Last week we had our failed transfer follow-up appointment (a.k.a. The WTF appointment) with our doctor to discuss next steps. Everyone (including our doctor) seemed surprised that our last embryo transfer wasn’t successful as everything “looked perfect”. We were at a loss as to what we should do next based on the 3 options we were given.
Unfreeze our remaining frozen embryos and have them tested
Just try again
Go through a mock cycle with uterine biopsy
Test Our Remaining Embryos
After our egg retrieval in September 2018 we had to choose whether to PGS test our embryos before freezing them. PGS (preimplantation genetic screening) is used to determine whether an embryo contains the normal number of chromosomes (and if they do, the embryo is considered normal). The idea around PGS testing is an “abnormal” embryo has a less likely chance of becoming a viable pregnancy than a “normal” embryo. In theory, we all are at risk for having abnormal embryos. For example, out of the 9 embryos we had to freeze, some could argue that half of them could be abnormal. But there is evidence out there I could also have created 9 normal embryos. There are also arguments that even though, under PGS testing, an embryo is considered abnormal it could possibly correct itself in utero or the “defect” isn’t something that would actually be harmful to the pregnancy or the baby. Science just has to give the “less than perfect” embryos the abnormal title and some clinics (and patients) choose not to use those because of that title.
Both our fertility doctor and my acupuncturist (who I run everything by) both agreed that due to our health and no known issues that PGS testing wasn’t necessary. It was our choice. It’s an expensive test and since most didn’t think we needed it, we chose not to.
The question we are asking now is whether we want to take the risk of unfreezing our remaining embryos, PGS test them and then refreeze. The problem with this is you always risk an embryo not surviving the thaw and at this point, messing with them too much can impact its implantation success rates. And at this point, that isn’t a risk we are wanting to take on our remaining 6 embryos. So we are going to move forward with our 6 frozen embabies and hope they are all nice and normal.
Just Try Again
The “problem” we have is our first transfer worked. We know I can get pregnant and the transfer protocol can work...I just lost the baby. Because our first transfer worked and our second one didn’t, it puts us in a weird place. Certain tests or theories the doctor may investigate further if 2 transfers had failed don’t apply to us. The 2 main things that were different between our 2 transfers is our second one had a much thicker uterine lining than the first and we decided to transfer 2 embryos instead of 1. At the end of the day, transferring 2 shouldn’t hinder at least one of them implanting. Our doctor thinks we may have just had really bad luck on the second transfer and transferred 2 abnormal embryos. So if we assume this round was just bad luck, we could dive into our next transfer with the same medicine protocol and hope for the best.
At this point, we only have 6 frozen embryos left and both of us really don’t want to go through another egg retrieval (it’s the most expensive part of the process and the most taxing on my body). Just trying again and hoping for the best is a scary proposition when there is no guarantee.
Mock Cycle with a Uterine Biopsy
Besides redoing all of our blood work that we did last year to just double check everything (which we are doing this week), the only other diagnostic test we can do to see if we can find ANY answers as to why we aren't getting pregnant on our own or having a viable pregnancy after an IVF embryo transfer is to do a mock cycle with a uterine biopsy. A mock cycle means I will go through all of the same medicine and monitoring appointments I would be doing if I were doing another frozen embryo transfer. This means starting birth control, taking estrogen and monitoring my uterine lining to reach the desired thickness and taking the 5 days of progesterone shots (in the backside) - and all the wonderful side effects that come with each of those medicines. The only difference this cycle will be that instead of going for a transfer and putting in an embryo, we will be going in for them to take out a part of my uterus for testing.
So after much debate, we have decided to move forward with a mock cycle and uterine biopsy. Maybe the biopsy will find some answers as to why we are having such a hard time getting (and staying) pregnant. But if the biopsy doesn’t show anything, then at least we know we did all the other diagnostic tests possible before we give another transfer a try.
From the biopsy, we are going to have 2 tests done on my uterine lining sample: an ERA (Endometrial Receptive Assay) and a ReceptivaDx Assay.
ERA
Using a sample of the uterine lining, the ERA test helps to identify whether you need an additional day of progesterone shots before transfer. If you haven’t had an ERA test done before, you will more than likely start the progesterone shots 5 days before your transfer date.
For reference, the progesterone supplementation (in my case, shots in the backside) is a critical part of getting and staying pregnant during fertility treatments. I read a great article on Your IVF Journey where it explains the need for progesterone really well. “The reason IVF patients need extra progesterone is purely chemical. After natural ovulation, the follicle that contained your egg turns into the corpus luteum. Intimidating Latin name, but a simple function: it secretes progesterone and makes your womb lining super-ready for your fertilised embryo. But IVF isn’t natural. You’re down-regulated. Your medication produces multiple follicles. The brakes are then applied to stop egg release before egg retrieval. And your eggs are unceremoniously collected when your body least expects it. In short, IVF disrupts your natural progesterone function. So you need lots more of it for proper luteal support, from egg-retrieval day onwards. Progesterone facilitates implantation and can stop a miscarriage in its tracks.” (This is one of the reasons I didn’t miscarry on my own after my first transfer and had to not only stop my progesterone but get medical assistance to jump start the process)
Okay enough of a progesterone lesson, back to the ERA test. From the test, you will be identified as ‘Receptive’ or ‘Non-Receptive’ for the implantation window. Receptive means that the implantation window is correct with 5 days of progesterone shots and an embryo transfer should follow the same pattern. Non-receptive means that the implantation window needs to be longer so women will switch to 6 days of progesterone shots before their next embryo transfer.
My doctor doesn’t think we need to test this since I did get pregnant with our first transfer on 5 days of progesterone, but since we are going to be doing a biopsy for the other test we have decided to pay for this test as well just to be safe.
ReceptivaDx Assay
This test is the main reason we are going to do a uterine biopsy. The test was designed to assist in identifying obstacles to implantation (endometriosis, adenomyosis, and other inflammatory conditions in/on the uterine lining).
The test examines levels of BCL6 which is a marker for endometriosis. If this marker is elevated, it can mean that the endometriosis is interfering with the embryo being able to implant. While I have not shown any signs/symptoms of endometriosis, this test will possibly give us some insight into whether I have it in an undetected form. I recently read on article on BusinessWire about the ReceptivaDx test and an interesting stat I found stated “In a nine-year study published in the December 2017 issue of Fertility and Sterility, over 75% of patients with unexplained infertility tested positive for the BCL6 marker. The positive rate is believed to be even higher in women with multiple failed transfer attempts.”
We just got the great news that our insurance is going to cover the clinic costs of this cycle so we will only have to pay for the 2 tests. Our clinic should be contacting us soon to get everything scheduled out and then a couple weeks after the biopsy we will maybe have some answers! Stay tuned for that!
**This is not meant to be medical advice. Be sure to consult your doctor with any medical concerns. This is the account of my personal journey through infertility**
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