Gestational Carrier Update

I’ve been a little quiet this week, but today I’m happy to share an update about our gestational carrier journey. It’s been a week (plus?!) of appointments, questions, flexibility, and changes to the original plan. With the blessing of our carrier, I’m sharing a bit about what we’ve been up to!

Initially, we planned to do our first frozen embryo transfer to our carrier on Wednesday, June 5. In preparation for the frozen embryo transfer, our gestational carrier took estrogen and had a monitoring appointment to make sure her body was responding to the medications appropriately. (Well, appropriately for a frozen cycle and per the clinic’s guidelines – remember, every woman’s body is different and what is appropriate for one might not be for another!)

After nearly two weeks of twice daily estrogen pills, our gestational carrier made the trip to our clinic to meet me for our monitoring appointment on May 29. At that appointment, our doctor was looking for a thick uterine lining (more than 7 mm), no fluid in the uterus, no ovulation, and no structural abnormalities (like a cyst). Structurally everything looked sound, but there was a bit of fluid in the uterus at that first appointment and the lining wasn’t as thick as my doctor would like. After reviewing the blood work on our carrier, our doctor upped her estrogen dosage substantially to try to build the lining and asked her to come back in 48 hours - which she graciously agreed to do.

48 hours later, we met for the second monitoring appointment. The fluid in the uterus was gone (YES!), but the lining was actually a bit thinner than it was at the first appointment. We discussed our options, and we all agreed to delay the transfer and have our carrier continue with the increased estrogen protocol for five more days with a recheck on the day of our originally scheduled transfer (June 5).

On June 5, we met at the clinic again, and our carrier had another scan and blood draw. The lining was a bit thicker, but it was still not up to the minimum required by the clinic for a transfer. At this point, we had some decisions to make. One option was to scrap the cycle - which would mean having the carrier stop her medications and wait for her period to start a new round of estrogen in an attempt to thicken the lining the next month. Another option was to convert the cycle to a testing cycle, and complete an ERA (endometrial receptivity assay) to test for uterine receptivity to receiving an embryo. We decided that rather than “waste” the medications our carrier had so graciously been administering, we would move forward with a test cycle.

The test cycle means that we will go back to the clinic and the carrier will have a uterine biopsy in the next several days. It also means that in addition to her estrogen protocol she is starting progesterone shots. The test cycle requires us to do everything exactly as we would as if we were having an embryo transfer, but instead of the transfer she will have a biopsy. The biopsy test result is timed (literally to the hour) to correspond with her first progesterone shot, and the result should tell us if she is “receptive, pro-receptive, or post-receptive” to receiving an embryo during that time window. I’ll do another more in-depth post on the ERA testing in the future, but for now know that our carrier is a trooper!

We are all feeling glad to use the cycle to gain a little more insight into the best time for an embryo transfer. The delay does mean a little more uncertainty about timing and when we will move forward, but for now the risk averse side of me (and of our carrier) is focusing on the fact that we will all feel more comfortable with a transfer once we have the information from the test.

Thanks for the continued support. We've felt so much love from so many this week who knew the exact transfer day that we had planned. Though we didn't move forward with the transfer, we appreciate all of the prayers and well wishes, and we hope you will share them with us and our carrier again in the coming weeks for the biopsy, results, and (hopefully!) transfer!

The Fertility Work-up

One of the first things you might face as a fertility patient is something called the fertility work-up. It's basically an in-depth look at a couple’s overall health, reproductive history, and a first pass at tests that might identify an easily “fixable” problem that is keeping a couple from conceiving. While the process may seem tedious when you desperately want a baby, the results of the work-up will ultimately shape the course of your treatment and might save you valuable time and money in the long-run.

While a doctor will order specific tests based on a couple’s history, some components of a work-up are fairly standard. Here is what was included in our work-up, but please keep in mind that every patient is different and your doctor will order the right round of tests for you.

• Q&A: Your provider will likely ask a series of questions about your general health (do you exercise, smoke, drink, do drugs, etc.). He or she will then ask questions about your cycles, your use of birth control, your sexual history, and any past pregnancies. 

• Physical: Your doctor may opt to do a shortened "physical" just to check for general health and well-being to rule out any obvious or glaring health concerns.

• Blood work: A fertility work-up often includes blood work panels, some of which are drawn at specific times in a woman’s cycle to test for certain hormone levels. Blood tests are usually measuring the levels of estrogen, FSH (follicle stimulating hormone), AMH (anti-Mullerian hormone), and LH (lutenizing hormone). Your blood work may also include a panel checking for more general health items like iron levels, and it will almost certainly include a screening for sexually transmitted diseases for you and your partner.

• Hysterosalpingogram (HSG): An HSG is an x-ray of a woman’s uterus and fallopian tubes. Mine happened in a hospital where a radiologist filled my fallopian tubes with dye while taking x-ray photos to make sure the tubes were not blocked. I was very scared while the procedure was happening - I had heard it was uncomfortable at best and painful for most. All in all my experience was not bad, although my tubes were open and many women who report pain have blocked tubes. I’d suggest talking to your doctor about taking some Tylenol to help with possible cramping, and taking lots of deep breaths while the test is happening. Keep in mind that this may also be one of the first tests you undergo in a hospital with x-rays, catheters, etc., so it's bound to be a little more intimidating. 

• Ultrasound: A vaginal ultrasound gives your doctor a chance to look for any abnormalities in the uterus or on the ovaries, and it allows your doctor to rule out any major structural or anatomical issues.

• Semen Analysis:The semen analysis is probably the quickest and easiest test in the work up (though your partner may say otherwise!). The doctor will analyze a semen sample and look for sperm count (the number of sperm in the sample), sperm morphology (the shape of the sperm in the sample), and sperm motility (the ability of the sperm to move and swim towards the egg in the fallopian tube.

• Genetic Screening: Some doctors and clinics will order genetic carrier screening during the initial fertility work-up. We did not do genetic screening as part of our work-up (though we did prior to starting our IVF cycle).

All of this might seem a bit overwhelming and daunting, but your physician will walk you through each step of the process, and many of the steps can be completed in one or two cycles. There isn't much you can do to prepare, but it is helpful to bring a calendar and notebook. You'll use the calendar to discuss your past cycles and to chart out the timing of your future tests as many of them are very specific to certain days of your cycle. The notebook is helpful to jot down information your physician shares, follow up question, or frankly words you just don't understand - fertility can feel like its own language when you start down this path! As an aside, please make sure you ALWAYS ask your doctor when you don't understand something. This process is tough enough emotionally, physically, and financially to have the added burden of anxiety because there is a test, a word, or a concept you don't understand. In my experience, your doctor wants to help you and they definitely want you to be knowledgable about as much of the process as possible. 

Some additional resources and more information about what might be included in a typical work-up visit can be found here and here. You can also check out this podcast and this YouTube show for more on the types of questions and testing that might happen at your fertility work-up appointment.

Please remember that I am NOT a doctor, and nothing in this post (or any of my posts) should supercede the advice of your doctor. It is so important to have a strong, solid relationship with your medical provider as he or she will know your history and goals, and he or she will provide advice and treatment personalized to YOU.