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.

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! :)

Infectious Diseases Specialist Visit

With the crappy news of another operative hysteroscopy, I got distracted and never posted about our appointment with the Infectious Disease Specialist at the U. Overall, it was a good experience. The TL;DR version: the initial CE finding was probably due to retained POC. It's probably unnecessary, but I can do 14 days of doxy and repeat the biopsy.

Here's the long version: The doctor (who was very pregnant herself) was extremely thorough. She spent well over an hour with us and walking through my complete medical history, going back to childhood. She even sent a follow up note to me asking if I'd had blood clots in the past, because she'd spoken to a colleague who is a rheumatologist, to see if my history of juvenile arthritis (JRA) might be playing a role.

The downside of such a long conversation and discussing so much history is that the conversation was a bit meandering. It's hard to tell the red herrings (JRA, recurrent sinus infections, 12+ years of incurable infection in two of my toes) from the relevant (chronic endometritis, recurrent UTIs). She mentioned something that I thought was really interesting, if frightening: in a proportion of women with recurrent UTIs, there seems to be a chicken and egg issue, where the surface of the bladder is inflamed, and that inflammation makes it more prone to bacterial growth/infection. No one is sure which comes first: the inflammation, or the infection. It can be really hard to break the cycle. This could be what's happening with my uterus, but there's no clear treatment approach if so.

She thought the CE from the biopsy might simply be because of the amount of debris that was in my uterus - retained placenta. She wanted, partly for research, partly for me, to have me do another biopsy before starting antibiotics. Our initial discussion was that we would do the biopsy, and if the CE is gone, I wouldn't do any antibiotics. However, I realized that with the FemVue, I would have to take a few days of antibiotics. Once we discussed that, the doctor agreed that if we were going to be on 4 days of doxy, we might as well do the 14 days of doxy that would be the normal first line treatment for CE. So, the plan was: biopsy and Femvue on 10/4. 14 days of doxy starting on 10/14. Repeat biopsy when my next cycle starts.

Of course, we didn't account for the repeat hysteroscopy in the plan, but it doesn't really change anything. I finished my doxy yesterday morning, and I'm now booked for what I really hope will be my last biopsy on the 30th. The pathology from this last hysteroscopy came back with no evidence of CE (YIPPEE!), and also no retained placenta. It appeared there was just a bit of scar tissue.

Nothing Much

There's nothing much going on here, which I hope is a good thing.

A quick glance in my pill bottle tells me I have 4 doxycycline left! I have no side effects or symptoms, so I'll just hope they've done their job.

Last Friday I received the order for the repeat Infectious Diseases screens for DH and I. I still think this testing is utter bullshit, since we're using TI and have been through multiple screens in the last 16 months. We pose no infection risk to anyone at the office (and shouldn't even if we were carriers, given the need to follow UP). Alas, sometimes you have to wade through bullshit to get what you want, so in I go.

It's looking like I'll get my screen and my repeat biopsy done around 10/31, which should be CD6. Of course, by having written that, I'm sure my cycle won't start as expected! I have 25 days left until surgery. I'm trying to make the most of the time - back to daily workouts and a fairly clean diet. Once my next period starts, I'll go hardcore on the clean eating. I doubt it makes a difference, but I also don't think it hurts, and I continue to want the comfort of feeling like I've done everything within my control in this utterly uncontrollable situation.

If everything goes well with surgery, I'll have to make a decision about when to start cycling. Dr. Haney told us he wanted us to have one period before going back to the RE. If my cycles stay roughly the same as they have been, that should mean CD1 falls about 10 days after surgery. If I do well, it shouldn't be a problem to start stims then. Given my age and insurance coverage, I'd much rather cycle in November, but I'm not sure what will give us the best chance or be the best for my body. I guess we'll wait and see.

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.  

Same Bat Channel, New Bat Time

Wednesday's surgery went ahead as scheduled. When I came out of surgery, I was told that my doctor had removed some scar tissue, and quite a bit of retained placenta. They gave me the photos from the hysteroscope, which I've included below, along with a comparison photo of my own uterus, in a "clean" state after my very first operative hysteroscopy. If you don't want to see the inside of my uterus, look away now!

Clean uterus in 2016

Here are two from yesterday:

Left uterus -retained POC & scar tissue

Right uterus -retained POC & scar tissue

This leads me to ask my body: "What is up why you, hmmm? How is it that you hold on to placentas for so long, but you can't hold on to the babies in them long enough? What the heck did I do or not do to you to make this happen every time? WFT, body?"

Probably not the most helpful conversation I've ever had. I'm trying really hard to be hopeful that this worked and will be worthwhile.

I'm not sure if it was because this surgery was more extensive, or because my body is just tired, but I'm in more pain this time that usual. I've been really lucky that with all my past surgeries, I've had some cramping, and I've felt like someone used a serrated-edged, 8" diameter speculum to access my cervix/uterus, but I haven't had much pain beyond that. This time is different. My vagina is really raw and unhappy, my cervix burns, and my uterus keeps sending off stabbing pains and gnarly cramps. I guess that's to be expected and I should be really happy that it wasn't the case before!

Next steps: follow up visit and removal of the stent on Tuesday. We'll need to discuss the pathology for what was found in my uterus, the cultures from the biopsy last week, tubal patency, and what comes next. Exciting, no?

Oh and one final note to the surgery center: If you give patients specimen cups with their name, age, and gender, and have them give samples in the bathroom so you can confirm there is no pregnancy, it's probably unwise to throw the empty but labeled cup and the test stick into the open trashcan next to the sink in the bathroom. Because I looked down while washing my hands, I now know more than I want to about the other woman getting a hysteroscopy that day.

Endometrial Biopsy & SIS

Last week I went in for an endometrial biopsy and SIS. I've had two previous saline sonograms, so I knew what to expect from that: place speculum, swab cervix with betadine, insert catheter through cervix, remove speculum, insert ultrasound wand, push saline into uterus through catheter while scanning uterine cavity, remove wand, remove catheter, gush water on table/floor, done. I've always had bleeding right after and at least a few days of red/brown spotting following a SIS. That said, the worst part of it is always the speculum, and the rest, while not fun, has not been painful or extremely unpleasant. (Note: I can't say the same of the results, which have always sucked.)

Last week's SIS was no different, but I wasn't sure what to expect from the endometrial biopsy. I've seen ladies who reported it wasn't a big deal, while others said it was extremely painful. The scheduling nurse told me to take 800 mg of Ibuprofen an hour before, but I can't tolerate NSAIDs, so I went with 600 mg of Tylenol and half a valium that expired in 2013.

The TL;DR summary: the worst part was still the speculum.

In my case, they needed to take two separate biopsy samples. The speculum was placed, my cervix was swabbed with betadine, then my doctor went to get the first sample. I have a tilted uterus, so she had the sonographer do a transabdominal ultrasound so she could visualize the sample she was getting. I was told to expect some sharp cramping, but didn't feel too much - maybe because I was distracted by the discomfort from the speculum. She got the first sample and passed it off to the waiting nurse. She went back for the second one - same warning, that there would be sharp cramping. I won't say I felt nothing, but I can honestly say what I felt wasn't pain, just discomfort. I did a lot of yoga breathing and kept waiting for it to get worse, and it never did. After she passed the second sample to the nurse, we moved on to the SIS.

Since the biopsy came back positive for CE, I expect I'll have to do a repeat in a month or two. I won't look forward to it, but I also won't dread it the way I'm dreading the stent placement.

BFP - But Not That Kind

Big Fucking Positive. Not the good kind that you dream about and hope for. My OB called me to inform me that the first of the endometrial biopsies is back, and it's positive. Do not pass go. Do not collect $200. Proceed directly to the pharmacy for antibiotics in advance of Wednesday's surgery, because your uterus shows histological signs of chronic infection and inflammation.

How many doctors have told me that chronic infection isn't possible because the uterus is like a "self cleaning oven?" How many have dismissed my concerns? Getting to say "I told you so" has never felt shittier.

In case you've ever wondered, here's the diagnostic criteria for endometritis:

• Acute endometritis is characterised by the presence of more than five neutrophils in a 400 power field in the endometrial glands.
• Chronic endometritis is characterised by the presence of more than one plasma cell, (and lymphocytes) in a 120 power field in the endometrial stroma.

We're still waiting on the culture to see what's growing in there. For now, I'm on oral clindamycin three times a day. I'm guessing they'll run clindamycin and gentamycin during surgery on Wednesday as well, if they haven't yet gotten the culture back, but I'll confirm with my OB. I had both of those via IV for 48+ hours after losing the twins, and then for ~12 hours after the cerclage was placed. In retrospect, that may have been what got us nearly 3 weeks with Quinn, as opposed to only a single week past pPROM with Alexis and Zoe. That said, I don't really have faith it's enough, and it's not the standard of care for true chronic endometritis. 

Some treatment recommendations on CE, from the literature:

• 100 mg of doxycycline twice per day for 14 days (My RE's office does Doxy standard for a few days on all IVF cycles.)
• CDC's PID recommendations:
• Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH* or WITHOUT Metronidazole 500 mg orally twice a day for 14 days
• OR Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days
• OR Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days WITH* or WITHOUT Metronidazole 500 mg orally twice a day for 14 days

If you're interested in a few good articles on chronic endometritis and RPL or Infertility, here are some links:

Chronic endometritis due to common bacteria is prevalent in women with recurrent miscarriage.

Chronic endometritis and infertility. 

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.

First Day

Today was my first day back at work. I got up at 5, got ready, and was just starting breakfast when our power went out. Really? Really. DH helped me get the garage door open, and out I went. I probably should have taken it as a sign and stayed home. Silly me.

The woman who sits directly across from me went out on maternity leave in mid-June. She told everyone she'd be back in late September, and posted a note at her desk saying the same thing. I figured that meant I'd have a few weeks to adjust to being back before she arrived and all of our coworkers were over at her desk talking about the baby and her leave and so forth. When I got in, I confirmed her note still said "late September." Apparently she changed her mind, because today was her first day back. I am so happy for her that her family is now complete, but it was a hard day to get through, and the cooing over her wonderful little boy made it harder.

I guess I shouldn't complain, though, because tomorrow is the biopsy and SIS. Physically speaking, the lowest point for me, the point when I almost gave up, was the week I had the balloon stent in place after surgery to remove scar tissue in my uterus. It was just so miserably, constantly uncomfortable. If tomorrow's SIS shows more scarring, and I need to do another week with a stent, I don't know how I'm going to get through. I'd rather do another 26 hours of labor than a week with a stent. I know that makes me a huge wuss, but it's true. Please let one thing go right and let me have avoided scarring this time.