It's Ectopic...Slight Change of Plans

Nothing like a shot of chemo in your ass to start the weekend off right! Really, can this week take any more turns?  I better not say that out loud and test fate, because Lord knows it will the moment I even mutter the words.

A week ago I found out my hCG levels were dropping and that this was turning out to be a non-viable pregnancy. We met with our RE, talked about a plan going forward, and felt that although things were not ideal, at least we had a plan.  I became a toilet paper detective and just kept waiting for the miscarriage to take it course.

Well fast forward to a few days later, and upon another follow-up hCG blood draw, they realized that my hCG was increasing, and not in a good way.  It went back up to 205 from 185. It's supposed to be dropping! When this happens, it's an indication that the pregnancy is not taking care of itself naturally on it's own. I did a repeat test the next day and it was 207. They asked me to come in for an ultrasound to see if they could locate the embryo in my uterus, and they could not. The reason they could not see an embryo in the uterus could be one of two reasons...

1) My hCG never reached 1000, which is when you can usually see an embryo via ultrasound.
2) The embryo had implanted inside of the fallopian tube, rather than the uterus, where it's supposed to.

With the recent findings that my hCG is being wacky, I've been spotting for over a week now, and there is no embryo detectable in the uterus, it was determined that this is very likely an ectopic pregnancy. I was not shocked to be honest. All week I have been worried that something wasn't going as planned. I've had an early miscarriage before, and something here was very different. There was no real cramping, bleeding, and it had been a week already since receiving word I should be expecting to miscarry any day. I just knew something was off, and call me psychic, but I had a feeling they were going to say that the hCG wasn't dropping. I had even told my husband every day of the week, something is not right here!  I think he finally believes me now.

Apparently only 1% of the population has 2 or more miscarriages and only 2% of pregnancies are ectopic. I feel like I have won some sort of twisted lottery.  Ectopic pregnancy can be VERY dangerous, so I'm glad I was being monitored so closely and realized this somewhat early. What I'm not as thrilled about is that this means there was something that caused the embryo to implant there. By something, I mean disease, damage or blockages in my fallopian tube(s). That is really the only reason an embryo would implant in the tube versus traveling into the uterus to implant correctly.  I had an HSG (hysterosalpingogram) in Sept. 2011, which showed the dye used in the procedure traveled through both tubes into the uterus. However, it's still possible that I could have endometriosis inside the tubes not quite detectable via the HSG and/or there has been new damage that could have formed over the past 1yr+.  Really the only way to truly know what the inside of your fallopian tubes look like is to do laparoscopic surgery, something I haven't done because we've felt the risks outweighed the benefits thus far.

Finding another piece to this puzzle is a major game changer. Why? Well, it explains a lot. It could explain why we've been trying so long without a successful pregnancy. In fact, my RE said that my first miscarriage could have even been ectopic, but that we were lucky and it took care of itself naturally that time. It could have also just been a genetic defect. There is no way to ever know now if that was the case with #1, but it's certainly plausible given the recent development with this pregnancy. It's also a game changer, because it totally changes our RE's recommendations for treatment going forward.

Our initial plan was to hope that hCG dropped to zero on it's own and proceed with another Femara/IUI cycle....pretty easy right. However, since it didn't, I was given two shots of a chemotherapy drug called methotrexate to make sure the embryonic cells stop diving, and that the embryo doesn't continue growing. If we did nothing, the pregnancy could continue to linger, possibly grow a little more inside of the fallopian tube, and could cause tubal rupture and could be life threatening. The only other option to end the pregnancy would be to do surgery to physically go in and remove it. No way I am going to choose surgery over a simple shot, especially when surgery has it's own risks. Hubby and I asked A LOT of questions about the methotrexate, and all parties determined this is the easiest and best option for us to make this end as quickly and safely as possible. It's pretty standard protocol for ectopic pregnancies actually.

The other big game changer is finding out that obviously something is obstructing at least one of my tubes that we know of at this point. People who experience ectopic pregnancy have more trouble getting pregnant AND are more likely to have another ectopic pregnancy in the future. Because of that, our doctor's recommendations going forward have also changed. Yep, you guessed it....IVF. I never thought we'd get to this point, and I really hoped we wouldn't, but now it is looking like the smartest course of action.

In Vitro Fertilization was actually invented as a sole treatment for people with blocked fallopian tubes, but it's now used for many more infertility related diagnoses including:

-sperm production, number, or function
-endometriosis
-pelvic adhesions
-tubal blockage
-diminished ovarian reserve
-abnormalities involving the uterine cavity or cervix
-ovulation disorders
-unexplained infertility
-recurrent miscarriage

Obviously, we have been trying everything we possibly can to avoid doing IVF. It's invasive, difficult emotionally and physically, and as we all know COSTLY! However, looking at everything we have been through over the past 18 months (and really starting in 2008 when I became anovulatory for 2.5 yrs straight) I think it's safe to say I fit the description for someone who may need IVF if I ever want to have a family. Out of the list above I have been diagnosed by a reproductive endocrinologist with 6 out of 9 of those listed diagnoses above, 7 if you count the possible endometriosis my RE suspects is in my tubes. I think I had an "aha!" moment reading that list yesterday, realizing that IVF is likely our best option considering the circumstances.

Sure, plenty of women might choose to give it one more shot with IUI, but if I do that and do become pregnant, I'm still more likely to have another ectopic. I honestly don't know I would be able to endure another pregnancy loss, and it doesn't seem smart to continue putting myself at risk when we know the possiblity is pretty high that could happen. I could choose to have laparosopic surgery to go in and definitively diagnose and remove endometriosis or whatever is blocking my tube(s), but anytime surgery is done on the female reproductive system, there is high risk of scarring, which would just end up causing more blockages in the future. Surgery would also require quite a bit of recovery before even being able to try again, and then who knows how long it would take to become pregnant again. Even with injectables and IUI (my best case scenario outside of IVF) we'd only have about a 20% chance at conception each month we tried. Furthermore, if it's endometriosis blocking my tubes, and we remove it via laparoscopy, it can just return again rather quickly within months. Laparoscopy is many times more of a bandaid than it is a permanent solution. We are really analzying our options from all angles, and continuing to discuss things, but as of now it's really looking like we may proceed onto using IVF.

I am still continuing to do recurrent miscarriage testing in the meantime. My RE did a few tests, and I tested positive for cardiolipin antibody. This antibody is found in those with antiphospholipid syndrome, and can also be a cause for miscarriage (usually late term miscarriage). We don't think this could have caused any of my issues, but it's good we are testing for things across the board. In light of finding that I carry this anti-body, I will most likely begin taking a prescription blood thinner when I become pregnant again. This will help reduce any risk of a later miscarriage ever occurring.

I'm also being referred to a top notch hematologist/oncologist, Dr. Dudley Youman, for further testing. He was actually Lance Armstrong's oncologist, so I think I will be in good hands. I will call Monday to make an appointment for a consult and complete blood work-up. Even though he's not a fertility specialist, my RE has worked with him for years and is referring me to Dr. Youman because he is simply the best when it comes to hematology. We want to make sure I am uncovering any auto-immune or blood disorders that could cause issues that we haven't thought of. I love that my RE is so thorough and entertains every last concern I have....I am one of those people who asks a bazillion questions, and he makes sure they are ALL answered to my satisfaction. I am happy to make the visit to Dr. Youman if it means dotting more i's and crossing more t's. We want to make sure that if and when we choose to do IVF, that we are not missing any other pieces to the puzzle first.

Over the next couple of weeks, we'll continue to monitor my hCG and pray that the methotrexate works accordingly. I've been given a list of things I can't eat or drink while on this drug, and unfortunately alcohol is one of them. Kick me while I'm down why dontcha?! In spite of all the ups and downs this past week, we are still thankful for a lot. I don't know if I am truly becoming numb to it all at this point, but I haven't cried in a couple days. I am really just thankful that I didn't have a tubal rupture. I'm thankful that I have an amazing husband, and that he is healthy. I am thankful I have a specialist I completely trust who can guide us. We are thankful for more things than I can even write here, and it's those things that are keeping us going.