- Natural vs. medicated FET
- Endometrial Receptivity Assay (ERA)
- Endo Scratch
- Thyroid, prolactin, Vit D levels, etc.
- Hysteroscopy
- Transferring more than one embryo
- Immunologic implantation dysfunction (IviG)
- Additional embryo testing beside PGD
- RPL workup
- Getting a second opinion
- His phone skills
In a natural FET there are a lot less hormones but a lot more office visits because you have to be very closely monitored. The risk is that they do not do transfers on Saturdays or Sundays so if you happen to ovulate at a time when transfer would be one of those days then the transfer gets canceled. They don't do enough natural FETs to justify staffing everyone over the weekend and so there would be no one there to transfer.
The ERA biopsy protocol is similar to the FET. Birth control for a few weeks, followed by shots as a "pretend transfer." They mimic everything you do at a regular transfer then instead of transferring an embryo, they take a biopsy of your uterus and send it off for testing. They're testing to find out if the transfer window they use for you is in fact correct. If it is, test comes back normal and you can transfer next cycle. If not, repeat everything again for another cycle except delay biopsy for a day. The idea is to narrow down the most receptive time for your uterus to accept a transfer. I asked what happens if after the second time it doesn't come back normal? He said he would have to take it to the panel of doctors at the clinic since it hasn't happened yet. So at the very worst we'd be delaying by two/three cycles while we do this testing. It is also expensive and not covered by insurance ($850 each biopsy).
Endo scratch is where they irritate the lining of the uterus a week before transfer. The idea behind this is that the uterus starts to heal itself and makes it more receptive to an embryo. There isn't sufficient medical data backing this up. He offers it if we want to try it but says he's skeptical that it actually works. Even if a transfer works he says he can't necessarily attribute it to this. There are no known downsides to this - it doesn't delay a transfer and insurance covers it.
We reviewed all of my hormone levels and all are measuring normal with no changes from 6 months ago, when they were also checked.
I asked about his opinion on getting a hysteroscopy (sticking a camera into the uterus to take pictures) and his response was that the benefit was so small and the risk was so high that he doesn't recommend it. I have no symptoms to indicate that there's any issue; usually they recommend this for someone with unexplained bleeding. It's not worth doing this minor surgery where the risk of perforating the uterus or finding something that not actually an issue is much higher than the tiny chance of finding anything the HSG or transvaginal ultrasounds have been missing.
He says there is too much risk to advise transferring more than one embryo. There is a higher risk for premature birth, pregnancy complications, and possible stillbirth. The only pro is that it's better financially because you're saving one FET by putting two in there. He said that the embryo quality is high for both embryos and whether or not anything sticks has to do more with uterine receptivity than the number of embryos.
We briefly discussed IID with IviG therapy but it's so beyond anything I could need at this point that it was pretty much irrelevant. This is something that's offered to women who have gone through dozens of procedures with multiple losses.
There is no additional testing offered beside for PGD. If there is any chromosomal abnormality with the ones we're transferring (or with me or my husband), there has not yet been a test created to check it. We're literally doing everything we can to ensure healthy embryos.
As a way to make me feel like we're not leaving any stone unturned, he offered to do a RPL workup which is a blood test offered to women who have had recurrent pregnancy loss. This is generally only offered to people who have had multiple miscarriages before the 10 week mark and tests to find out if there are clotting issues which might interfere with the placenta growth. It's easily treated with baby asprin and lovonox but they need to know it's an issue in order to treat it. This isn't something he necessarily recommends to someone who has had "only" three failed FETs, but I appreciate that he brought it up and if it's just a simple blood test I'm happy to rule anything else out. Why wait for more losses if this is just a blood test and so easily treatable? Did that this afternoon and results should come in about a week.
He brought up getting a second opinion saying that if we want to see someone else that he doesn't hold anything against us or get offended. I'm not interested in starting over with someone new at this point, but I think it's good to hear he wouldn't take it personally if we did. I don't know that there's anyone better and at this point I think it's too soon to shop around.
He apologized for last week's hectic schedule which didn't allow him to speak longer. I told him that I completely understand I'm not his only patient but that when he does talk to me I'd prefer if he was in front of a chart instead of trying to wing it from memory. I wasn't trying to make him feel bad or get an apology - I honestly just want to be able to get accurate information when we talk. I feel better now that I brought it up. I think it was important to me to not let it go unmentioned because it was a big deal and I don't want a repeat.
Overall we're feeling good about next steps. My husband and I are on the same page about wanting to do the ERA test. We're not totally in agreement about the endo scratch. Even though the endo scratch sounds like something I would try, I think it's pointless if we don't narrow down the transfer window first. He thinks it's a waste of time regardless. If we do the test and it comes back normal, at least we'll know we tried and will have no regrets moving forward with another transfer regardless of the outcome. If it comes back not normal then we'll get a possible answer as to why things weren't sticking. Either way it sounds like it's worth the pain, expense, and delay of another transfer. We can't do both: it's either the ERA or the endo scratch. Once you do the ERA you're mimicking the transfer so you can't throw in a monkey wrench into the system by introducing something new at the actual transfer. Since the endo scratch is unproven and we don't get an any answers from trying it, we're going to try the ERA and see where it takes us.
This means that we're not transferring anything in July, possibly not in August either. So if I have the time anyway, I'm going to make an effort to use the time wisely working out and losing weight. Even 5 or 10 lbs off will help me justify the delay for the next transfer. I know I don't need justification, but for an impatient person such as myself, it helps keep my mind focused by having a tangible goal within my control. Exercising helps me feel good and eating healthy can only help. I'm going to set a goal for 10 lbs and reevaluate if I reach it before it's time to transfer (that should be my biggest problem!).
I'm glad you got some answers and were able to express your concerns! I think concentrating on yourself during the next few months, so that you are feeling your best when it's time for your next transfer, is a great goal.
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