Author Archives: lyra211

One Month of Testing Becomes Three…

Well, so much for “One month of testing and you’ll be done!”  I haven’t yet seen the RE for a follow-up appointment, but apparently after reviewing my SHG and endometrial biopsy results, she wants to also do an HSG.  But since she didn’t realize it until a week into my current cycle, I have to wait another cycle to get it done.  I guess technically we can try to get pregnant this cycle, and if it works, great… but I’m not optimistic.  At least the HSG doesn’t prevent us from trying next month, so it’s not as though we really lose time, but I was just hoping to be done with testing and ready to move on to planning.

Here’s the recap on the testing results that are in so far: apparently everything is pretty much normal.  The endometrial biopsy was negative, all my blood tests were normal, the SHG showed nothing weird except for a slight thickening of the lining on the anterior wall, which I already wrote about — and if it were anything serious, the endometrial biopsy should have picked it up.  So no answers, but also no identified problems.

So then, what triggered the HSG, you might ask?  I’m not actually sure, since I didn’t get a chance to talk directly to my RE (I was supposed to have an appointment this coming Tuesday, which she suggested over electronic messaging that I cancel and reschedule for after my HSG).  But here’s the story as I see it:

Before the HSG, the APRN doing the test did a baseline ultrasound.  Everything looked just as expected, but she did point out an odd cyst-like thing near but not on my right ovary.  She said it might be a paratubal cyst, and that it looked like it was in the location of my right fallopian tube, but didn’t seem too concerned.  After the test, I mulled it over and remembered that during the 6w ultrasound where we found out I was miscarrying my last pregnancy, the ultrasound tech had seen the same thing, although she didn’t mention that it might be tubal — she just told me that it was a cyst-like thing that wasn’t on my ovary.  Just to back up a step, these two ultrasounds were actually pretty close together in time — we found out I was miscarrying the first week of November, and then the testing cycle and SHG took place right after I had my first post-miscarriage period in December.  So it’s clearly the same cyst-like thing, which was not there in June when I was going through my second miscarriage, but was there immediately after my third (most recent) miscarriage.

Now, combine this with the fact that I had high hCG levels in my most recent pregnancy — the last measurement at 5w was 2700 with a doubling time of less than two days.  At those levels, you’re supposed to be able to see a gestational sac on ultrasound.  But at my 6w ultrasound, there was no gestational sac… just two small irregular lumps in my uterus that the tech said might be bleeds.  And I know that the right side is the side I ovulated on for the pregnancy, and it’s also the side that this possible tubal cyst is on.  So, after remembering all of this, I wondered… is there any possibility that my most recent pregnancy could have been an undiagnosed ectopic, and the thing on my right tube is not a cyst but rather the missing gestational sac?  Obviously I wasn’t in any danger, since the RE did follow my hCG levels back down to zero, so if it was ectopic it resolved on its own (like 80% of ectopics, apparently).  But it seems like it would be an important thing to know to figure out how to proceed — and I already knew I had elevated risk for an ectopic since my second HSG showed scarring of both tubes.  Since I’d been seeing my local OB for the miscarriage, and then went back to the RE for RPL testing, nobody had all of the information, so it makes sense that the RE wouldn’t have considered it.

Anyway, I wrote a message to the RE’s office containing this question, and asking whether I should have the records from my most recent two pregnancies sent to the office.  The RE replied that an ectopic pregnancy was plausible, though difficult to know for sure, and that I should have the records sent over… and that’s when she suggested an HSG to assess tubal patency.  If you’ve been reading my blog for a while, you already know that my tubes were somewhat damaged during my first pregnancy, which we found out during my second HSG.  But since I then proceeded to get pregnant three times on the right side, it’s pretty clear that at least my right tube was still functional.  However, apparently now this cyst thing (or possible gestational sac?) is weird enough that she wants to make sure it’s not blocking my right-side tube.

I’m not actually sure what to hope for in this case.  Part of me is just sick of endless trying to get pregnant and miscarrying, and as I’m turning 35 I’m sort of thinking… I kind of hope it’s blocked, because then we can just do IVF already, and then they’ll do PGD and make sure they’re implanting chromosomally normal embryos and maybe it’ll finally work.  Of course, I’m not exactly excited about doing IVF, so in that sense I hope my right tube looks no worse than the last time they did and HSG and I can just get pregnant the old-fashioned way again.  I’m also just generally feeling grumpy about doing a THIRD freaking HSG, right after I’ve just done an SHG and an endometrial biopsy.  Enough messing around in my uterus, already!

Anyway, much as I’m not wild about the idea of another HSG, I am a sucker for information, and I do want to know whether my tubes have gotten worse or not.  So, I’ll go along with it, and wait for my next period, and do the HSG, and see what happens.  But that means I probably won’t have the results of the HSG and meet with my RE until, like, late February or even March.  UGH.  I hate the slowness with which this sort of testing and treatment moves.

And in other news, I’m currently away for three days at a conference (in Washington, DC), and I miss my little guy something fierce.  I felt so guilty leaving him, especially since he had a fever the day before I left and was super clingy and only wanted his mommy.  I hope he doesn’t think I abandoned him!  I cannot wait to snuggle that little munchkin tomorrow afternoon.

So, that’s where we are now.  I hope all y’all’s new years are off to a better start!

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So Long, 2017!

I’ve rarely been happier to say goodbye to a year, but the flip side is that I’m looking forward to a fresh start in 2018.  Here’s the Cliff’s Notes version of 2017, and what I’m looking forward to in 2018:

The Good

  • My son.  He continues to delight and amaze me every single day of his life.  This week at home with him has been truly lovely.  He’s starting to have the patience for longer books (Dr. Seuss’s ABC, Angus and the Ducks, and Do You Speak Fish? are three current favorites), and his sense of humor is just wicked (this week it’s all about the yes/no questions and giggles: Is this hairbrush your dada?  NO!!!!  Is this pillow your dada?  NO!!!!  Is that doggie your dada?  NO!!!!  Totally cracks him up every time).  We have a Solar System rug in his playroom, and he loves running from the Sun to Jupiter to Neptune upon request, and playing Solar System Twister by trying to stand on as many planets as possible at the same time.  He likes to play hide and seek, mostly by hiding in plain sight and dissolving into giggles as we pretend to search for him (Is S under the table?  Is he in the bathroom?)  I could go on and on, but I’ll stop. 🙂
  • Work stuff.  My first postdoc got a job offer!  This was a huge deal, since I have been worried that he would not get an academic job and would be forced out of academia after which I would have been convinced that I ruined his career by bringing him to my rinkydink little college for a non-traditional postdoc opportunity.  Instead, he was offered a potentially permanent job that he would most certainly not have been qualified for before working in my group for four years.  I am so happy for him.  And I shouldn’t jinx it, but my year of supervising three thesis students isn’t going as badly as I feared, and I think they’ll all have high-quality theses come May.  There’s also a light at the end of the tunnel for a really big invited review paper that I’ve been working on for about a year now — it should be done by the end of next week.  It’s a ton of work, but will have high impact, and I’m pretty proud of it.  And as I wrote a few days ago, I totally rocked my 5th-year pre-tenure review and am optimistic about the tenure process that will start next fall.
  • My support network.  Having difficult years really makes you notice all the wonderful people in your life who are around to help you through the crumminess.  First prize goes to my amazing husband, of course, but I’ve also got prizes to hand out to other relatives and friends as well — the list is long enough that it makes me feel good about where I am in life right now.  Having a kid hasn’t totally squelched my important relationships as I feared it might.  I’ve been leaning on them a little more than usual of late, though, so I’ll have to make sure I’m giving back in the new year.

The Bad

  • Two miscarriages.  Recurrent Pregnancy Loss diagnosis.  Ongoing testing with no answers yet.  Coming up on a year of TTC living baby #2.  Oh, and the due date for my first post-S pregnancy is coming up this week.  Blargh.
  • My father died.  I had a complicated relationship with him, which has made it tough to sort through my feelings about his death, but the short version is: it sucks.  I think my grieving process has been largely focused on morbid thoughts about the mortality of my son and husband (also myself), which is not fun.
  • My mother had major surgery two weeks ago (a hip replacement).  Recall that I am ruminating on mortality, so it freaked me out emotionally right from the start.  My mom also lives a two-hour drive away, which is better than a plane flight away, but since she lives by herself she really needed help.  I made three round-trip drives in a week (one overnight stay the day she came back from the hospital, plus two day trips).  Thankfully, she’s on the mend now and I can relax a bit.  But I’ve really been feeling the whole “sandwich generation” thing this year.
  • Work-wise, this fall was a survival semester, in the sense that I phoned it in on a lot of teaching stuff and was kind of a crappy collaborator on a couple of projects.  Mostly I managed not to be too crappy at any one thing, which I feel like I can be at least a little bit proud of when you consider how my semester went.  Another part of my grieving process seems to be occasional irritability, which is out of character for me, and there are a couple of emails I wish I hadn’t hit “send” on — although I have to say that the people on the receiving end did basically deserve them, even if I am usually more diplomatic.  Oh, well…. I don’t think I burned any bridges too badly.  And I did an OK job of circling my wagons and prioritizing critical stuff like my research group and paper drafts, so hopefully I managed to mostly insulate my professional list from my personal problems.

The New Year

  • Getting back on the TTC wagon.  In a way, it feels good to have a fresh start after this most recent miscarriage, and to know that I’m back with the RE who will keep a really close eye on everything and do whatever she can to help us conceive the living child that we’re dreaming of.  I had visions of being a normal pregnant lady at my local OB’s office, but the silver lining of being abnormal is that I get more support and reassurance and can work on developing a plan.  I’m optimistic about our chances of success, since S is proof positive that my body is capable of carrying a baby to term.  I wish I could see the future and know how long it will take and what we’ll have to go through to get there, but I’ve been through enough at this point that I’m also feeling relatively calm and confident that I can just go with the flow for a while.  I am definitely in a much better place than I was three years ago after the loss of our daughter.  It seems like I shouldn’t be, since I’ve had three times as many losses by now, but for one thing I have S, and for another thing I’ve developed a certain amount of resilience.  I have hope for 2018.
  • The push to tenure.  There’s a certain narrowing of focus that happens when you’re less than a year from putting in your tenure packet. I’m in a good place right now: I already have a really solid portfolio of work, and I have a bunch of things in the pipeline, and I know what I need to do before next fall.  I’ve already done most of what I need to do, and the rest is in process.  Some of it is dependent on other people (like my students), but not too much.  I’ll be working hard this year, and I’ll have to prioritize like crazy, but the tenure process is another thing that I’m optimistic about for 2018.  I am so looking forward to submitting my tenure packet next fall and knowing there’s nothing more that I can do.  I think I’ll feel good about the body of work that I’ve accomplished on the tenure track.
  • The adventure of parenting.  I know people say the twos are terrible, and plenty of people will tell you that threenagers are worse, but you know what?  I’ve loved every age and stage of S’s life so far, and while there are certainly challenging moments/days, the thrill of seeing this little person growing up into himself more than outweighs the difficulties.  I am more crazy in love with this kid than I ever knew I could be, and I am looking forward to seeing what new skills and interests and ideas he develops in the new year.  I’m looking forward to getting more insight into his odd little mind as his communication skills improve.  And I’m looking forward to more snuggles and giggles as the toddler years wear on — I know that all too soon he’ll be too grown up for mama snuggles, so I’m soaking up every moment of it while it lasts.  I also love watching my husband surprise me with his parenting ninja skills, and I fall in love with him again every day as I see him growing into an amazing father.  He is so creative and funny with S that it just melts my heart.  Our family is so beautiful right now, and I hope that it will always stay that way — or perhaps even grow in love with a new member on the horizon.

And that’s the year!  Happy 2018 to everyone.  My hope for you all is for a brighter year full of love, laughter, new memories with your loved ones, and wishes coming true.

Brief Tenure Update

As I wait for the endometrial biopsy Friday and the follow-up visit with the RE, I thought I’d give a (sorta) brief follow-up update on my tenure saga.

After all my angst, my 5th-year pre-tenure review happened promptly and smoothly.  At my university it involves an official letter summarizing the department’s evaluation and a one-on-one conversation with my department chair.  Both were glowingly positive.  The conversation with the chair may have made me blush a little bit.  It was basically my chair talking for maybe ten minutes about how great I am at my job.  Then, when he asked if I had questions, I was like, “Um, thank you, this is all wonderful.  But if I had to concentrate on one thing this year to make my tenure case stronger, what would it be?” and he said, “Really, there’s nothing.  Just don’t let your teaching evaluations slide, because the university-level committee gets hung up on trajectories, and yours started out so high that it’s hard to show an upward trajectory.”

So, yay!  But also, ack!  My department has never yet officially told me anything I can do to improve, and it constantly freaks me out — because everyone can improve in some way, of course, and having no direction is disconcerting.  And also because I watched a close friend go through a horrific tenure debacle last year in a closely related physical science department, during which she worked really hard on fixing the things they told her to fix (mostly related to teaching) and then after a whole long saga her department ultimately denied her tenure on the basis of something they hadn’t told her to fix (purely research).  There were many major WTF moments during her case, and it really soured me on my institution (particularly the offending department), and has made me far less trusting of the tenure process and some of the people at my institution.  I’m pretty sure that my department is a heck of a lot more functional than my friend’s former department, and that my case is a heck of a lot less borderline than hers was, but still, I worry (she and her husband are now happily employed at a small college back in the Midwest, closer to their families, so her story thankfully has a happy ending).

And, what about all my angst about thinking that my chair was going to recommend that I use my extra year before going up for tenure?  It didn’t amount to anything, or at least nothing that I could decode.  We talked about the timeline a little, and he said that the main thing was to make sure that everyone is on the same page about my timeline, but that he wanted to make sure I understood that I only get one chance to go up for tenure, which I assured him was very clear to me (for the non-academics: the tenure decision is up-or-out, in the sense that if you are awarded tenure then you are more or less guaranteed a job for life at your university, but if you are denied tenure then you are fired and you have one year to find a job before you are unemployed).  My impression was that he was basically covering his / the department’s butt, to make sure that I couldn’t come back later if my tenure case was denied and say that I didn’t understand that going up early meant I couldn’t also go up on time.  Which I get.  Everything else about the review pointed to the conclusion that my department thinks I’m doing great and doesn’t foresee an issue with letting me go up “early,” but they can’t officially say that because it would look like a promise that I will get tenure next year, which they can’t officially make.

One bizarre thing about this whole interaction is that we have a new chair this year, who also happens to be the second-youngest member of the department (after me) and also the person with whom I am most friendly.  So it’s been awfully weird interacting in this very official way with a friend, and we have both had to carefully monitor our verbal filters in a way that we do not normally do.  He’s usually the first person I go to for advice on sticky situations or to kvetch about some problem in the department, and I am usually really appreciative of his honest and thoughtful advice and perspective.  But as chair, there are things that he’s not allowed to say, and also things that he is obligated to say that he wouldn’t normally say.  And there are things that I would normally want to ask him that I am no longer allowed to ask him (for example, I am no longer allowed to discuss with him which scientists at other universities to solicit for external reviews of the research portion of my tenure case, which stinks because he is the person who works closest to my field and also the person in my department who has been through the tenure process most recently and I would really love his advice).  It even came up towards the end of the review when he gave me some official-sounding line about how we don’t have an official junior faculty mentoring arrangement in the department but that I should feel free to go to any of the faculty for advice (I think this is an awful way to “mentor” junior faculty, by the way, but that’s a subject for another post), and I said that I always appreciated his advice and then there was this moment where we both acknowledged that it stinks that he is now chair and can’t give me unfiltered advice when I really need it.  Ah, well… this is one of the down-sides to being in a tiny department.  The flip side, of course, is that my department chair is a friend who I am confident has my best interests at heart and genuinely wants to keep me as a long-term colleague.  He’s inexperienced, but capable and ethical.  It could definitely be worse.

And that’s the update!  I now have written evidence that my department thinks I am doing a great job, and verbal assurance that there are no obvious weak spots in my tenure portfolio that I should try to fix in the next year.  I definitely have an agenda of things I would like to get done before I submit my portfolio, which I briefly outlined with my chair.  I think it’s achievable and will represent a body of work that I feel proud of.  I’m feeling good about going up on my desired timeline.  And, honestly, I’m feeling much more positive about my job than I have for a while.  It’s amazing what a little bit of acknowledgement and appreciation can do for your motivation.  I’ve felt more creative and committed to my department.  During our meeting, my chair included a little pep talk about how the department loves the work I’ve been doing and how it seems like my interests and skills are really well aligned with the department mission so I should just keep doing what I want to do and try not to worry too much about external pressures (like tenure criteria, I guess).  And I do feel like I’ve grown into the position — I’ve gotten my sea legs with teaching, and I’ve reached some sort of equilibrium with finding a research advising style that is effective without being too draining.  I can almost feel the breath of fresh air that I felt when I got my first faculty job offer — suddenly, I felt freedom to define my own research program rather than worrying about working on projects that would get me letters from specific superstars in my field.  Tenure is also supposed to grant that sort of freedom, and I can almost feel the burst of creativity and self-direction that is supposed to come with tenure.  I have ideas for ways to experiment with teaching that I’ve been afraid to try because they’d introduce unpredictability into my student evaluations.  I have ideas for research directions that are a little wackier than I was comfortable with when I needed to show that I could get proposals funded consistently.  Now, if I can just keep my teaching evaluations from sliding this year, maybe I’ll be able to take advantage of that freedom and space for trying new things!

Testing Cycle and Tenure Ruminations

OK, quick update for the people who care about pregnancy/RPL, and then longer rumination for people who care about tenure.

I’m now about halfway through the testing cycle that my RE had recommended.  I had my second SHG last week, and have gotten the results of most but not all of the blood work she ordered.  The short news is: everything looks pretty much normal.  Of course, I have mixed feelings about this.  On the one hand: yay, no obvious problems!  On the other hand: if I have no obvious problems, then there are no obvious solutions to help me stop having miscarriages.  The SHG did show that the lining on the posterior wall of my uterus was noticeably thicker than the anterior wall, and they said that it was slightly unusual but might not be clinically significant.  So my RE recommended an endometrial biopsy, apparently forgetting that she had already recommended an endometrial biopsy, which I already had scheduled for December 29.  So, endometrial biopsy it is!  Now I’m just waiting for that test date to roll around, and after that, we can presumably start trying again.  My follow-up appointment with the RE isn’t until later in my next cycle, so perhaps technically we should hold off for another cycle in case there’s more testing or treatment she recommends, but we probably won’t.  Since there’s been no significant abnormality so far, there seems no reason to wait.  Plus, it probably won’t matter anyway, since I ovulated on my “good” right side this month (two follicles, apparently!  Blargh, I was bummed to miss the opportunity…) and next month I’ll probably be ovulating on my “bad” left side, which means all attempts at conception are likely to be futile.  Oh, well… but one cycle of missed opportunity still seems worth it, just in case they can find a treatable cause of our recurrent miscarriages.

Now, on to the tenure rumination.  If you don’t care about tenure, feel free to skip the rest of this post.

First, some context: Friday was the deadline for my department to submit its letter for my 5th-year review to the administration.  At our university, the 5th-year review is the last check-in before the big tenure review one year later.  It’s a department-level review, but the administration wants to see the letter before they give it to me, basically to cover their a$$ses legally and make sure there’s nothing controversial in there that could come back to bite them if I get denied tenure in the future.  My chair tells me that usually this administrative rubber stamp doesn’t take too long, and he hopes that we will be able to have our one-on-one meeting about the review before the end of the calendar year (though obviously at this point the timing is out of his hands).  Which of course means that I’m freaking out a little, so keep that in mind for the rest of this discussion.

The other context has to do with parental leave and the tenure clock extension policy at my university.  Since these policies vary from place to place, it’s worth a bit of explanation about how it works here: these days, the parental leave policy is that you get a full semester of leave at full pay if you are the “primary parent” (usually birth mother) of a child.  (If you’re not the primary parent, the leave policy is less generous.)  Then our clock extension policy is that all parents have the option of taking zero, one, or two semesters of tenure clock extension for each child born/adopted while on the tenure track.  I agonized over whether to take the clock extension and how much clock extension to take, but in the end my (previous) chair made the point that at least in theory there’s no down side to taking the full two-semester clock extension, since there’s no penalty for going up early for tenure at my university, which means that even if I take the full year of clock extension, I can still go up for tenure at the normal time if I am ready.  So, that’s what I did, and I have been discussing with my department all along that my plan is to go up “on time” according to my original clock (which would be one year “early” with the extension that I got because of the birth of my son).  So according to my current plan, I would submit my tenure materials next fall, around October or November.  This review is therefore an important final check-in about my progress towards tenure — if there are any red flags, I can delay the submission date of my tenure materials by up to a year, but I’m hoping to just get it over with and submit on time.

Yesterday when I checked in with my chair about the progress of my 5th-year review, he said a few things that made me think that he was going to encourage me to take the extra year, which freaked me out a bit, and I’ve been ruminating on it ever since.  The caveat here, of course, is that he didn’t actually say “I think you should take the extra year,” and I’m probably reading way too deeply into offhand remarks, but I actually think it’s probably not a bad thing for me to do some thinking through the issues so that I will be prepared for our official 5th-year review conversation.

If he asks me, “Why do you want to go up early for tenure?” … what will I say?

I think my answer breaks down into two major professional and personal answers, and two minor but still valid supporting answers.

Professionally: First of all, I want to remind my chair that I’m not going up early.  I’m going up ON TIME according to my original clock.  Basically, I don’t want to spend an extra year on the tenure clock unnecessarily even though I am grateful to my university for giving me the option.  Because I think I’ve earned it, darn it.  And because I don’t think there’s any substantial deficit in my tenure packet that an extra year would fix.  My reviews so far have been glowing.  Advisors inside my department, outside my department at the same university, and outside my department at other universities have told me that my department would be nuts not to give me tenure, and a few of the people outside my department at my university have told me I should *actually* go up early… like submit my materials now.  And when I look at the evidence, I think they’re right.  My university requires “excellence” in three categories: teaching, research, and colleagueship (this last category is also known as “service,” and even though we are technically supposed to be excellent, nobody ever gets denied tenure because of colleagueship, and my colleagueship is just fine).  As a liberal arts college, the emphasis is a bit more on teaching, and the research expectation is a smidge lower than at a research university.  My teaching evaluations are consistently the highest in my department, and comfortably above average for the university and my division within the university.  I’ve taught every level of course that we offer, multiple times.  I will have supervised six theses, an average of one per year, by the time I go up for tenure, which is consistent with my department’s number of majors per faculty member (and I’ve never turned a student away from my research group who wanted to work with me).  My thesis students have gone on to be very successful, both in and out of academia, even when it wasn’t a priori obvious that they would be (and my first postdoc just got an offer for a permanent job this week, woohoo!).  As for research, here I also think I’ve clearly exceeded my department’s expectations.  My department expects that we should publish 1-2 papers per year.  In my five years on the tenure track, I have been an author on 33 papers, with 8 originating directly from my research group (where I or one of my students or postdocs is the first author).  There will be at least three more from my group in the next year (one already in revisions, one to be submitted this week, one drafted and to be submitted next semester; in my field it’s rare for a submitted paper to not be published within six months, as in, it has never happened to me).  Anyone in academia knows that h-indices are fraught with all kinds of issues, but as a blunt instrument they’re commonly used to indicate research impact.  My h-index is essentially identical (+/-1) to the next two most senior members of my department.  Let me be clear: it’s not identical to what theirs were when they went up for tenure.  It’s identical to their current h-indices, even though one is 8 years ahead of me post-PhD and the other is a full professor who is a couple of decades ahead of me post-PhD.  For them to deny me tenure on the basis of research quality or quantity would be absurd.  External letters matter too, but I am well known in my field and have received several high-priority invitations in the past year that will get me significant visibility in my final pre-tenure year — and I’ve been networking and inviting senior people in my field to my university for talks to make sure I have enough exposure.  There’s no official guideline about external funding (just that we should seek it as needed), but I’ve brought in almost $1 million in grants during my time on the tenure track, which is a typical milestone for tenure at a research university (which ours is not).  Professionally, when I look at my case objectively, I just don’t think there’s a reason to wait.

Personally: I think I probably shouldn’t bring this up with my chair, but there’s one huge personal reason that I want to go up for tenure this year: I do not want to be worrying about tenure when (assuming we’re lucky enough to get there) our second child is born.  I really hate that I put pressure on myself to be productive during my first parental leave, and to come back to work and start traveling again before I would have if I hadn’t been worrying about tenure.  I don’t blame my university, but it is an unassailable fact of my personality that if I have tenure hanging over my head, I will be worrying about my productivity while I am on leave.  I know that no matter when our second child is born, I will need to worry about some professional things: I will still have a responsibility to my research students and collaborators to help move projects along.  But I want to remove the tenure pressure from the equation.  I’ve worked so hard to earn tenure, and so hard to have kids, that I think I’ve earned a parental leave that is on my terms.  I also have the feeling that if I take this one tenure clock extension, and have a second kid during the clock extension, that I’ll have no choice but to take the additional clock extension, and that means I’ll spend nine years in pre-tenure purgatory, which just sounds miserable.  We’ve been trying to have a second kid for almost a year now, and if it had worked out, I most definitely would have used this clock extension — but in my mind, the silver lining of two miscarriages in a row is that now my second baby definitely won’t be born before next fall so I can get tenure out of the way before baby #2 comes along.  While I think a year is a reasonable long-term approximation of the impact of a child on one’s career, the impact is extremely front-loaded, and in the short term, a year is not enough.  I can’t shake the feeling that the more clock extensions I take while my kid(s) is (are) young, the farther behind I’ll fall as tenure approaches, though I am quite confident that in the long term I will be an asset to my department (and in the short term as well, as I discussed above).

In addition, the two minor issues that I mentioned are:

(1) The feminist in me wants to get tenure on time because I see how parental leave and clock extensions put women behind men and I think it sucks.  The last successful tenure case for a woman in the sciences at my university took nine years (two parental leaves) and a bunch of controversy before it went through.  Meanwhile, the guy in her department with three kids and a stay-at-home spouse sailed through early — and in fact, her department encouraged the woman to delay her tenure case so that she wouldn’t go up for tenure the same year as the man.  So now she’s less senior than him (and paid less!) even though he started after her, and even though they both had kids on the tenure track.  I think it sucks.  I don’t want to delay my seniority, and I want to show other women in my university that they don’t have to be scared to go up when they’re ready.  I think the clock extensions are a good option to have, but I don’t think anyone should be putting pressure on pre-tenure women to use them for any reason other than their intended purpose.  Not to avoid going up in the same semester as the hotshot young guy, and not (in my case) for no clear reason other than that it’s expected.  One question I would like to ask my chair (but probably won’t) is: if you pretend that I don’t have a baby, but that my record is otherwise identical, would you still be sitting here now at the end of my 5th-year review telling me that if I only had an extra year on my tenure clock it might make or break my ability to meet tenure expectations?  I am really quite confident that the answer is no.

(2) Money.  With tenure comes an 11% pay raise.  One of the main reasons that women’s salaries lag behind men’s salaries is that they advance more slowly in the childbearing years.  I don’t have any interest in being part of that statistic, thank you very much.  I did a sketchy calculation yesterday about the difference in lifetime earnings between getting that boost one or two years from now.  It’s definitely in the tens of thousands and approaches the hundreds of thousands of dollars (depending on what you assume you do with the extra money).  My husband and I are not strapped for cash, thankfully, but I want fair compensation for the work that I do, including timely raises when I have earned them (like now, I think).

Of all of these reasons, I think I’ll have to focus on the professional reasons when I talk to my chair.  But I think the other reasons are important, and I wish I could talk about them.  Particularly the personal one about wanting my next baby to be post-tenure.  I get a little weepy when I think about how I might have spent more time with little baby S if I hadn’t been pushing myself to get back to work and not fall off the tenure track.  I still get weepy every time I think about being away from him while he’s so little.  After all I’ve been through for S and the future sibling we are hoping for, I want to take the professional pressure off a little and just be there for them while they are small.  Possibly this is exactly the kind of thing my university dreads when it considers the institution of tenure — that it provides a license to take a step back from professional responsibilities.  But I’m not that kind of faculty member.  Believe me — I don’t have a dead wood bone in my body.  I have every confidence that over the course of my career I will be an enormous asset to my department.  I’m just a human who wants to shift priorities a bit for a few years and not jeapordize my entire career as a result, which is the nature of the up-or-out tenure system.

 

Update and testing cycle

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.

Bad Luck Math

Because I’m me, I’ve been doing the math on my bad luck.  And because this is my blog, I figured I’d share it with you.  If you hate math, this might be one to skip, but I find it to be a helpful perspective.

My question: Among all women who have been pregnant four times before, what is a typical outcome, and how common is my type of outcome?

Assumptions: I’ll assume that first-trimester miscarriage has a ~20% probability, since that seems to be in the middle of the 15-25% estimates.  It depends a bit on week of gestation, but mine have been in the 6-8 week range, and I think 20% is probably about right for that gestational age; I also think first-trimester miscarriages at that gestational age are pretty typical. As for 2nd trimester losses, it depends a little bit.  The overall risk is something like 1%, but the risk of losing a chromosomally normal fetus like I did is about half that, or ~0.5%.  If I were being totally self-consistent, I’d make the probability of live birth ~79% and first-trimester loss ~19% to account for the ~2% of pregnancies that are lost in the 2nd and 3rd trimesters, but it won’t change my answer much so I’ll keep using round numbers for at least these initial back-of-the-envelope calculations.

What is a typical outcome for a woman with four pregnancies? 

The highest-probability event in any pregnancy (other than mine, that is) is a live birth, with a probability of ~80%.  The probability of having four live births in a row is (0.8)^4, or about 41%.  So, fewer than half of women with four pregnancies will have all live births.  That jives with my experience — most women I know with three kids had one miscarriage along the way.  So let’s explore the probability of three live births and one miscarriage.

There are four ways to have one miscarriage in four pregnancies: either your first pregnancy can result in a miscarriage, or your second, or your third, or your fourth.  So the overall probability of having one miscarriage among four live births is 4*(0.8)^3*0.2 = 41%.  That means that just according to the typical probabilities, 80% of women who have been pregnant four times will have either one or no miscarriages, and it’s more or less a coin toss between those groups.

What about the other 20%?

The other 20% are women who are less lucky.  They might have had two or three or even four miscarriages, typically in the first trimester.  But which fraction is which?  The easiest to calculate is having four miscarriages in a row: (0.2)^4 = 1.6%.  So, how unlucky do you have to be to have four miscarriages in a row, just by chance?  Unluckier than 98.4% of other women.  If you somehow manage to collect 100 women who have been pregnant four times in a room, you would expect about 2 of them to have had this outcome by chance.

But what about the other 18 women who had more than one miscarriage?  Most of them will have had two miscarriages.  There are six ways to do that (1st and 2nd pregnancy, or 1st and 3rd, or 1st and 4th, or 2nd and 3rd, or 2nd and 4th, or 3rd and 4th), so the probability is 6*(0.8)^2*(0.2)^2 = 15%  So a whopping 3/4 of the 20% of women who had more than one miscarriage had two miscarriages, and there are only 5 women in our hypothetical room of 100 G4 women who had three or four miscarriages out of four pregnancies, just by chance.

That’s actually more than I might have expected.  I mean, I don’t know very many women who have had four pregnancies, but of the ones I know, they mostly had one or two first trimester miscarriages along the way.  I think the largest total number of pregnancies I know of in my normal everyday life (not counting blogland, which is a very biased sample), is a grad school mentor of mine who once shared that it took her six pregnancies to have her three kids.  (I was appalled at the time, but now I’m 2/3 of the way to her total number of pregnancies and I only have one kid to show for it, so there’s that.)  But the point is that if you somehow collect 20 G4 women in a room — this is the size of a typical seminar course that I might teach at my college — you would expect only one of them to have had more than two miscarriages just by chance.

What about later losses?

So far I’ve ignored 2nd and 3rd trimester losses, because they are so improbable that they make up a pretty tiny fraction of all pregnancy outcomes.  For example, the chance of having one late loss out of four pregnancies is 4*(0.98)^3*0.02 = 7%.  That’s not nothing, unfortunately, but it’s also fairly small — it’s about the same as the chance of having 3 or 4 first trimester miscarriages out of four total pregnancies.  The more times you get pregnant, the more likely you are to have an improbable outcome like a late loss, alas.  The good news is that for a typical woman, even if she gets pregnant four times, she has a 93% chance of never experiencing a late loss — and probably it’s actually significantly better than that, since I’m assuming that all pregnancies are equal, whereas the research shows that women who have had one late loss are more likely to have another, so in reality it’s almost certainly skewed so that women with generally poor reproductive outcomes account for a larger-than-chance share of the late pregnancy losses, and a truly typical woman is less likely to ever have a late pregnancy loss.

So, how unlucky am I?

Let’s explore the probability of my particular reproductive outcome: four pregnancies, one late loss, two early losses.  We’ll assume that the order is random, although it might not be — for example, the adhesions from my first pregnancy could conceivably have contributed to my early losses in later pregnancies, or I could have some sort of weird immune-mediated thing that got worse after a live birth.  But those are fairly speculative possibilities, so I’ll just assume that the order is random.  In that case, the probability of having an outcome like mine (one late loss + two early losses, random order) is something like 12*0.02*(0.2)^2*0.8 = 0.8%.  So, if you got 100 G4 women in a room, maybe one of them would have a history like mine, but maybe not.  You’d need a thousand to get me some buddies for sure.

And I’ve also been generous in defining what “like mine” means.  If you narrow the definition to the loss of a chromosomally normal fetus in the 2nd trimester (plus two early losses), that brings the numbers down by a factor of 4 to 0.2%, which means that I’d need a room full of 1000 G4 women to maybe have one friend who’d been through something similar.  This thought experiment is also interesting because it brings the probability of having an outcome like mine below the threshold of 0.3%, which means that my outcome is 3-sigma bad, or that there’s a 3-sigma probability that my obstetrical history is not just due to bad luck, but rather to some other contributing factor that predisposes me to poor pregnancy outcomes.  That’s significant enough to get you publication in a journal in my field (though not in all fields).

Now, of course, when you get down into the weeds of these small-number probabilities, there are a lot of outcomes that look similar.  Another outcome that has a probability of 1-2 women in a group of 1000 G4 women is having two late losses and two full-term births, and you can add a bunch of different permutations that also give you similar answers.  But the point is, by the time we get into the land of both late losses and multiple losses, we’re down in the tenths digits of the percentages, which is a fairly lonely land to be in.  It’s also increasingly absurd to be told that your problems are due to “bad luck” and told that you should just try again — when you’re out in 3-sigma land, while it’s certainly true that your outcomes could be due to bad luck, the probability is low enough that it seems like any reasonable person with at least a slight grasp of statistics would want to do more investigation.  It’s easy to say that investigation is a waste of resources when you’re talking about two first-trimester losses out of four pregnancies (roughly a 1 in 5 chance), but not when you’re talking about an outcome that only a few in 1000 or even 10,000 women will experience (since most women don’t get pregnant four times and therefore aren’t even represented in the above numbers — you actually expect overrepresentation of poor pregnancy outcomes in G4 women for exactly this reason).

So there you have it.  I am so statistically significantly unlucky that it seems unlikely that my issues are due to random chance (i.e., they are probably more than just “bad luck”).  However, I’m not as dramatically unlucky as I guessed going into this exercise (I guessed that I’d be 4-sigma unlucky, but I’m not that unlucky).  So, that’s good news, I guess?  The other good news is that I live in a time when the internet exists to connect me to all the other women having a tough time out in 3-sigma land, so it doesn’t feel as lonely as if I’d been a prairie mama trying to deal with this all in isolation, never knowing another woman who had been through something similar (waving at you, blog friends!).  Though in that case I’d probably already be dead and/or completely infertile from the infection I contracted after my 2nd-trimester loss, or from hemorrhaging due to retained products of conception before the infection — huzzah for 21st century medicine!  It’s keeping me alive, even if it’s not telling me how to keep my babies alive.

Miscarrying and Hypothesizing

Well, I opted for medical management of this miscarriage, and it’s proceeding slowly.  I took the first round of medication Friday night, and not much happened, so I took another round Sunday morning, and finally things are moving.  I don’t think I’ve passed the main pregnancy tissue yet, but hopefully soon (I was so afraid it was going to happen in the middle of my lecture yesterday!).  I’ve got another week before they’ll start pushing a D&C on me, which I’d like to avoid if possible since I have adhesions from my first pregnancy.

In the meantime, I’ve started to do some research on causes of recurrent pregnancy loss.  I’ve already been tested for clotting factors and some of the immunological stuff, and other than being heterozygous for Factor V Leiden it all came back normal.  But it’s hard for me to believe that FVL is the only culprit, since it’s not associated with an increased risk of 1st trimester loss.  The main thing I haven’t really been evaluated for is heritable chromosomal issues, like a balanced translocation in my husband and me — but I find it hard to believe that that could be the source of our woes, since we know that two of our four pregnancies at least have been chromosomally normal, including the daughter we lost in the 2nd trimester.  It’s also not particularly associated with 2nd trimester loss.

There are actually very few issues that are associated with increased risk of both 1st and 2nd trimester loss.  But one thing that I read about immediately clicked for me, and now I am anxious to talk about it with my doctor on Tuesday.  You’d think that with everyone looking at my uterus in every which way over the past four years someone would have brought it up before now, but I’m about 95% certain that on one of my recent ultrasounds the tech noted a slight septum that she didn’t think was clinically relevant.  But anatomical abnormalities like a uterine septum are one of the most common — and most treatable — causes of recurrent pregnancy loss.  They are also one of the few etiologies that causes both 1st and 2nd trimester loss.  The ASRM guidelines on recurrent pregnancy loss note that the likely mediating factor causing 2nd trimester loss is abnormal placentation, which was the leading hypothesis for our daughter’s death.  It just all makes so much sense!  If I have a slight septum that isn’t bad enough to cause total infertility, but is enough to cause poor blood flow to the embryo/fetus, it would explain why I keep getting pregnant but keep losing the pregnancy, sometimes early and sometimes late, even in the absence of chromosomal issues.  It at least seems worth asking about, since the prognosis for treatment is really, really good — there are some studies where the live birth rate jumps up to like 85% (normal!!!) after surgery to correct a septum.  I would love to have an 85% chance of a live birth, instead of the 75% chance of miscarriage that I seem to have had in my pregnancies so far.  Maybe my doctor will tell me I’m nuts and that this slight septum can’t possibly be causing my problems… but I feel like I have to at least bring it up.  And if my regular OB doesn’t listen, I have an appointment with the RE on the 28th and will bring it up again then. And again and again until someone listens and has a real conversation with me about it.

I’m just ready for someone to take this problem seriously and stop telling me it’s just bad luck — it seems so clear that whatever is going on, it’s more than just bad luck.  One 2nd trimester loss… maybe?  But that’s already really bad luck, since it happens in only ~1% of pregnancies.  Two losses?  OK, fine, a single first-trimester loss out of three pregnancies does seem within the realm of normal.  But three losses out of four pregnancies, including a loss in the middle of the 2nd trimester?  How can people keep attributing this stuff to bad luck?  I mean, I know it’s not always possible to find a cause, but it would be so much more helpful if someone would say, “Look, your history is crappy and indicates a problem.  We don’t always know what the problem is or how to solve it, but here are the things we can check for and here’s why I do or don’t think that each of them might be a problem for you specifically.”  That’s what I want.  Why is it so hard for doctors to talk to patients that way?

Anyway, that’s where I am now.  Waiting to finish miscarrying this pregnancy, walking around, acting like everything’s normal in the meantime, diving back into the literature on pregnancy loss to try to find some answers about what’s happening to me.  This semester has just been so hard, with my dad dying the first week of the semester and my third miscarriage happening in the middle of the semester.  I’m kind of amazed that I’m still functioning, but at the same time I really don’t think I can take any more, and I’m having to bite back yelling at people or bursting into tears all the time.  I have very little patience for anything even a little bit trivial right now, which is really not the frame of mind I should be in during advising week for our freshmen, who are freaking out about their schedules for next semester.  I also can’t handle any kid-related stress, and when my toddler was clinging to me at daycare dropoff yesterday I actually started crying right in the middle of the toddler room.  I don’t think the teachers noticed, and I got myself out and to the car before I really let loose, but I wanted to cling to my son as much as he wanted to cling to me!  You’d think I’d be used to pregnancy loss by now, but I don’t think you really ever get used to it.  Having a living child makes it easier, for sure, but it’s still awfully hard.