Whew. A couple of weeks and four doctors later and finally I have a plan that makes sense.
When I say four doctors, that’s not as nutty as it sounds — one doctor saw me right after the ultrasound that told me I was miscarrying, and she’s the one who prescribed medical management. She’s also the one who told me it was probably just bad luck and I should try again. Then I had a follow-up appointment with the totally socially inept but otherwise great senior OBGYN in the practice, who told me that it probably made sense to go back to reproductive endocrinology, but that they’d probably just tell me that at least I could get pregnant. Then, just by chance, I had my annual visit with my primary care doctor the following week. She asked me how things were going, and when I told her that in the last six months I’d had two miscarriages and my father died, her response was essentially “Wow, that’s awful… have you tried yoga?” I’m obviously condensing that conversation a bit, but it was just such an inadequate response that it was both bizarre and painful. Plus, she gave me a mini-lecture about the benefits of yoga last year, so I don’t even think the yoga talk was specifically related to everything I’ve been going through. I think she just didn’t know what to say and didn’t really want to go there.
After all of that, I was feeling pretty down in the dumps about the medical establishment. I mean, the best thing my doctors have to offer me after all this crap is “bad luck” or “at least you can get pregnant” or “have you tried yoga”?! It made me feel awfully alone, as though nobody was going to take me seriously or help or even have a real conversation with me about what was going on. Even if they don’t have the expertise of an RE, they could at least be sensitive and/or check on my mental health — there’s actually some literature showing that feeling supported and getting mental health care during RPL can increase the chances of a live birth in the next pregnancy. But “Have you tried yoga?” was as close as those first three doctors got to asking about mental health.
Yesterday was my appointment with the reproductive endocrinologist. It did not start off auspiciously. That morning, I got a phone call and an electronic message from the nurse working with my doctor asking me why I hadn’t done the testing the RE had ordered the last time I saw her and whether I wanted to postpone my appointment until I got it done. It was the middle of a busy day while I was running around dealing with broken equipment and trying to get eight groups of freshmen through labs with TAs who are shaky on their own understanding of the material, so I just replied briefly that no, I didn’t want to cancel my appointment, and no, I hadn’t done the labs, but my local OB had done some of the bloodwork over the summer and here are the results. A couple more messages back and forth and eventually I figured out that they didn’t know I’d had two miscarriages since the last time I saw the RE, despite the fact that I had a long conversation about it with the front desk when booking the appointment and left two phone messages with the nurses asking questions that my local OB had said I should ask the RE before I passed the pregnancy tissue (mostly asking about whether or not it was worth trying to save the tissue for testing at this point). Since doctors’ offices are apparently universally horrible at communication, the message never got through, but I drove the half-hour to the appointment fighting off tears thinking that yet another doctor was going to dismiss what I’d been through, when really the doctor just didn’t know about my miscarriages.
The reality was much better than I’d expected. The RE actually sat and talked to me about the causes of recurrent miscarriage, the testing they can do, the chance that each of the problems was consistent with my history, and what she recommended the next steps should be. Then, she asked about my mental health, and gave me the card of their social worker / therapist, encouraging me to call and talk to her about options for emotional support. Finally! A reasonable response to everything I’ve been through.
The RE ordered a bunch of tests, including an endometrial biopsy that can’t be done during a conception cycle, and so this next cycle will be reserved for testing rather than trying to get pregnant again, but that’s OK with me. It seems like she basically ordered a full RPL workup, minus the tests I already had after my 2nd trimester loss. I was a little skeptical about the endometrial biopsy at first, since I’ve read that they can have a lot of false positives and are usually used to check for luteal phase defects, which are kind of controversial in their link to RPL, but she explained to me that there’s some promising research showing that chronic endometritis can play a role in RPL and that a course of treatment with antibiotics can improve the live birth rate in subsequent pregnancies. I looked it up when I got home, and it seems that there are some legit-looking studies from the past 2-3 years on the role of chronic endometritis in RPL, so I’m going along with it. Otherwise, there’s also a repeat sonohysterogram to check the uterine cavity for adhesions (since I’ve had those before) or polyps/fibroids, and then a bunch of bloodwork, including karyotypes of both me and my husband to make sure we don’t have any of the rare chromosomal weirdnesses that are associated with RPL (translocations and the like) — she emphasized that this is low probability, but would be important to know if we happen to be in that category.
At this point, I’m totally fine with spending one cycle on testing before moving forward. I’m not wild about the idea of more painful and invasive testing (the SGH I had before was much worse than either the HSGs or the hysteroscopy, but it was also the only test that I had done at my local OB, and they seemed kind of inept at it, so maybe RE will be better?). But it seems worth it just to make sure that there’s no treatable cause lurking undiagnosed before we move forward with pregnancy #5.
That’s where we are now. The timing could be worse, since there’s only one week left in the semester, which means that all of this testing will take place between semesters — much easier to schedule inconvenient and inflexible medical procedures when I’m not teaching, thank goodness. But after yesterday’s appointment I feel a little bit more hopeful and supported than I felt before, which is probably the best possible outcome.