Tag Archives: IVF

Breastfeeding and Trying Again

OK, here’s the thing… we are three weeks away from my son’s first birthday.  There are many amazing things to reflect on at the end of this first year.  I am acutely feeling the parenting cliches: on the one hand, it feels like only yesterday that I was holding my wide-eyed newborn son in my arms, and on the other hand, it feels like he’s been with us forever, and I can hardly remember my life without him.  There are many more things I hope to write about as his first birthday approaches and passes, but another thing I’ve started thinking about as his first birthday approaches is our strategy for conceiving the  living sibling we hope that he will one day have.

Surprisingly for me, my thoughts on trying to conceive our third child are all tangled up with my feelings about breastfeeding my son.

Conception and pregnancy have never been easy for us.  It took 2.5 years from the time we started trying to conceive to the birth of our son.  There were two pregnancies along the way, including the loss of our daughter in the middle of the second trimester.  Both pregnancies involved consultation and testing with a reproductive endocrinologist, and the second time around the RE had recommended moving onto IVF due to tubal factor infertility, which we were in the process of preparing to do when I became spontaneously pregnant with my son.  I am not expecting conception or pregnancy to be easy the next time around either.  Tubal factor infertility (in my case, due to the infection and scarring that occurred after the loss of our daughter) does not tend to get better with time, and it might have gotten worse since the birth of our son.  It is likely, though not definite (we might get lucky again!), that IVF is in our future.

What does all of this have to do with breastfeeding?  For one thing, breastfeeding influences menstrual cycles.  My period returned when my son was 10 months old, but it’s been irregular.  While I’m breastfeeding, it may remain irregular, but I won’t know whether the irregularities are due to breastfeeding or some other hormonal imbalance.  Muddying the waters, I had wildly irregular periods for 11 months before conceiving our daughter, and then clockwork regular periods for 8 months before conceiving our son.  We’d like to try for a while on our own before going back to the RE, but it’s trickier while my periods are irregular.  There are also some data indicating that breastfeeding might impede implantation and reduce the likelihood of pregnancy.  Finally, most REs make a blanket recommendation that you should cease breastfeeding before starting fertility treatments, although it’s not clear how evidence-based that recommendation is.

Many women think of it as a tension between their living child and their hoped-for child: do I prioritize the breastfeeding relationship with the child I have and love, or do I wean in order to maximize the probability of conceiving the child I hope to have?  I suspect there’s a middle-of-the-road option I might be comfortable with, but I’m not yet sure what that looks like.  My breastfeeding relationship with my son is still going strong as his first birthday approaches, but he doesn’t seem to be as attached to breastfeeding as some of my friends’ children.  He doesn’t really ask to breastfeed very often, and he’ll often refuse when I offer because he’s much more interested in seeing what’s going on in the world around him and doesn’t want to take any time out to nurse.  So a bit of mama-led weaning might be well received.  At the same time, I love our breastfeeding relationship and am not sure I’m ready to encourage its end, plus I know that my son derives comfort from it, especially when he is sick or tired.

So, what does our plan going forward look like?  When he was first born I thought “We’ll start trying when he’s a year old, and go back to the RE at six months.”  Now, with no end to breastfeeding in sight (and, honestly, with sex still kinda uncomfortable thanks to the breastfeeding hormones), I’ve started to think “Maybe we’ll start trying when he’s 18 months and go back to the RE when he’s 2.”  I don’t want to wait too long, because I’m not expecting the road to be easy, and I’m not getting any younger.  I’m turning 34 next week, and staring Advanced Maternal Age squarely in the face.  I know that timing can make a huge amount of difference in IVF cycles, and that waiting to even go back to the RE until I’m already 35 (when my son turns 2) might be risky, especially since we’d love to keep the option of a third living child open if we are lucky enough.   I feel sad contemplating the end of our breastfeeding relationship.  But the experience of having our son in our lives has only made our desire for another living child stronger, and my husband and I don’t want to wait too long.

So, are you going to have another one?

The questions have started.  It really didn’t take long.  Mostly I just shrug them off with a blithe “We’ll see!”  But in the past few weeks I’ve had lunch with a couple of friends who really helped me through the dark time between our daughter’s death and our son’s birth, and both times it’s come up.  With them, it was harder to shrug it off.

The honest answer is “We want more kids, and I’m terrified.”

I guess it shouldn’t be a surprise that giving birth to a dead baby scars you for life in the baby department (literally as well as figuratively, in my case, alas).  But I still found myself tearing up as I talked with my friends and admitted that we absolutely want another baby, but that the thought of going through all of this again is terrifying.

I do think it’ll be easier to handle the uncertainty this time around, because I have a beautiful baby boy to distract me and I won’t have to deal with those awful feelings that I might never be a parent at all.  This time, I’ve got my son, and he’s a precious and amazing gift that I will never take for granted.  He also makes the time speed by — without him, as we waited for him, it was so easy for time to crawl.  So, there are a lot of things that will hopefully make this time around less daunting.

But it’s still daunting.  When my period does come back, I may still have to deal with irregular cycles.  The scarring of my uterus and fallopian tubes won’t have gotten any better, and might have gotten worse.  IVF might well turn out to be our best/only option.  If I manage to get pregnant, I’ll go back on daily injections of Lovenox.  I have to face the possibility that I might lose another baby, miscarriage statistics and my history being what they are.

It’s not something I’ll have to face immediately (for one thing, my period still hasn’t returned, hallelujah!).  But we also don’t want to wait too long.  It took us 2.5 years to have a living baby the first time around, and I’ll be 34 by the time we can start trying again.  Biology is ticking along: Advanced Maternal Age, here I come.

For now, I’m content to hang with my amazing son who is getting more amazing by the day (he just started pulling himself up to a standing position this week!).  His presence in our lives is so incredible that it feels extremely greedy to hope for more, and difficult to imagine that another baby could be as wonderful.  And I won’t lie — as things finally get easier, it’s also daunting to think about starting all over again with a newborn.  But my husband and I both want him to grow up with a sibling.  It still feels like there’s someone missing from our family.  There is no doubt in our minds that we’ll try again, however scary it feels to take that leap.

And as I snuggle my baby boy, and watch him grow bigger and stronger and start to become he independent person he’s supposed to be, one of the things that consoles me about the loss of his babyhood is that there might be another babyhood on the horizon.  As excited as I am to see him grow, I’m also not ready to give up being mom to an infant forever.  It’s such a special time.  I’m sure all ages are special in their own way, but as my baby stretches taller and moves faster and transforms into a toddler before my eyes, I can’t help but yearn to someday have another infant strapped into the carrier on my chest, snuggled into my lap, sleeping sweetly (if only occasionally).  What a beautiful time of life this is.  How tantalizing to begin to hope that I might get to experience it again.

5.5-week Update

Tomorrow is our first ultrasound to make sure that this is not an ectopic pregnancy (we are not expecting a heartbeat this early).  I thought I’d give a few updates as we hold our breath until tomorrow (not recommended, by the way!).

– My second beta at 20dpo was 2361.  For those keeping score at home, that’s a doubling time of about 35 hours (yippee!).  Everything’s on the high end, which is probably good news (unless it’s an ectopic pregnancy).  My mom, the women’s health nurse practitioner, says that the doctor in her practice mentioned that with betas as high as mine, she’d expect me to start having symptoms of an ectopic pregnancy around now — so far no spotting or pain, so I’m starting to get dangerously optimistic!

– Because of my history of placental abruption and second trimester loss, my RE put me on supplementary progesterone this week.  I’m on Crinone 8% gel twice a day — this is icky stuff, you guys!  But hey, I’m not complaining — whatever it takes to have a healthy pregnancy!

– Assuming we’re in luck tomorrow and it’s not ectopic, I can confirm (as a public service announcement because I tried to google this six ways from Sunday after our first loss): if you have implantation bleeding in a first pregnancy, you will not necessarily have implantation bleeding in your second pregnancy.  Just FYI.

– Symptom spotting: sore breasts (since, like, before the BFP), bloating, cramping/stretching, fatigue, and a bit of nausea.  Before we lost our daughter last fall I’d never in my life had trouble falling or staying asleep, but since then I’ve hardly been able to sleep through the night — lots of awakening at 4am, 5am, etc. with my mind buzzing.  Turns out that a side benefit of pregnancy is that it cures insomnia!  I don’t know if it’s purely psychological at this early stage (getting pregnant again has felt like it’s healed a deep wound in my soul), or physical (this is what I remember most from the first trimester of my first pregnancy — the deep and constant need to be unconscious), but whatever it is, it feels good!

– Social awkwardness: we had told a few close friends/family that we were starting IVF.  Since they’re awesome, they keep asking how things are going.  So far I’ve mostly deflected inquiries — I want to wait at least until we know that this thing is in my uterus and not my fallopian tubes.  Fortunately it’s not a lie to say “we have a doctor’s appointment on Tuesday and we’ll know more then.”

Thanks so much for all your good wishes as we deal with this nail-biter of a wait to make sure this pregnancy isn’t ectopic, and to find out if it’s viable.  I’m so very hopeful, and feeling so good about this pregnancy, that it scares me.  If it’s going to end, please let it end soon.  If it’s not… wow.  Wow, wow, wow.

Plot Twist!

Warning: pregnancy discussed.

This morning I woke up early and took my temperature.  I double-checked the thermometer, then stumbled into the bathroom.  A few minutes later I came back out, stood by our bed, and said to my husband,

“Hey, [husband], want to hear something crazy?”

Him: “Sure”

Me: “I’m pregnant.”

Him: “Hunh.  Hope it’s OK.”

Me: “Me too.  I hope it’s not ectopic.”

Him: “Yeah.”

Then we went back to bed.  (I didn’t sleep, of course.)

There’s no doubt that I’m pregnant.  I had one old First Response test in the medicine cabinet, and after I dipped it, it only took a few seconds for both lines to appear.  The test line appeared immediately, at the same time as the control line, and wound up being about twice as dark.  No squinting or worries about evaporation lines for me today.  It’s as though the First Response test was saying, “Please, this is child’s play — give me a challenge next time!”

Immediately my mind was off and running in circles about the implications of this plot twist.

First: the danger of ectopic pregnancy.  After my recent abnormal HSG, we were gearing up to start IVF.  During the HSG, when I asked if I’d be able to get pregnant with scarred tubes, both the radiologist and the fellow told me that it was possible, but that I’d be at high risk of an ectopic pregnancy and that I should discuss it with my doctor.  Since I knew I’d ovulate before I saw her next, I sent her a message through the practice’s electronic messaging system, asking if we should hold off on trying because of the danger of ectopic pregnancy.  Here is her verbatim response:

I have reviewed your report as well as images of HSG- yes there is concern about the status of your tubes – while both tubes did spill the dye, there is concern about how freely open the tubes are. Your risk for an ectopic pregnancy Is higher based on this appearance but it is not 100% by any means!

You can try to attempt timed intercourse but recommend close monitoring with serial bloodwork in the event that your period gets delayed, as if it is an ectopic pregnancy, we want to diagnose it in its earliest stage. I believe you are scheduled for follow up with me next month – it is however OK to avoid pregnancy until the office visit, so we can discuss options/strategies.

That sounded pretty good, so we went for it.  When we saw her a couple weeks later, she told us that our chances of getting pregnant on our own were very low and presented our options, including surgery to try to repair the tubes or moving straight to IVF.  She recommended the latter.  We agreed, and have been going full steam ahead on starting IVF as soon as possible.  Then this happened.

I guess “not 100% by any means!” is encouraging.  I’ve looked up some information, and while of course there’s nothing out there about my specific case, it sounds like a ballpark probability for ectopic pregnancy in the case of known tubal disease (or previous ectopic pregnancy) is about 20%.

While walking the dog this morning, I did some math.  If we assume a normal first trimester miscarriage probability of about 20%, and a risk of ectopic pregnancy of about 20%, then this pregnancy has approximately a 64% chance of making it through the first trimester.  I’ll take it, I guess!

So, I suppose I’ll be getting a lot of bloodwork this week.  It’ll be a bit tricky since I’m scheduled to fly to Tennessee for a conference on Tuesday, but hopefully I can find a lab that can do the test there and fax the results back to my doctor?  Not sure exactly how that’s going to work.

I have other worries as well, but mostly they’re just the sort of worries that involve rearranging your conception of the future around new information.  Bizarrely, the part of me that believes there’s no way this pregnancy will survive is frustrated at the delay in starting IVF.  Assuming that this embryo dies, either through miscarriage or ectopic pregnancy, it means a whole ‘nother round of heartbreak and waiting to start the more safe and effective route of IVF.  I realize that I’m borrowing trouble here, but I’ve hit the crappy end of the probabilities in so many different ways now that I just assume that I’ll hit them again this time, and I certainly don’t relish the prospect of going through either an ectopic pregnancy or a first trimester miscarriage.  I was so optimistic about the probability of a healthy pregnancy with IVF, and the possibility of saving extra frozen 32-year-old embryos, which would be like gold if we ever got to the point of being able to think about a second baby.

Anyway, I can read this and logically know how absurd it all sounds.  I’m pregnant!  I’ve been working so hard towards this goal for so long, and I’m extremely fortunate that I don’t have to go through IVF after all!  (At least not yet.)  I should be over the moon!  I should be jumping up and down!  And my husband and I are all “meh” instead — what is wrong with us?!  I think it’s mostly that I can’t possibly believe at this stage that this pregnancy has any chance of working out, and I’m emotionally insulating myself against the (high, at this point) likelihood of another loss.  I’m also thinking about the long path in front of us if things go well: blood tests and ultrasounds for the next two weeks to make sure it’s not ectopic.  Starting Lovenox injections to mitigate the threat of clotting.  Repeat ultrasounds to make sure the pregnancy is viable and growing on schedule.  Getting through the screenings for chromosomal abnormalities and making it to the end of the first trimester.  A normal 18-week anatomy scan (this is huge for us since we found out that our first daughter had died at our 18-week prenatal visit).  Telling people we’re pregnant again.  And then the second half of pregnancy, which I’ve never experienced before, but which for me carries a 30% risk of placenta-related complications.  And then labor and delivery, which I’m completely freaked out about since my only experience with it is delivering a dead baby and I’m irrationally convinced that if we ever make it to full term something terrible is going to happen during delivery and the baby and/or I will die.

It’s a lot.  Even if we’re fortunate enough to have everything go textbook normally from here on out (which is unlikely), it’s not going to be easy.

But, one step at a time.  Today I am pregnant, and that is a very, very good thing.  I need to keep that in perspective.  Seeing those two pink lines this morning was very different than the first time we saw them, and this is going to be a very different pregnancy than the first no matter how it turns out.  But for now I have hope, and that’s a really good feeling.  I’d say at the moment I’m feeling anxious but cautiously optimistic.  There are much worse places to be (and I’ve been in a lot of them).  Wish us luck — we’ll need a lot of it.

The Inadequacy of the English Language

wordle

A word cloud created from this blog.  I guess I say “like” a lot?

I’ve been thinking a fair amount lately about the inadequacy of the English language.

I’ve had a lot of doctor appointments recently, and have had to talk about our experiences with various members of the medical staff.  There are still several apects of our experience that are hard for me to describe, and I find that my speech becomes halting whenever I have to talk about them.

The image that goes along with this post was created with Wordle, and shows a graphical representation of the frequency of the words I use on this blog.  It’s not a bad place to start.

Miscarriage – As I look back through my blog, I find that I used the word “miscarriage” more frequently in the beginning of the blog, and now I use the word “loss” more frequently (they’re almost equal sizes on the plot).  I find it more and more difficult to find the right words to describe what happened to us.  In a medical setting “fetal demise at 18 weeks” feels right, but with most people it’s too technical.  “Miscarriage” doesn’t feel right either.  When I think of a miscarriage, I think of a first-trimester event.  I know that first-trimester miscarriages can be just as emotionally traumatic as second-trimester losses, but the physical experience, etiology, and prognosis for future pregnancies are undeniably different.  I’m therefore uncomfortable with the word miscarriage, since I think a lot of people misunderstand my experience when I use it, but I don’t have another word to replace it.  Stillbirth is clearly inappropriate — I was about a week and a half shy of the miscarriage/stillbirth line in the US, so it’s medically inaccurate, in addition to which it feels presumptuous to use a word that is generally understood to describe the loss of a baby at full term.  “The loss of our daughter” or “after our daughter died” are phrases I’ve used a fair bit, but even though I certainly consider her our daughter, I know some people wouldn’t, and I worry that people who don’t know what happened might get the wrong idea — I don’t want to sound melodramatic.  “Pregnancy loss” isn’t a bad compromise, but it’s vague as well — a pregnancy loss could refer to any stage of pregnancy, so again it requires people to assume.  I’ve tried “pregnancy loss at 4.5 months,” but that’s clunky as well.  I tend to adapt my description based on the situation, but amazingly, even after talking about it for nine months, I still don’t feel like I have a good grasp of the language.  Every time, I hesitate before saying the words, because I have to carefully choose which words to say.

Infertility – This word is very, very small on the graph.  I had to check to make sure it even appears.  There is no doubt in my mind that we are experiencing infertility, i.e., the inability to conceive or carry a pregnancy to term after a year of trying (in fact, we’re going on two years strong, baby!).  We’ve also got a clear tubal factor infertility diagnosis, although since it only happened a few weeks ago I’m still ruminating on this new aspect of my identity.  Obviously (from the word cloud) the experience that looms largest in my mind from the past two years is our pregnancy loss, not our infertility.  We clearly weren’t infertile before our loss — perhaps subfertile, but not infertile, and the serious infertility started as a direct result of my first pregnancy, so in a way we’re experiencing secondary infertility… although technically “secondary infertility” only applies after a live birth.  So, what the heck are we?  Newly infertile?  Crappy at producing live babies?  Really unlucky?  (Yes, yes, and yes.)  I recently mused to friends that I was thinking about joining one of the two major support group organizations in our area, but I wasn’t sure which group to join: do I join the pregnancy loss support group, or the infertility group?  I’m sort of an outlier in either, although I clearly belong in both.

Trying naturally – This is a phrase I’ve used before myself, but these days I’m coming to heartily dislike it.  It’s not the “trying” I object to (in fact, I find it an amusing euphemism for having lots and lots of sex), but rather the “naturally.”  As we move closer to starting IVF, I worry that thinking about this method of conception as “unnatural” will bleed over into our thoughts about the child that we hope to bring to life through this method.  That child will (I hope!) be our natural, biological child, just conceived with the assistance of some folks in lab coats.  I find myself stuttering over the language of moving to IVF.  We’re not “giving up” on “trying naturally,” we’re allowing for assisted conception.  We’re trying with assistance.  We’re using assisted reproductive technology.  Nothing quite feels right.  Perhaps the simplest thing to do is shrug it off and say “we’re moving on to IVF.”

So much of what we’ve experienced in the last year has defied words.  How do you describe those first fluttering feelings of your first-born child in your womb?  Some people say butterflies, some people say slippery eels, but there are just no words for that incredible sensation.  Then there’s the moment in which you realize that your longed-for baby has no heartbeat, that in an instant your life has changed, that nobody can reverse the terrible stilling of the heart that you’d hoped would beat for a hundred years.  There are no words for the fragility of life that you feel, suddenly realizing that your husband’s heart might stop beating at any moment, or your mother’s, or your own.  There are no words to describe that tiny, red, beautiful body with the perfect fingers and the perfect eyelids that is your first born daughter.  No words to describe the feeling as she slips from your body and leaves you empty inside, emptier than you’ve ever realized you could be.  No words to describe the apathy and remoteness you feel in the weeks and months after her death, when your mind is constantly rearranging its conception of your future around this terrible truth.  No words for that constant nagging sense that you’ve forgotten or misplaced something — but when you pay attention to the feeling, you realize it’s your daughter that you’re missing.  No words for the hopeless tears that take you by surprise, for the obsessive circular thinking, remembering, and fears for the future.  No words for the sudden knowledge that your fertility has been permanently lost to infection and scar tissue, that you will never again have the experience of making love with the hope of a child resulting from that perfect, private union.  No words for the hopeful miracle of IVF as it starts to consume your life, both body and mind.  No words when you see parents with their children and remember the one time you held your daughter, or wonder if you’ll ever hold a living child of your own.  No words when someone asks “Do you have kids?” or “How is your baby?”  No words to describe the terrifying blank slate of the future.

There are just no words.

IVF, here we come.

All of a sudden this image represents my reproductive aspirations: a 5-day blastocyst in a petri dish.

Today was the big follow-up appointment with our RE following my recent abnormal HSG.  It was short, only about 10 minutes, and I sort of already knew what she was going to say, but somehow it still felt surreal: she recommended that we go directly to IVF.

It’s felt a little surreal all day.  Is this my life?  How did I get to the point that all of a sudden the safest and most effective way for me to have a baby is to inject myself with a bunch of creepy hormones and then have a scientist extract mature eggs by inserting a giant needle through my vagina and ovaries, which will then be combined with my husband’s sperm in a petri dish?  Really?  For real?  It just doesn’t seem like this could possibly be my life, but it is.

I felt a few things after getting her recommendation.  I felt angry at the midwife who didn’t give me antibiotics despite my concerns about pain and foul-smelling discharge (classic pelvic infection symptoms).  After the disastrous delivery of my daughter at 18 weeks, the placenta had to be manually removed, which is a clear risk factor for infection — and yet she ignored clear signs of the infection that would go on to scar my fallopian tubes.  A simple course of antibiotics would have prevented the loss of my fertility that resulted.  And going further back, I’m still angry at the doctor, who pushed me straight into medically induced labor without even mentioning the possibility of a D&E, even though I specifically asked her if I had any options.  I now know that the complication rate is almost an order of magnitude lower for D&E than for medically induced labor in the second trimester (4% vs. 30%).  I almost certainly wouldn’t have had to deal with retained placenta (which to first order only happens during medically induced labor), and I would have received antibiotics during the procedure, so it’s highly unlikely that my cascade of complications would have happened.

While I’m angry, I think I’ve got the anger under control.  I’m allowing myself to be angry, and considering writing a letter to the practice to let them know what happened (I was so unhappy with so many other things that happened during the loss of my daughter that I immediately switched practices, so they have no idea about everything that’s happened since before I started writing this blog).  At the same time, I really do feel that I’ve accepted that there’s nothing I can do about the past, and it doesn’t make sense to dwell on it.  It’s constructive to write a letter so that they are aware of the extremely serious consequences of their poor care during my pregnancy, and so that hopefully it won’t happen to other women in the future.  But the only thing I can change at this point is my future, so that’s where I’m putting all my mental energy.

And aside from the anger… I really do feel fine.  I can’t explain it — I feel like my worry and despair have been at such extreme levels though the fall, winter, and spring that something finally snapped, and now I’m just sort of OK with everything.  Like I said, I’d done enough reading to basically know what the RE was going to say today, so I don’t feel shell-shocked.  I do feel impatient about getting this process moving and not wanting to waste any more time, but I’ve felt much more depressed and anxious about much less significant setbacks in the past nine months.  I do feel hopeful that IVF is going to be a productive way forward for us, so I’m anxious to get started on it.

I’m worried about the impact IVF will have on our marriage.  I’m worried about the impact it’ll have on my career.  I’m worried that it won’t work — that I’ll be a poor responder, or that my damaged endometrium won’t grow enough to support a pregnancy, or that we’ll need to go through many cycles without success.

But I’m also grateful that we have spectacularly wonderful insurance that covers unlimited IVF cycles, that I’m only 32 with apparently good ovarian reserve, and that we’ve found these problems sooner rather than later.  My medical care has been so thorough (thanks to my own self-advocacy and finding my way to some really good doctors) that I feel like we have answers about what went wrong and a plan for how to avoid the same thing happening in a future pregnancy.  I feel good having a plan.  And I feel good knowing that I have a solid support system.  A second trimester pregnancy loss and nine months of follow-up treatments and procedures for complications and tests have showed me that I have some truly amazing friends and family.  They’re not all the ones I would have expected, but I’ve already gone through the painful process of accepting that there are people whose support I had counted on who just aren’t going to be there for me.  Now I’m in a different place.  Moving on to IVF, I already know who my anchors are, and they’re ready to be there for me.  I’m very lucky.  (And good news!  My very close friends, whose daughter was due the same week as mine, are moving from California to the East Coast this summer!  They’ve been one of my main anchors through this process, and I’m so happy that we’ll have them only a two-hour drive away very soon!)

Anyway, I know I’ll write more soon, but I wanted to get my feelings down on paper this afternoon, and to get the news out there.  I also want to thank the women who write the blogs I read who have chronicled their own IVF journeys.  It makes it seem less scary and mysterious now that I’ve already read about other women who have been through it and come out the other side. This sucks, but we’ll get through it.  One way or another, whether through IVF or adoption, we will be parents to a living child one day.