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.

Baby #6, Beta #2

Still pregnant. Our little embryo is clearly trying. Today's beta was 137.7. According to the Babymed calculator, given the 43.5 hour time lapse between the two, that's a doubling time of 42.15 hours.

Do I feel good about this? I feel ok, not great. Last time I went from 249 to 877 in roughly 24 hours. I'm clearly not doing as well this time, and my beta is still on the low side of normal, per beta-base (median hcg for 15 dpo is 194). If I'd never been through my last pregnancy, I'd probably be feeling much better about these numbers, but the comparison effect is hitting me hard, and I can't share my fears of aneuplodies or blighted ovums with these numbers.

Still, for today, I am pregnant. For today, I can assume that there's an embryo growing and trying in there. For today, I'm going to continue talking to it and telling it to be strong and healthy. For today, I'll continue with the progesterone and estrace and hope for the best.

I go in for my first ultrasound on 4/10. Here's hoping for darkening lines and no bleeding between now and then.

Finish Line

Well, we made it to the injection finish line. At my ultrasound on the 8th, after 11 days of stims, the last four of them at 300 iU, I had one follicle at 20.8 and one at 14. My lining had dropped from 7.9 to 7.0, but I was told it looked great and was trilaminar.

We triggered that night with Pregnyl. I started prometrium on Saturday and stay on estrace. RE's office tells me I should test on Wednesday the 22nd. I'll probably test out trigger again this time, but with the way the cycle has gone, I'm not anticipating seeing two lines once that trigger is out. Last time it was pretty much gone at 10 days post trigger, and I got a bfp at 12 days post trigger, but last time it was twins and I had really strong betas. My luteal phase has dropped since losing the girls, I"m now at 9 days. The prometrium should hold that off, but if it doesn't, CD1 will actually come before it's time to test. Awesome.

I need to email my RE's office and ask about meds for next cycle, so I have time to order them. With everything going on, I'm finding it tough to motivate myself. While I don't think this cycle is likely to be successful, it also feels like I"m giving up if I admit defeat already, 4 days post trigger. But there are other issues that I'll save for a future post.

Epinephrine vs. CVS Caremark

For the last ten days, I have been trying to get medications for my next round of treatment from my god-awfully incompetent prescription insurance and their specialty and mail order pharmacies. Let me tell you, in the five months since I last dealt with CVS Caremark, they haven’t improved. Here are some highlights:

My doctor faxed the prescription. Two of the medications need prior authorization, the other two don’t. Thus, two come from CVS Caremark’s specialty pharmacy while the other two come from their mail order pharmacy. The two pharmacies do not talk to each other. Separate on-line systems with separate patient log-in information. Separate call centers. Neither pharmacy has any idea what the other one is doing or knows. Thus, I have to place twice the calls when nothing at all happens with both sets of meds.

Call 1 – CVS Specialty. They confirm that they have the order and even have the prior authorization info from my doctor, but are waiting on insurance information.

Call 2 – CVS Specialty. They inform me that my insurance has denied the claim. This is odd, because I should have just enough coverage left for this order, and then I’ll be out. I ask for more details. The call center agent tells me that my Aetna PPO has denied the claim. I tell him I have never had an Aetna PPO, I have CVS Caremark insurance. He tells me that the claim was submitted to Jennifer Haines’ Aetna PPO plan. I have already told him my name, it is not Jennifer Haines. I reconfirm this with him. Despite this, he proceeds to read off Jennifer’s plan number to me. Awesome. I reiterate, for at least the 5th time, that it isn’t my information. He gets the correct info entered (in theory) and says they’ll submit to my insurance next.

Call 3 – CVS Mail Order. They have my prescriptions, but need information from my doctor. No, wait, they already have the information from my doctor. The prescriptions should ship soon.

Call 4 – CVS Specialty. They inform me that insurance has approved the claim, but I can not yet order the medications because, “they’re not in the system yet.” What the fuck does that mean? The call center rep can’t explain.

Call 5 – CVS Mail Order. Still not in the system. Should be in the system in the next day or two and will ship then. Sorry for the delay, don’t know why it’s happening.

Call 6 – CVS Specialty. Still not in the system. Try calling again tomorrow.

Call 7 – CVS Mail Order. Not in the system. Wait, yes, they are in the system. But, unsure if pharmacy has enough in stock to meet the order. What in the fuck? This is a mail order pharmacy and these are common drugs. Also, I communicate that I’m concerned about the prometrium, because it’s a gel capsule and our temperatures are supposed to hit -22F. I’m worried it will freeze in transit and be destroyed. They transfer me to a pharmacy tech, who can’t tell me anything, but transfers me to a pharmacist. He agrees that it will probably be an issue, but “we can’t do anything about it.” I can either pay for expedited shipping or wait for the meds to arrive and file a claim if they’re ruined. There’s customer service for you.

Call 8 – CVS Specialty. In the system! Ordered! Shipped! Shipped without telling me, and by the way, adult signature is required, so now I have to make last minute arrangements to work from home so I can get the package.

While in the hospital, I lost enough blood that no one could find my blood pressure or pulse on either arm. When the doctor arrived, he gave me epinephrine, which stabilized me so that I could be taken to surgery. Sometime later, when I could talk again, I told my husband that he should have just leaned over and said “CVS Caremark” to me. Hearing their name is enough to get my blood pressure up without any medication at all!

Vanity (un)Fair

I like to pretend that I'm not a terribly vain person. I care about my body's physical ability, and I engage in enough personal grooming to fit within corporate america, but I don't think of myself as fixated on my appearance. While I dress appropriately for work, I wear socks with sandals on the weekend, for god's sake! How vain could I be? And if my hair isn't perfect, and I'm wearing clothes that are out of style by a few years, I've always been belligerently ok with that, because I'm still clean and presentable, and I don't care what anyone thinks beyond that.

But, seriously, the TWW-acne is killing me. On Friday, I stopped counting at 3 dozen whiteheads, just on my neck, chest and shoulders. Three dozen. They keep popping up, more and more. This happened last month, as soon as I started the crinone, and again this month with the prometrium. I don't think progesterone is supposed to cause acne, but this isn't without precedent for me. I was on Depo-Provera for many years when I was younger. From college through grad school, and then into my first several years of working. Depo is progesterone based birth control. For all the years I was on it, about once a quarter I'd get acne just like this. Dozens of little whiteheads. The last time this happened to me was while on Depo, and it never happened again during my 6 years with Mirena or my year on Nuvaring.

I am so uncomfortable and self-conscious. It's summer, and the hottest one we've had. The one part of my body I like are my arms/shoulders. The bike riding I do has made me feel good about them, and I have a ton of sleeveless summer clothes that I love. Thanks to the revenge of the progesterone, I hate wearing them. I hate the thought of anyone seeing how bad my skin is. My belligerent uncaring is gone by the wayside and I feel ashamed. It'll all be worth it for a lasting pregnancy, but it sure isn't easy now. As always, nothing about recurrent miscarriage or infertility is fair.