Some History - 2015, part 2, Low AMH & Another Hurdle

The time leading up to the appointment with the RE was far more stressful than the actual appointment, but it went by quickly. My brother got married to a fabulous woman! So there was lots to celebrate and pass the time.

The RE was great, very informative and positive.  We had already started a 4th round of Clomid, because, why not?  We had to wait for the appointment anyway, it was only $20, and if it worked, we might be off the hook!  He said he would treat this cycle as an observation / diagnosis cycle.  We could go ahead and do all the blood tests (except for a few where timing in the first days of a cycler was essential). 

The first visit Sep 21 (day 12 of my 4th Clomid cycle), they took 14 vials of blood, a urine sample, and did an ultrasound.  I didn't run away from the nurse when she plopped these down on the table, for that I was very proud of myself:

My 14 vials

My cup for pee (empty)

The lab techs at the RE office are awesome.  Lori and Kim.  They do this all day everyday, and they are good at it.  All my life, I have hated needles, but they make it easy and relatively painless, which is good, because I would be back for more...quite a bit more.

The ultrasound showed 2, yes TWO!!, follicles on my right ovary.  This meant I could ovulate 2 eggs!  They told me this is good news, and shows that I responds well to stimulant medicines (i.e. Clomid) and to stick to a strict "schedule" that week, and to resist the urge to take a home pregnancy test until 15 days after ovulation.  The RE also put me on a progesterone supplement, which was precautionary, to ensure that any embryo(s) we created, would have the best chance of implanting.  The supplement was a vaginal suppository, so that it can get as close as possible to the uterine tissue and have the best effect.  It was messy, but it was an extra tool in the toolkit! That week, we took the "like bunnies" approach.  Figured we'd throw everything we could at the two little eggs. Then we had to wait.

The blood test results started to trickle in.  Some of them before the day was done.  The lab is right there in the office, so for the main things like estrogen, progesterone, FSH, etc, they get the results back same-day.  Others had to be sent off.  The genetic tests took the longest.

My "Patient Portal" had everything updated as it arrived.  It is a secure website where I can log in and see my appointments, fill out forms, get my lab results, and email my nurses.  It is designed with cool, calming colors, and cute baby-themed imagery.  I would probably prefer it be sterile, black & white at this point, but whatever, I'll take it.  Data.  Data is good...

All the tests they got out of my 14 vials of bood and cup of pee.

The way this portal works, the results come in and are mostly just a number.  No reference range or anything that helps you determine if it's good / bad / normal / abnormal.  I assume most people are ok with being patient and waiting to go hear what the doctor has to say at their next appointment.  I'm not one of those people. 

So naturally, when my results started to come in, I started consulting Dr. Google to see what they meant.  Most everything was coming back in the normal range, it seemed.  Except for 2 things.  My vitamin D was a little low, and my AMH (Anti-Mullerian Hormone) was very low.

A normal 32 year old has an AMH ~2.5ng/ml.  AMH over 4.0 indicates PCOS, whereas an AMH below 1 is indicative of diminished ovarian reserve.  My AMH was 0.24ng/ml.  What does this mean?

  

To quote my favorite fertility information site:

• Research shows that the size of the pool of growing follicles is heavily influenced by the size of the pool of remaining primordial follicles (microscopic follicles in "deep sleep").
• Therefore, AMH blood levels are thought to reflect the size of the remaining egg supply - or "ovarian reserve".

So my egg supply was not just low, it was very low.  My AMH is what you would expect to find in a 40+ year old woman.   Not only that, but Dr. Google goes on to tell me that many fertility clinics turn away patients with AMH <0.5. 

Rather than find relief in the fact that this is what has been keeping us from getting pregnant, I panicked.  It was confirmed, I was broken.  It also felt like not just a "little" broken, but a LOT broken.  I'm scraping the bottom of the ovaries for eggs.  What does this mean for our chances?  Does this mean we can't have kids?  What if they turn us away?  What if our insurance coverage, which I was just learning was pretty damn good, disqualifies me from being covered?  If we hadn't gotten pregnant in November, would we have found this sooner?  Would it have helped?  I start searching for cases of under 35 women with low AMH / low reserve...

Michael peels me off the ceiling at this point and brings me back to earth.  He reminded me that figuring out what was wrong was why we were doing this.  We should be glad to know what the issue is so we can tackle it.  The RE had said there was a protocol for just about everything, and we need to wait to hear from him on what the prognosis and options are.  Plus, we didn't even know how this 4th cycle of Clomid was going to turn out.  We had 2 follicles that we need to focus on!  He made me put that bastard, Dr. Google, away for the night.  He was right, but it was really hard to hear.  I just want to make sense of it all.  To know what it is and how to ask the right questions.  My head was swimming. 

They told us to wait 15 days past ovulation to test.  I cracked at 14.  It was October 6, and I was at a work conference in the Woodlands for a new role I was about to start.  I had just enough time to drive all the way home and back between the last meeting of the day and the work dinner that night.  Michael was there...we could do a test together and (hopefully) know.  He thought I was a little crazy and he tried to get me to wait, but I talked him into it.

In the bathroom together, we waited.  After all my practice, and just in case we needed a secondary test, I peed in a cup.

It was POSITIVE!!!  The line was very feint, but it was there.  Just to be sure, I took out a digital test and it agreed.  We were pregnant.  The Clomid worked!

Oct 6, 2015

We were so excited. We jumped up and down, hugged and kissed...I cried. Then I headed out the door, back to my work dinner meeting! I called my parents on the way. I was 15 mins late to the dinner, but I didn't care. When the table ordered a bottle of wine, I had to figure out a reasonable excuse..."too tired, have to drive a ways home...I'll just have water." I could barely breathe I was so excited.  I quickly texted some close friends under the table. Friends who had been rooting for us and knew what was happening. One was the gal I was handing over with at work, who was pregnant with twins (from IVF!).  She and I had already spent several of our first handover meetings talking fertility stories.  Another friend I texted is one of my best friends, who also struggled to get pregnant, and was currently pregnant with her first. I was so excited at the prospect of being pregnant at the same time, having our kids be the same age.  It was an amazing feeling.

We went back in to see the RE and they joked we had "slipped one past them", we all laughed.  We started a schedule of weekly ultrasounds and blood tests to monitor the pregnancy.  After a couple of weeks, the HCG levels were going up at the right rate and we could see him/her on ultrasound!

First Nugget 2.0 sighting, Oct 2015

We called the baby "Nugget", just like we did with the first one, and argued lightheartedly over whether or not to find out the gender when the time came.  We spent lots of time with our pregnant friends, and it felt wonderful and right.  At night I would put my hands on my stomach and think about Nugget and how grateful I was.  I was so happy, even when I was tired or feeling nauseated,  That was exactly how I was supposed to feel.  In the back of my head, I was also feeling nervous.  After the last miscarriage, I didn't know if I could let myself get too carried away just yet.  I wanted to get past the first trimester as soon as possible. 

The first week of November, we got to hear the heartbeat.  It was a wonderful sound.  It also meant there was a much higher chance of this being a healthy pregnancy.  It was 94 bpm.  >90 is what they look for.  It was such a relief.  But Michael noticed that the nurse and RE had a look on their faces.  They said that Nugget was measuring a little small...closer to 6.5 weeks than 8, where it should be.  They said maybe the ovulation / conception date was likely just a few days later than we thought. They said to come back the following week and we would check it again.  I started to do the math.  Based on our "schedule" and the last time we did it, Nugget was starting to measure just outside of the reasonable range.  This was likely the cause of the look Michael noticed.  I allowed myself to dismiss this.  The heartbeat was good, and I proceeded to consult Dr. Google to find as many cases as I could that turned out just fine at this point.

The second week of November, we went in for the next scan.  Nugget hadn't grown much, and the heart rate had slowed.  Michael held my hand while the doctor said he was so sorry, and that it didn't appear to be a viable pregnancy. It wasn't completely definitive at that point, but that we were entering "miracle territory".  They asked us to come back in a couple of days for another scan, just to be sure. They told us to take our time, and the left the exam room.  I sat there on the table, paper sheet over my lap, and Michael held me while I cried.  All I could think was "NO!!! Why?!  We just heard the heartbeat!  It was fine!"

On November 12, it was confirmed.  The heartbeat had stopped.  A small part of me, I realized as the RE told us, had kept hope for that miracle.  He gave us 3 options.  We could let the miscarriage happen naturally, which could take weeks.  He could give me a pill that would help it happen sooner.  Or, we could opt for a procedure called a Dilation & Curettage (D&C).  In a D&C, they would put me under anesthesia, dilate my cervix, and suction out the contents of my uterus.  This not only definitively allows my system to reset, but it would allow us the option to send a tissue sample off for genetic analysis.  The data would tell us if the baby's chromosomes were normal or not.  He said, ideally, the results come back as bad chromosome pairing, which as we learned before is the cause for most miscarriages.  If the baby's chromosomes were normal, that meant there was some other issue or complication that we would need to figure out.  

We chose the D&C.  Nugget was gone no matter what we did.  We wanted something good to come from this, some bit of knowledge that might help. They booked me for the next day, Friday the 13th of November.  The waiting room was full.  A few families with babies.  I hadn't eaten or had anything to drink since before midnight.  They took me back and asked me to change and sign all the forms.  I was able to select an option that would donate any additional remains to scientific study, which felt a little better.  They put in my IV, and finally allowed Michael to come back and sit with me.  I kept tearing up.  The guilt was back...could I have done something to cause this?  Eaten something?  I had slipped and fell about a week ago...could that have been it?  I wanted to be anywhere else.  Think about anything else. 

Turned out that my doctor had been called away, so the new doctor came in and walked us through everything before they took me into the procedure room.  He was nice, but I was a little thrown not to have my doctor there.  The nurse led me into the procedure room.  They had me untie my gown before climbing onto the table.  From there, they folded the bottom half of the table into leg braces and they put each of my legs in place.  Let me just say, this was not a time for modesty...there were at least 6 people in the room that got both the open gown view and now this one.  They quickly and gently covered my legs and lap with a blanket, and the anesthesiologist said they were starting the medicine.  We talked briefly before I fell asleep.  I woke up in recovery feeling sore.

Michael was brought back and helped me change back into my clothes.  he said that it all went well and it was time to go home.  The nurse put me in a wheelchair and rolled me out to the parking lot.  Michael wrapped me in a blanket in the car, and on the drive, he got me a Whataburger chocolate milkshake.  We got home and learned of the attacks on Paris on the news.  It was too much to take in.  Michael switched it over to a cartoon movie about penguins, which, silly as it may seem, made me feel better.

In the end, we worked through this one better and talked more openly about we felt.  We both had started to get our hopes up with the heartbeat.  This time, we spoke more about our feelings of loss and disappointment.  Michael wanted this as badly as I did, and this was wrenching us both back to square one.  I tried to articulate to Michael better what it had felt like to be pregnant, and why losing our Nugget was more  than just disappointment.  Being pregnant, particularly this second time, was in an odd way like being in love.  It had made me so ridiculously happy.  As with love, before you've truly felt it, it's so hard to describe that feeling.  For me it was a fullness of heart and connection to something essential and vital, which in feeling it fully, was so much more authentic and real than it ever was in concept.  Losing our pregnancies was like losing a true love, which had just made me feel whole.  I missed Nugget dearly, and it was heartbreaking.

We grieved together, and focused on getting ready for Thanksgiving guests, which was a nice project and distraction to have.  It still hurt deeply and was very hard to get back to a feeling of normal, which wouldn't come until after Thanksgiving.  It was then we found out the results from the chromosomal testing on Nugget, which confirmed she (we found out Nugget 2 was a girl) was trisomy 16, which means there was an extra #16 chromosome, which is not compatible with life.  Our RE said that usually trisomy 16 embryos don't even implant and form a pregnancy, but for whatever reason, ours did.

The RE recommended we move to IVF with PGS.  Not only does it increase our chances by pulling more eggs at a time, but after 2 miscarriages, the genetic screening of our embryos could help us avoid another.  Our time was short, and with my low ovarian reserve, IVF could let us freeze enough embryos to be able to have more than one child, even after my ovaries stop producing eggs.  (More on how this all works later)

Within a week or so, we went out to dinner with friends to celebrate a birthday.  We knew one friend who would be there was currently pregnant.  As it turned out, two of the three women in attendance had their babies with them, and two of the three were pregnant.  For the majority of the evening, the conversation revolved around babies and being pregnant.  These women had all gotten pregnant easily, and around the time that they had intended.  Listening to them vent about their frustrations with being pregnant and dealing with their children made that one of the most difficult meals I have had.  Just a few short weeks ago, experiencing those early symptoms had me literally shedding tears of joy while sitting in my car a Kroger parking lot.  I would gladly take all of their symptoms plus worse, just to be lucky enough to be pregnant.  Squeezing Michael's hand tightly under the table, we both tried to change the conversation to something else...anything else.

I have not yet slapped anyone...but I have been tempted.

The next step before IVF was to have a hysteroscopy and tubal cathetarization, a procedure where they can look inside my uterus with a camera to ensure everything looks ok and there's no scar tissue or polyps that might interfere with carrying a successful implantation and pregnancy.  It would also allow the RE to check that both of my fallopian tubes were open by filling them with a fluid that shows up on a specialized x-ray device.  We knew at least one of the tubes was open, given our two pregnancies, but checking both could be useful.  He put me on birth control, keeping my cycle steady, and scheduled the procedure for the week after Christmas.  It was very similar to the D&C, except far less depressing and sad.  Everything checked out, and we were ready to start IVF in January.