Category Archives: Diagnosis

A Cause for the IUGR

I had my 6 week postpartum appointment yesterday. Baby A came with me and screamed a lot. I ended up breastfeeding her while walking into the appointment room and during my pelvic exam…surreal. Everything looks good on my end!

We discussed several things throughout the appointment. 

•I expressed to her that I do not wish to be on birth control. Firstly, I am not convinced that it didn’t contribute to our difficulties TTC. Secondly, we plan to try again (although I cannot imagine that right now…more on that in another post). Lastly, I have switched to all natural products and I am not interested in introducing hormones into my body at this point. 

•She said that since I had an uncomplicated vaginal delivery we could try again as early as 6 months (I think that’s crazy).

•When my cycle returns and is regular, she can order a follow up FSH, AMH, and E2 so I don’t have to go back to my HMO fertility clinic right away. I am relieved about that (even though I had a pretty great experience with our RE). I’m wondering how those numbers will have changed a year or so after having them drawn. I also hope it will give us an idea of what to expect. 

•And now the main point of this post. The results of my placental pathology. It was small (as we already knew from looking at it after delivery). This could have been due to the UU (meaning the smaller size of my uterus) or uteroplacental insufficiency. The placenta showed signs of chronic uteroplacental insufficiency. Basically this means that the blood flow from my uterus to the placenta was insufficient for a good chunk of the pregnancy. Thus the IUGR diagnosis. I have lots of thoughts about this. 

Firstly, the baby was in the 38th percentile at the 20 week anatomy scan. That is normal. Then, right before 30 weeks at our growth scan, she was less than 3rd percentile. So things went wrong somewhere between 20-30 weeks. I stopped taking the baby aspirin at 28 weeks (which I was taking to hypothetically increase blood flow to my uterus…who knows if it helped. I feel it did help). I don’t think that would have affected growth that drastically in 2 weeks but I can’t help but wonder if I had stayed on it (or restarted it) if her growth would have been less restricted. 

Secondly, I wonder if the less than ideal blood flow had anything to do with my 3 miscarriages. I did not take aspirin until before the 4th pregnancy (which actually worked). I do have signs of poor egg quality with high FSH and boarderline AMH. All the miscarriages were missed, with no growth each time past 6-6.5 weeks. Could that have been due to poor blood flow and not egg quality? My gut says its egg quality. I guess we will never know but I wish we could. Too bad we were unable to test the embryos that miscarried.  

Thirdly, I wonder if the pregnancy being successful is because the embryo implanted in an area of the uterus that had better blood flow and the majority of my uterus has poorer blood flow. Those with a unicornuate uterus can have poor blood flow due to the abnormal formation of the uterus. Am I doomed to have tons of miscarriages? That remains to be seen.

Lastly, I wonder if I am lucky enough to get pregnant for a second time (and not miscarry) if this will happen again. And if not, how much more will my uterus grow? Can I make a bigger baby in my half uterus? It obviously stretched a ton this time but not like a normal sized uterus did. 

I made my OB cookies and wrote her a thank you note because she was so incredibly kind and supportive throughout the entire pregnancy. I know I was a high needs patient (for good reasons I think) and I wanted to let her know how thankful I am for her care. I ended the card saying “I am so thankful for my beautiful baby”, and I teared up as I wrote that. The gratitude I feel toward having her is immense and I don’t think I could put it into words. 

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I am a Unicorn

I had an HSG right after my SIS at the beginning of November. It was “optional” per my RE, as he felt the SIS had showed us the probable polyp and we were already going to remove it at the hysteroscopy. Of course, I am a glutton for all the information I can get regarding my fertility, so I went ahead with the procedure.

It was done by a nurse practitioner. She prepped me for the procedure, the radiologist joined us, and we got started. The x-ray machine was turned on and they injected the contrast.

Side note: the procedure didn’t hurt at all, and I like to think that as a nurse, she was more gentle than my doctor (I am a nurse also). She inflated the catheter balloon very slowly, as that was the worst part of my SIS, and it did the trick. So I’d recommend that you ask whoever does these two procedures inflate the catheter balloon slowly and it may help with some of the cramping and pain associated with these procedures.

They had a hard time visualizing my full uterus so I turned from side to side and did everything I could to help them get a full picture. Then the NP said it…

I think it’s unicornuate“. 

The first words out of my mouth were “Oh shit, that’s not fixable”. She said she’d talk with my RE as soon as she got back to the clinic, and I received an email later that night from Dr. N saying he agrees with the NP and he’d be able to tell more at the hysteroscopy.

For those of you that don’t know, a unicornuate uterus (UU for short) is a type of Mullerian anomaly (mis-formed uterus). Basically, I only have half a uterus that is connected to 1 Fallopian tube and 1 ovary. Something went wrong and the other half of my uterus did not form as I was developing. It happens very early on in embryo development. Apparently, it’s the most rare of all the uterine anomalies, occurring in 1/4000 women. Women with this anomaly have poorer pregnancy outcomes according to my research.

My RE confirmed that it’s a right UU at the hysteroscopy, and the tissue they removed did not show a polyp (although it showed some “necrotic” tissue, which he is unsure about and wonders if it’s left over from the last miscarriage). At our follow up he said this is no reason I can’t get pregnant and carry a baby to term. He still believes that the miscarriages are due to my egg quality and not my uterus. So apparently if we catch a good egg, then things should be good. However, now I only have a chance to get pregnant naturally if I ovulate from my right ovary, as the right side is actually connected to my uterus.

There are a whole host of other issues that come with a UU. The most notable for TTC are pre-term labor and IUGR because the baby runs out of room to grow since the uterus is not a normal size. So in the exciting event I can catch a healthy egg, I will have lots of other high risk pregnancy fun to deal with. And of course there are no guarantees that my uterus isn’t to blame for the miscarriages due to poor blood flow or something along those lines. Also, those with a UU also have a 50% chance of only having 1 kidney. I had an MRI that confirmed the UU and that I have 2 ovaries, 2 kidneys, and no rudimentary horn (meaning the remnants of the left side forming were not visible).

So what’s the plan? For now, my husband and I are continuing to try naturally since I have been getting pregnant. My RE suggested IVF with a single embryo transfer (as with my half uterus, the risks with multiples are very real and much more pronounced). I have a second opinion and two other IVF seminars in my area next month so I can pick a place for IVF that I am comfortable cycling with. IVF is completely out of pocket wherever we go, so I want to make sure the clinic is reasonably priced and puts its patients individual situations first.

Our first IVF consult was with Kai.ser and while I loved Dr. H, I am not wild about doing it there because they cycle their patients at the same time and only use 3 protocols. I’m worried with my DOR that I may need a more individualized approach and I am scared to go on birth control for the 2.5-3 months before the stims start. I took it just now for 6 weeks prior to my polyp removal and my ovulation this month is super delayed. I’m scared it’ll cause me to be a poor responder. Dr. H also confirmed that he believes my miscarriages are due to my egg quality, and he thinks I can have a successful pregnancy with the UU.

I am glad to have more answers as to why things are not going my way, as I believe more information will help us achieve our goal to have children. I was saying to a friend that I can make peace with donor eggs, surrogacy, or adoption, but I cannot imagine a life without children, so I’m on this roller coaster for the long hall. We are not done trying with my eggs or uterus yet.

Happy 2016 everyone. I hope we can all realize our dreams this year. Let me leave you with a sign I found. I am learning to embrace everything about my body, and since I now know about my UU, I have to learn to love it. 

A Diagnosis? Sort-of…

As I write this, I am two tests away from a complete RPL work-up (according to my RE Dr. N). This is what I’ve had done (please note that my lab values normals are according to the Kaiser Lab and my RE). I have loosely grouped the tests below based in my understanding of them.

Genetic:
Chromosomal analysis on myself (normal)
Cystic fibrosis carrier (negative)
Chromosomal analysis on my husband (normal)

Clotting issues:
Lupus Anticoagulant (negative)
Cardiolipin Antibody (negative)
PT/APTT (13.3/30.1seconds, normal)
Factor V Leiden and prothrombin mutation (negative)
Homocysteine (5.7, normal)
Beta 2 glycoprotein IGG, IGM, IGA (all <9, normal)

Hormonal:
Testosterone (19, normal)
Hemoglobin A1C (5.1%, normal)
Fasting Glucose (83, normal)
Thyroperoxidase antibody (27, WNL)
TSH (2.11, my RE wants <2.5)
Prolactin (12, normal)
Vitamin D (25, normal)
AMH (1.24, low, want >2)
FSH (13, high, want <10)
Estradiol (<50, normal)
LH (3.6, normal)

My husband and I are taking a 10 day course of Doxycycline just in case there is an infectious component to our losses.

These are the two tests I have left to do:

Progesterone level at 7 DPO
Saline Infusion Sonohystogram (SIS) to evaluate for fibrosis and polyps

After I ovulate this month I’ll do the progesterone and I’ll be doing the SIS hopefully next month (there were no openings this month and the test apparently has to be done after your period stops but before CD 12…obnoxiously short window). Hopefully these will be normal. I will update once I have those test results.

So, what does my RE have to say about all this? Basically, he thinks the reason for my miscarriages is due to poor egg quality. Since my AMH and FSH are abnormal, my ovarian reserve is low and my egg quality is on the poor side. His exact words are: “When the [AMH] level is between 1 and 2, this shows egg quality is starting to change. It’s what we call the “gray zone”. It’s not bad, but makes it harder to conceive. Once the level drops under 1, we know that the number of quality eggs remaining are much lower. It is harder to conceive and we tend to see more miscarriages.” And “Your FSH of 13 is high (over 10), showing hormonal evidence of ovarian aging.” His recommendation is to start taking 75 mg/day of DHEA since research shows this helps improve egg quality and reduce the risk of miscarriage.

Of course I was freaking out and immediately asked him if we should proceed directly to IVF because I would really like to have a child that is genetically mine. He, however, says “Since you are still young, I think your egg quality is better than the AMH level.” I guess he thinks we should be ok with these numbers, but only time will tell.

I visited an acupuncturist recommended to me by co-workers who gave me some dietary tips, supplements, and will start my treatments next week. He does not think the DHEA is necessary at this time but did not tell me to stop it since my doctor told me to take it. He does not think my AMH is too terrible but is hoping to work to lower my FSH and my TSH. His plan is to relax me and increase blood flow to my uterus and ovaries in hopes to improve my egg quality and help with implantation.

My plan is as follows for the next 3 months (we will still continue to try naturally as I make these changes): DHEA per my RE, Co-q 10, vitamin e, vitamin c, prenatal vitamins, b-complex vitamins per the book “It Starts With The Egg”, and 81mg aspirin, diet changes, and acupuncture per my acupuncturist. I am also continuing to exercise. At the end of three months I will ask for a repeat of my AMH and CD 3 FSH/LH/estradiol to see if there are any changes. As long as they are not worse, I will probably continue on this supplement regime as we keep trying naturally. If the numbers are worse, I am going to start exploring the idea of IVF with PGS. I may also start exploring the use of medicated cycles to maybe try and ovulate more than one egg to increase our monthly chances but from what I am reading, using these types of medications is not great for people with increased FSH (since my ovaries are already working harder to ovulate each month). That’s something I will need to discuss more in depth with Dr. N after three months. If we do happen to conceive, we will see what happens and if we have another miscarriage I will strongly consider proceeding to IVF (my hubby isn’t wild about this option).

My long term plan if I cannot successfully have a baby is to do donor eggs, so at least my husband can have a biological child. I would still like to be pregnant/breastfeed if possible.

Obviously this could all change but it’s the plan for the moment.

I’m not sure how I feel about all this. I was convinced that something was wrong, but I was not expecting it to be ovarian reserve or egg quality because I am still relatively young (32 next month). Also, it really does feel like a “sort of” diagnosis since I’m getting pregnant. And I’m not wild about my TSH. I wish I could convince my doctor to treat it as I think it could only help. But it’s not my realm of expertise. I’ve done a ton of reading and it seems like there is a chance we will be able to have a baby, it will just take longer. Honestly, being well versed in medical crap is more like a curse because I can’t just listen to the doctor. I’m constantly researching and asking questions but if there is anything I’ve learned in my nursing career it’s that you have to be your own advocate in the health care world or you will never get what you want or need.

Any thoughts? Or any suggestions? Or can anyone point me in the direction of bloggers with a similar problem?