We went back for a scan and consultation today, pending the start of a repeat cycle on Day 3 of my period. Today is Day 30, my basal body temperature (BBT) has crashed out to below its baseline level and the HCG tests were of course, negative on Day 23 and Day 30. I had hoped Dr N. would be able to see many antral follicles, and that would give us a hopeful indication but there didn't appear to be anything. I stared at the white screen in horror and for a second, I thought, oh God, there's absolutely nothing, it has completely shut down and given up on me.
He explained that there might be several factors: first, it was too early for the hormones to have kicked in. Second, my lining was thick and weighing downward, as would be typical pre-period, my bowels were extended and the left ovary could hardly be seen from under my heavy intestines. Charming, I know. So we will scan again on Day 3 and see whether to proceed.
His plan is to use a similar Elonva protocol but to vary the second week of meds, using a single antagonist (so Menopur all the way, instead of varying between Menopur and Puregon), because the HCG in Menopur may have a better result. Highlight the word 'may'. He also has thought about using Menopur the whole way, although the Elonva gave fairly good results the previous time. He has also thought about lowering the dosage, as there is a belief that too high a dosage can compromise egg quality — the difficulty with that is that without a pyramid of egg number and quality, the natural attrition of retrieved eggs and embryos means that the chances of getting the odd better eggs is actually higher if you start with a larger, than smaller, crop.
To me, it just seems like all the doctors are running out of ideas for us and in truth, they don't know what will work or what might help us get over that line of good-enough quality embryos. The truth also is that because I don't respond well to the meds in the first place and because our quality issue is so poor, there is perhaps not much left that can be specifically done to improve the result.
We are also changing labs to a more boutique lab. This may prove to have no advantage at all, except that this is the only lab in Singapore to do PGD or pre-implantation genetic diagnosis. This refers to genetic profiling of five-day blastocytes prior to implantation, and sometimes even eggs before fertilization (this second part is disallowed in Singapore, but it should be allowed, especially given the high risk for sub or infertile women). It basically tells you if there is a specific genetic disease, if you were both thalysemia carriers, for example, or if there is a chromosomal abnormality that is causing the low-quality embryos to arrest, or would cause the pregnancy to terminate if the embryos implanted.
I haven't been sleeping well. I'm scared. I keep thinking about it, as was the case before my second, disastrous IVF at NUH. There is this same feeling of repeated failure and fear and for some reason, I feel especially vulnerable. I think this is because when you have this ridiculously hopeful and then poor outcome, you fear that it will just happen again. I can't get myself to a positive place of thinking, that compared to the first time, we didn't get 1 egg out of 10 follicles, we got 12 eggs out of 15 follicles and so honestly the fear should at least be elevated to a slightly less depressed platform. I'm trying, but I can't get there.
In my mind, I keep thinking, what if they are all just chromosomally abnormal. What if we don't even get to blastocyte this time. What if my whole system just shuts down, the way that it did the second IVF (the answer to this last one is the most straightforward, that you would have wasted some meds and be pissed off but you would have to try again, as it was just the wrong cycle to have tried). What if it doesn't shut down but the follicle and egg count is just low, since I don't respond that well to meds nor produce eggs well anyway.
The eight embryos that we had were observed by the embryologist to be small and dense, to be fairly low quality right off the bat. That was common through the whole cohort, which increases the predictive likelihood that it will occur again. It may mean that the whole store of eggs that I have is congealed. It may also be the reason that in the first IVF, we had a paper-perfect 10 follicles of similar, mature size, 15-21mm, but then the doctors could only extract one egg. It is unlikely that the follicles were really empty, so it may be because the eggs were small and sticky and they didn't bother, or felt the quality was too low anyway. (The problem with a public hospital and a terse doctor is that this was never entirely made clear to us). The fact that that one lone egg didn't even fertilize definitely suggests that I've never actually had a quantity problem, but a quality problem.
Despite that, eight of the eleven eggs fertilized, two made it to five days and one made it past five. So that's good. The one that made it past five didn't have enough inner cell matter and if implanted, might not have had a fetal pole. So that's bad. There are two issues: first, the health of the eggs and embryos, to give it the metabolic strength to just keep splitting and growing, which most of ours clearly didn't have. The low quality is represented through the slow cell split and the high degree of fragmentation in the embryos. The second is chromosomal abnormality, which might be the whole, or part of the reason that even the best blastocyte, i.e., the one with the best metabolic strength, wasn't normal.
This happens in regular women too, many of whom miscarry again and then even the second time, because of chromosomal abnormality. Of course, they made it past production, fertilization, conception and implantation all on their own, which we did not and never have.
So compared to these women, and compared to many 40+ year old women on IVF who have great embryos, or at least viable embryos of less fragmentation, we have truly awful quality eggs. Of course, the hope is that the egg quality turns out to be differentiated, turns out to be improved by tweaking the meds and we get lucky with something good enough. Or, we may again get truly awful quality eggs, with nothing that pushes us across the line. This is my fear.
It is also my fear that there is no fix for this, that if the overall quality is poor, or it is indeed a consistent chromosomal abnormality, then other than trying repetitively to extract a rare good egg that makes it all the way through, or laproscopy to clear away endometriosis that may be causing the poorer egg quality (which I really don't want to do because the effects are temporary, the improvement in pregnancy rates is 12-15% and the surgery itself may damage your ovaries), we are just going to pour more time, more cost and more heartache into this process.
The funny thing is, the swing from being so positive in the last cycle, telling the doctor we would not try more than two transfers before going to surrogacy with embroyoes, and being so negative going into the next, thinking that who cares, our embroyoes will be screwed up anyway.
I am finding it really hard to look at it in a positive way and be easy on myself for doing it, although sensibly, you should be positive that you have the opportunity and resources to find out or to keep going. I just want our luck to change, but I am scared that it never will and it was pre-determined, through something like chromosomal abnormality, that it was never possible. I resent knowing that it was possible ten years ago and this might be just a taunting prelude to knowing it isn't now.
Other days, I think, statistically, 70% of all natural or IVF embroyoes have chromosomal abnormality anyway, there are many people who go through three cycles and all the eggs are abnormal, there are also people who have everything abnormal the first time and then three normal the second. So yes, we have the worse odds because we can't seem to fertilize naturally either and get only the rare blastocyte, but we just need a big enough move in the right direction, not a sea change in quality.
I'm trying to manage it as best I can, which is why it's mostly in sleep that it is eating me up and chasing me down. I dread knowing, I dread doing nothing, I dread trying to do everything at the same time. That seems to be my risk-adverse mindset these days. Do I want to not do it or not continue? No. Do I believe that it will work? Some days I hope and know that it will work on one particular cycle. It has a high chance of working, because if it's about powering through slim odds, we're young enough to reiterate the process often enough for luck to occur or for God to flick the switch.
But my problem is, to be honest, there are just as many times when no, I don't believe it will work on this next cycle, because our blastocyte wasn't viable enough to transfer or freeze so unlike other people, there is no gaurantee it will ever be any different. I fear we will do everything and still fall short again. But I know that we will never know, unless we try. Even though tangibly I know I am doing very little and dragging my feet on the little that I do, I am so tired of what I am doing, everything that I am doing.
-------
The outcome of the Day 3 scan was two follicles on the right, one follicle on the left. In Nov, there were three on the right, two on the left. Dr N's recommendation was that given how expensive the process is, it was better not to start the cycle, to take the DHEA supplement and scan again in March or in April for a better crop of antral follicles and to start then. He said that we could start this cycle, as my AMH tested last month at 8.01 but if the response was poor, we would wind up cancelling. To maximise the likely outcome and quality, it would be better to wait for a higher antral follicle count, when the ground was more fertile, so to speak.
He's right, I know he made the decision for our own good. But I was a bit disappointed, even though it seems ridiculous to be upset that you can't be on IVF. I guess I had pyched myself up to be positive and to know that I'd have to do so again, just a little down the line, made me wish that we had started last month, or that I didn't have to travel for work next month, which I probably do. It sucks to be told to wait, when that's all you've been doing.
There was an Indonesian couple who was in there for the Harmony pre-natal test. I could tell right away, from the happy way they greeted all the nurses that they had succeeded. It's just hard and it makes me sad, they were so excited. We have worked so hard, and for so long at this. I just hope one day, one way, it will be our turn.
