Endometrial Biopsy Results

A couple of weeks ago, I endured having an endometrial biopsy to determine the status of my endometrial lining at 7 DPO (days past ovulation) and to determine if my lining secreted a protein known as Beta-3 Integrin.  Testing for beta-3 integrin is a fairly new procedure and doctor's are currently researching the purpose of this protein and it's significance for getting pregnant.  This procedure was calculated in advance by my doctor so that testing was done at an optimal time during my monthly cycle.  Being the organization nerd that I am, I have a calendar that helps me keep track of my cycle days, medication regimens and scheduled procedures. 

Dr. Carolyn Givens for InfertilityDoctor.com, tells us that "one protein produced by the endometrium during the implantation window that has some evidence for a scientific basis for a role in implantation is the cell-to-cell adhesion molecule known as beta-3 integrin. Integrins are a class of cell surface proteins that appear to act in all types of cell-to-cell recognition and adhesion processes. The beta-3 class of these proteins has been shown to be produced in response to progesterone in the endometrium and are purported to be one of the key proteins for adhesion of embryos to the endometrium. Failure to express this protein appropriately has been theorized to be a cause of unexplained implantation failure(1)." To simplify, beta-3 integrin is the "glue" that binds the embryo to the uterine wall for successful implantation in the endometrium (uterine lining).  Without this "glue", the embryo will not attach properly and could result in miscarriages.

Despite having to pay $475 out-of-pocket for this test, Dr. G feels like the lack of this protein could be the missing link to my miscarriages.  Last Thursday my mom and I met with him to discuss the results in more detail as well as treatment options.  He said that I have an "negative, in-phase" endometrial lining which means that based on the timing of my cycle, my lining had developed sufficiently (20+cm) but the beta-3 integrin chemical was missing which means my lining was not ready for implantation.  I did use vaginal suppositories for added progesterone last month which helped develop a think lining however research says that "Beta-3 integrin NEGATIVE in a patient with a normal “in phase” endometrium is associated with unexplained infertility(2)".  So here we are....again.

Dr. G. would like me to start ovarian/hormone therapy whenever I'm ready.  When that time comes, he will prescribe me, in addition to my pre-existing medicines, Gonal F which is a highly pure version of follicle stimulating hormone (FSH) used to treat fertility problems. It will be used in combination with another hormone (hCG or Ovidrel) to stimulate my ovaries for ovulation.  Since Gonal F is an injectable fertility drug, I have to attend an injection class at the RE clinic to learn how to inject myself properly .  Fun times!!!

I'm not sure how long I'm supposed to take Gonal F, but I'm anticipating the new and improved baby-making cocktail to look something like this:

Day 1-3:     Initial ultrasound/bloodwork (for base line testing)

Day 3-12:   Daily injections of Gonal F (FSH)

Day 15:      Injection of Ovidrel (hCG) - to trigger ovulation

Day 17-26:  Vaginal suppositories of progesterone supplements

In additional to these medications, the doctor has forewarned me about the possible side effects (i.e. nausea, bloating, weight gain, and um multiple births) and the mandatory frequent visits I'm expected to make to the RE clinic (he mentioned like 5-6 times in one month!) for monitoring.  Again, fun times!!!

Overall, I'm feeling positive about what's going on.  Although I am nervous about injecting myself on a daily basis I feel like we're headed in the right direction and that we're on our way.  I find myself not worrying about it as much because I know that God has this thing already figured out.  Hubby and I are just passengers going along for the ride.


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References:
(1) - http://www.infertilitydoctor.com/2006/09/05/beta-3-integrins-and-embryo-implantation/
(2) - (www.etegritytest.com/patterns.php)

Endometrial Biopsy - Done!

It's been 24 hours since my biopsy and only now can I say I survived and write about it.  This was one procedure I don't ever want to go thru again.  


Please note this entry contains graphic language so be forewarned.


I arrived at the ER clinic at 1:15pm ready to get the procedure done and over with.  The waiting room was empty and for once, I didn't have to feel the awkwardness of being there.  Soon after I arrived the women started pouring in.  I was glad with the nurse called my name, "Melissa, we're ready for you".  Great!! Just what I wanted to hear.  I was escorted to the room and was told to undress from the waist down.  Dammit!!! I wore a dress today which meant I'd have to get all the way undressed (which was an awkward feeling considering my RE is a male).   I waited for what seemed like an eternity and it was during this wait that my nerves finally set in.  I realized I should use the bathroom before the procedure so I redressed, opened the door and asked the nurse that walked by where the bathroom was.  I quickly scurried to the bathroom that was all the way at the end of the hallway and to the right.  While in the bathroom, I noticed there were Playboy magazines neatly tucked in a magazine organizer on the wall and a chair sat in the corner.  It took a minute for it to register with me, but this was the bathroom that the men usually use to provide their "sample". Gross!!! I quickly did what I had to do and left the bathroom being careful not to touch a thing.  I'm sure a blacklight in here could be a featured special on NBC Dateline special about RE clinics.


Once back in the room, I got undressed (again) and waited patiently.  I could hear the doctor talking to the nurses on the outside and my hands started to sweat.  What was taking them so long?  Don't they know how hard it is to wait?  A couple of minutes later, the doctor and nurses (two) came in.  Dr. G was jovial as usual.  He started talking about my progesterone levels...."wait, I didn't give any blood today" I exclaimed.  "Oh I must have you mixed-up with someone else" he responded.  WTF!!!!  Now I realize doctor's aren't perfect but come TF on!! At least know that I haven't given a blood sample before you start talking about the results.  I think he felt a little embarrassed because he quickly called for a nurse to come draw my blood.  "I'm sorry Mrs. Lee" he added.  "We'll get this all sorted out now". 


So after this drama, he finally prepped me for the procedure.  Two nurses were in the room.  One that would be passing him the instruments the other who would be comforting me.  Fantastic!!! This is going to be so painful I'm going to need someone to hold my hand, soothe me and wipe away my tears.


The procedure started off as usual with the doctor explaining what he was doing and how I may feel this or that.  When it finally came to the point when he was to clamp the instrument to my insides (before the extraction) he told to me cough.  He obviously did this to distract me from the pain.  It worked...a little.  I still felt the sting of something that was not right within.  But it was tolerable.  A couple of minutes later he said something to the effect of..."ok, now comes the main event".  This is when he was going to suction my lining out (think plunger).  The nurse grabbed my hand and was coaching me, "you're doing great", "we're almost done".  At that point, I remember saying, "f@!k, what have a signed up for"?


Like the SHG procedure I had a couple of months ago, the doctor was having some trouble getting the instruments to work.  My cervix wouldn't stay open so the instruments were sliding out...or something like that.  I just braced myself as a felt pulling and tugging and intense cramping.  At some point he finally got things to work and he said "here we go".  At this point, I felt things couldn't possibly get worse but then....OUCH!! OUCH!!! OOOUUCCCHHH!! I experienced the most intense cramps I've ever felt.  I didn't scream but I held on the nurses fingers tightly and moaned silently.  I could feel a tear welling up in my left eye.  Just when I thought I couldn't take any more, the doctor said "we're done".  "That's a big piece!" the nurse said.  Just the words I wanted to hear.


Once the procedure was over I laid on the bed, "recovering".  My instructions are to call the doctor next week to discuss the results of the biopsy.  I was told not to get up to fast and take as much time as I needed to recuperate.  I laid for all of 3 minutes.  I was ready to go.  I'd already decided that I was going to treat myself at Pei Wei afterwards and enjoy a quiet afternoon.  

Injection Day

Wednesday was Injection Day.  It was one of those events, that when I woke up in the morning, I knew it was going to be on my mind the whole day.  It's kinda like knowing you have a presentation to give at work and no matter how prepared you are, you think about it the whole day and try not to drive yourself crazy before showtime.  For me, I didn't think much about the injection throughout the day but when I came home from work, the anxiety set it.  Have you ever given yourself a shot or inflicted pain on yourself? It's not an easy thing to do by any means, but my choices were limited.  I just continued to think about the greater picture and the "prize" in the end-God willing.

Since hubby was out of town, I decided to record the injection on my laptop.  I thought he'd get a kick out of seeing my performance when he returned.

Now on to the main event.  I gathered all my supplies and set them on the bathroom counter.....laptop, pre-filled syringe, rubbing alcohol and gauze.  I then pressed record on the laptop and started.  

"Good evening family and friends, today is June 9th and I ummm am going to attempt to give myself my first injection ummm..."I'd later find out I said "ummm" the whole way through.  I washed my hands, wiped the injection site (my stomach) with rubbing alcohol and opened up the package that contained the shot. When I saw the needle I screamed and cussed.  "Shit, this is a big ass needle!!!!".  The needle was long and sharp (as any needle would be silly).  It took me a couple of seconds to work up enough nerve to do the injection but I did it.   I DID IT!!!  I ended up having to do it twice because the needle came out the first time but the pain was minimal the second time around.  Thank God!!!

So I survived my first (and hopefully last) injection.  Next week is the big one, the biopsy.  I keep hearing horror stories about this procedure.  It's basically when they will yank (Yes, yank!!!) a sample of my endometrial lining out and send for testing to make sure it contains all the right chemicals and elements necessary for a successful implantation.  You can read more about the procedure here.  I'll be sure to keep you posted.

OB-GYN Appointment Update

Today I had my CD 13 (cycle day 13) ultrasound appointment at the reproductive clinic. If you can remember from my post a couple of weeks ago, we're in the process of mixing and formulating our "Baby Makin' Cocktail" (for five days last week, I took Femara, an ovarian stimulant, to increase the number of follicles my ovaries would produce).  I had to wake up early as heck as my appointment was at 7am and I had to drive one hour to Troy.  Surprisingly, I made it on time (yall know I'm not an early person).


When I arrived at 7:05am (again, somewhat on-time) there were already 4 women waiting in the waiting room. What time did they get there?!?!? I'd later find out that the earlier you get there the quicker you'll get out (this clinic only does bloodwork and ultrasounds from 7-8:30am).  After about 10 minutes the nurse called me back for the blood draw.  It was quick and easy.  I'm so used to being poked and prodded, needles and giving blood don't bother me at all.  I was instructed to go back and wait in the waiting room until the nurse called me for the ultrasound.


As a waited in the waiting room a second time, I looked around to notice that the number of patients doubled.  I couldn't believe how many women had come in during the 10 minutes I was gone.  It's so awkward sitting in the waiting room at the "reproductive clinic" (aka infertility clinic).  No one makes eye contact, there's no woman-to-woman chatter, no "hello's" or "goodbyes", just pure silence.  As I looked around, it's obvious that we're all there because we are having some type of problems conceiving naturally, and that's awkward enough.  It's not like going to see your internal medicine doctor where people in the waiting room could be there for a number of reasons (cut finger, headache, sore throat,etc).  At the infertility clinic, the diagnosis is the same for all the patients.  We're infertile and we need help.


The ultrasound was next.  They called me back and I was escorted into the ultrasound room.  Once settled, the u/s technician quickly took her pictures and told me that I had three follicles, 2 on the left side measuring 16cm and 17cm and 1 on the right side measuring 11cm.  She also managed to point out that the doctor's like the follicles to be 20cm++.  She then told me that the nurse would call me later to give me an analysis of my blood work as well as tell me when to take my trigger shot and schedule my biopsy.


Around 3pm in the afternoon, the nurse called me with these results:


Estrogen    353.0
LH                5.5
Prolactin     31.0


It turns out that my prolactin levels are still slightly elevated.  Prolactin is a hormone gland that is secreted by the pituitary gland in your brain.  The role of prolactin is to stimulate milk production in pregnant women to allow for breastfeeding. Prolactin doesn't just cause a woman's body to increase milk production but it also affects ovulation and menstrual cycles. (This is why women who are breastfeeding rarely get pregnant). Prolactin inhibit two hormones necessary for ovulation: follicle stimulating hormone (FSH) and gonadotropin releasing hormone (GnRH). When you have high levels of prolactin in your blood (a condition called hyperprolactinemia), you will not ovulate and this will result in infertility.  Additionally, a high prolactin level could sometimes just be because of stress.  The normal range for prolactin levels are less than 20ng/ml (mine was 31ng/ml).


Because of my elevated levels, my doctor wants me to go on a medication called Dostinex to treat this condition.  Another medication to add to the list.


The nurse also told me that I'm to inject myself on Wednesday with the Ovidrel shot (in my stomach).  I'll keep you posted on how that goes.  I'm also scheduled to have the endometrial biopsy next Thursday.  I'll definitely keep you posted on that.  


So, in all the visit went good.  I feel like we're getting closer to getting the cocktail recipe right.

Baby Makin' Recipe

I realize I'm writing this post a day after my appointment, but I was so exhausted by the time I made it home yesterday, I barely had enough energy to shower and go to bed. 
My appointment with Dr. G in summary was very hopeful. We arrived ON-TIME (just barely) and as I sat in the waiting room, I started to get nervous about the results of my ultrasound.  I was quickly called back to Dr. G.'s office and we proceeded with the follow-up.


Bloodwork - My blood work results didn't indicate anything suspicious except for my elevated Prolactin levels that were 0.4ng/mL over the normal range.  The doctor didn't seem to be overly concerned with this but he decided we are going to continually check it as part of my "Baby Makin' Recipe".  He also wasn't overly concerned with my elevated Protein C levels which suggests that I don't have any coagulation issues.  My MTHFR (methylenetetrahydrofolate reductase) was negative so we don't have to worry about that either.  So far so good.


Ultrasound Images - Unbeknownst to me, I have 4 fibroids that are outside of my uterus.  The size of them are pretty small, with the largest of the four being 2.3cm x 2cm x 1.8cm.  Dr. G was inconclusive about what this means for me in terms of my fertility and if this is related to my miscarriages.  He presented two options:  We explore having them removed or we leave them alone.  Removal consists of a *real* surgical procedure that will cause me to be out of commission for 6-8 weeks to recover.  Plus they cut thru your abdomen...sounds scary!!!  With the other option, we'll just have to continue to watch them.  Unfortunately, as he explained, fibroids are hard to assess and it's hard to know if they are harmful or if they impede with TTC.  However, this is something he wants us to keep in our thoughts as we proceed with finding the best ingredients for my "Baby Makin' Recipe".  For now he wants to leave them alone.


The Recipe is as follows:

• Dr. G. has prescribed me Femera (Letrozole) which is a ovulatory stimulant.  I'm to start taking it my next cycle on CD 3-CD 7 (5 days)
• Prolactin blood draw on one day during CD 1-3
• An ultrasound will be performed on CD 13 to check for follies (number and size).  Also on this day, I will have another prolactin blood draw.
• Once they assess the nature of my follies, I will be instructed to take Ovidrel (HCG) injection to trigger ovulation.
• 3 days after the Ovidrel (HCG) injection, I am to start Prometrium (vaginal progesterone supplements).
• 7-10 days after the Ovidrel (HCG) injection, I will have an endometrial biopsy.  This will assess the overall vitality of my endometrium lining and also if my lining contains the chemical b-integrin.  I am not thrilled about this part but oh well!!

So as you can see, for the next month or so, I'll have a strict schedule to abide by.  I'm in the process of creating a calendar that tracks the cycle dates and testing dates.  I feel good that we're making process even if it's one day, one test, one pill and one injection at a time.  I'm sure the end product will be the sweetest thing ever.