Questions and Next Steps

Since our WTF on June 12, I’ve been in major research mode: I’ve consulted with my Ob/Gyn about how to proceed with our next transfer; I’ve had my autoimmune blood test results; yesterday I had a second opinion consultation with a top RE, Dr. T; and I am drafting an email to my current RE, an edited version of which is the basis of this long post.

TL;DR:

• We will transfer two embryos, one of each sex
• I will push for staying on estrogen for longer
• I will push for doing the transfer on Day 6 of progesterone
• I will push for doing the ERA test over the ReceptivaDx (an updated eTegrity test)

♥

Autoimmune

Autoimmune: all my results came back normal, except for one MTHFR (homozygous C665T). Dr. T says it’s not a factor in why I have three failed FETs, so we’re shelving the autoimmune protocol for now.

Uterus

I asked my Ob/Gyn if she saw any evidence of scarring, adhesions, or Asherman’s when she performed my hysteroscopy. In her own words, she said: “No, nothing. I was actually surprised by how normal your uterus looked.”

Risk of Twins

I also asked my Ob/Gyn what, if any, additional risks I would face if I were to get pregnant with twins. She said there would be no additional risks—actually my risk is lower because I have proven I can carry to term and I had no episodes of bleeding or contractions. (I never had a Braxton-Hicks contraction, even at 37 weeks!)

Now that we have the green light from my Ob/Gyn, we plan to do a two-embryo transfer.

A recent article in The Guardian said that transferring two embryos can actually lower your chances of pregnancy because the body focuses on the embryo of lesser quality. However, I’m not convinced that applies to PGS-tested embryos. Also, Dr. T said that it makes sense to transfer two because, in his opinion, it would increase my chances of pregnancy. He pointed out that I transferred two the first time and ended up with a singleton. (I’m the only person I know who transferred two PGS embryos and didn’t have twins!)

Estrogen

As we discussed in person, I would like to stay on estrogen for longer. I acknowledge that my records show that the length of time had no bearing on endometrial thickness, however the outcome of being on estrogen for 23 days was markedly different—namely, the fresh Feb 2014 cycle resulted in my daughter!

Regarding the dosage, your notes from January 20, 2017 show I was on 1cc of estrogen “previously.” From this, I infer I was on 1cc for my fresh/successful cycle, but only 0.3cc for my subsequent FETs:

Fresh Feb 2014:   1cc estrogen 23 days before starting progesterone
FET Oct 2016:   0.3cc estrogen 6 days before starting progesterone
FET Dec 2016:   0.3cc estrogen 16 days before starting progesterone
FET May 2017:    0.3cc estrogen 9 days before starting progesterone

Questions for my current RE:

1) Why was the dosage changed?
2) Is there any advantage to increasing the dosage to 1cc, particularly with two embryos?
3) How long do you think I should be on estrogen for at 0.3cc? At 1cc?
4) What supplemental options are available to me to boost endometrial thickness?

Progesterone

The length of time I’ve been progesterone has also been inconsistent across my cycles, and I wonder if that is significant to my window of implantation:

Fresh Feb 2014:   progesterone 6 days before transfer, Day 6 embryo
FET Oct 2016:    progesterone 7 days before transfer, Day 6 embryo
FET Dec 2016:   progesterone 5 days before transfer, Day 6 embryo
FET May 2017:   progesterone 5 days before transfer, Day 6 embryo

Obviously this is a small set of data, but it suggests transferring a Day 6 embryo on Day 6 is a reasonable modification!

This brings me to the Endometrial Receptivity Array (ERA) test, which is a uterine biopsy that is done on Day 5—and Day 7, if results show Day 5 is not the optimal day—of progesterone to ensure that the embryos are being transferred into the uterus on the optimal day. (This varies from person to person.)

ReceptivaDx vs. ERA

The brochure my current RE’s assistant handed me says the ReceptivaDx [which tests for BCL6 protein, as well as eTegrity’s ß-3 Integrin protein] test is a non-surgical way to diagnose endometriosis. It’s not clear to me how this test would benefit me: I already have an endometriosis diagnosis and have been pregnant twice before (not including my recent chemical pregnancy), so it seems reasonable to conclude that I have the proteins essential for implantation and ongoing pregnancy.

Also, the ReceptivaDx test potentially requires 2-3 months of Lupron, compared to the ERA test which would require no further treatment. In the interest of time, I would prefer to do the ERA test with a biopsy on Day 5 and Day 7 (by process of elimination, Day 6 would be tested) before next transfer.

Questions for my current RE:

1) Is the ERA test something that your clinic offers?
2) Would you be willing to do a Day 5 and a Day 7 biopsy in the same cycle?
3) If you still think the ReceptivaDx test is more valuable for me, would you explain why?

In Conclusion

We have four (PGS-tested) embryos left at our current clinic. Back in January, we paid a package deal for unlimited transfers (which, in our case, meant five) but as we plan to transfer two at a time, this means we have two transfers left at our clinic. Given that my uterus appears to be totally normal, this leads me to conclude it’s more likely that the embryos have been compromised by either the vitrification process, or the PGS biopsy process, or a combination of the two. If I am not pregnant by the time we’ve used up our embryos, we will move our 13 frozen eggs and vial of sperm to Dr. T in the hopes that we get at least a couple of embryos (he recommended we transfer two in this scenario).

Of course, I just really want the next transfer to work, so that’s what I’m focusing on. I’m so ready to be done with this painful chapter of my life.