Follow Up Questions

These are the questions I asked our doc...

1) We'd love to know your personal gut reaction, thoughts, musings or otherwise. As the professional, we defer mostly to you to tell us in your opinion, why you think we've had 3 failed IVFs as a healthy young couple. What would your plan be moving forward. 

2) Endometriosis... given the fact that we have never gotten pregnant successfully, I am beginning to feel that perhaps it is time to pursue laparoscopy/surgery to discover how extensive the disease is. 

- Do you support this/think this is a good idea?

- Do you think it may aid with implantation?

- Do you think that the endo is a significant factor in our implantation failure?

- What are your opinions on other treatments in terms of FET protocol (lupron, prednisone, bcp prep, or otherwise)?

3) Immune Response

I've sort of felt from the get-go that my body rejects the embryos. I know we did Intralipid, but I'm just curious on your thoughts since they recommend blood thinners in a lot of these cases. I had asked about baby aspirin, but that was not recommended. Most of the immune related treatments would also likely be linked to the above endometriosis topic, but I am curious about the chance of a clotting disorder or what could be done to stop this immune response. 

- I believe I might have celiac (given my severe response to wheat along with confirmed lactose intolerance which often go hand in hand). Do you recommend I have a scope? What would this tell us in terms of treatment (I'm already GF/Dairy Free)?

- Is more testing needed?

- What tests/information is out there for immune related infertility?

4) Assisted Hatching - this is something I sort of had asked about prior to our transfer but was not recommended. 

- How did the zona pellucida on each embryo look before transfer? 

Is this something that may be a factor in our implantation failure? 

- Did any of our embryos begin to hatch before the freezing stage?

If not, could this be indicative of blastocyst arrest (I think that's the term at least)?

5) Male Factor

- How did the sperm sample look on retrieval day?

- Given my clear results (minus MTHFR), could there still be a reason to have Homme InFertile genetically screened (ie. if my eggs are not "strong enough" to compensate for poor dna (or repair it?)?

- Could this be a factor in why we are not getting pregnant?

- How were our PICSI results? Did a large number appear to be normal whilst using PICSI for sperm selection?

- Would you recommend we pursue the DNA fragmentation test at this point to get further insight to any or the extent of the fragmentation? 

- If so, and if Homme Infertile's results are highly fragmented, what would this mean in terms of our likelihood to conceive with his sperm? Would any course of treatment differ?

5) PGS - we had contemplated doing this, however financially were not fully in a position to do so, and in addition, were not certain at our age how necessary it would be. 

- Do you think there is a high likelihood genetic abnormality is the primary reason for our lack of success?

- How were our embryos frozen? 

- If they were vitrified, have you ever done a thaw, test, and re-freeze? What are the outcomes like? 

...I have also heard of thaw, 24 hr test turnaround and day 7 transfer, but not common - thoughts?

- Do you have any recommendations on this factor for us, given the position we are in?

6) Progesterone 

Because I spot during my luteal phase for many days every cycle, progesterone has always been a concern for me... I did NOT spot at all during use of suppositories this cycle which is encouraging.

- Have my progesterone levels been checked and HOW normal were they? (I know there is a normal range, but was I on the low end of normal? etc)

- Many women speak of PIO shots, would this be a stronger course of action for me in the future for FET?

- My progesterone was not monitored throughout my cycle, is this something you would consider moving forward?

7) Lining

I know we briefly touched on this this a.m...

- How was my lining on transfer day? (ie. thickness, evenness etc)

- Receptivity, I know we're both concerned about this, but what would be different in terms of protocol or prepping for transfer? 

- Uterine Scrape (I know this is mostly new, and more common in UK), what are your thoughts?

- Would this mostly be addressed through laparoscopy/hysteroscopy?

8) Further testing

- Thrombophilia ... especially with endo I was surpised you didn't recommend at least aspirin, but is there a chance I have a clotting disorder? Am I crazy to think there is a link?

- male or female karotyping defects (not even really sure what this is)?

- confirm my NK cells or elevated inflammatory cytokines levels? (relates to immune above)

- anti-sperm antibodies in Homme InFertile? I'm probably making tests up ;)

- anything else I'm missing/not thinking of?

9) Surrogacy 

- Given my endometriosis and repeated failure, is surrogacy a strong option for us if lap/surgery come up with no explanation?

- Do eggs/blastocysts conceived by a person with endometriosis have good results with surrogacy pregnancy and live birth rates?

- What are your general opinions/thoughts on this for our case? 

- Obviously this is really expensive, if I had a friend (doubtful but just covering bases) willing to do it for me, what is the testing process like?

Bloodwork cancelled!

Hey all... so my clinic called me as I was on the way to my appointment to have blood work done for immune and NK testing. They didn't realize their lab doesn't do that specific testing on Fridays....

REALLY?

ARE YOU KIDDING ME?

WTF?

These were the emotions and thoughts that rushed through my mind. I've been waiting a while to do this test, and we picked a day and time that was most ideal for my hubby (all appointments are between 9 and 11 am and he works). Had we KNOWN in advance that blood testing for NK and immune wasn't doable on Fridays we obviously would have scheduled another day earlier this week because....
.... he's away for a full week starting tomorrow. This pushes EVERYTHING back. So frustrating. I took a few deep breaths, whoosawwwwd a little (if you don't know what I'm referencing, it's from the movie Bad Boys haha) and then once I calmed myself sent this email to my doc:

Good morning Dr. _____,
My husband and I were supposed to come in today to get blood drawn for immune testing but were called last minute to be advised that it cannot be done on Fridays.
We were somewhat disappointed we were told 30 minutes before our appointment especially since my husband is away all next week. Had we known in advance, we could have done this another day earlier this week. Disappointing as this is, mistakes happen and we just want to put together a plan to move forward and I'm trying to decide whether at this point we should bother.. so a few questions would help us if you don't mind...
I noticed in some of my research that sometimes NK activity can be recognized in the uterine biopsy. Is this true?
Is there a difference between localized NK activity in the uterus versus the bloodstream?
What information would we be gaining from this testing that would alter our protocol other than possibly a steroid like prednisone or intralipids? ie. what information from Eric's or my test results would contribute to a change in approach?
In your professional opinion do you feel as though this immune testing is of high importance to our treatment? or will it depend on what results come of our biopsy/shg?
On a separate note:
What is the cost for PGS? We are considering the possibility of doing it if we have a high embryo yield.
Is PGS something we need to decide on prior to beginning our cycle, or is it something that can be flexibly added/removed as we progress?
Thank you, as usual, for your time and expertise! :)

Now hopefully I came across as a calm, sane person (inside I didn't feel that way haha). I'm a little hot headed sometimes and out of principle hate when people are stupid. I felt like this was one such instance, but not sure who the stupid individual was... haha whooosawwwwww ... let it go. poof. gone.

I did NOT mention the funny thing. What's the funny thing you ask? Well the funny thing is that all morning I had been questioning whether this was a road I really wanted to go down. Do I believe in Intralipids? Do I think its the answer to our infertility woes? The fertility industry is very torn on the topic, more heavily weighted against it with articles explaining elevated NK could be related to stresses from the blood sample drawing, to the fact that elevated NK are existent in perfectly fertile couples, to little to no evidence or correlation to therapies used and positive outcomes. I mean its all over the place. Do I want to be successful? Yes. Do I want to sit and get multiple IVs and pay out of pocket for it if I don't need it? No. Do I want to pay $500 out of pocket just to have the test when I don't know if I even want the therapy or believe in the validity of it? BLehhahghhh... I dunno!?!!? NO?

Why is there so much for an infertile to decide about!?

So moving forward, Monday I still have my biopsy/SHG/trial transfer, and part of me believes that's what I need. Honestly... part of me thinks my uterus just needs a good scratch, clean out, and ripe new start. I dunno. I feel so confused right now.


*****
update:

Doc got back to me. I think we'll forego testing and if the therapies are covered just go ahead and do them. We're only doing 2 more transfers tops at this point, so might as well go all in and give ourselves the best chance possible.
I also read this blog post of another gal, and it encouraged me to just give it a go. Never know.

To PGS or to NOT PGS... that is the question...

So I count myself incredibly fortunate to not only have amazingly supportive, intelligent friends to discuss my infertility journey with, but also one in particular who not only once upon a time offered her own womb to grow my child (you kidding me!? amazing) but who is also a genetic counsellor. Let's call her Genetic Gina. Genetic Gina is super smart, always has been. I've known her since primary school, though I recall our friendship really blossoming in grade 8. Genetic Gina has always been someone I could count on for good, solid, well thought out, and logical advice, and yesterday was no different.

Now I don't like to take advantage of my friends, so was hesitant to reach out at first, but knowing she's also not one to pry into my personal life (she herself is very private), I felt that if I didn't just ask we'd likely never talk about it. So I texted her to see if she'd be open to having a phone date to discuss the pros/cons of PGS and what her thoughts were for my particular circumstance. She of course said yes, which I was super grateful for.

Now most of my friends have no idea all the terminology and vocabulary used in IVF and fertility/infertility etc. Genetic Gina is of course different, working specifically in a fertility clinic as a genetic counsellor. So its such a nice experience to talk to a professional, who is also your very dear friend who has a vested interest in your outcome.

We started out by me explaining that it is something we are considering given our "unexplained" diagnosis. At least, unexplained recurrent IVF embryo implantation failure...
So I said that our doc believes in immune issues and I really believe that's a source of my personal problem, even knowing she's very logic/science driven and probably herself doesn't stake much weight in intralipids etc. I skimmed over it quite quickly and explained that should that testing come back negative, we are strongly considering PGS, and wanted to know if its something I should consider regardless.

Her take was basically that if I was willing to do more than the 2 cycles I'm planning (1 fresh, 1 frozen) she'd say maybe not due to the high cost and our young age. But since I'm only planning on stimming once more and then doing a frozen transfer if needed, she suggested that if I have a high yield of embryos that it would pinpoint the best place to start and would be a good way of ensuring the best possible outcome. Ultimately, if I get 10 or so eggs and we have the money, she says go for it. If we only have 5-8 eggs she says maybe consider doing an additional cycle instead. All really good advice and hard to put into words on this blog.

Anyways, a lot of our decision is going to be based on how our tests come back, and how our yield is. So its really just sit and wait until we know more at this point. But I definitely have a better sense of my plans based on various IF___ THEN___ scenarios. And on top of that I know I have her to chat to about my decisions anytime!

Just feel pretty grateful right now.

PS> if any of you are interested, here are some articles about PGS/PGD that she forwarded me to help me make an informed decision.

xx