only about 25% – 35%, which would be a reasonable explanation (“bad luck”) if I had no prior loss history or if this loss did not suggest a failure late in the implantation and subsequent fetal and placental development process; and
- Given my loss history, this loss is statistically more likely to point to some underlying, undiagnosed (and possibly not diagnosable) issue.
Finally, in yesterday’s conversation, the RE said it made sense that I am observing changes in my allergic responses to things during the luteal phase of my cycle, when women’s immune systems are suppressed/altered by the progesterone our bodies produce (or that we’re given in a medicated cycle). It felt good to be heard. It felt good to have a Western doctor acknowledge the observation powers and expertise about my body that *I* bring to the table. Thanks, doc.
We talked about the flaws with the natural killer (NKa) cells testing protocol. Essentially, the test measures blood levels and function of NKa cells in response to intralipid therapy, not uterine NKa cells and how they might react to such treatment. Apples and oranges. Not particularly illuminating, in other words. I knew that, too, but the LP did not so it was important to review. I agreed with the RE that undergoing that testing, if we were prepared to adopt a treatment protocol that would incorporate treatment of positive results (i.e., assuming I would test positive), then the NKa testing need not be done.
We also talked about the pros and cons of short-term steroid use to lull a woman’s immune system into accepting implantation and allowing fetal development to proceed when a subclinical or undiagnosed immune response would otherwise prevent that development from continuing. In short, this is what we are suspecting is at play in my case, though we have no test results to confirm that.
The RE raised serious concerns about long-term steroid use and risks to the baby even though, as he noted, several of his colleagues in the field or reproductive medicine prescribe long-term steroids before and after embryo transfer and during early pregnancy for women with diagnosed (and undiagnosed, in some cases) immunological conditions. I had these concerns already myself, knowing first-hand some of the very dangerous side effects long-term steriod use can have (my Mom was in a study about just this after developing premature osteoporosis requiring multiple joint replacements following long-term steroid use).
The RE also mentioned, however, that he treated a woman with a similar pattern of early pregnancy losses (similar to all 3 of my 2014 losses and 2 of my 3 losses in 2013) using a protocol that included a short course of steroids before/after embryo transfer that was successful and resulted in a live birth (Amen for that Mama!). I have (mild, controlled) asthma and have had pneumonia more than once, meaning I have personal experience with short-course corticosteroid use and its benefits. Both of my parents and my one living brother also had/have asthma and I’ve seen both short- and long-term steriod use and the pros and cons of each as I grew up and to this day. In short, I’m no stranger to the use of corticosteroids, what’s good about it and what is not so great. As applied to making humans, it makes me nervous if used during the pregnancy’s early development, but not so nervous used during the time at which my uterus seems to be killing our babies.
We also talked about IVIg, with which I’m uncomfortable (and so is the RE) and blood thinners (Lovenox or Clexane if you’re in the UK and low-dose aspirin). The RE felt that clotting does not appear to be my issue given my gynecological, RPL and one live birth history. On that basis, he did not recommend using any of those treatments if we decide to go ahead with another transfer using one or both of our two remaining embryos. I can’t really disagree, plus my Mom had a severe allergy to salicylates so I’ve always stayed away from them on doctor’s advice when I was young, so I figured this was not a bad experimental treatment to reject for now. If anyone has had a history like mine and success using Lovenox or similar meds, I would truly love to hear from you – please consider emailing me if you’d like a private chat: firstname.lastname@example.org
The RE was confident that a natural FET is still the right choice for me. He was happy with my lining, which would have been somewhere between 8 and 9 mm at ovulation (it was 7.6 mm two days before) and insisted that current research shows anything over 6 mm will work and over 7 mm with a trilaminar pattern (mine had that well before ovulation) is sufficient for successful implantation and live birth after heartbeat is detected at 6-8 weeks. I was a little nervous about this but I’ll be working extra hard on getting my lining in tip-top shape if (when?) we go ahead with another transfer now that I’ve learned things I did not know about how to do that before our last transfer.
The last topic we discussed was “one or two?” The RE said his recommendation is always one, but also noted that he would support whatever decision we made and would welcome discussion if we have questions or want more information to help us decide. We said that although the LP is opposed to twins for a slew of reasons, I am not opposed to having living twins, but I am fearful of complications with a twin pregnancy for me given my history of cholestasis with our own successful pregnancy. I was told after that pregnancy that my risk of developing cholestasis in future pregnancies was 50-70%. I also understand that cholestasis is more common in twin pregnancies. It’s something to think about because the greatest risk of having it is that your baby/ies can die in utero so they deliveries are often scheduled before babies’ due dates (I had an emergency induction at 37 weeks the same day I was diagnosed with cholestasis as my liver enzyme levels were ridiculously high and they were worried about the effect on baby).
The decision about whether to transfer one or two therefore remains unmade. We will think about it.
We also have to decide whether to proceed with another transfer and if so, when. I expect that we will do at least one more transfer because I can’t imagine how I would live with myself later if I discarded these two embryos without at least one more whole-hearted attempt. As for when, we are thinking of cycling in either July or August.
This month will be dedicated to healing and trying to rebuild my hope and some means of having faith that I can actually carry another healthy baby to term (or close enough). That’s no small order, frankly. It is hard to wish for a 10th pregnancy when you’re in the process of losing number 9. I’ve got my work cut out for me.
Please wish me luck. Lord knows, I need it.