Thalia's fertility journey

ESHRE meeting: What our doctors are talking about when they get together

You all probably saw the sexy articles that were presented at the European Society for Human Reproduction and Embrylogy meeting in Prague last week. You know, the ones about the clowns during embryo transfer, and the one about how 20 anovulatory women who got therapy started ovulating, thus proving that we all have to just relax. Well, I was curious enough to go read all the available abstracts. Below is my summary. Because I used to be a scientist I've probably used more scientific language than is helpful, although I've tried to be clear. I hope it's helpful.

There was a lot going on at this meeting. Which puts the lie to H's rather cynical comment when I told him where Dr Candour was last week: "Good to know he's off drinking vodka and visiting titty bars." Then we both cracked up at the thought of Dr Candour in a titty bar. Sadly H's comment probably says more about H's experiences with sales conferences than about how our esteemed doctors spend their time.

I should point out that lots of studies contradict each other. I focused on the talks rather than the posters (at scientific meetings the sexy stuff gets presented in person, and the less sexy or less prestigious stuff is just stuck on a wall for people to look at if they have time). I lost the will to live part way through reading the abstracts for the 1000 or so posters. I also focused on the stuff that's relevant for me, so I'm sorry, I didn't read the stuff on PCOS or anything much on male infertility. I'm fairly sure you will forgive me.

Protocols, response rates and egg quality

1. Antagonist (short) protocol gives lower pregnancy rate (Al-Inany, Egypt)
2. Antagonist protocol doesn't give lower egg quality in a subsequent FET - pregnancy rates with blastocyst transfer in FET cycles are the same whether blastocysts came from antagonist or agonist cycles (Lee et al, Korea)
3. The flare protocol is better than both long protocol and antagonist in poor responders (meta analysis of other studies by Franco et al, Brazil)
4. In most cycles these days, the stimulation drug is recombinant FSH - rFSH (e.g., Follistim/Puregon). Making recombinant FSH involves isolating the gene and inserting it into a production cell culture like chinese hamster cells (lots of cells grown together in a nutrient broth). The hormone is purified out of the broth. Only the pure hormone is produced. This means that unlike un-medicated cycles, there is no involvement of LH in priming the follicles for release. This was not an issue with earlier protocols because earlier stimulation drugs (e.g., Menopur) were produced by purifying the urine of menopausal women, so there was a low level of LH present. This has been an area of investigation - to see if adding low levels of LH will improve the egg quality.
   Adding rLH to stimulation protocols which use pure rFSH in agonist (long) cycles reduces the rate of miscarriage (pregnancy rates are the same). You might therefore expect that protocols using puregon/follistim which are pure recombinant (r)FSH, would give a slightly higher miscarriage rate than Menopur which contains LH as well in small quantities because it's produced by purification from human urine. This was not tested - the study just looked at adding rLH (e.g., Luveris) to the rFSH. Abdelmassih et al, Brazil.
5. BUT adding rLH to rFSH in a long agonist protocol did not result in higher ongoing pregnancy rate. Andersen et al, Copenhagen, Denmark. My thought is that perhaps women's metabolism is so finely tuned that it's hard to see population effects here, it's about the individual woman and her response. But then I'm not an endocrinologist.
6. AND Pre-treating with rLH prior to starting rFSH stimulation in a long agonist cycle (treating with the rLH for a week after down-regging) resulted in a higher percentage of embryos fertilised (number of embryos was the same). No difference in pregnancy rate. Fleming et al, Glasgow, UK and lots of other places,
7. Women with an abnormal response to FSH stimulation given their age and in vivo FSH level may have FSH-receptor mutations. Lalioti et al, Yale, USA.
8. Taking longer to reach the blastocyst stage leads to poorer pregnancy rates in fresh cycles, but not in frozen ones. The hypothesis is that ovarian hyperstimulation may advance the day of receptivity of the uterus, so that putting back blastocysts a day later than the usual day 5 results in lower implantation - the window of implantation has already passed. The same would not be true in a frozen cycle. Mitwally et al, Detroit and Michigan, USA.
9. Prolonged treatment with DHEA does improve ovarian function in women with decreased ovarian reserve. Although a small sample size, there were significant improvements in oocytes retrieved, fertilised oocytes, and normal day 3 embryos. Gleicher and Barad, New York, USA.
10. Antagonist protocol for priming egg donor recipients has a higher pregnancy rate than the traditional agonist treatment. Casan et al, Valencia, Spain.

Implantation and embryo quality

1. Endometrial receptivity is governed by the upregulation and down-regulation of 100s of genes. This gene expression is different between un-treated cycles at day 7 after the LH surge when compared to ovarian hyperstimulation cycles at day 7 after hcg. At days 1, 3, 5, and 9 the gene expression pattern was the same between the two sets. This indicates that at the day of maximum receptivity the endometrium differs in a stimulated cycle, possibly leading to lower receptivity - although we don't know that. Horcajadas et al, Valencia, Spain.
2. Embryo scoring parameters that affect implantation significantly are: Nuclear alignment; nucleolar (the nucleolus is one part of the cell nucleus) number, size and alignment; day 2 cell number, symmetry and nucleation. Everything else did not significantly affect implantation rate (ie many of the characteristics our clinics use including day 3 cell number and alignment etc, and the morphology at day 5). L. Scott, address not given.
3. Many embryos are mosaic - i.e., some cells are chromosomally normal, while others are abnormal. Oocytes are much less frequently abnormal than the resulting embryos (7-10% versus 70% in young women), indicating that errors come during embryonic cell division, rather than arising in the egg itself. The only way currently to screen for mosaically abnormal embryos is PGS, which is controversial and has yet to be proven in a large scale study to result in higher levels of implantation. Lundin, no address given.
4. Cigarette smokers have less receptive uteruses (uteri?). Statement of the bleeding obvious by Soares et al, Valencia, Spain.

Other factors affecting cycle outcome

1. With a yah, boo, and sucks to the article which got all the publicity, which showed that some women with no ovulation who received therapy started ovulating, this study shows that levels of stress had no effect on IVF cycle outcome. Lintsen et al, Nijmegen, Netherlands.

Miscarriage

1. Women with premature ovarian aging have a lower pregnancy rate and higher miscarriage rate, need higher doses of stimms yada yada yada, but interestingly their embryos do NOT show a higher rate of aneuploidy. I.e. something else is causing the higher miscarriage rate , not a simple eggs are crap --> embryos have the wrong chromosomes problem. Weghofer et al, USA
2. Women with recurrent fetal loss (pregnancy loss after seeing cardiac activity) had increased expression of inhibins a1β1and a4β1 compared to women with recurrent loss of empty gestational sacs. They can't figure out the mechanism. Anim-Somuah et al, Liverpool, UK
3. The strongest predictive factor for secondary recurrent miscarriage (after number of previous miscarriages) is the gender of the first child - having a boy is hypothesised to activate the mother's immune system. How that fits with all the controversy around the immunology stuff I don't know. Nielsen et al, Copenhagen, Denmark

Immunology

1. Peripheral blood concentration of natural killer cells (PBNK) bears no relationship to uterine concentrations of natural killer (uNK) cells. PBNK levels don't vary during the menstrual cycle. Levels of PBNK were similar between recurrent miscarriers who carried their pregnancy to term versus those who had another miscarriage. Rai et al, London UK (From Lesley Regan's lab)
2. Uterine NK cells have a strong role to play in implantation, providing the mechanism guiding maternal epithelial cells towards the embryonic trophoblas cells via oxygen sensing and synthesis of a compound called VEGF. Higher concentration of uNKs leads to higher pregnancy survival rate in pigs - concentration goes up three-fold at critical points in healthy embryonic development. Croy et al, Ontario, Canada.

Genetics

1. The egg's polar body can be used to do genetic testing even before selecting which eggs to use for insemination (very creative technique developed by an Italian group in response to the law in Italy which says that only 3 embryos can be created and all must be transferred). More than 50% of eggs in women over 35 had aneuploidy. Ferraretti et al, Bologna, Italy.
2. BUT this misses post-fertilisation genetic problems. Evidence from Delhanty (not sure of address) says that more than 50% of genetic abnormalities in the embryo are post-meiosis and would therefore not be picked up in polar body testing. They found a similar ratio of abnormal embryos in those with recurrent miscarriage and those with recurrent IVF failure.
3. Women with recurrent miscarriage or multiple IVF failures produce very few viable embryos. Only 7.5% of embryos surveyed were normal with PGS, only 1.5% implanted and only 1% produced ongoing pregnancies. Bianchi et al, Yale, USA.
4. Severe male factor infertility contributes to a high rate of chromosomally abnormal embryos (95% in non-obstructive azoospermia). Magli et al, Bologna, Italy.

Endo

1. Endometriosis may be present in everyone, and only become a pathology when a certain stage is crossed. Not clear what that stage is
2. Women with mild or moderate endometrisis have a decreased ovarian reserve as measured by anti-mullerian hormone (AMH) which is produced by small antral follicles. Antral follicles are also more diverse in size in women with endometriosis compared to those without endo. Cunha-Filho et al, Porto Allegre, Brasil.
3. Surgery of even mild endo has a positive effect on pregnancy and live birth rates. Mohammed Saleh et al, Saudi Arabia

Long term effects of IVF/ICSI

1. ICSI children at 8 years old had no substantial differences in development to children who were not the result of ICSI. There was a higher incidence of congenital malformations (10% vs 3.3%) but these were all correctable by minor surgery.

Pregnancy

1. Vanishing twins lead to a higher incidence of intrauterine growth restriction later in pregnancy for the surviving singleton. The later the twin vanishes, the more likely there is to be an issue. Pinborg et al, Denmark

Surviving

I feel like I owe everyone an update, although I'm singularly un-inspired. A few days of travelling will do that to you.

We ended up at A&E on Saturday. By the time Dr Casual had spoken to my GP on-call, who had then spoken to the gynaecologist on call at the hospital, they decided I needed to be seen. So at about 1915 we headed off to the hospital. H took a book and an ipod, I just took a book. It was a long, boring evening so I'll spare you the details. Needless to say, we never saw the gynae on call, despite her having promised my GP she'd see us. We did see a very sweet junior doctor who did all the right things including swabbing for infection, taking blood, and doing an internal exam. He then made us wait while he waited for the gynae on call to come and see us. At about 2310 H decided this was ridiculous so he went to find Mr Junior, who told us that it was ok to go home and he'd send our results through to my GP. He gave us some paracetomol with codeine, which also didn't touch the pain, sadly. So that was a waste of an evening.

The one thing that H had been holding on to throughout this experience was that our local good pizza co delivers til 12 on a Saturday night. So as we walked out of the hospital at 2325 I called them. "We're closed." They said, in no uncertain terms. I tried arguing, then hung up, and burst into tears. I was inconsolable. I guess I was crying about more than the pizza (you think?). It lasted through driving home, making a cup of tea and a bowl of cereal, H going out to pick up a chicken kebab, him coming home and holding me while he watched the football highlights, and me eventually falling asleep.

Sunday morning I felt a bit better - better enough to have made muffins and done all the dishes by the time H got out of bed. They were very good muffins. The advent of wireless internet in our house has totally changed my internet habits, and probably not for the better. I spent quite a bit of Sunday going through food blogs looking for good recipes, and let's face it people, I have no self control when it comes to good food. I am now definitely overweight again and I've got to find some motivation from somewhere. Where I don't know, but it's got to come.

Since Sunday I've been doing ok, and I'm now barely bleeding. I still cry, quite a bit, but I'm not in physical pain. I'm impatient for 4 July when we see Dr Candour. I know which conference he's been at and I've been reading the abstracts. I'll do you guys a summary of the interesting nuggets when I get the chance.

Off to catch a plane.

What they don't tell you about an ERPC

One of the reasons I wanted the ERPC is that I wanted this over with. I didn't want to walk around, waiting for the miscarriage to happen. By my melt-down day on Wednesday, I wasn't bleeding enough any more to need a pad. Part of me felt lucky to have escaped the ickiness of bleeding through a miscarriage in all the ways I've read about.

Sadly, my uterus didn't seem to have read the rule book. On Thursday evening I started feeling cramps, and noticed I was bleeding a bit. I put on a pad, took ibuprofen as instructed by the doctor, and went to bed. When I woke up in the morning the cramping seemed to have died down and I got up and went to the loo as usual. When I wiped I found a big clot. I was a little surprised given how I thought I'd escaped all of that, but at least it explained the cramping. I got throught the day at work on Friday with just a little bleeding and no more cramping. The cramping started again Friday night, particularly after a shitty journey home on the tube in the rush hour and a seemingly endless walk in the heat from the station - yes I know I was stupid. I took more pain killers and went to bed. And got woken up at about 5am by concerted pain on my left side, about where my ovary is. I took more ibuprofen but after 30 minutes it wasn't having any effect and I was still awake so I got up and came downstairs to make a nest on the sofa. I've had a day today of bleeding - not a lot, but consistently - and a few more small clots.

The pain has been consistent enough, unaffected by ibuprofen enough, and on my left side enough that I decided to call the clinic to see if they thought I should come in and see if something was wrong. I spoke to Dr Casual who told me that everything was probably ok, that this was just my uterus getting with the programme, expelling what was left and shrinking back in size, but to add paracetomol to the ibuprofen, and to go to A&E if things got worse. That was a couple of hours ago. The pain is still there, although it comes and goes. It's not just on the left side, so I'm trying not to panic that it's an un-diagnosed ectopic. I'm very whiny because it's just debilitating to have been in pain consistently for nearly 24 hours. We were going to go and get delicious sushi tonight, but it seems a shame to waste on a time when I'm feeling so shitty. I'm going to give it til tomorrow morning and if I still feel like this then we will go to A&E and see what they say.

In the middle of this, our dear friend sube has found out that her embryo has no heartbeat. Words can't express how sorry I am. Please go and let her know you are thinking of her.

Coping/Not coping

Yesterday, I thought I was doing ok. I still think I'm doing ok, in that I know it's completely normal to be up and down, but I'm not doing ok in that I can cope with everything - or anything, in fact. I sent out a couple of notes to people this morning. I had to tell a client that I wasn't going to be able to make a dinner with him this evening. That made me cry. I decided to tell my evaluator what was going on so that I had some cover for tomorrow. That made me cry. I just watched the Buffy episode where Oz comes back to Sunnydale having discovered how to stop himself becoming a werewolf, and discovering that Willow is with Tara makes him lose that ability so he leaves again. That made me cry. I got a note from a colleague saying how sorry she was, that made me cry.

I'm panicking about going to work tomorrow. I don't know how to get myself back into work mode. I'm supposed to be in a workshop all day Friday and the person who is organising it is doing a crappy job and I don't know how to intervene. H thinks I should take more time off but I don't really see how it's going to help. I can't stay off work forever. I've somehow got to find the wherewithal to cope with a normal life again. I managed to go to work after that first bad ultrasound, and yes, I cried at some points during the day but I coped with all the relevant meetings. So I know I can get through work even when bad things are happening. But I don't want to. I just want to sit at home and watch Buffy and be alone. Or with H, preferably.

I've realised something about telling people about this. No one can ever say the right thing. There is no way that anyone else can ever express adequately how awful this is, so the poor things are all doomed to failure. That note from my colleague that I mentioned above made me cry because it was so inadequate. But that's not her fault. It's impossible for anyone else to help. That's what I think I've been looking for - the knowledge that someone else really understands, I want to hear the right thing from people, to know that they appreciate what I am going through. But actually it's only some of you that can do that, those who have been through this and know what worked for you and what didn't. And even then, because we are all different, sometimes we don't get it right for each other, either.

Having said that, my brothers and one SIL have both done really well this week. I sent them three links on Sunday night and asked them to read them. One was Tertia's "How to be good friends to an infertile" classic. One was the empty arms video, and one was a leaflet from the miscarriage association for friends and family of those having a miscarriage. Both my brothers and one SIL have written back having read them with their thoughts and thanking me for sending them through. The SIL who wrote back's mother died of cancer a few weeks before my brother and SIL were due to get married 7 years ago, so my SIL wrote about that loss and how what we are going through takes her back to some of that. She also wrote to apologise about the photo incident. I wrote back and told her not to worry, and to thank her. It was a good correspondance, I'm very glad I sent the links. They are all trying really hard.

I'm off to eat some breakfast, 3 hours after I woke up, in desparate attempt to hope that it's low blood sugar that is causing these crying jags this morning. We'll see.

Endings and beginnings

Yesterday happened as expected. Dear Leggy, thank you for clinging onto hope, but really there was none. I did have flashes over the last week of thinking we'd go in and there would be our embryo, heart beating away, but they were just flashes and I was fundamentally unsurprised when the sonographer's wanding showed a gestational sac that had started to collapse. It was long and thin like one of the balloons that you use to make balloon animals with. Only not orange or purple or anything. There was no sign of anything in it, the yolk sac from last week had already reabsorbed. The pregnancy had definitely failed. I got her to tell us our hcg result from last week. It was 9,100. Not really what you're looking for at 7w1d. So really, I think we could all have declared this over last week. No matter, this is the life (or not) we got and I'm not going to get angry at anyone after the fact.

We went up to the private ward to get checked in etc for our ERPC. It stands for the Evacuation of the Retained Products of Conception (that link is patient info from another hospital in the UK  - best explanation I found through googling). It's supposed to be more gentle than a D&C. Then of course we waited and waited. Turned out Dr Candour was in a consultant's meeting that morning so he didn't show up until 9ish to do our pre-op discussion. That was after the nurse had checked us in. During which she asked me if I was pregnant. Which I thought was a bit of a dumb question. And which, for a change, I actually said to her. Well, what I said was: "That's kind of the point, isn't it?" She had the grace to blush, and said, "Sorry, we have to ask everyone."

We also had a little drama in that it had not occurred to me to contact my health insurance company. After the nurse had found this out, the insurance lady bustled up to my room and told me: "You know you must call them to get pre-authorisation before you come in, this really isn't the right way to do things." Luckily I remembered that in February when the insurance co had authorised the wrong date for my lap we had called them that day and they'd been good at sorting it out, so I pointed this out to her, told her she'd have a letter in the files from them from February with all the contact info on, and that my company has a dedicated line to them so presumably I could call them and we'd get it all sorted. She went off to get the letter and I burst into tears. She didn't come back at any point during the day so I assume she got it sorted. Insurance ladies aren't famous for letting you leave the hospital - or even have the procedure - until you've paid.

When Dr Candour turned up he was his usual calm, kind and reasonable self. Which of course made me cry. He hadn't seen the notes from the clinic so I told him that everything looked bad. He was, of course, not surprised, went through the procedure, the risks etc. The anaesthetist was also very kind. It was the same woman who'd done both of my laps, and she remembered (from the notes presumably) that I had problems with dehydration so she told me to keep drinking water until we had to go for the procedure. Which wasn't until around 11:30. So we waited. At around 11:10 a junior doctor came to tell me she was going to insert a drug which would start to soften the cervix. She was, to put it mildly, cack-handed. That made me cry a bit. After that I started to get mild cramping and at 11:30 they wheeled me down to theatre. In the prep room I started to cry again. Not sobbing, just tears running from my eyes. It just all felt so sad. Although I'd started to give up on this pregnancy two weeks ago, I guess it's not really over til it's over. Dr Candour came out to see me again, and after all the prep I was put under at about 11:40. At 12:15 I was waking up in recovery, and by 12:40 I was back upstairs in the room, and H was there waiting for me.

As always after a general my mouth felt horrible, and no matter how much water I drank it wasn't helping much. The nurses were very sweet to me, and H kept asking if he could get me anything. He was trying to work but gave up and watched the tennis instead after a while. I felt ok, just crampy. They kept giving me painkillers, but told me I had to eat before I could have the good stuff. That was encouragement enough so I ate a sandwich at about 13:30 and got some di-hydro-codeine shortly afterwards. That made me feel a bit better. At this point I wasn't really teary any more. I'm not sure why. Perhaps it was a relief that things were over.

Around 14:45 Dr Candour came to see us. He said that everything had gone well. The uterus wall looked good and smooth afterwards so he was confident I would not need a second ERPC (happens in about 8% of cases). He also said that everything looked very sterile and intact, so he did not think I had suffered from an infection that caused the embryo demise. He had sent samples off for histology and genetic testing. I asked if they really had enough for genetic testing given we couldn't see any embryonic tissue on the scan, and he said he didn't know but it was worth trying (This is where I get a little cross about the delay. Presumably we'd have had more chance of finding something if everything hadn't already deteriorated. Oh well). The histology scan will see if there was a problem with blood clotting etc. He asked us to make an appointment to see him in about 3 weeks, when he'll have all the results back and we can make a forward plan.

I had been freaking out over the last few days about whether I am kidding myself even trying this again. At 39, having been pregnant only once in my life, and then with an embryo that had no chance of developing, I wonder about whether my eggs are just never going to make it. I saw that the chance of genetic abnormalities of the embryo at my age is 1 in 70. That's pretty high. So I asked Dr Candour whether he thought that was our chance, that we've had our pregnancy, it's not worth us trying again. He answered that the fact we got pregnant was definitely a good thing. That what they worry about most is lots of cycles of negatives with no sign of implantation. That it's implantation that is the biggest barrier to successful pregnancy, and one that they can do the least about - and the one they understand the least. So the fact we got implantation this time gets us over a hurdle, and, as far as he is concerned, makes it worth trying again. I can't tell you how much of a relief that was. I know that it is entirely possible that we won't get pregnant again next time, or that if we do, that we may have another miscarriage. I know that. But I want to try again so it matters that the doctor I trust to help us make that decision thinks it's worth it.

We were released at around 1600 with a packet of augmentin - prophylactic antibiotics. Unlike last time, the nurse in charge sent a junior down to the pharmacy to wait for our prescription, and wrote URGENT all over it so we didn't have to wait two hours. That was a relief. H and I got home fast and decided on gazpacho for dinner as it was another horribly hot day, and I thought it might work ok with how horrible my mouth felt. H went off to get the ingredients, and we then chopped and blended together. He did a bit of work and I watched a soppy movie. We had dinner (delicious. First time I've made gazpacho but totally worth it) and watched an episode of ER (not sure that was our best choice, but our next Lost episode is the one where you get the back story of the Mr Eko group and it looked pretty terrifying so I thought probably not my best option).

All evening I was mostly doing ok. Each family member texted me which was nice. I wasn't teary. I felt sad but not bereft. I was bleeding a bit but not too much. Dr Candour told me that a little light bleeding might continue all the way to my next period. Around 10 I went to bed and read some more of my fantastic chick-saga type novel that I'd carefully selected last week. No pregnancies, just lots of family feuding and delicious jewels. Then I slept. With a fan blowing because it was so bloody hot, but I slept and I don't really remember the dreams. I slept a lot better than the previous night when I kept waking up with Imelda Staunton singing into my subconscious "maybe they're really magic, who knows" in my ear (yes, I've been overdosing on Into the Woods).

This morning I woke up sad again, but I do feel ok. I'm not going to work til Thursday, but yet I don't feel ill - not like recovering from a lap when I really needed the time off because I was in pain. I have a few cramps, but Dr Candour told me that was the uterus shrinking itself back and was a good thing. And they're really not bad - not even bad enough to take painkillers any more. I'm bleeding a bit, but nothing major. I'm sad, but it's a dull kind of ache, not the sharp, immediate panicky pain of seeing that ultrasound last week. The kind of ache I'll carry around for some time, I imagine. Dr Candour told me I'd really feel the hcg and progesterone coming down, but other than the sadness and feeling of fragility I'm not noticing anything. Luckily the heat has broken a little, so it won't be too miserable being at home today with no air conditioning. I've got gazpacho for lunch and plenty of work admin to keep me busy if I so desire. Or else that chick-saga to finish.

I'll be ok. I want to get on with further treatment so we can see if we can finally get that baby we're dreaming of. I know I'm going to be sad, and I feel a bit lonely, but I know that that's normal. I don't know how I'm going to manage to cope with work again, but I guess I'll manage that, as well. My first appointment on Thursday morning is to get my annual review feedback. Not sure that was my best option, but it's the only time my evaluator can see me. How much do you bet that at least some of the meeting involves me crying? My evaluator is a sweet, but conservative, Polish man so I'm not sure how well he's going to cope. Poor guy doesn't know what he's got coming.

Hairdressers: a most pressing issue

You may remember that my hairdresser conceived around the same time that we did, with the same due date. She called me on Wednesday to see how things were going. I told her, she fell apart. She was really very sweet. I asked how her 7w scan had gone, and of course it had gone fine, no problems. She told me that if I want to come in and see someone else I could, that I could come in on days when she won't be there, whatever I want she will organise. For now I have kept my next appointment with her, but I don't know when the time comes if I will be able to handle it. The last time I saw her we were both pregnant. The next time I see her, just one of us will be.

The dilemma is that I've just settled down with her after a couple of years of peripatetic searching for a hairdresser I was really happy with. For most of my life I'd been to the same guy (he was an apprentice at the salon where my mother went when she first got married, so he was the first person ever to cut my hair), and frankly, he still gives the best cuts ever. But in the six months before I got married I had two bad colour experiences with his salon and so after the wedding I decided to look around. I went first to the salon renowned for colour in London. I quite liked them, but it was extremely hard to get an appointment, and I was often asked to change to a different colourist at the last minute. After a couple of months of that, I tried the other colour salon. I sent in a web enquiry, and the next day my current hairdresser's assistant called to book my appointment. L and I bonded immediately. She does colour, and someone else in the salon does the cut and blow dry. He's fine, nothing special, but the colour is wonderful. It may be that someone else from the same salon will do just as good a job, so that I don't have to see L, but I'm always going to know that the reason I'm not seeing L is that she is just as pregnant as I should have been...I don't know, I guess I should leave this one for another day.

In another amusing hairdresser-related incident, my mother, who still goes to the first guy's salon, has obviously shared our news with him and his half-his-age second wife, who is the receptionist at the salon and is lovely, but who got pregnant with an oops baby on basically our wedding night as far as I can tell, so there is some pent-up jealousy from me there. The reason I know that Mum has told them about us is that I received in the mail quite a sweet note from the hairdresser's wife, with an info card about someone doing acupuncture and chinese herbs for infertility, who she knows socially. The note says things like: "My heart breaks for you," and "I hope that something will help you get what you deserve." It's all very well meant but somehow just didn't sit well with me.

Perhaps because it came the same day as a note from my mother attached to a recent news article about the Finnish study that showed that we might as well all go back to single embryo transfers. Is it just me or am I reasonable in being suspicious that the reason why this study has had so much publicity in the UK is that the HFEA really wants us all to go to single embryo transfers to minimise multiple pregnancy, despite other studies which show precisely opposite results? Forgive me if I'm not too keen on that bandwagon. The thought keeps occurring to me that perhaps if they'd put three back I might have another one still happily developing in my uterus right now. Unlikely, I know, but for goodness sake I've got to have something to hang on to.

I'm still a bit of a basket-case, and H had another breakdown yesterday. It's just so hard for both of us to give up on this pregnancy. H has made an appointment to see the counsellor at the clinic tomorrow. I can't quite bring myself to do the same. I'm not sure why, as I've found therapy very helpful before. Perhaps I'm just not at that stage yet.

By this time tomorrow I won't be pregnant any more. Not that I've been feeling pregnant for the last two weeks. But for some reason I still haven't let myself drink or eat sushi. After tomorrow I will have no such compunction. Thank you again, so much, for the amazing messages and emails. I have now read through a lot of material on miscarriage and loss that I wasn't previously aware of. Katie had previously recommended The Miscarriage Association, and their leaflets, while not telling me anything I didn't know from all of you, have been very helpful to read. Thank you to all of you for taking the time to provide what comfort you can. It's been wonderful. It's made me cry, but it's still wonderful.

The banality of suffering

I've always enjoyed the poem: "La Musee des Beaux Arts" by WH Auden. I generally like Auden's poetry, but there was something special about this one. Or perhaps it's because I had to do a lit crit on some poem sometime when I was about 14 and my father suggested this one so I learnt if off by heart and my father said lots of interesting things about it. Anyway, it's come to mind a lot over the last few days. Go and have a quick look before you go on. I think typepad will open a new page so you won't even navigate away from here.

Walking out of the clinic on Tuesday was a weird experience (I've realised after all that stuff about how I care about spelling and punctuation that there are some words I habitually spell wrong. Wierd/weird is one of them. I have to correct it every time). It's been a week of beautiful weather in the UK. So the front of the hospital was full of people having a nice day. Sunning themselves on benches, chatting with their friends, having a quiet sandwich break. As H and I clung together, he reluctant to get in the taxi that would carry him back to his training course, I reluctant to dive into the hospital to get my repeat prescription for progesterone and heparin, we both remarked that it felt all wrong. I suddenly understood why films do things the symbolic way. I always laugh when it happens, but it's so necessary, so right. That when the tragedy is occurring, that the external world recognises it and responds accordingly. An eclipse, thunder and lightening, pouring, torrential rain. That's what we felt and that's how the world should have responded to us. But instead, like the scene as Icarus crashes into the ocean, everyone gets on with their lives. They don't notice the pain, because it's not visible enough, we're trained to keep it in.

Monday night was even worse on that basis, the dinner with my entire family to celebrate my mother's 70th birthday. I had booked the restaurant, organised the cake, bought the present, made the card. Everyone knew about our situation. I knew that we would get bad news the following morning. I know you were still hoping for us at that point, and I know my family was, but I knew after that first ultrasound that things weren't going to go our way. So I barely held it together through dinner, as my brothers and SILs talked about their beautiful sons and the lovely things they've done recently. My father gave my mother a picture of her taken exactly 40 years ago at the Grand Canyon, when she would have been about 2 weeks pregnant with me. My mother talked about how much happier she was at this birthday than she was at her 60th. And I continued to barely hold it together - and smile - while my extraordinarily beautiful SIL got the waiter to take our picture around the table.

Once the meal was over I made sure that H and I paid first. As we got up to leave the others to finish their coffee, my SIL asked for another picture outside, as it would look better than one around the table. No, I said. No. I don't want there to be another picture taken of this evening. And then I lost it, and I left. I feel bad as my SIL is a lovely woman and she didn't mean to upset me. But I'm dreading anyone even showing us that first picture. And when I got home I broke down again and cried to H, shouldn't our pain infect the people around us? Shouldn't they feel it too? How can people who love us go on being so happy when our lives are falling apart? It doesn't feel right.

And then I feel horrible for wanting other people to feel miserable. I honestly don't want them to suffer, but I do want some acknowledgement that our lives suck right now. Just like I want the weather to reflect our pain. Our families all know, and told H when he called them how sorry they were. But no one has done anything other than send an email (my mother). No calls, no other emails, not even a text message. One of my college friends called Tuesday night, and another has texted me. One has emailed. Why doesn't my family get it? I don't really want to talk about it but I do want to know that they are thinking of us, however impotent they are to help.

But I guess the answer is that this doesn't really affect their lives. Of course they are sad for us, but then they have to get up to feed their baby in the middle of the night, or go to that important meeting, and that's their life and it takes over. And that's all fine and normal. But it's hard to take when it feels right now as if this sadness that I feel is never going to go away. Maybe that's right, maybe that's true. I know the sadness will get easier (much easier) to deal with and I know we will agitate for our next cycle and in time we will either have another baby or we will move on in other ways. But I think I know that there will always be a part of me that will mourn this loss. Our 22 January 2007 baby. The baby that never really existed. Certainly I will never look at a positive peestick with the same joy again.

This post hasn't really ended up where I thought it was going. It was going to be a musing on how suffering is so hard to understand, from an intellectual perspective. But I see that it's too raw, too present for me right now for me to be able to take that intellectual position.

I remain awed and cared for by all your comments over the last three days. Words can't thank you enough.

Bringing the end a bit closer

It pays to say (or type) what you think to your doctor. In writing to Dr Candour yesterday to let him know that I didn't want to take him up on his offer of a consultation, I explained that I wanted to go for the ERPC as soon as they could confirm that things were over. He has just written back to say that he can fit me in next Monday, so he suggests I book my scan for first thing that morning, then come straight over for surgery later that day. Sounds like a deal to me. I need to check with him if being on heparin changes anything, but other than that, consider me booked in.

Just FYI, he said that the reason for their conservatism is that about six years ago in Bristol, a woman was told she had had a miscarriage. A week later things were found to be ok. The same thing then happened again with the same woman two years later. Since then "all units scanning this early have diagnosed a miscarriage over two separate scans." Seems to me I've already had the two scans, but I think because the first one did show (perhaps) a fetal pole, that it doesn't count. At least I understand the protocol now. That poor woman.

Thanks for all your comments. I actually found it harder to wake up this morning than I did to get through yesterday. It's the waking up and realising that things are just going to go on being really bad that hurt the most. I don't have the words to type about it right now, no doubt I will in due course. This is why we blog, right? Anyway, thanks again. 

The beginning of the end

The sonographer looked for ages. I can't fault her for thoroughness. My bowel was in the way so she massaged my abdomen to try and move it. The picture still wasn't great. But it didn't look good. There was a gestational sac. There was a yolk sac. There was no clear evidence of a fetal pole, let alone a heart beat.

She went to get a doctor, who has to view the scan in all cases of a miscarriage. I asked for Dr Casual as opposed to Dr ICU. As the sonographer left the room, H started to sob. I have never seen him sob before. Tears have come to his eyes as I have wept over our misfortunes, but today he sobbed. We sat there, me awkwardly holding the paper sheet over my nether regions, and waited. And waited. And waited. After 10 minutes Dr ICU popped in, noticed there was no sonographer, then left again. I cried some more, thinking that Dr ICU (who I'm sure is a lovely person, but I just don't like him) would be the one to confirm my miscarriage.

Eventually Dr Casual appeared with the sonographer. He'd been doing the transfers upstairs. In the meantime Dr Candour had called down to speak to the sonographer to hear our results, she told us, and had asked them to get a blood test as well. So Dr Casual did a further scan. Lots more pushing and prodding to try and get a good picture, with the same outcome. There was a gestational sac. There was a yolk sac. But there was nothing that could be described as a fetal pole.

The sonographer and Dr Casual agreed that this was not good. Then they told us we needed to come back in a week for another scan. "You're joking!" was my reaction. No, apparently they are not. Because they couldn't get a good picture, they don't want to initiate a surgical 'completion' of the pregnancy, nor do they want to stop the progesterone support and see what happens (I don't want that one either, thank you). So we have to continue with progesterone, and heparin, etc etc etc, for another week.

It's a different week than last week though. There is no hope. They agreed that although there was some minuscule, microscopic, vanishingly unlikely chance that this would work out, none of us really believe in that chance. 7w1d with no fetal pole doesn't really bode well. "If you start to bleed," said Dr Casual, "you must come straight into the hospital." But I'm not actually likely to bleed because the progesterone is keeping everything going. So next week we will return, they will confirm that everything looks shit, and then, hopefully, they will let us have a surgical procedure, which they didn't call a D&C but I didn't catch what they did call it, to 'complete' this pregnancy. Dr Candour has sent me an email saying that he is available this afternoon if I want to see him. Other than showing up and weeping, thus making him feel awkward, I'm not quite sure what this would accomplish, so I think I'm going to say no.

On the way to the hospital the one thing I was hoping for was no more ambiguity. It's not really ambiguity, but the doctors are treating it as if it is. What, precisely, did I do to deserve this?

In the 'life is shit' category

Zarqa's pregnancy is ending. Her baby, a girl, had Down's syndrome. Zarqa is about to disappear from the bloggy world. Go and tell her you're thinking of her and you'll miss her before she goes.

Limbo defined

In November, many papers reported that a year-long commission on limbo was about to recommend to the Pope that he abolish limbo. I cannot find a news article that says whether this happened or not, so I guess this decision is still in limbo (I know, cheap shot). For those of you who aren't Catholic, the concept of limbo is that it is neither hell, where wicked people get to know the wrath of Gd forever, nor heaven, where they get to be close to Gd forever. Limbo is therefore populated with the souls of babies who never got to be baptised, and those who lived before Jesus could redeem them, but who were otherwise good. They get neither one nor the other. Dante saw limbo as the first circle of hell, but before the gate of judgement. A beautiful but dull castle where righteous pagans resided. Catholic official doctrine never formally recognised limbo, but apparently most people believe in it, making it hard to abolish. Maybe why that's why they don't seem to have made a decision.

Limbo in colloquial terms, of course, simply means being held up without being able to move forward. The Amstrad computer, apparently, used the term 'in limbo'  to refer to files which had been deleted but which could still be restored.  Neither in one state or the other. Sounds pretty apt to me. I'm still here, in our own current limbo. I'm having good days and bad days, or probably more accurately, good moments and bad moments. Yesterday afternoon was a bad moment. I got overwhelmed by the immense need of my mother to talk to me, despite me telling her I didn't feel like talking about it, and the immense need of my family to get me to organise my mother's 70th birthday present, and the immense need of my mother for H and I to show up at her house for tea this afternoon despite the fact we're having a posh dinner with her and the whole family tomorrow, on her actual birthday. I'm fed up with people needing stuff from me, it's hard enough to get through the day with a smidgeon of politeness and niceness for my colleagues, without needing to do the same for my family all weekend. I know they care and they're just trying to show it, but frankly I just wish they'd go off and care somewhere else.

H is also majorly stressed about work, as well as very sad about what is happening to us, and I'm finding it hard to know what to do to help him, he's just so bloody miserable and he doesn't want to talk about it. Instead he just Fs and blinds whenever anything tiny goes wrong (burning the toast this morning, the coffee spilling, his computer going to sleep, the neighbours playing the radio), and finds it very hard to calm himself down.

Yesterday was also not a good day as I had to go shopping for something to wear to a black tie event next weekend. One which I really, really don't want to go to. I am a bit fat right now and looking at myself in a changing-room mirror is all I need to make me feel like a big blimp. I remember when, only 18 months ago, I was on the small side of a size smaller than I am now. So bloody depressing. H and I have agreed that if this doesn't work out, our summer holiday will be at a spa in Thailand where I've been before, where they serve you such totally delicious food that you don't realise you're only eating 1000 calories a day, and there are exercise classes at all hours of the day so you can get fit and relax. And everyone is really really nice to you. The two times I went there before I lost about 8 pounds in 2 weeks which was a great confidence booster. I need that right now.

I mostly feel that we are going to get bad news on Tuesday. It just seems that that is the way our life works right now. Also, I just don't feel pregnant - see below table for the scientific examination of signs that I am or am not still having a pregnancy. The boob thing upset me. They shrunk back sometime last weekend, and my nipples are no longer that bit darker. That was my one compelling symptom! Yes, I know, symptom, schmimptom, but still, don't tell me that those of you with pregnancies under your belt didn't spend a chunk of time looking for those illusive symptoms?

Reasons why this pregnancy might still be continuing	Reasons why this pregnancy might not be continuing
Boobs ache a lot towards the end of the day, bra doesn’t fit well	Boobs are back to a ‘normal’ size, as are nipples back to a 'normal' colour
Round ligament pain, often excruciating
No bleeding; stretching type aches in the uterus-type area	Period-type aches and pains
	No constipation
	No nausea, not even a smidge
Still very tired	Have been working very hard and not sleeping well

I've decided that I want a D&C if there is nothing in that sac this time. I don't want to spend weeks waiting for a miscarriage, and I'm scared of the pain and the blood if we let it happen on our own. And presumably the heparin treatment has some implication here? We'll have to see what the doctor says.

The general lack of feeling pregnant has an upside in that I can sometimes forget that this is happening. And then I get excruciating round ligament pain when I roll over in bed, and I remember. Last Tuesday seems in a way like a bad dream, one in which we are still living. I wonder how this Tuesday will feel. I'm scared. I have to give a speech first thing Tuesday morning (which I should be writing right now), then I head off to the hospital to get the news. I've booked the rest of the day off. I don't know what I'm going to be like. Despite my negativity I still have hope. Just a little. There is still a chance, but the likelihood that we will get given this chance seems so very small.

You were all right, it's been a long week. Two sleeps until we find out either way.

Last night I dreamt...

...that somebody loved me. No, sorry, that was just for Pru and Pamplemousse's benefit.

Last night I dreamt that we went back to the clinic. Actually just I went back to the clinic. One of the embryologists was there with my mother, looking at my ultrasound pictures (not sure how they did them without me but somehow this didn't matter in the dream). They handed me a newspaper article - it looked like the Daily Telegraph - which had a detailed "artist's impression" picture showing my embryos and where they had implanted. That's right, embryos. One had implanted high in the left wall of the uterus - which is where we saw our gestational sac on Tuesday. The other was hard to see but it was right down near the cervix. "That means placenta previa," I noted to the embryologist. He nodded sagely. The embryos were drawn in a vaguely humanoid shape, surrounded by vasculature, and the wall of the uterus showed similar detail.

I then had a conversation with my mother who was very angry about something. She had donated her eggs, but I hadn't used them, and something had gone wrong with the egg collection procedure and one of her ovaries had been messed up. She was in a bed in the middle of the clinic. I tried to resolve things but we didn't quite manage to.

Then I left the clinic and went to meet one of my teams. They were having an outing at a castle. I was clutching the Daily Telegraph article, and kept looking for other copies of the Daily Telegraph to buy. It was a hot day. I realised that I'd left the clinic without knowing if the embryos had a heartbeat. I thought it would have been pretty cruel to give me that newspaper article if they didn't have a heartbeat, but still I really wanted to check. So I was alternately calling my mother and the clinic to try and find out, but no one was answering.

At some point my team wanted to climb up to a burial mound on the top of a very steep hill so I decided I wouldn't join them. I wandered off through the town and came across my sister-in-law to be (not either of my current SILs) who was looking for a place to get married outside. One of our family friends had a great house in this town we were in, with access to a communal garden, and this SIL was scoping it out. She decided it was not for her, but not before we'd spent time in this friend's house, who turned out to also be some kind of cousin with lots of family photos arranged on her piano. The SIL decided to get married somewhere in the US. I'm still trying to call the clinic.

I was very much involved in the dream. It had seemed totally real despite the wierdness. I believed it. Both embryos. Twins. Sometime after that I woke up. And it wasn't true.