Embryo Testing

So far so good, the first pregnancy test was positive!  They had me check a blood pregnancy test 2 weeks after the egg retrieval.  This makes sense, since normally I tell patients to check a pregnancy test two weeks after ovulation/conception potentially occurred.  This usually ends up being around the time of the missed period in women who have regular cycles.

Since the embryo transfer occurred at Day 5, the wait was only 9 days, so it didn’t feel like eternity to me.  Since I’ve spent most months of the past two years waiting two weeks from ovulation to the pregnancy test/period, 9 days wasn’t so bad.

Next, I will check the hCG level again to make sure it’s rising appropriately.  From there, I’ll have to wait another couple of weeks for my first ultrasound to see if a fetus is present.  And even then, we’ll want to check a little later to make sure it’s still viable.  So there’s still a lot of waiting to do.

I’m aware of all of the possibilities.  There is a possibility that the pregnancy will end in miscarriage again.  With IVF pregnancies, the risks of ectopic pregnancy are much higher.  An ectopic pregnancy means that the embryo implants somewhere outside of the uterus, usually in the fallopian tube.  If not detected early enough, and it keeps growing, the tube could rupture and cause hemorrhage, which would be an emergency, requiring surgery.

In many cases such as this when we know someone is pregnant from early on, we can often detect an ectopic pregnancy early based on the hCG levels rising more slowly than normal.  If detected early, a medication called methotrexate is often used to treat it medically.

Another possibility is twins.  We only transferred one embryo in the hopes of reducing the chances of twins, but sometimes the one embryo decides to split and becomes twins, or rarely more.  I hope this doesn’t occur, since twins are at high risk for complications like preterm delivery.  Also, when twins share the placenta (called monochorionic twins), there’s a higher risk for them to have an unequal distribution of blood supply.  It’s called twin-twin transfusion syndrome, and in some cases could be severe.

For twins that come from two separate eggs and sperm, such as if two embryos were transferred or a woman naturally ovulated two eggs, you’d end up with fraternal twins and wouldn’t have to worry about the twin-twin transfusion syndrome.  You’d still have to worry about risks like preterm delivery, though.  Not to mention the craziness of having two babies instead of one.

We decided not to test the embryos for genetic (chromosomal) disorders, which is why we did what’s called a fresh embryo transfer.  Many people choose to do the testing, which requires freezing the embryo to allow for the testing, and then transferring it into the uterus a little later.  That would have been a frozen embryo transfer.

The testing I’m referring to is called preimplantation genetic screening (PGS).  The test is designed to screen for chromosomal disorders in general, as opposed to looking for a specific disorder.  For people who have a known disorder, it definitely makes sense to test the embryos for that specific disease, and to only implant the unaffected embryos.  This targeted testing is called preimplantation genetic diagnosis (PGD).

Based on my limited knowledge, I don’t think there’s a right or wrong answer when it comes to the decision to test the embryos.  I’m 37 yo, will be 38 soon, so statistically the chances of chromosomal disorders are less than say, for a woman who is 40 yo.  But since I’m over 35, there is still a higher chance than in a younger woman.  One of my friends who had to do countless cycles of IVF before finally having her baby said that they didn’t do the testing of the embryos.  Her doctor mentioned the possibility of false positive results- meaning the results can occasionally show that there is an abnormality when none is present.  Also, she was concerned about the theoretic risks of disrupting an embryo at its early stages to perform the genetic testing.

I think what my friend’s doctor was referring to is the embryo testing that is most commonly performed now, called the blastocyst biopsy.  When the embryo reaches the blastocyst stage at about Day 5, it’s made up of more than 100 cells.  The biopsy takes cells from the outer cell mass which eventually becomes the placenta, as opposed to taking a biopsy from the inner cell mass which will become the baby.  Sometimes the biopsied cells don’t reflect the actual cells of the baby, and therefore you could end up with erroneous results.

My impression is that the errors don’t happen too frequently, which is why many people are commonly having the testing performed.  I have friends and colleagues who have had the testing performed, and their babies turned out just fine.  Not to mention celebrities like Chrissy Teigen have been open about doing IVF.  She mentioned knowing the genders of the embryos before implantation, so they clearly had the testing performed.

The benefit of having the testing done is to greatly reduce the risks of a chromosomally abnormal baby.  Because many chromosomally abnormal embryos/fetuses do not develop beyond a certain stage, this would theoretically reduce the risks of miscarriage.  Also, it would be terrible to later do the genetic screening during the pregnancy, only to find out there is an abnormality.  That would result in the difficult decision for many couples as to whether to terminate the pregnancy.

Our thought was that if there is a chromosomal abnormality, then there’s a decent likelihood that either the embryo wouldn’t develop well enough for transfer, or that there would be a miscarriage.  Our doctor said that in the many years he’s been doing IVF, there have only been a few times that there ends up being an abnormality like Down Syndrome that is detected later in the pregnancy.  When it comes to gender, that doesn’t matter at all to us.

Of course, I’m a little nervous about the prospects of having a miscarriage, or later doing the blood test in the pregnancy and finding out there’s an abnormality.  In case this embryo doesn’t take, we thankfully have a frozen one as backup.  Apparently it is possible to thaw it to test, and then refreeze it.  There would be more of a chance with that scenario to damage the embryo during the process (compared to if we’d decided to do the testing in the first place).  So it may not be worth it.  But if neither embryos take and we have to go through the egg retrieval process again, then it would make sense to consider the PGS from the get go.



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.



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.