The Balloon Analogy

This month, we decided to try letrozole, which like Clomid (clomiphene) is another ovulation induction medication.  In other words, it also helps one ovulate more than one egg per cycle.  For someone like me, whose aging eggs aren’t as fertile, it helps to potentially have a few eggs at a time instead of one, to provide more chances of conceiving.  For some women who don’t ovulate regularly on their own, these medications are also useful.

My doctor said that letrozole can be less harsh on the endometrium (uterine lining) and cervical mucus compared to Clomid, so he thought it would be worth a shot.  In other words, Clomid can sometimes thin the uterine lining too much to make it hospitable for implantation of the embryo.  And if the cervical mucus is not right, it can prevent the sperm from making it to the egg.

As I mentioned before, there is a wait time to get in for IVF at my fertility office.  Apparently right now there is even more of a backlog since they are short on embryologists, who are critical in the process.  So they gave me a date in late November.  It’s possible that if something opens up sooner, they’ll be able to move me up.  But that’s what I’ve been given thus far.  I hope it ends up sooner.  And I also hope that I get pregnant on the medications before then.

I have some random parenting advice to share today.  Back when I was pregnant, I started subscribing to Parents magazine because of a promotion, and then they hooked me and I’ve continued to subscribe because I found the issues helpful.  Recently, there was an article about explaining death to children.  The gist was that it’s better to explain it in a concrete way, in an age-appropriate fashion.  Using euphemisms like, “They are in a better place” are not a helpful way for explaining loss to children.

Not too long after reading the article, my friend posted a picture of her toddler, so happy with his balloon.  Her husband commented, “Until it popped.”  It dawned on me that it would be a good analogy for death for children- a balloon popping.  Perhaps there are some situations where there is a small leak and it’s reparable.  But in most cases, the popped balloon is beyond repair.  Thankfully, we haven’t had to explain the loss of a loved one or pet to WZW, but the day will come.  Maybe this will help explain it better to him.

On parenting trick that we heard from a friend that has been really helpful with transitions is counting down.  Since toddlers often have a hard time with switching tasks, like stopping playing to do something else, it helps to give them a little warning.  I tell him, “You’re gonna be done with [whatever activity] in 10 seconds!  10, 9, 8…”  Now I’m constantly counting- “You have 10 seconds to get into the car seat!”  Of course, it doesn’t always work, but it definitely helps.  For us, it’s been a high-yield toddler parenting trick.

Another time-saver I learned from Parents magazine is that for young children, you can forgo the pajamas and put them in their clothes for the next day to sleep in.  That way, it saves the effort of changing them in the morning, which is usually a battle.  I forgot and put him in pajamas last night.  This morning, when WZW got up and the first thing he said was, “I’m ready to change!” I was incredulous.  That NEVER happens.  Only thing with this hack is that if he pees too much and leaks through his overnight diaper, then we have to change his clothes anyway.  Good thing that doesn’t happen too often.

 

 

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Tired of Being Tired

While my sleep is certainly not as interrupted as it used to be when WZW was less than a year old, it continues to be affected thanks to him.  I think the best time was when he was a year old.  He would sleep for 12 hours a night and take 3+ hour naps during the day.  It was amazing for us parents!  As he got to about 2 years old, his sleep needs diminished and he now sleeps on the order of 10 hours at night and takes 2 hour naps.

During the work week, we are all up before 6 am.  But that also means that on weekends, WZW goes to sleep around the same time and still wakes up super early.  Even if I have an uninterrupted night, I can count on being woken up in the 6 am range, sometimes earlier.  My problem is that I need 8-9 hours to feel truly rested, so it’s hard to get to bed on time.  I usually have a bunch of things I need and want to do after WZW goes to bed.  Even if I go to bed at the reasonable time of 10 pm, getting up around 5:30 am means that I’m still feeling a little groggy.

Also, more recently WZW has been having nightmares and will start crying at night and need to be attended to.  Even though my husband takes care of him most of the time, the interruption seems to affect my sleep.

The result of all of this is that even on weekends, I’m often finding myself still feeling tired.  And having that continue chronically is tough.  Granted, I usually do get some restful nights here and there.  But still, I am tired of being tired all the time.  And then in the back of my mind, I do wonder if that is affecting my fertility.

One of the acupuncturists said that maybe 60% of her clients who are trying to conceive are those who have children already.  I’ve mentioned one friend from residency who has tried cycle after cycle of IVF and is finally well into her pregnancy with baby #2.  But I recently spoke to another friend from residency who is also having trouble conceiving baby #2, and is starting IVF.

Of course, it doesn’t help that we’re all in our late 30s and our fertility is declining.  But part of me wonders if the combination of our modern lives with the inherent stresses from work, combined with the stress and lack of sleep of having a young child, then affects our fertility.

I repeated my labs because it had been a year since I’d last done them, plus they wanted updated ones as I get set up for IVF.  The FSH, which is typically drawn on cycle day 2 or 3, was still stable around 5 and hadn’t changed since last year so that’s reassuring (lower is better).  My AMH, which is a marker of ovarian reserve, last year was 1.64 and now it’s 1.01.  Last year it was in the normal range, and now it’s on the low side (higher is better).  Many women with an AMH below 1 do still conceive with IVF.  I’m not super familiar with these labs since I’m not a fertility specialist, but my understanding is that the labs give us a general sense of the fertility potential.  In other words, is it normal, low, or clearly past the point that IVF would work?  The change in my AMH confirms that my fertility is declining thanks to age.

Part of the reason I made the decision to move to IVF is that at my particular location, the fertility docs have a backlog and it can take a few months to get in for the procedure.  I have my consultation scheduled in a couple of weeks, and from there the actual IVF procedure probably won’t happen for a few months.  So I figure I’ll continue the Clomid until then.  And if I haven’t conceived, then it’s clearly appropriate to go to IVF by that point.

This month, I decided to take a break from even the Clomid since I was tired of all the appointments and such, plus my husband was supposed to be out of town around the time ovulation was anticipated.  I have to say it’s kind of nice not having any ultrasound appointments or taking the medications.  Plus since my insurance coverage for acupuncture has maxed out, I’ve stopped that as well.  So it’s been nice not having my off days be filled with acupuncture and fertility appointments.

The Transition

Happy Mother’s Day to all of the wonderful mothers out there!  My husband outdid himself again, and put together a video montage of WZW learning to say, “I love you, Mama.”  It started late last year when most of what he was saying was still unintelligible, to now where we can understand most of what he’s saying.  It helps that his hair was really short when the video clips started, and you can see the time progression based on how his hair grew back.  I’m lucky to have such a thoughtful husband.

I’m feeling better since my last post.  With that said, the length of time that we’ve been experiencing infertility is wearing on me (and my husband).  Every time I get that negative pregnancy test or get my period, it’s like a big fat:

F on test

 

And we doctors aren’t used to those. 😉

The finality of it every month is starting to feel devastating, even if it’s for that one day.  Even though I tell myself that it doesn’t always happen right away, and that it’s a good sign that I did conceive recently, it’s impossible for me not to feel a sense of failure with each passing month that I don’t conceive.

I did ask the nurse practitioner in the fertility office how long Clomid causes side effects affecting mood, and she said that she thinks about a week after the course is completed.  I usually take it for 5 days starting within the first few days of my cycle.  That means that how I’ve been feeling at the time of the next period shouldn’t be attributed to the Clomid, according to her.  So I guess it’s just me.

I feel like I’m reaching a transition point this month.  Now that it’s May, we’ve been trying for a year and a half.  We tried IUI twice, then got pregnant on the first cycle of Clomid, which ended in miscarriage.  This is the 2nd cycle of Clomid since then, so my third cycle total.

It’s also been one year since I had my FSH and AMH checked, which are tests to assess fertility.  Last year, things looked fine which is why the REI docs didn’t urge me to go straight to IVF.  But if the tests show declining fertility now, then I’m sure they’d tell me I should go to IVF.  Also, based on the time I’ve spent trying to conceive, I think I’d need to try IVF soon.

Previously, I’d been hesitant to go to IVF because I felt like I should be able to conceive without it based on my labs, and based on having conceived WZW without any problems.  After I did conceive on Clomid, that solidified it.  Plus I’m aware that IVF adds an additional layer of stress.  I got a taste of it with the IUI, but the IVF is more involved- more medications, office visits, undergoing a procedure with the egg retrieval, etc.  I think the nature of it just adds a certain gravity to the process.  My impression is that compared to IUI, it would put me under more pressure and stress, from speaking to friends/colleagues who went through it.  So I was hoping to save myself from that.

But I don’t want to be naive about the fact that my biological clock is ticking away, and that if I wait too long, my fertility will continue to decline.  So long as I do IVF before my fertility declines too much, it would generally result in better chances for us to end up with a viable pregnancy.

One benefit that my friend who did IVF mentioned is that I can have testing performed on the embryos to check for chromosomal disorders.  So rather than taking my chances with nature, especially given my age, and possibly having a baby with Down syndrome or other chromosomal disorder that is diagnosed during the pregnancy, we could start with a normal embryo from the get-go.  She also said I could potentially choose the gender, but I realized that I don’t want a girl that badly.  I’d be perfectly happy with another boy; I just want a healthy baby.

So I’m finally mentally prepared to take the leap and start the process for doing IVF if I don’t conceive this month.

 

Temporary State of Madness

Infertility is one of those things that you don’t quite understand how difficult it is until you experience it yourself.  I admit, if I had a patient just like me prior to this, I would have thought to myself, “It’s ok, she’ll be fine.  She has a child already, she got pregnant on Clomid so she’ll conceive again, probably without IVF.  She’s 37, so she still has time.”

The reality is that when I get my period, it sends me into a temporary downward spiral.  I got my period again yesterday, and all of a sudden I feel like a failure again.  All of these negative thoughts take over.  I wonder what I’m doing wrong- am I too stressed?  Am I eating too much sugar?  Am I not sleeping enough?  The reality is probably nothing.  I’ve been telling myself that we’re just starting to try again after the miscarriage, so it probably won’t happen right away.  But I can’t help it.  It’s like the quote about grief being incomparable.  Pain and emotional difficulty- no one can tell me what I’m allowed to feel.  Even myself.  I’ve tried to talk myself out of it.

I started to feel angry about everything, and unfortunately my husband bears the brunt of it.  He worked yesterday on a Sunday, and during the day while I was alone with WZW, I started having some light bleeding,  I figured it was my period, so I started feeling sad, but tried to hold it in, and didn’t tell him about the bleeding.  We had already agreed to do the pregnancy test together when he came home based on the timing since ovulation.  But when he came home, he started doing work around the house and such.  So by the time I did the pregnancy test, it was getting late.

When I finally got the negative pregnancy test and had a chance to let my feelings out, I was a mess.  It was 10 o’clock at night when we both needed to go to bed, but I was crying, and angry that we didn’t do the test earlier.  I felt like he knew it would upset me, so he delayed it.  Now it was going to affect my sleep and the following workday.  I just felt like a crazy, emotional, irrational person.

I know it was the right decision for us to move again (this is WZW’s third home in his 2.5 years).  But it’s stressful not feeling settled, and not being able to find things because they are either buried in clutter/boxes or somewhere in storage.  When I’m already feeling bad, then every little inconvenience upsets me.

With puffy eyes, I got myself up early this morning, and got WZW ready so he could head to daycare.  I went into work, early as usual, and started reviewing my charts for the day.  I got through a handful, but I couldn’t keep going.  Being mentally present to take care of 20-something patients all day requires me to be at my 100%.  And instead, I felt daunted by the day ahead, and still wanted to cry.  I didn’t want to set myself up for another breakdown at work, so I decided to cancel and head home.

So now I feel like a failure for missing work.  We doctors feel like we have to go to work unless we’re on death’s door.  But the fact is, my work requires so much mental energy, and requires me to be engaging for all of my patients.  It would be a disservice to them if I tried to get through my workday given how horrible my emotional state is today.  And God forbid I miss something important clinically because I’m not fully with it.  Since I’m the type of person who got through high school without ever getting a detention, I still feel guilty.  Even though it was the right thing to do for me and my patients.

I really want to be pregnant, but thinking about the nausea with the recent pregnancy, I also dread it on some level.  I know that pregnancy is going to have its own discomforts and inconveniences.  I almost feel a sense of resentment towards this child that doesn’t even exist yet.  Don’t worry, I won’t actually feel that way when the baby arrives.  I’m just being honest with all of the negative and crazy thoughts that run through my head when I’m feeling this way.

I am aware that Clomid can cause mood changes.  I don’t know how long they last, and if it’s possible that part of my craziness is due to the Clomid.  I’ll have to ask the fertility office the next time I go in.  I don’t want to be one of those women who blames her emotions on hormones/medications, but I do wonder if that’s why I feel extra unhinged this time around.

My husband asked if I have unresolved feelings about the miscarriage.  Perhaps I do, but I didn’t think I did.  I think that having the negative pregnancy test again is a reminder of failure and loss for me, so it’s upsetting.  It’s hard to go through this over and over again when we’ve been trying for a year and half.

I know that things will get better, and that this is temporary.  I try to remind myself of that, but sometimes I can’t handle things and it gets really difficult.  And that is ok, too.  Thanks for allowing me to vent.

The Shoe Edition

Now that more time has passed, I’ve been feeling better.  Emotionally, what I feel now is disappointment in having this setback, and having to go through everything again.  I feel bad that some women have such a difficult time emotionally.  The author of the Lenny essay that I previously referenced said it best, but essentially she was aware that logically, she shouldn’t feel so deeply affected by her loss, and yet grief is incomparable.  As a doctor and now as a woman who’s been through it, I just feel bad that anyone feels that kind of hurt, and wish they didn’t.

I think it helps that celebrities are being more open and talking about their miscarriages.  And on social media, many regular women are also able to open up about their experiences, which hopefully makes it easier for those going through it to know that they are far from alone.

About two weeks after the miscarriage, my home pregnancy test had become negative, and then not too long after, I got the LH surge on my ovulation kit.  My bleeding got lighter and lighter but never fully stopped, and then about a month after the miscarriage is when I had my first period.  With that cycle, I resumed my appointments at the fertility office and started back on Clomid.  So we’ll see how that goes.  Everything feels like eternity: waiting a couple of weeks from ovulation to see if the pregnancy test is positive.  Knowing that I got pregnant in January, and now the earliest I’d conceive again is April.  I know that in the scheme of things, 3 months+ is not that big of a deal, but it feels like forever when you’re already feeling impatient.

On a lighter note, I decided to write about shoes.  They’re not Paleo and not OB-related, but they’ve been on my mind as I’ve been in the market to buy shoes for WZW as well as myself.  It’s mind-boggling that shoes for toddlers can cost $50 at retail price.  We first received Stride Rite shoes as a gift for WZW and have found them to be of good quality.  We found that out when we bought a cheaper brand, and the tread was shallow to begin with.  In a short time, WZW wore out the soles and we had to get a new pair.

For an active and growing little guy, we want good shoes, but knowing how quickly he goes through them, I can’t bring myself to buy $50 shoes.  He got his current pair at Christmas, a full size larger than he was measuring, and now he’s at that size.  So that means he will need a new pair soon.  I decided to look into other brands, and have heard about Pediped, but those are expensive as well.  I was talking to some moms recently about shoes, and one said that her 5 yo daughter will only wear See Kai Run.  And another brand that came up was Momo Baby.

I decided to Google “best toddler shoes” and found this list:

https://www.lucieslist.com/best-walking-shoes-infants-toddlers/

She mentioned another brand called Tsukihoshi that I’d never heard of before.  I would have liked to try Pediped or See Kai Run, but couldn’t find an affordable pair in my son’s size, so I just ordered a Tsukihoshi pair.  Any other brands I should consider?

As for me, I decided I need some slippers to wear around our house since we have hardwood floors, and I need more support.  Plus despite removing our shoes at the door, my socks inevitably end up dirty.  I’d previously found a pair of comfortable flip flops from Vionic, which are supposed to provide good arch support.  It just dawned on me to check, and they make slippers as well.  Score!  And then of course as I’m looking through their site, I want everything else they carry.  I can only vouch for the style I own, the Tide II Toe Post Sandal.

https://www.vionicshoes.com/women/sandals/tide-ii-toe-post-sandal.html?76=266

It has great ratings and I once met a woman who had the same color and style, and she told me it was her second pair.  Now I’m planning on trying other types of shoes that they make.

I’ve worn my Cole Haan Air Tali wedge shoes with a low heel a ton, and had a similar pair previously.  Unfortunately, I bought another pair that had the same low heel height but not the wedge and it wasn’t as comfortable, and I didn’t end up wearing them all that much.  With Cole Haan, definitely wait for sales as they seem to have them frequently.

I’ve also gotten TOMS wedges with a significant heel height that were surprisingly comfortable.  I got a second pair of the same shoes in a different color, but the fabric used was more stiff, and dug into my skin a little.  These days, I have no interest in wearing heels since I have to worry about chasing after a toddler.  Or in some cases, carrying a screaming, kicking one.

One woman said she likes to splurge on Rothy shoes because they’re cute and comfy.  I looked at their site, but none of the shoes have any heel.  For me, since I’m short, I prefer to have a low heel, so I think the Vionic brand might have some better options for me.

These are brands I’ve come across or had personal experience with (no paid advertisements here).  It’s always so satisfying to be able to find a really cute, comfortable pair of shoes that I can wear all the time.  Any other brands/styles you swear by?

A Challenging Week

Continuing my previous post about the D&C vs. medication for miscarriage- I hope it’s clear that I do give my patients all of the options, and allow them to choose what is right for them.  All factors being equal, I prefer the medication over the D&C for the earlier gestations because a procedure has inherently more risk than the medication (or waiting).  But the risk is slight, and the medication and spontaneous passage of tissue have risks as well.

I also realized that one factor that is unique to my institution is that we unfortunately don’t have an outpatient procedure suite where patients can be sedated for minor surgeries and procedures.  So the D&C option is a little more cumbersome in that if they have it in the operating room, they have to be added on as an urgent case.  But occasionally if a more emergent surgery comes in, then they can get bumped.  That means they may end up waiting for hours.  Not fun when you’re already upset that you’re having a miscarriage.

I often do outpatient procedures in the office, but those patients are still awake.  They receive medications to help make them feel more comfortable, but it’s not the same as getting sedation where you’re not aware of what’s going on.  We do D&Cs this way when needed, but in my experience it’s not ideal for patient comfort.  So those factors play into my decision-making as well.

It’s been 2+ weeks since the miscarriage, and as time has gone on, I’ve had my ups and downs.  The week after was really hard.  The medical part of it was fine- I had the expected heavy bleeding the first day, and it’s been gradually improving since then.  So it’s like an extra long period.

It’s more so the emotional part of it, as well as being physically exhausted, that have been hard.  Many of my patients with heavy periods tell me about how tired they feel each month during their cycle.  They often have normal blood counts (meaning they’re not anemic from the bleeding), but still feel drained during that time of the month.  I felt similarly.  I checked my blood count just in case, but it was totally normal.

On top of the physical and emotional drain with the miscarriage, we just moved last week.  It’s a local move, but nonetheless we are uprooting our lives, living out of boxes- the usual bit when it comes to moving.  I deluded myself into thinking that I could handle all of this.  Instead, I ended up breaking down and crying at work one day at lunch.  I cancelled my afternoon patients and headed home.  And then I cancelled the rest of the week.  I had just been so sleep-deprived from the move, from not being able to sleep well at the new place.

Even being off of work, I felt like I was in my own little hell.  I was so exhausted, and our new home didn’t feel like home yet.  Most of our old furniture doesn’t fit in our new smaller home, so we don’t have a dining table yet, just a counter and bar stools.  So my little WZW was initially sitting on the dirty floor to eat.  I’m not a germaphobe, but for someone who is used to taking off her shoes in the house, the newly post-move dirty floor was not somewhere I wanted my kid to be eating.

So that first week was tough.  In the end, I know it’s the right decision for us to move.  But the adjustment period is tough, especially for someone like me who is a creature of habit.  In this subsequent week, we’ve been unpacking and making the place a little more livable.  My husband made good use of our Roomba to vacuum the above dirty floors.  I’ve tried to balance unpacking- which ultimately makes me feel better and more settled- with also having a chance to just rest.  This past week, having a usable kitchen and less boxes around have made a huge difference in how the house feels.

Thankfully, WZW has done really well with this move.  He’s at an age where we were able to talk to him about how we were going to be moving.  He came to the new house a couple of days before the big move.  And the day of the move, we picked him up from daycare early and brought him to the empty old house before bringing him to the new house.  Aside from some difficulties sleeping in his new room, he’s been fine.  He’s never asked to go back to the old house.

It’s interesting going so quickly from pregnant to not pregnant how differently I feel physically and mentally.  Physically, I went from feeling nauseous and only being able to eat small quantities to being able to eat normally again.  When I delivered WZW, I remember suddenly going from not liking regular water to glugging down tons in the hospital.  But since the nausea was more significant with the early pregnancy, the change was much more dramatic.

Mentally, I suddenly feel more relaxed about what I’m eating and using.  When I was pregnant, I wondered about the kombucha drinks, which have a trace amount of alcohol from the fermentation, but usually not enough to require the labels that beer and wine do.  In the end, after drinking one, I decided not to continue, mainly because I didn’t want to worry about it.  Even with skin products, most are ok but some ingredients like hydroquinone and retinols are supposed to be used with caution in pregnancy.  So I’d stopped using some of my skincare products, whereas now I feel a sense of freedom in using whatever I want.

By the way, Mother to Baby has a lot of great info regarding what’s safe in pregnancy.  Here’s their fact sheet on topical acne medications, and they have a lot of other categories:

https://mothertobaby.org/fact-sheets/topical-acne-treatments-pregnancy/

And between suddenly being free of nausea, and also feeling a little down emotionally, I’ve been eating whatever I want.  I’d lost some weight from the nausea, so I don’t feel as bad about it.  I will have to eventually go back to choosing healthier options, but for now I figure I’m allowed to temporarily not worry about it.

At this point, I’m taking it one day at a time.  As I get used to our new home and we get more settled in, I am feeling better and better.  And emotionally, while it still hurts to have experienced a loss, I’m doing ok.  It’s disappointing to have this setback, and to have to spend how many more months going through the process again.  Part of me tries to have an emotional separation, kind of like I do with my patients, to protect myself.  I tell myself logically that I don’t need to be that upset, because this is very common and that I have no reason to believe I won’t have a healthy pregnancy in the future.  But sometimes I have to remind myself that grief isn’t logical, and that it’s ok to be sad about it and to let myself cry when I need to.

 

WZW’s hair is slowly growing back, and he’s been having fun with all of the boxes used in our move:

IMG_6556

IMG_6557

 

 

Miscarriage

Two days ago, I went in for my ultrasound at what was supposed to be 9 weeks, and it turned out that the embryo had stopped developing.  From the looks of it, it probably stopped developing shortly after my ultrasound around 7 weeks.

It’s certainly a sad and disappointing turn of events.  In the 5 weeks since I’d found out I was pregnant, I had started to get excited about what’s to come.  We wondered if it would be a boy or a girl.  I started thinking about the timing of my maternity leave, and how the new baby and WZW would both be September babies.  We’d told our families and a few close friends.  But I’d also noticed in the past week that my nausea had improved a bit, rather than worsening at 9 weeks as with WZW’s pregnancy.  So it did make me wonder, but then I thought about all the women who have different symptoms in different pregnancies and told myself not to worry so much.

It’s a loss, and over the years I’ve learned to treat it as such for my patients.  All of the hopes and dreams attached to this baby that was to be are now gone, and it’s very hard for many people.  So I remind myself of that, because as a doctor on the other end, it’s sometimes hard to completely understand how devastating it is.  On our end, there is an element of knowing that it’s not that bad in the scheme of things.

Last year, I read this Lenny article by Jessica Grose regarding her experience with miscarriage:

https://www.lennyletter.com/story/the-wait

It was very eye-opening for me in terms of how deep the pain and grief associated with a miscarriage can be for some women.  More so than the article itself, what spoke to me was her intro in the email that was sent with the articles in that Lenny newsletter, which had the theme of grief:

“I had a miscarriage in late fall 2014. I wrote the story that appears in today’s newsletter in real time, as I was experiencing it over a two-week period that included Thanksgiving. The loss wasn’t something that happened spontaneously; I had a sonogram that showed the fetus probably wasn’t developing properly, and I had to wait fourteen days to confirm that initial diagnosis and schedule the procedure to remove it. It was awful.

It’s taken me over two years to feel ready to publish this story. Whenever I would think about trying to run it, I would balk. So many women have miscarriages (somewhere between 10 and 20 percent of “known pregnancies” end in a loss), and so many of them are much more crushing than mine. I did end up having another healthy baby. What right did I have to keep talking about the miscarriage like it was some big fucking deal?

But the thing about grief is that it’s incomparable. There’s no universal pain arbiter who gets to decide whether your upset is worthwhile.”

For me, it helps immensely that I’ve seen so many patients go through it before.  I already know that it’s a very common occurrence.  I had to look up the statistics since I didn’t know them off the top of my head.  According to ACOG (The American College of Obstetricians and Gynecologists), 10% of clinically recognized pregnancies end in an early miscarriage (under 13 weeks).  The frequency of these early miscarriages for women aged 20–30 years is 9–17%, and this rate increases sharply from 20% at age 35 years to 40% at age 40 years and 80% at age 45 years.

Studies have shown that half of these miscarriages are due to chromosomal abnormalities.  In other words, the older a woman gets, the more likely it is for her eggs to have chromosomal abnormalities.  And therefore the higher the risks of a significant abnormality that is not compatible with life.  So in someone like myself over 35, this is the likely cause.

What I’ve also seen from experience is that the vast majority of my patients that have a miscarriage go on to have normal, healthy pregnancies.  In clinical practice, one or two early miscarriages are considered common enough that no further workup is recommended.  It’s not until a woman has had 3 miscarriages in the first trimester that it’s recommended to do things like labs for the patient and chromosomal studies of the couple to determine a possible underlying reason for the pregnancy losses.

Based on the above, I know that there is nothing that I did or didn’t do to contribute to the miscarriage.  I always try to remind patients of that, so that they hopefully don’t blame themselves.  For myself, I’m thankfully not sitting here feeling guilty or wondering, “Why me?”  Based on my age, why not me?  I didn’t even realize how high the rates of miscarriage were until I looked into the stats above.  So at 37 years old, my chances of miscarriage are somewhere between 20 and 40%.

For me, just the fact that I was finally able to conceive after trying for so long was a victory.  And that it was accomplished on the first try of Clomid.  So I’m hoping to conceive again on it, but in case that doesn’t occur, we haven’t even tried IVF.  It’s comforting to know that there is still a great chance for a future viable pregnancy.  This loss is just a hurdle on the way there.

Once a nonviable pregnancy is diagnosed, there are a few options in terms of what to do.  One is to wait.  In the majority of cases, if you wait long enough, the body will realize that it’s not a normal pregnancy, and will start to pass the tissue.  As long as it’s not months and months, it’s not harmful to wait.  The downside is that the bleeding may occur at an inopportune time, so the next option is to use a medication to induce the miscarriage.  That medication is called misoprostol, and will cause the uterus to contract so that the miscarriage can occur at a time that is more convenient for the patient.

The third option is a D&C procedure, which involves suctioning out the contents of the uterus.  This is a preferable option for women who prefer not to have the painful cramping and heavy bleeding at home.  Or occasionally it is helpful in situations where we want to send the sample for further evaluation for chromosomal abnormalities.  For pregnancies that are farther along where there is more tissue and therefore more pain associated with the miscarriage, I tend to offer the D&C more.  For the earlier pregnancy losses, the medication (or waiting) is the less risky approach over the procedure, so I encourage it more.  But ultimately it’s up to the patient depending on the situation and her preferences, as each option has its pros and cons.

I decided to go ahead with the medication that afternoon.  There are two ways the misoprostol can be used- orally or vaginally.  If you take it by mouth, it tends to work better if you dissolve the tablets between your cheeks and lower gums for 30 minutes, and then swallow the remainder.  It’s called buccal administration, and the medication absorbs through that area on the side of the mouth which helps it take better.  The other option, preferable for those who are prone to vomiting, is to place all 4 tablets in the vagina.  The medication absorbs and works through that route as well.

I went the oral (buccal) route, and started having the bleeding 4 hours after I swallowed the remainder of the tablets.  I surprisingly didn’t have all that much cramping, granted my pregnancy had ended pretty early on.  I’ve occasionally had more painful periods.  If anything, it caused my stomach to cramp and make me nauseous, which is a common side effect.  The bleeding was heavier initially, and I changed my pad frequently just to make sure it didn’t get on my clothes.  But it was like a very heavy period.  I suspect that some of my patients with problematic periods have had heavier bleeding than this.

Since the bleeding started in the early evening, it was still on the heavier side when I went to bed.  By the next morning, it was lighter.  Still like a full flow period, but not crazy heavy.  Despite not sleeping all that well overnight, I still went to work and the bleeding was not bothersome.  I was just tired, but nothing I haven’t experienced before with a young baby.  And I think it helped keep my mind off of it.  And in fact I spoke to a patient on the phone who went through a very similar experience.  She’d had a normal fetus with a heartbeat at 6 weeks, then a month later there was no longer a visible fetus.  So I talked her through the decision of what to do.

Of course, every woman’s experience is different, so some women have more pain than others.  But my experience solidified my current clinical practice that the misoprostol is often the better choice for the earlier losses.

I don’t regret telling our families and close friends, and I don’t regret blogging about my pregnancy.  We always knew that it was a possibility that this might happen.  I think that given my experience as a doctor, I wasn’t as afraid of people finding out in case I miscarried.  Yes, it’s disappointing and there have been tears, but I thankfully haven’t felt the kind of grief that Jessica Grose did.  Besides the support of my husband, it has been comforting to have an innocent toddler who doesn’t know what’s going on, and continues to provide me immense joy.  Interestingly enough, some of the most comforting words came from a text from my mother-in-law, someone I’m not particularly close to, but nonetheless whose words were very meaningful and appreciated.

I tell myself that it’s a matter of time until a better outcome occurs.  I have so much respect for women who have had miscarriage after miscarriage and keep trucking on.  I have a couple of patients that easily come to mind who have done so, having 3+ miscarriages.  They kept trying and trying, and went on to have healthy babies.

Despite the disappointment, I have to say one upside is finally being able to eat normally again.

Here We Go Again!

At long last, after over a year of trying:

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It was a little unreal to finally see the positive test result.  I’d left a specimen cup with my urine and the test stick with my husband, thinking we’d do the test together when things calmed down with our son.  But then I saw my son running around, holding the stick flashing Pregnant and couldn’t quite believe it.  I started thinking, “But I didn’t tell my husband how long to dip it, so what if he did it wrong?”  But then once my husband came into the room, it hit me, and I started crying tears of joy.  Much to my toddler’s confusion.

We’d done two cycles of IUI (insemination), then decided to go to the next step, which was an ovulation medication.  My fertility doctor decided to start with Clomid, because he said it had better rates of success for unexplained fertility compared to letrozole, the other alternative under consideration for me.  Clomid causes you to ovulate more than one egg, so the way he described it is that rather than just having one egg per month, this gives you the chances of 2-3 months.  Especially in someone like myself who’s apparently been ovulating but it’s just not taking, the chances of multiples is low.  So even if the Clomid works as intended and you get 2 or 3 eggs in a given month, it’s not like you’ll necessarily end up with twins or triplets.  When they did my ultrasound prior to ovulation, there appeared to be 2 dominant follicles developing.

Because it was around the holidays, the scheduling for doing the insemination was more tricky, so we just decided to time intercourse on our own with the help of the ovulation predictor kits I already had.  And frankly, aside from timing things, I’m not sure there was much of a point in the IUI for our particular situation.  The most beneficial use of IUI is for men with poor sperm quality, because the process concentrates the sperm with the best quality for insemination.  It was kind of a relief for us not to have to go to the office, for my husband to use the “collection room,” and that whole bit.  It’s certainly necessary in many cases, but adds to the stress of it all.

The fertility office had me confirm with hCG levels, so at least very early on, the levels were going up appropriately.  They also like to check progesterone levels.  It’s not something I order routinely for my patients, but the levels can also suggest whether it’s a normal pregnancy or not.

At 7 weeks, I had an ultrasound which confirmed a viable pregnancy.  Just one baby.  Phew!  So far so good, even though I know it’s still early.

With WZW’s pregnancy, I started feeling nauseous right at 7 weeks, and it peaked from 9 to 12 weeks.  This time, at 5+ weeks I started to feel it.  That gross feeling in my stomach, where I’m not sure if I’m hungry or what.  I have to remind myself not to eat too much at one time, because then I’ll feel worse.  And if I get overly hungry, then I feel desperate for food, so that’s not a good feeling either.  Like they say, eat small amounts frequently.  Not always the most practical, though, as you get busy with work and such.

I’ve been eating mostly carbs.  Since I don’t feel great as it is, it makes me want to eat less healthy.  I feel like snacking on crackers and chips.  Last time I started wanting sandwiches in the 2nd trimester, but this time I’ve started feeling that now, mostly because I want the bread.

Despite this fun nausea (and fatigue), I’m very grateful that I was able to conceive on my first round of Clomid.  I was prepared for it to potentially take a lot longer, and perhaps require the IVF route.  I really think my stress levels are what affected my fertility.  I cut down my schedule several months ago, and it’s made a huge difference.  I knew I was burnt out and stressed out, but being on the other side of it magnified how bad it was.

Supposedly the research on stress and fertility is mixed, meaning there isn’t definitive evidence that stress affects fertility.  In fact, when I was having a difficult time and seeing a therapist, she reminded me of this with the best of intentions.  That may be the case, but I strongly believe there is a correlation between stress and infertility.  Maybe it doesn’t happen for everyone, and there are women who conceive despite war and famine.  But it makes sense to me that given the significant suck of resources that pregnancy is on a woman’s body, our bodies would avoid it if already under stress.  From early on, we feel exhausted, can’t eat normally, and our immune systems are compromised.  Why would you want to be put in that vulnerable state if you’re in a stressful situation already?

On the Chinese medicine side, they definitely think stress affects fertility.  Part of the purpose of acupuncture is to help relieve stress to aid in fertility.  The acupuncturists say that it takes about 3 months for the eggs to mature, so the interventions can take at least that amount of time.  I told one of the ladies that I was planning on going to part-time in November, and she said she thought I’d conceive in February.  Well, I ended up cutting down my schedule in October, and I was pregnant in January.  While there are many reasons for infertility, for someone like me who had “unexplained infertility,” I think stress was the factor for sure.  And my aging ovaries didn’t help, either.

The other thing that happened is that as I got less stressed, I began to lose a little weight.  I lost about 5 lbs in the course of a month or two without trying.  I wasn’t stress eating as much, so the extra few pounds came off easily.  Maybe the other thing that helped is that in Chinese medicine, they advise you to eat hot foods.  If you must eat a salad, then at least balance it out with some hot soup or tea.  So I started drinking a lot of broth, which is very comforting with the cold winter weather.  I think it also helped me avoid snacking as much.  That wouldn’t have happened in the summer, though, because I can’t imaging wanting hot broth when I’m already feeling warm.

I have to say, the first trimester is tough because you feel nauseous and tired, but it’s too early to tell people you’re pregnant.  So it can be a pretty miserable existence.  I’m starting to see patients that are around the same gestational age as me, and I wish I could say to them that I understand what they’re going through.  Like really understand.  But that will have to wait a bit.  Despite the nausea, I’m really grateful it happened and am cautiously excited about what’s to come.

 

Uterine Transplant

Happy 2018, everyone!  I’ve been meaning to write since I read this article about the first baby born in the United States from a uterine transplant:

http://time.com/5044565/exclusive-first-u-s-baby-born-after-a-uterus-transplant/

A woman who was certain she did not want any more children donated her uterus to a woman who did not have a functioning uterus herself.  It’s kind of like a kidney transplant.  The recipient had functioning ovaries, so she was able to conceive using her own eggs and her husband’s sperm via IVF.  This is part of a larger study being done at Baylor University, and this was the first live baby that resulted from the study.  Previously, this had only been done in Sweden.

My limited understanding of transplant medicine is that because the organ is being donated by another person, then the recipient must be on immunosuppressant medications so that their body hopefully doesn’t reject the donated organ.  In some cases, the body does start to attack the transplant as foreign, and it must be taken out.  Which means that in the case of say, a kidney transplant, they’d need another kidney.

I’ve occasionally taken care of pregnant patients who’d had kidney transplants.  So there is a precedence for women who have had a transplant and are on immunosuppressant medications who have had babies.  I don’t know what the research says, but I figure if there was a concern for significant adverse outcomes in the children, then they would not allow this to occur.  Given the complexity of uterine functions that occur with supporting a pregnancy, though, this an entirely different level than a kidney transplant.

It did make me wonder why women would want to undergo the risks of having a transplant, and expose their babies to immunosuppressant medications in order to have a child.  After all, there is the option of surrogacy.  That is what Kim Kardashian is doing for her third child, since she had complications with her previous pregnancies.  With surrogacy, the child would still be genetically yours, but the difference is that another woman would be carrying the child.  So you wouldn’t be able to experience the pregnancy for yourself, but on the upside you would not have the transplant risks.

What says a lot are the statements from the physicians involved in this study.  One says, “We do transplants all day long.  This is not the same thing. I totally underestimated what this type of transplant does for these women. What I’ve learned emotionally, I do not have the words to describe.”  Another says, “A lot of people underestimate the impact that infertility can have on a person’s wellbeing.  It can have such a profound impact.”  The article goes on to say that uterine transplant is not a replacement for the options of surrogacy and adoption, but rather another option for couples.

Reading the statements above made me think about my own feelings.  Experiencing infertility myself has given me a deeper understanding of the feelings related to pregnancy and childbirth.  I understood the heartache of wanting children and not being able to.  But going into it, I didn’t think I’d be bothered so much by it since I’d already had a child.  And certainly, the feeling is different than for those who don’t have any children.  But I underestimated how disappointed I’d feel, and how I’d feel like my body was failing me.

The other thoughts that come up regarding these transplants is how important it is for many women to not only have a child that is genetically theirs, but to also want to experience the pregnancy for themselves.  As an obstetrician who sees the worst symptoms of pregnancy, I feel like pregnancy is often pretty miserable for many women.  And how often do I hear my patients, pregnant or not, say how good men have it.  After all, we women have to deal with periods, pregnancy, delivery, breastfeeding, and menopause.  And for the most part, the responsibility of contraception falls on us.

Despite all of that, the above goes to show how special it is to be able to carry one’s own child.  It’s not something that every woman wants, or should be expected to do.  But for those who do want to, it can be deeply disappointing to have that option taken away.  For the women who are candidates, it’s a remarkable achievement to now have the option to have a baby using a uterine transplant.

Find the Good

This year, as we celebrate another Thanksgiving, I have to remind myself that I have a lot to be thankful for.  They say it’s human nature to focus on the negative.  After all, back in the caveman days, it was the bad, scary stuff we had to pay attention to in order to stay alive.  Enjoying the pretty flowers without being aware of possible dangers would have gotten us killed.

In this day and age, I have to remind myself to focus on the positives rather than the negatives.  A while back, I came across an exercise called Find the Good in this New York Times article:

It involves writing down 3 things that went well that day.  You do so right before bedtime, and also write why each good thing happened.  Per the article, it helps train your mind to focus on the positives.

I happened to go to a conference on physician wellness last month, and one of the speakers was someone who is involved in research with this exercise.  He said the reason to do it before going to sleep is that it helps solidify the thoughts.  In a similar fashion, he said it’s good to study important things before going to bed, if say you have a test the next day.

By doing this exercise nightly for just 2 weeks, he says it improves people’s moods better than an antidepressant like Prozac.  And even when they stop doing the exercise, there are lasting improvements.

For me personally, I’d done the exercise nightly for much longer than 2 weeks, but I was still under so much stress from work that I still felt burnt out.  So I eventually stopped doing it, and haven’t been doing it lately.  With that said, I think there is still value in this exercise and it’s worthwhile to spend the time doing it.  The time commitment is minimal and the possible rewards are significant.

Since I’ve gotten away from the daily exercise, I need to remind myself to focus on the good things in my life.  Especially since it’s Thanksgiving weekend.  I have an amazing husband, who has been unbelievably supportive this year as I have struggled with the stresses of work, and infertility.  He takes care of much of the things around the house, cooks dinner on his off days, and foots more of the child care responsibilities than I do.  Oh yes, and he still works full-time.

We have a healthy, happy son who is thriving in his new preschool 2 days per week as we’ve transitioned away from the in-home nanny.  He is an active kid, learning new words rapidly, and is full of laughter and fun.  Well, you know, except when he’s tired and cranky.  In other words, he’s a normal toddler, and I am very grateful for that.

The rest of my family is healthy as well.  I am grateful for parents who are able to take care of WZW one day per week now that we no longer have our nanny.  My brother and his wife have twins who are now 16 months old, and it’s a joy to see all 3 of the cousins interacting as toddlers.  My mother-in-law is helping pick up WZW from preschool, and it’s really helpful to be able to ask my husband’s side of the family for help with him as well.

Despite the stresses of my job, I still enjoy what I do and feel rewarded by taking care of my patients.  It is a stable job that provides financial security.  With the recent fires in the North Bay, as well as the other natural disasters that have occurred this year, I feel grateful to have a stable home.

My tendency is often to focus on the negative- so far I’ve tried one cycle of IUI unsuccessfully and will continue to try.  It is a challenge, but I have to keep reminding myself that there are others in much more difficult situations in terms of their fertility struggles.  One of my friends recently told me she is on her 8th frozen embryo cycle of IVF.  She already has one child like me, so even then we both know we are lucky to already have one child.

So I have to keep actively reminding myself of all of the above, rather than letting my mind focus on all of the challenges I’m going through.  It’s fine to acknowledge that there are various things that are stressful and difficult.  And some days are going to be harder than others.  With that said, even writing what I just did about all that I am grateful for makes me feel better, and helps put things into perspective.

Here is our little guy with his new haircut.  Mommy wanted a break from WZW’s hair care for a while, so for Halloween we chopped all of his curls off.  Don’t worry, we’ll let it grow back.

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