Where do I go from here?

07may07 · December 2010

I have my WTF next week. Usually I am prepared and have tons to talk about to move forward. But, after my latest loss, I just don't know how to proceed. I'm hoping you ladies have some advice.

Brief history: I've had 6 early losses. All losses have been around 5 weeks. My betas never really double as they should. I've had 2 losses TTC without RE help, 2 losses with IUI, and 2 losses with IVF/FET. In September I had a hysteroscopy where a muscle tumor was found and thought to be the cause of my 5 previous c/ps. But, I just had another loss in December. I've had all sorts of testing and discussed almost everything under the sun with my RE. This is my second opinion RE.

We had previously talked about doing IVF with PGD to see if I have an egg issue. We tabled that once we found the muscle tumor b/c we thought that was the issue. I think my RE will suggest doing the PGD with the next IVF (although I want to find out what the difference between PGD and CGH are and if one is better than the other). My FSH levels have always been fine and my embryos usually develop fairly well in the days after ET (no fragmentation) but I guess that doesn't mean my eggs still don't stink.

I wonder if I should request another hysteroscopy prior to proceeding to see if they really got everything.

If it is an egg quality issue, it may tell me that DE is my option. But, if PGD/CGH doesn't tell me it is an egg issue, where does that leave me. I don't want to go through a DE cycle if I don't know why I keep miscarrying.

Okay, now I'm just rambling. I'm overwhelmed and don't know where I'm going. I know my WTF will give me some ideas but lately I'm just feeling so low and like there is no hope for me. Any advice from you ladies is appreciated.

emca · December 2010

I am so sorry you have gone through all of that. I have also had 6 early losses, all at around 5-7 weeks. They could never figure out what the cause was either. I had a lap/hysteroscopy and they found a fibroid and polyps, but I still had another loss after that.

I just recently finished my first IVF cycle where we did CGH testing on the embryos. Out of the 8 embryos tested, only 2 came back normal. I am not sure if we were to try CGH again if we would get the same results, but 2 out 8 are not very good odds. Each embryo had a different chromosomal abnormality.

CGH testing tests ALL chromosomes, where PGD tests some chromosomes. One of the abnormalities found in one of our embryos would not have been found if we only did the traditional PGD testing and that embryo might have been implanted and I would have miscarried again. I am not sure if it worked yet...beta is tomorrow, but I would try IVF with CGH testing if I were you. It really helped me and gave me some idea of what might be causing the miscarriages.

Best of luck at your appointment!

smeyer · December 2010

First, I'm assuming that a recurrent loss panel was part of your previous testing? If so, you may want to double check and make sure karyotyping was done on DH and you (*if* you can get it covered). Chances are very small for a chromosomal issue for either of you but you might want to rule it out if you can. My 1st RE did my RPL panel but didn't include the karyotyping. My 2nd RE thought it would be useful to rule out all possible issues.

Second, how do your embryos do in the dish? Do they seem happy and healthy or do they sputter out? With my 1st RE we had an so-so number of embryos but they were always pokey to divide and none ever made it to blast in the dish. When we switched clinics, my new RE thought that co-culture and assisted hatching would be good additions to our plan (I asked about both). My 1st RE poo-pooed the idea and made me feel silly for asking about either because he said neither was needed. After getting a total of 6 or 7 embryos out of IVFs 1 and 2 with RE #1 we got 17 pristine quality embryos out of IVF #3 with my 2nd RE. I'm no dr but something sure helped and our protocol really didn't change much. If you have similar results, co-culture and/or assisted hatching might be worth discussing.

Thirdly, I asked RE#2 about PGD because I too wondered if we had egg or embryo quality issues after all of our losses (all were from assisted cycles, 1 from IUI and 3 from IVFs). He steered me away from it because he felt the chances of false positives were too high. Their research showed that healthy, viable embryos can be discarded while "faulty" embryos could be ok'd. He felt that PDG was good for ruling out specific genetic disorders (we have none in either family) but not so great for checking for embryo quality as a whole. As for CGH... I don't have much experience there. I know that it's much more comprehensive than PGD but that's the extent of my knowledge.

Last but certainly not least, I'm so sorry for your losses. They really mess with your head and take the hope away from cycles. With every BFP you are almost more worried about the "what ifs" than you are happy. It really sucks. ((huge hugs))

labbylover03 · December 2010

First off, I am so very sorry for all of your losses. I can't imagine how hard it has been for you and your DH. The not knowing why is the hardest to accept.

emca:

CGH testing tests ALL chromosomes, where PGD tests some chromosomes. One of the abnormalities found in one of our embryos would not have been found if we only did the traditional PGD testing and that embryo might have been implanted and I would have miscarried again.

This is correct. For our diagnosis, we know that my DH has a balanced translocation on his chromosomes 6 and 8. We're doing PGD and they are specifically testing for this BT since this is our main hurdle. We could add in additional chromosomes to be tested, but it still doesn't cover ALL chromosomes. I think if you do not have a specific diagnosis (knowing specific chromosomes that you have issues with), then CGH is probably a better route. Unfortunately for us, our first PGD cycle only resulted in 1 out of 11 embryos testing normal/balanced...and that 1 little guy/gal was a poor quality blast. We did have some amazing looking expanded blasts and even hatching blasts that were genetically unbalanced. Like PP, if we hadn't done the PGD at all, they would have transferred these embryos and I would have most likely miscarried....again.

We're trying our second attempt with PGD in Feb. Best of luck to you at your appt and I truly hope you can find some answers soon! ((hugs))

hollymichael · December 2010

I'm so sorry. I would definitely ask about PGD/CGH. If you haven't had RPL testing, I would ask for that to be done too. Let us know how it goes.

07may07 · December 2010

Thank you so much for your responses. They definitely gave me a better understanding of the PGD/CGH process. I think that my RE wants to use CGH then. When we first starting talking about PGD (probably almost a year ago), she had the same concerns that smeyer's RE had. However, when we revisited it in Aug/Sept she said that they now had the technology to test all of the chromosomes. She did say that there was still the chance of false positives, but thought that I was the type of patient they had in mind for this testing.

We did have karotyping done after our second loss and everything came out normal for us.

As far as how my embryos do in the dish, I'd say they do okay. I am not a high responder and my highest number of embryos has been 4 (with IVF #1 & #3). Since I have so few embryos, I've always had a 3 day transfer. The embryos generally divide as they should up until that point. (For IVF #1, we transferred a high quality 10 and high quality 8 cell embryo and froze two 8 cells. For IVF #3, we transferred high quality 9 and 7 celled embryos and froze a high quality 6 celled embryo) Also, my clinic freezes the embryos on day 3, so I never have seen if my embros will make it to blastocyts. If we do CGH, the embryos will have to make it through testing and to day 5 before ET.

We talked about Assisted Hatching and my RE feels like my embryos do implant but cannot grow past a certain point. It is definitely something I will re-visit with her, but she seemed convinced that it assisted hatching wouldn't solve my problem. I will definitely ask her about co-culturing.

I really cannot thank you guys enough for taking the time to respond to my post. Even though I am still sad about all that is going on, I want to be armed with as much information going into my WTF to be able to make a plan I am happy with.

ETA: Emca--good luck with your beta tomorrow!

hollymichael · December 2010

If you don't end up doing PGD/CGH, then maybe you can ask to do a 5 day transfer. Of course you run the risk that they don't make it to day 5, but this would be good information to have. It might help to see what happens to your embryos between day 3 & 5. Had we not decided to move on to donor eggs, I was going to ask to do a 5 day transfer even though we never had many embryos to transfer. I thought it would be helpful to see what happened.

theworms · December 2010

i just wanted to wish you GL & PPV

i really hope that you and RE come up with a great plan that gets you KTFU for good

((HUGS))

we may be doing CGH testing with next fresh cycle if we have same outcome when we use our frosties in march

NicoleeBonsai · December 2010

i'm sorry i don't really have any advice for you because i haven't gone through everything you have. i just wanted to wish you good luck at you appt and i hope you get some answers,

patchen30 · December 2010

I'm so sorry you're going through all this. ((Hugs))

Don't give up and just try and take it one day at a time. Something WILL work out.

I've done a lot of research on PGD/CGH. Basically, PGD is a catch-all bucket for genetic embryo testing. CGH is a type of PGD which tests all 23 pairs of chromosomes, as opposed to traditional PGD which tests more like 9 pairs of chromosomes - but those mostly likely to carry chromosomal defects. The testing can be done via a day 3 embryo using 1 cell, or via a day 5 embryo using 1 cell. Usually w/ a day 3 biopsy the results are back in time for a 5DT. With a 5 day biopsy you either get the results in a few hours and transfer that day, or you freeze the embryos, send the sample out for testing, and transfer back in a month or two. So far, I believe only CCRM does this freezing/FET method of testing.

There are pros and cons to all of it. First, in order to be a candidate, you usually should have a dx genetic defect or RPL. There is a little bit of risk of damage to the embryos (about 1%). There is also a fairly significant risk of mosaicism, which means that the cell they're testing may not be representative of the entire embryo. From what I understand this is increased on day 3 as opposed to day 5, b/c often mosiac cells will repair themselves. Also I believe there's less risk of damage to the embryo on day 5.

I asked Cornell why they do 3 day PGD as opposed to 5 day CGH. Apparently CGH is only allowed in certain states, and NY isn't one of them. I'm not sure why they do 3 day PGD though vs. 5 day PGD/freezing/FET.

Due to the limits of PGD, it's possible to have an embryo test abnormal that is actually normal, which I believe is why Cornell isn't a huge fan and would rather just keep transfering embryos and let your body decide which is genetically normal rather than having the lab decide and risk errors.

That said, w/ all your m/c, I def. think you're a candidate. You mentioned that PGD could help dx egg quality problems; that's not necessarily true. It could dx embryo quality problems - you don't know whether they're from the egg or sprm. But, if you did have a embryo quality issue, it might push you to gamble on an egg vs. sprm donor if there's a reason you might have probs w/ one over the other. Or, it could work for you to find that embryo that doesn't have genetic defects.

Either way, I would def. talk to your RE about that option.

bbakersgirl75 · December 2010

I have no advice hun, but I just wanted to give you a bunch of ((HUGS))

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