A Positive Regroup

We had a very interesting regroup with Dr. B Thursday. I had a list of questions, and we wound up somewhere I'm really happy with, but didn't necessarily expect.

Question 1. What's your take on why this keeps happening? Lining? Aneuploidy? Something else?
A: Most likely aneuploidy. She'd like to see my lining get to at least 7, and there's no way to rule it out for sure, but everything suggests it's an egg issue for these last two CPs, not a lining issue, while the Dec and 2016 CPs were probably lining.

2. Let's talk prednisone again.
A: If I want an immune protocol, CCRM isn't the right clinic. She will put me on low dose prednisone for my next cycle. (I brought a list of six peer reviewed journal articles supporting this. I also acknowledge that I could find just as many that show no result.)

3. Lining was thicker in May. Does that suggest it could improve or give us ideas on what to do to improve it?
A: It could improve. It's most likely that having more days of estrogen exposure due to the long stim was what helped it. As a result, we'll take the following approach: 1 estrace/day vaginally until the dominant follicle hits 14, then increase to 2. We'll keep using the viagra. Estrogen is what makes the lining trilaminar, nothing else can change the pattern, so there's no way to help that.

4. Do my lining issues indicate I need a repeat hysteropscopy?
A: Not yet. We've seen it trilaminar since my last surgery, and we've seen it up to 6.7. I've also been through a lot of "instrumentation", no reason at this time to repeat. We looked at my u/s from trigger day, and there is no clear pattern. When I asked why, she noted that it's probably because things were thicker in some spots than in others. At this point we really just have to hope for the best in future cycles.

5. Ovaries didn't respond until we backed off the estrogen. Thoughts?
A: Largely addressed this with #3. We'll reduce the estrogen and aim to stim for ~12 days - longer than many of my cycles, but shorter than this most recent one.

6. We ordered cetrotide after our August '17 regroup. When would I use it?
A: Only if your LH was rising indicating ovulation. The estrogen seems to be supressing that really well for you, so there's been no need. That might change if we try to stim you for 12 days, so hang on to it.

7. Best guess on our chance of pregnancy if we continue this approach? Where's the tipping point when we should move to IVF, either OE or DE?
A: Impossible to say. She noted that we clearly have fertilization and embryos that reach 12-14 days every time, so she would expect that even if we only retrieved 2-3 eggs, we'd get a blast or two. It's a numbers game as to whether those would be euploid or not. Obviously, changing to donor eggs makes the numbers more likely to fall in our favor. The advantage of IVF is it would allow us to rule out aneuploidy as a problem, and eliminate many of the worries about a late first-tri loss. The disadvantage is that we'd probably only get 2-3 eggs. Also, even euploid blasts don't implant and do miscarry, so IVF would really be diagnostic.

8. If we moved to IVF, is it possible to get a better lining if we don't care about ovulation?
A: Maybe. My OI protocol is their 'poor lining kitchen sink' protocol, so it might give us our best chance. We could try delestrogen injections plus vaginal estrace and vaginal viargra in a mock FET to see what my lining did, and that might get better. Hard to predict. She'd really like to see me at 7 before a FET, and I have gotten to 7 before.

9. If we did IVF, is there any way to improve ovarianresponse?
A: We could do a clomid/FSH cycle if it's IVF and we don't care about lining. That might get us another follicle or two. Still, don't expect more than 2-3 embryos.

10. If we did OE IVF, is there anything we could do to improve egg quality?
A: We could add in HGH. In fact, we could add that now. So, Saizen goes into my current protocol.

11. Do I retake doxy for a future cycle?
A: Yes, unless it's making me really sick.

12. Is a plan of ~3 more OI/TI cycles, followed by a mock FET to test lining, then OE/DE IVF if lining is good enough, reasonable?
A: Yes. Probably wise to test lining before investing in IVF of any sort.

I'm really happy with this. If we throw my current meds, plus prednisone, plus HGH into the mix for 3 attempts and I'm still not pregnant with a baby that can reach the second tri, I'll feel pretty good that we're not going to find the 'gold egg' from my ovaries via IVF, and we can move to DE or DINK. That's a different decision point.

Po-tay-to, Po-tah-to

Today was my first  fertility acupuncture session. We started out with a consult. She went through my fertility history. Then she told me all the things I've done wrong. IUD? Bad for the lining! D&Cs? Terrible idea, guaranteed to have lining issues after 3 D&Cs. Should have managed a natural miscarriage after my first loss, even though my body hadn't miscarried 5 weeks out. Egg quality? Likely poor. Exercise habits? Bad - wasting my life energy on exercise. Should avoid sweating. Feeling stressed when pregnant? Terrible for me and baby. She also noted that some people have actual problems to fix, some just have symptoms. I fall into the actual problems category.

She summarized: "you have bad soil."

Fair, I guess. I say 'my lining sucks', you say 'bad soil.' Po-tay-to, po-tah-to.

She wanted me to take 3 months off from trying (100 days) and focus on weekly acupuncture sessions and 24 herbal pills a day, with the intent of helping egg quality. I indicated that if CD1 falls early enough in April, I will start fertility treatments. She said most patients don't want to wait, so we'd do one month of pills and treatments once a week. Once I start injections, I stop the pills, but try for twice a week and try to schedule on ovulation day. 

We'll give it a shot. I mean, hey, it's only hundreds of dollars more and additional unpleasant poking and prodding, right? And hey, the placebo effect produces results, and all I really care about is the results, not the methodology!

First acupuncture session was . . . not terribly pleasant. She placed needles in my hands, feet/lower legs, abdomen, and one in my head. She focused a heat lamp on my abdomen, and did electrical stimulation of two of the abdominal needles. The heat was nice, the electrical stimulation went from being unnoticeable to unpleasant and back over the 20 minutes I was there. I didn't feel most of the needles during the session, but my hands and feet are sore now. I've taken my first 12 pills (6 Shao Fu Zhu Yu Pian and 6 Wen Jin Pian, twice a day). She said I might have more bleeding as a result of the treatment, but so far, nothing.

Back again next Thursday. We'll see what that this month brings.

Nope

The answer to the question could my lining improve? Nope.

At monitoring appointment #4, follicles were at 24 and 18.5, lining was 5 and cystic. They told me to trigger as we weren't getting any change from more stims/estrogen.

Basically, I just spent about $4k to accomplish the same thing I could have accomplished with a natural cycle: lining that's just thick enough to cause a chemical pregnancy.

I'm sad, although not so much about this cycle as about the fact that maybe my lining can't recover. Maybe I've been through all this horror and heartbreak for nothing. I knew that was the risk if I did the TAC surgery, but I didn't know how bad the complications from that would be. I'm stubborn enough, I probably would have done it anyway, but still. . . 

Not a great place to be going into the holidays. Off to get my mom from the airport . . . mother in law, brother in law and mother in law's fiance all arrive in the next few days. There will be holiday cheer. Or something.

Oh, and crowning glory? Earlier this week I got my first "just relax and it'll happen!" From my mom. Actually she said maybe my stress was inhibiting my lining. I know it comes from a place of love, but e-gads! I believe strongly in the mind-body connection, but my stress level isn't going to fix this any more than my mom would have recovered from her breast cancer or Grave's Disease by relaxing.

Monitoring #3

Monitoring, again. Follicles look great. E2's going up, P4's stable, LH is good. Lining? Down to 5 with only patches of triple stripe pattern. Since my LH is stable, they're having me up my vaginal estrace to 3 a day, do another Menopur, another 225 of FSH, and return tomorrow. I'm super glad the follicles look good and have responded, but I'm worried about the implications of my lining. Asherman's strikes again. 


Day 4
             2016         |   Feb 2017  |     Dec 2017
R:        11, 9, 8.5   |     6.5          |     12, 10.5
L:        12.5, 8, 8   |     9.8          |     5, 3.5
E2:      803            |       ?           |     188
P4:      2.68           |       ?           |      < 0.5
LH:     8.25           |       ?            |     3.38
Lining:  6.9 triple | 5.9 triple   |     4 uniform
FSH    600             |   600           |    900
Menopur   0        |       0            |     4 vials    

Day 7
             2016                |   Feb 2017  |     Dec 2017
R:        19, 13.6, 7        |     9.5            |     20, 17.5
L:        16.5, 15, 10, 8  |     14.5         |     6, 8
E2:      1294                  |       432        |     718
P4:      1.66                   |       <.05       |      .07
LH:     1.03                    |       1.15       |     2.84
Lining:  6.9 triple        | 7.0 triple    |     6 homogenous
FSH    1050                 |   1275           |    1575
Menopur   0              |       0               |     7 vials


Day 8/9
             2016               |   Feb 2017  |     Dec 2017
R:        22,18,7,4        |     11            |      20.5, 18
L:        18,16,10,8      |     16.5         |     7.5
E2:      1690                |     1027        |     1087
P4:      2.59                 |      0.12        |     .18
LH:     0.76                  |      1.15       |     3.18
Lining:  6.9 triple      | 6.0 triple    |     5.0 partly triple
FSH    1200                |   1875          |    2025

Menopur   0              |       0            |     9 vials
Trigger       Yes!          |   Not yet    |     Not yet

Micro-blog Monday: A Micro Period

Here's attempt #2 at Micro. Want more Microblog Mondays?  Head over to Stirrup Queens to read more!

As an Asherman's patient dealing with IF, you know the one thing that's worse than having your period go missing?

Realizing that the light spotting you had the morning of 11 DPO, your usual period day, WAS your period. Apparently my lining is so jacked up, that with a 24 day cycle, ovulation on day 14, and prometrium from 16 to 24, I only got enough lining to spot.

I am wishing, hoping, praying, etc. that with Estrace and stims to increase my endogenous estrogen, I'll be able to build a lining. But I've never had this little before, so I guess we'll see.

When Formalin is Not Your Friend (aka: Biopsy #3)

In general, I like my OB. Far more important than liking her, I think she's competent and will work with me on my care. Yesterday was not, however, one of our finer days together.

I went in for what I hope will be my last biopsy. She asked if I wanted to get three samples again: one for histology, one to culture for bacteria, and one to culture for yeast. Only the histology was positive last time, so it was reasonable to ask if I wanted to go through the unpleasantness of three samples. On one hand, I really hoped there was no need, and had no expectation of a need for bacteria or yeast cultures. On the other hand, if the histology comes back positive, I don't want to have to wait for another cycle to get another biopsy for bacterial culture. So we agreed to get three samples again.

She got three samples. I got up and got dressed. Just as I was about to walk out, she came back in and told me she'd put all three in formalin by accident, and you can't culture a sample that's been in formalin. If I wanted bacteria and yeast cultures, I'd have to do another biopsy.

Bloody hell.

Since we'd already run a catheter into my uterus once for the initial biopsy, it increased the chances of pushing in new bacteria and getting a false positive. Also, those biopsies are no bloody fun. I didn't want another. So I declined.

Let's hope the histology comes back negative for CE.

Other interesting notes:
October 30, 2016 was the day my water broke with the twins. During the biopsy, I mentioned to my OB that it happened a year ago. She commented that it must have been scary for me, and that she was scared, specifically that she was scared during my delivery a week later. I knew things were bad during delivery, but hearing that they were bad enough for my OB to be scared. . . I guess that's why my Dad, who saw them wheel me out to surgery that day, encouraged me to think about my own health before continuing to try to get pregnant.

I've had bleeding since the biopsy. More bleeding than my last period. I'm trying to tell myself that it's a good sign that my lining isn't shot. I have no idea if that's true or not, but it's giving me hope so I'll hold to it!

I told my OB that if I'm able to get pregnant again, I'll be coming to see her pretty early on, since I'll want the NIPT referral as early as possible due to the TAC. She told me she's happy to see me weekly if I'm pregnant again. She may regret saying that! :)

Past and Future

Today marks two weeks until surgery. Only a few days until my next biopsy. If all goes well, it's less than 30 days until I'm cycling again. I am suspicious that getting pregnant again is going to be somewhere between 'a lot more difficult' and 'impossible'. Why? Because even though I took estrogen this cycle, my period was 2 days of what could barely be classified as more than spotting. I'm worried my lining is totally and irrecoverably shot.

I am oddly zen about it all. Yes, the surgery is unnecessary if my lining 'can't get it up' as it were. But since we won't know about my lining until we cycle, and I absolutely will not cycle without the surgery, well, it all falls into the category of 'it will be what it will be.'

Tuesday was three months since we lost Quinn. The twins' first birthday is coming up. I don't feel right calling it a birthday, but there isn't another term I like better. Others just feel too cutesy (angelversary) or too harsh (stillbirthday). Let's just say that it's almost a year since we met and lost them. In some ways, it seems like it was yesterday. In other ways I can tell that I'm doing better than I was, even a month ago. I am having fewer bad days. The seasonal triggers produce moments or hours of memories and pain, not days. While medical stuff is on my mind a lot, when I think about my babies it's with love and longing, not the overwhelming grief I've felt recently. The only thing that makes me not zen is remembering that Quinn should have been born, at term, a month from now. Remembering that breaks my heart in a completely un-zen-like fashion.

At this moment, with the future still unknown, I'm ready to move forward even if moving forward doesn't bring us another pregnancy. I think that's the zen talking. I hope I can hang on to this zen in the coming months.

Lessons from Surgery

I realized last night that having had seven surgeries in less than two years, I might have some advice that's helpful to anyone else preparing to go through gynecological surgery. Thus, here are my "credentials" and also my experiences/advice.

Surgeries since 1/18/16:

1. D&C for missed miscarriage - Jan 16
2. Operative hysteroscopy to remove scar tissue and retained POC from missed miscarriage - May 16
3. Emergency D&C due to postpartum hemorrhage - Nov 16. To be fair, they did two of these, since I Started to hemorrhage again while in recovery before regaining consciousness.
4. Operative hysteroscopy to remove scar tissue and retained POC from losing the twins - Feb 17
5. Rescue cerclage placement - July 17
6. Operative hysteroscopy to remove scar tissue and retained POC from losing Quinn - Sept 17
7. Operative hysteroscopy to remove scar tissue and retained POC from losing Quinn - Oct 17

Things I have learned throughout this process. These may only apply to me, but I thought it was worth sharing:

• If you can, get a morning surgery. Going without food until an afternoon time slot makes an unpleasant day worse.
• Be aware that even though you're groggy, you'll have awful insomnia starting around midnight the night of/after the anesthesia (this applies only to the general anesthesia and not the spinal)
• Be aware that you'll stay groggy the day AFTER surgery.
• Know that it's ok to ask to have the IV placed in your arm, not your hand - often that hurts less. Either way, plan on about a week of bruising from it.
• Expect 2-3 days of sore throat from the anesthesia. How sore will depend on how long you were under. 
• If you're allowed, plan on a shower as soon as you get home - different hospitals do a better or worse job of cleaning up the betadine they use on you, expect that you'll still be orange in a few places until you can shower. 
• If you're outpatient, be aware that the doctor will tell the person you came with the outcome of the surgery. This means that if you have specific questions you want answered, make sure to tell that person. I expect my DH to know what's going on and ask the right questions, but in reality, all he's able to process without specific guidance is, "It went well."
• Wear comfy clothes and a bra that are easy to get back on. At the hospital, a nurse dressed me while I was in post-op. At the surgical center, I had to dress myself in the tiny pre-op/recovery room. In either situation, you want easy to doff/don clothing. 
• If you get cold easily, bring a jacket you can throw over your shoulders while waiting. Yes, hospitals and surgical centers have warm blankets, but they're often about 2" by 2", so it's tough to really bundle up! My local hospital offers a warming gown, but the surgical center doesn't, so having a jacket over my shoulders while waiting to be taken back for surgery was awesome.
• Have a pain management discussion with your doctor before you go under. My first two surgeries, I was given narcotic painkillers and rx strength ibuprofen. I never needed the narcotics, I did appreciate the rx strength ibuprofen. Surgeries 4, 6 and 7 we never discussed pain management, and since I can't take NSAIDs, I went without once home. That's ok by me, but if it's not ok with you, be sure to discuss with your Dr.  
• Have a plan for what to do when you get home. My plan is Netflix under a blanket on the sofa, but figure out what low-energy thing will be a treat for you, and have it ready.  

Most of all, my advice is that you CAN get through this, no matter how scary it seems. 

Still Not 1/18

I spent quite some time trying to come up with an appropriate title for this post. A few I tried on:
You've Got To Be Kidding Me
Really, Uterus?
Again!?!
Motherf*cker!!

That last one still feels the most appropriate.

Today was the repeat endometrial biopsy and FemVue. The FemVue's goal was to check my tubes and make sure nothing was left in my uterus. Tubes looked great. Uterus? Not so much. Don't know if it's placenta or adhesions, but up near the fundus something remains. It was obvious enough I could pick it out on ultrasound, and I suck at reading u/s.

I'm not surprised - my period has been unusual, and there was fluid in my uterus before they started the FemVue, which didn't bode well. Alas, this means another operative hysteroscopy. If it means another week with a stent . . . if it means another week with a stent I'm thinking very hard about canceling the surgery and giving up. Because a uterine catheter is hell. Just hell. No better description. Surgery is booked for Friday, and if I think too long about it, I'll back out because I'm just not up for that hell again.

So I won't think about it, I'll just do it.

Oh, and for the record, today's biopsy hurt a lot more than last month's. The FemVue didn't hurt at all during, but I still have odd abdominal tenderness afterward. Fun times.  

At Least it won't be 1/18

There's scar tissue. Near the fundus and again near the cervix. I go in for surgery on Wednesday, and get another week with a balloon stent. I cried in the ultrasound room. Hysteroscopy #3, here I come. I knew better, I have Ashermans, so I knew I should expect it, but it's still one more blow and one more thing I'm dreading. At least this surgery won't be on 1/18.

One Surprising Step Ahead

Today was my MFM consult. Some of it went as I’d have expected, other things were very different. Starting off, the first and biggest recommendation the perinatologist had was to get a pre-pregnancy transabdominal cerclage. With Dr. Haney. I wasn’t expecting that at all, but it turns out she had a patient with an identical history to mine. Lost twins due to pprom. Lost a singleton to IC. Did a TVC and kept culturing and treating the bacteria they found during pregnancy. . . . and still lost that pregnancy. So they sent her for a TAC, and she recently delivered a 39 week baby.

To say that recommendation was a pleasant shock is an understatement. While I was hospitalized and talking to another MFM in the group, he told me we’d place a TVC at 12 weeks during future pregnancies. I had pushed back, hard, on why you’d do a TVC, especially in someone with infection issues, and not TAC. He was adamant about the TVC being the right choice. So to hear the number one recommendation being a TAC, and to be told to go to Haney, that made me feel much, much better about my decision. It also means I'm one step ahead of the game, having already consulted with him and booked surgery.

On the subject of infection, this perinatologist, Dr. N, agreed with Dr. Haney that the underlying cause of both losses was cervical issues. Even though my cervix was long and closed after Zoe’s water broke. Even though Zoe was the higher baby, and bacteria should rupture the lower baby’s membranes first. She truly believes that there’s no scientific benefit or merit in looking for chronic endometritis, and that treating any bacteria found in my uterus that don’t belong there would cause other problems, as she saw in the patient previously mentioned. Having said all that, we pressed really hard and she agreed to request an endometrial biopsy and a consult with the true Infectious Diseases department. So, on 9/6, I go in for my SIS and a biopsy. Based on what those show, we’ll figure out what comes next.

Dr. N mentioned that infectious diseases would probably screen me for various autoimmune issues that interact with infections. With my history, that seemed wise.

On the topic of progesterone, she noted that it’s shown to help in cases of cervical shortening before 24 weeks, but with the TAC I will not have cervical shortening. Thus, she can not see any clinical benefit. At the same time, she’s willing to discuss further/prescribe it, if I get there, because there’s no harm either. The same goes for additional cervical monitoring during pregnancy. No need, but no harm, and there’s something to be said about the positive impact on my anxiety levels.

With respect to my Asherman’s, and my history of autoimmune disorders, that’s unlikely to be related to pPROM. I will have my placenta monitored more closely during future pregnancy to make sure there are no IUGR or placental insufficiency issues caused by the Asherman’s.

So, the plan:
1. During next cycle (which started when I walked out to the parking garage after the appointment) get endometrial biopsy and confirm uterine cavity is clear of scarring. At the moment I’m scheduled for a biopsy and SIS, but that may be replaced by a biopsy and hysteroscopy.
2. Consult with Infectious Diseases. Determine treatment based on biopsy and results.
3. Have TAC placed.
4. Return to CCRM for COH.

DH and I need to talk a bit more, but it’s a plan I feel pretty good about. It may not get us a THB, but I will feel confident that we’ve tried EVERYTHING we could in getting there.

Tiny Bubbles

I am cramping and bleeding!!!

You might wonder why that statement merits multiple exclamation points, but it's simple: I'm getting a period. That means that surgery seems to have made things better. With the Asherman's, my last pre-surgery period bordered on non-existent. That's because the scar tissue prevented an endometrial lining from forming. No lining = light period. No lining also equals nowhere for an embryo to implant. So evidence that my lining is restored is a big, happy deal.

This leads us to the next hurdle: tubal patency. In light of the infection I had in November, my cadre of medical professionals and I are all concerned about the condition of my tubes. If they're blocked, then I'm faced with the choice of IVF or the end of the road.

So it's time to test my tubes. But herein lies yet another problem: my last HSG went catastrophically wrong. It showed only one open tube and almost no uterus. Further, within hours afterward, I was swollen and in so much abdominal pain that I couldn't stand upright. My RE and I both suspect that the image was invalid because my body reacted badly to the HSG/contrast. All of this means that another HSG is off the table.

My OB mentioned a product called FemVue. FemVue's website, in addition to having a bunch of dumb looking women on it (actually, they look like smart women who have been told to look stupid for photos), will tell you that it uses bubbles and ultrasound to test tubal patency. There was one problem, though: my OB has never used it. She suggested I contact my RE to get her thoughts on testing my tubes. If my RE didn't have ideas, my awesome OB would learn how to use FemVue, and we'd proceed down that path.

So I talked to my RE's office. I had to make another appointment to talk to my RE, which sucks given my lack of insurance coverage, but falls under the heading of 'it is what it is'. The awesome news was that she's not only familiar with FemVue, but did research on it back in med school. I will be in very good hands with her. The less awesome news? Per my RE, her research findings were that women reported FemVue to be more painful than traditional HSG.

The end result is that I go in next Friday to see if bubbles can shed light on the status of my tubes. One more week and we'll know if there's a path forward or not. I'm scared. I'm not sure how much more bad news I can handle, but better to know than not, right?

It Wasn't Mylar

Surgery took place as planned back on the 18th. Being back at the hospital was indeed hard. I might have cried a bit in the waiting room. I might have cried again post-op.

Surgery itself went well. During the follow-up appointment, my OB told me, and pathology confirmed, I had scar tissue and embedded retained placenta in my uterus. I suppose it's no surprise with what happened.

My OB cleaned everything out. Due to the nature of the scarring (Asherman's), she left behind a balloon catheter for a week. It looked like this:

It was the most miserable thing I've dealt with in this entire journey. In my mind, I'd assumed that everything would stay inside me. I know that sometimes IUDs are used for Asherman's patients, and I've had an IUD that only had a tiny string in my vagina. I just assumed this would be similar.

Nope. Wrong on all counts. First off, that tubing is just slightly smaller than a quarter of an inch. Not at all like the string on an IUD. Having a string the width of a thread coming out of your cervix is a very different experience than having a .25" tube coming out.

Second, the tubing was long. Long enough to go through my cervix, and vagina, and hang a good few inches outside my body. From a practical perspective, that meant that anytime I moved, stood up, sat down, or rolled over, the tubing got pulled on a bit. Tubing that was going through my cervix and into my uterus. Imagine what that might feel like. On second thought, don't. It sucked, no one should deal with that.

Third, there was a hard plastic connector on the end of the tubing. It allows the balloon to be filled with saline. That's great. Except from a practical perspective. From that perspective, no matter which way the tubing points, that hard plastic connector is going to be jabbing you in a sensitive spot of your anatomy.

Finally, surgery made my digestive system unhappy. Consider the logistics of trying to keep a dangling tube and connector out of the way as you deal with what you have to deal with when your digestive system is unhappy. This is especially fun in my case, since I know the bacterial infection that took my girls and led me to this point in my life was largely comprised of bacteria found in the digestive tract. And here was a fucking superhighway going right into my ute.

It sucked. But it's out, and it's over, and now we move on to the next hurdle: figuring out if the surgery worked and if  my tubes are clear. More on that to come.

Full Circle

My journey to parenthood started December of 2015. That was when I got the first positive test. That was when I experienced the first rush of utter elation that I was pregnant and DH and I were going to be parents. January 15, 2016 was the end of the elation. I was 10 weeks, and there was no heartbeat on the ultrasound. I was scheduled for a d&c the following work day, January 18.

Two chemical pregnancies later, I had a saline sonogram done. It found scarring, caused by the d&c. I went through an operative hysteroscopy to remove the scar tissue, and then went on to conceive the girls with the help of a great RE.

After losing the girls, and knowing my history of scarring, I went in for a saline sonogram in late December. I wanted to be sure my uterus was clear to try again in March of '17. Alas, this SIS made the last saline sono look like the "good" version. This time around, there are adhesions all over. I suppose it's to be expected, in light of the infection and the fact that it took two rounds of emergency surgery to stop the bleeding after delivering Zoe. I've gotten an official diagnosis of Asherman's.

Thus, I've been scheduled for another operative hysteroscopy. On January 18. It has to happen then, because of the timing of my cycle and the fact that my OB only operates on Wednesdays. I won't lie, I'm hurting at the thought of being back in the same hospital on the same day one year later, with only heartbreak to show for the intervening year. I've come full circle, and yet instead of progress or joy, there's only pain and loss. I'm terrified at the thought of waking up in the same post op facility that I last woke up in the night I lost the girls. Those are memories I don't want to re-live.

I'm just hurting. I'm hurting because I miss my girls. I'm hurting because everything for the last year has been so damn hard. I'm hurting because I don't know if this will work, if we'll even be able to try again, or if our road will end here. I'm hurting because I know if it does work, and I do get pregnant again, I'll never be able to simply enjoy it - I'll worry until the moment I'm holding a living, breathing baby in my arms. I'll say it again, I'm hurting because I miss my girls.

Now I just hold out the hope that this surgery will work and the scarring will stay at bay long enough for us to conceive again. I hold out the hope that my ovaries can pull off one more pregnancy. I hold out the hope that this time, my uterus can keep my babies safe. None of this may come to pass, but I'll pray that January of 2018 sees my DH and I somewhere better than here.

Verdict is. . . .

There are times when I feel truly bad for medical professionals. They spend years, decades even, studying and training. They continue learning as they practice and complete CE. Still, the human body is an amazingly complex system, and not every human's complexities follow an expected pattern. That means there are times when the best explanation a medical professional can give is, "I don't know" or "It doesn't make sense."

So, what was the outcome of my follow up appointment? Well, the saline sono, taken in early May, and the HSG from last Friday both suggest a horrendous case of Asherman's syndrome. But both of those are imaging techniques that don't directly visualize the uterus. The hysteroscopy, with photos taken after the saline sono but before the HSG, shows a normal uterus. The surgical notes written by the doctor who performed it didn't indicate any evidence of Asherman's, or anything other than mild scarring. The actual pictures should be the gold standard, but they are completely inconsistent with the sono and HSG. So the verdict? "It doesn't make sense."

Where does that leave us? Well, we could keep doing tests. Maybe we'd start getting consistent results, maybe not. Either way, we've now done all the tests that can be done, so we'd have to start repeating things. Verdict: probably not enough incremental value to be worth the drawbacks. Alternately, we can go back to the original plan: an injectable cycle in July, with monitoring of lining and follicles. Verdict: This approach will should tell us how my lining responds, which is a critical part of the question. The risk is that it won't tell us if both tubes are open. We could spend the money and the time on the cycle, and ovulate on the left side, where we don't know if my tube is open.

Total cost of more testing versus an injectable cycle will probably be similar. If they run multiple tests, that would be more expensive. It all comes down to a question of what really matters? And what really matters is: can I grow a lining that will support an embryo? Going the injectable route should answer that, because if I do have severe Asherman's syndrome, I won't grow sufficient lining no matter what medications they throw at me. If my uterus is healthy enough to grow a lining, it probably means the HSG was flawed, and I'm not as worried about tubal patency.

So, we will try the old fashioned way this cycle. We'll pray for a healthy, fully implanted embryo out of that. If I do get a positive test, we'll monitor the hell out of it! I am not optimistic, since I've had continued spotting since the HSG, but hey, I'm not going to turn down the excuse to spend some quality time with DH. ;) If this cycle doesn't work out, I call C.CRM on Day 1 and go in for Day 2 or 3 labs and an ultrasound, and then we start drugs and see what happens.

How will it all work out? Well, I'll give the most common answer from my own profession, which also deals with human beings and their irregularities: "It depends!"