Where do we go from here?

Merciful things: my hcg is below 5. I did not have to use my DIY Uterine Evacuation Kit. It is over, and was pretty painless.

That was my last shot on insurance. I have no idea what comes next. Crazy Al's IVF Shack? He has a clutch of my embryos from when I was a mere slip of a girl at 34. They're probably in better shape than my creaky miscarrying 38-year old eggs. Although it's possible the uterus is just broken. On the other hand, Al froze them in a second-hand popsicle maker, so the thawing attrition is likely going to be ugly. Al's documented success rate with frozen embryos is like 13%. If I wait until January I could have one more cycle covered at Al's, and out-of-pocket cycles are likely to be cheap because hey, Al.

From the clutch of 9 at Big Shiny Fertility Factory, I have three left. I could do at least one more cycle with them.  It would be out of pocket, and expensive. I'm a bit resentful about how expensive, considering that I now know exactly what the insurance reimbursement they received for the same cycle was, and believe me, it's less than half the amount I'd be shelling out.

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I don't know what's next. I didn't honestly believe that I'd be here. I somehow trusted in the narratively satisfying ending of my third attempt succeeding.  I am beginning to suspect that my uterus is not all that invested in my narrative satisfaction.

I would like to tag this with "moving on" but I'm not at all sure where I'm moving on to.

It's all over but the bleedin'.

Hcg 115. Game over.  Not too surprised -- after the bleed on Thursday night, on Friday I passed something suspiciously... embryo-like.  I had this wild fantasy that maybe it was one of twins (really, self? With those betas?) but yeah, no.  Honestly, I knew it was over then.

At least the timing is actually pretty good. I'm about to go to Vegas for a week for a conference, and now I won't have to bring shots. And I can drink coffee, and take the antihistamines I've been denying myself for the past two weeks. And it is blessedly not dragging me through beta hell, meandering across and down in a laggardly fashion -- that's a damn good sharp plunge.  Almost as if I'd, you know, passed the entire sac on Friday.  So I hope that's a sign that this will be over cleanly.

If not, though, I'm going to Vegas equipped. In my cosmetics bag I have a DIY uterine evacuation kit, leftovers from the last round: misoprostol, Zofran, painkillers. If this drags on in a painful way I can take care of it quickly. I probably won't use it, but I find it incredibly comforting that I have it.

It gets better.

Things are better. I'd have to look at a calendar to figure out where I'd be right now; it's fading, gently, covered with snow. Maybe not coincidentally, my hCG is falling, too. Two weeks ago it was 21. I have a recheck on Monday and expect it to be zero.

There have been a lot of babies around me lately. The lady in line in front of me at the thrift store had two huge baskets full of stuff. Checking her out took a while, so we had time to chat.

"How old are your kids?" I asked.
"One month, three, four, and five." She laughed and rolled her eyes. "How old are yours?"
"Three and a half."

I don't know. People don't get to choose the thing that's hard for them. This lady was, judging from her clothing and heavily accented English, a recent African immigrant. I'm willing to bet that the journey and adjustment hasn't been easy, even if she has had the best of circumstances. I don't know where I'm going with this. People don't get to choose the thing that's hard for them. A friend of mine, the thing that's hard for her is breathing. How is that fair?  I don't know.

But never mind, on to happier subjects. Her Indoors and I had been waffling about getting married until we knew the likely outcome of the pregnancy. I definitely wanted to be hitched before the baby was born, for the legal protection it'd give our family. That meant probably a small courthouse-type thing. But now that that is no longer an issue, the calendar opened wide up, and we could schedule it far enough in the future to give us time to plan the wedding we really want. So: next December! I am insanely excited.  I've been madly pinterest-ing and browsing for silk velvet and roses and sari fragments. I want this, and I can have this. I'm burying myself in wedding prep and it's really comforting.

I'm going to cycle again once I'm able, and maybe I will get pregnant and stay pregnant, and maybe I will be enormous and pregnant at our wedding. But you know what? I can't plan around it any more. I have to go ahead and live. If I get pregnant, we'll adapt.

Not 12 weeks

Today I'm not 12 weeks. 12 weeks, the last week of the first trimester, the time when most people start sharing the news. I'd be scheduling my nuchal screen.

I'll stop this self-pitying countdown eventually, I'm sure. I'll just forget one day, and not remember until Thursday or Friday or something. I'm not trying to be mopey about it. It's just Wednesdays are hard not to count.

My body is apparently remembering by offering a fresh bright red bleed. I guess it's good? I mean, action is good, right? And maybe it'll help my beta come down, in case there's a wee clump of trophoblastic tissue somewhere generating hCG.  My pee sticks aren't notably lighter, which makes me grumpy. Last Friday my beta was 467; recheck in two weeks.

Here is my riddle: how is a BFN different than a chemical pregnancy different from a 6 week miscarriage different from an 8 week miscarriage?  After all, they all end up in the same place: unpregnant.

I am not sentimental about embryos. With eyes focused on the bottom line (i.e. chances of success) I have always pushed for the production and cryopreservation of as many embryos as possible. If we have any left over, I will cheerfully donate them to Science.  If I am not sentimental about embryos suspended in cryoprotectant, then why be sentimental about embryos in my uterus, or no longer in my uterus?

There is a difference, and that difference is the difference between missing a bus by seconds, minutes, hours, days, weeks. How hard my heart was pounding, how much I thought I'd make it, how ferociously I clench my fists and dig my nails in frustration.

A BFN is missing the bus by weeks, I think. A pre-heartbeat loss is missing it by days, and a post-heartbeat loss is missing it by hours. I can only pray with all my heathen heart that I never experience missing this particular bus by minutes or seconds.

Not 11 weeks

Today I am officially precisely not 11 weeks pregnant. It's been two weeks since I took the misoprostol, three since the ultrasound where the RE said "I don't see a heartbeat".

Things are okay. I had a followup appointment two days after the misoprostol, and everything looked good and clear. That was the best I could've hoped for. My pee-sticks are still a lot darker than I'd like, but I guess it takes some women a really long time to clear out all the hCG. I can't start another cycle until my level is all the way down and I have another period, so I'm just spinnin' my wheels here. I have another followup on Friday. I imagine they'll start doing blood tests every week or two until I'm at zero.

Time floats by so aimlessly when you're unpregnant. Pregnant means that every day is an achievement, and is moving closer to Something Big. Unpregnant you're just waiting for something that may or may not happen. And if you can only conceive with fertility treatment, you're waiting to start waiting for something that may or may not happen.

I'm mostly back in the TTC mindframe (as opposed to the pregnant mindframe). I know how to do this; I've spent a lot more time trying to get pregnant than I have actually being pregnant.  But some part of me, maybe 10%, is still stunned and saying wtf happened here?  See, it all just seemed so right. The transfer was exactly on my birthday. The due date was exactly my mother's birthday. My BFF is pregnant right now, and we were going to be pregnant together. Some things are just meant to be, you know?

Some things, but apparently not this one.

A poem has been stuck in my mind: A Refusal to Mourn the Death, by Fire, of a Child in London. I don't know why. I have only a weak affinity for poetry, and almost none for Dylan Thomas; most of it just reads as word-salad to me. But this one has been drawing me back. I guess "unmourning water" is really a pretty good description of the resting place of those two tiny embryos, poor miniscule brine shrimp, released unto the municipal sewer system.

9 weeks: finding the reset button.

Today would've been 9 weeks. Last Wednesday I'd resolved to wait, zen-like, for my body to take care of this naturally, gently.

That decision lasted until the evening. I did a little research and found out that with misoprostol, it's frequently over within twelve hours. The old-fashioned way can take, literally, weeks. Weeks of bleeding, weeks of cramps, weeks of pregnancy symptoms.  I did the math (number of weeks multiplied by insanity factor) and by the next morning was super-keen to get the misoprostol.

Except it turns out that the misoprostol I was offered so lightly on Wednesday night was actually a pain in the butt to get. I called Thursday morning, with some idea that I could stop by the office on Thursday afternoon to get the prescription. Hahaha no.

I finally got a call back Thursday night telling me that someone would call me Friday morning. On Friday morning, the PA called and said she'd talk to the doctor and get back to me later in the day. At 5 pm she called me back and said "you'll have to come in for an appointment on Monday."  I'd dreamed that I'd be able get it all over with by the end of the weekend, and was bitterly disappointed to be denied.

Anyway, I dragged through the weekend -- I say "dragged" just because the pregnancy-fatigue was still going strong, along with the need to get up and eat a three-course meal at 2 am every night. Pregnancy symptoms are a lot of fun when you're going to have a baby. They're just an annoying inconvenience when you're not.

Monday morning I went in for my appointment. They'd mixed up the paperwork and had me down for an ultrasound even though I was only supposed to be there for a consultation. "What the heck," thought I. And maybe, just a little, maybe .05% of my brain thought what if it's all a mistake? What if it's a Christmas miracle? What if there's a little heart beating away in there?

There wasn't. There were two little embryos, measuring 6w2d and 7w4d, clearly sharing a placenta (i.e., identical). They looked like little packing peanuts curled up in there, two very quiet packing peanuts. I kind of wish I'd gotten a picture, but for some reason they don't offer you pictures of the dead ones. But in any case, I was still glad to have seen them again. Last week I hadn't gotten a measurement for Little Twin, so it was oddly satisfying to have that verified. 

The doctor's not a big fan of misoprostol. He gave a decent shot at trying to convince me to do a D&C. He assured me that they're "very gentle" and that they "only use suction" and "the chances of getting scars from a correctly-done D&C are almost nil". If I did a D&C it would all be over quickly. If I did a D&C I could have a chromosomal analysis done of the tissue. With misoprostol, 40% of women have to have a D&C anyway.

Unfortunately, I know that most of what he was telling me wasn't true. Don't get me wrong, I think this practice is very good at what they do, which is reproductive endocrinology. They don't know jack shit about Asherman's Syndrome. Yes, you can get adhesions from a properly-done D&C. No, using suction only doesn't prevent scarring.  No, a woman with Asherman's shouldn't get a D&C done unless there is absolutely no alternative. Misoprostol is more than 80% effective if you give it a whole week to do its work (this practice judges after three days).  I'm a walking dictionary of misoprostol trivia at this point. I spewed some figures and he sniffed and shrugged and said he'd go to get the consents.

He left, and then I cried. I wasn't really expecting there to be a living baby in there.  But seeing the pictures was still... hard. Little Twin was pretty indistinct, but Big Twin looked like such a perfect little fetus. Perfect, just dead.

I spent the next three hours getting my blood drawn (they require a hematocrit), waiting for the bloodwork to come back, waiting for this, waiting for that, waiting at the pharmacy. It was, apparently, lovely weather for a sleighride together with me. Also, I should have myself a merry little Christmas, and that's the Jingle Bell Rock. I did not stab anyone.

Four hours later I emerged with 8 200mg tablets of misoprostol, a strip of Zofran (anti-nausea), and a handful of Ativan, I guess in case the process made me edgy? I'd already filled a prescription for some painkillers.

I decided to wait until Wednesday morning. Misoprostol can be unpredictable, and if I were going to be doubled over/vomiting/yelling/cursing/hemorrhaging, I wanted it to happen when Small Boy was at preschool and not when the poor dude was trying to have himself a Merry Little Christmas.

So yeah. This morning I dropped him at preschool, went to the supermarket and picked up a party-sized pack of sanitary napkins. Went home, popped a Zofran and a Perc. Half an hour later I briefly dipped the misoprostol pills in 5% acetic acid, better known as white vinegar, and crammed four of them up the hatch (via my handy PreSeed applicator). I then waited for something to Happen.

An hour later I started cramping. Four hours later I felt like something was going to Happen. I shuffled over to the bathroom and then in a mighty rush, the entire universe fell out of my uterus.  In the space of five minutes I passed the gestational sac, the fetuses, and what Her Indoors was sure was at least some of the placenta (she's a biologist, so I have some faith in her identification).

Friends, that is some good stuff. I know everyone is not as lucky. Some women end up writhing and puking, and some women get no effect at all. But for me, it did exactly what it said on the tin. The cramping has been no worse than bad period cramps (admittedly, without the painkiller it probably would've been a whole lot worse). And holy god has it cleared a lot of underbrush out very quickly.

I've been bleeding briskly since this morning. The cramps have gotten better and worse, but the painkillers keep them bearable.  I won't know until Friday if the job's completely done. If it's not I'll likely have to fight not to have them "clean it up" with a D&C. But fight I will; if anything lingers, you bet I'd rather have another round of misoprostol.

Right now I feel wrung-out and crampy but so relieved, and grateful that the misoprostol seems to have worked for me. Fingers crossed that Friday finds that it truly is over.


¹The literature is a bit mixed on whether or not dipping the pills in acetic acid definitely speeds action/improves absorption. But I figured I'd try it on the grounds that at worst it would have no effect, and at best some studies have found it halving the time to completion (which otherwise averages about 12 hrs from administration). Since my uterus enthusiastically spewed four hours after inserting the tablets, I'm inclined to believe that it helped. It also makes a lot of intuitive sense to me. As soon as I dipped them they started to disintegrate. I was basically inserting a firm paste, not dry pills.  If any internet travelers stumble across this, I personally vote "yes" on dipping in 5% white vinegar.

8w ultrasound

No heartbeat. Game over.

I'm okay. Disappointed, to put it mildly, but okay. For the past ten days I've been worrying about the fact that she thought it was likely identical twins -- two yolk sacs, one gestational sac  -- and I am not a great candidate to carry twins, for a variety of reasons. But in retrospect, it turned out not to be an issue, huh?

Sigh.

Now I just stop my meds and wait for it to... pass. I was pleased and surprised to be given prescription pain-relief. My last doc didn't offer me that, but then again the miscarriages were much earlier last time. I hope this doesn't hurt too much. My theory is that doing it naturally will be less painful than taking the misoprostol. We'll see.

Just... damn.

In which I catch a break

Pathology is back; it was an intrauterine pregnancy. This is very good news. This means it's over.

I resisted the D&C so hard, but now that it's over I'm glad I did it. I hated analyzing every pain and every dizzy spell. I don't live well under uncertainty, and once there were no good outcomes possible, the best outcome was for it to be done with. I alternate between fits of cheerfulness and near-euphoria -- it's over, it's over, it's over! -- and dips of extreme sadness. Staying home today, lounging on the bed, catching up on Season 6 of Doctor Who.

My poor little blastocyst. It tried so hard, and hung on so long. It just didn't know when to let go. I can relate.


ETA: Doctor just called to let me know that there wasn't enough tissue for chromosomal analysis. I'm both disappointed and relieved. It would have been kind of nice to have any more information, but I know I would have totally lost my shit if I'd had to find out whether the fetus was male or female. Probably for the best this way.

Well, there's one off my bucket list.

The D&C is over. It was far from horrible; the worst part was the endless wait. My surgery time was 11:30 and I was told to be there at 9:30. I was taken back at 1:30pm.  Four hours is a long time to wait, especially when for three hours of it you're not wearing pants.

Good things:

• My IV went in beautifully first try (I've had some traumatic IV insertions in the past). 
• I was afraid I'd start crying on the table, but I didn't. I was okay. 
• They didn't use general anesthesia after all; instead it was the same lovely, lovely IV sedation that I had for my egg retrievals. Apparently I take anesthesia fabulously well. According to the doctor I was in "fine form" and very talkative; I don't remember a single thing. I lay down on the table, and then it was over.
• Recovery from the anesthesia was easy, easy, easy. I woke up feeling extremely mellow.  Lay there, drank some juice, and went home. 

Only dark spot was that we were unable to get a cab (WTF??) and decided to walk home -- it's barely a mile, very close, not a big deal -- but I had such a strong urge to be safely home, home, home that it was a bit harrowing. But we made it.

Now I feel pretty wiped out, but cramps are minimal.

I wondered if I'd feel devastated when it was over, saying goodbye to the last little scraps of what I so desperately wanted to be our second child. I don't, thought, not right this second. Right now I'm just so glad it's over. Based on details that I do not know and do not want to know, my doctor feels optimistic that the pathology report will show that it was an intrauterine pregnancy. We'll get the report tomorrow. Then this'll be truly over.

34dpo

Beta: 801. Progesterone 10.6.

Scheduled for the D&C at 11:30 am on Tuesday.

Gonna be a long weekend.

6w5d? 33dpo?

I don't know how to refer to myself. Thank goodness I haven't needed any unrelated medical contact, because I don't know how I'd answer the question "are you pregnant?"

Yes, but not usefully so?
No, in the sense that you should feel free irradiating me or giving me whatever teratogenic drugs you want, because the embryo no longer gets a vote?
Yes, in the sense that any test I'm given will instantly come up positive?

33dpo is good, I guess, because it's a reference to an event that definitely happened, rather than a state that implies something is going to happen.

No news. No spotting. Peesticks are mocking me. So, you wanted them nice and dark, huh? I get repeat bloodwork on Friday; if things haven't substantially improved, I'll have to book the D&C for Monday or Tuesday. I'm getting past the point where watchful waiting is prudent. If we could be certain it's in my uterus then waiting would be fine, but we're not. If I have the D&C we'll find out fairly quickly whether or not that's where my little zombie child has set up shop.

I called and ask a few questions, and I'm surprised? pleased? dismayed? to learn that they do D&Cs under general anesthetic. I didn't have a general for any of the egg retrievals, just a lovely, lovely IV twilight sleep. I had kind of thought and hoped it would be the same for this. I do like the idea of just really not being there for it. I've had friends who've had D&Cs under locals tell me in no uncertain terms that it is not a pleasant experience. OTOH, I've never had general; for my c-section it was a jacked-up epidural plus, I dunno, something else that made me super woozy but didn't actually knock me out. The general does make it seem like a bigger deal.

I've decided that I like the term pregnancy wastage. It sounds like what it is: a waste. A waste of time, effort, money, pain.

Things're okay. The last time I was in this position, in March of '08, it was pretty much "bottomless pit of despair". Now there's still some despair, but the pit has a bottom.  I am longing for this to be physically over, all of the phone calls and hold music and blood draws and small pains and indignities and reminders and hormones. I know I'll feel better then.

6w2d: Zombie embryo

Today's beta: 590, progesterone 18.

Poor little embryo. It doesn't know it's dead. Poor little thing just doesn't know when to quit.

I was offered a D&C tomorrow, but I just can't get myself organized mentally or physically for that. And there's still a hope that if I wait a bit longer my body will figure it out on its own. The danger is that, given the inconclusive ultrasound, we can't be 100% sure that it's not ectopic -- but it likely isn't.

I don't know what the right thing to do is. I'm scared of the D&C, but the idea of having this over with is very appealing. If (as is likely) Zombie Embryo is in my uterus, my hcg levels should go down pretty quickly afterwards. No more sore boobs, no more useless pregnancy symptoms. I could be good to try again in February or so.  It'd be over.

On the other hand, the logistics give me a headache. I'd have to figure out about getting Small Boy to and from preschool, I'd have to take time off of work, I guess I'd have to take cabs since Her Indoors doesn't drive, I know the whole thing would end up costing a mint which, although I am blessed to say is not my primary criterion, adds a special insult.  More, I think, the idea of lying there on a gurney in a hair-cover and gown is pretty awful. I'm afraid of it hurting. I don't know what kind of anesthesia they'd give me. I guess I could ask. I just want this whole thing to go away.
  
It's okay, little thing. Let it go. We'll try again, I promise.

Yep, nobody home.

Had a scan this morning. You know, I don't much think about the costs of scans on the other side of IVF. We socked away the money, whatever, when the bill comes we pay it. But I resented the hell out of every dollar this scan cost.

It was pretty useless, too. Not much of interest to be seen. A thinnish lining of 7mm, I guess I just get to wonder what that means. Was it my lining that borked this up, after all? Seems unlikely, though. Embryos are pretty robust where linings are concerned; otherwise extrauterine pregnancies wouldn't be half so common. A bit of fluid in the uterus, a smear of something that might have been a gestational sac with a fetal pole but clearly was never going to call me mama. A giant corpus luteum/cyst on my right ovary. No fluid in my abdomen, so that's good.

My pee-sticks are dark, dark, dark. I hope that things turn around during the weekend and start to lighten up. Otherwise I get to go back to "empty the uterus". I do not think that sounds like a particularly good time. Rechecking bloods on Monday.



Things are okay, I guess. I'm frankly sick of crying. Sick of tissues and snot. I've got a rotten cold, too, and I feel like I've been in an achy-headed stupor for a week now. Thick, sore, foggy.  I think I'll feel a lot better once this thing is actually out and my hormones can settle down. The moodiness, sore boobs, fatigue and intermittent nausea aren't half so fun when there's no prize at the end.