Next Steps and Continued Hormonal Funtimes

Hey, look, we've made it to six weeks! Good job, everybody!

Six weeks means that O is smiling (sometimes), cooing (occasionally), and extremely cute (all of the time.) It also means that I had my six weeks postpartum checkup, which ordinarily would have focused on healing Down There and birth control plans, but was a bit more interesting for me. The endometriosis that got us into this whole IVF mess is a problem that won't go away, so there are a few things we're going to continue to monitor going forward.

First of all, some good news. I passed another milestone this week: I'm off Lovenox! No more enoxaparin sodium for this girl, at least until/unless I get pregnant again. For those of you keeping score at home, this was nearly a full year of daily injections, with a few short breaks here and there. Someday I'll post the total number of needles that it took to get O from theory to reality, but for now I'm content just watching the bruises fade.

Also, the preliminary results suggest that the endometriomas have not recurred (or are pretty small if they did.) The one on the left was 4 cm right before my IVF cycle and we'll see what continued breastfeeding does to keep things quiet. I've seen it described as "natural Lupron," which would be nice since I want to avoid taking that stuff again if at all possible.

Since I had a complicated pregnancy, I also wanted to go over whether I'd have to be concerned about attempting any other pregnancies in the future. Yes, I will likely have to be on Lovenox again, but my risk of placenta previa is only slightly higher than normal and the fact that it resolved this time is a good thing. I also had some weird liver stuff that popped up on my bloodwork at the very end, but that just means they'll be on the lookout for pre-eclampsia as they would for anyone. Overall, I guess I'm not a terribly complicated patient when it comes to another pregnancy, which is nice!

Now for the tricky stuff. The endometriosis which caused my tubes to scar over and my ovaries to grow endometriomas will theoretically get worse every time I have an ovulatory cycle (though how much worse, and how much it will bother me, is kind of a question mark.) Ordinarily I would probably be prescribed a combination estrogen/progesterone birth control pill, but thanks to my DVT, I'm not a good candidate for that. I'm likely headed towards a progestin-only pill or maybe a Mirena IUD - and yes, I really am considering taking the pill despite my earlier protestations about systemic hormones. Why? Well, partially because the side effects are theoretically less problematic than the combined BCP, and partially because I can wrap my head around taking a pill if I know it's only for a short period of time.

All this to say: it's a matter of time before we're back on the IVF train. Don't think I've forgotten about those three embryos on ice, and because of a combination of family and medical factors, we're probably looking at attempting another cycle in a year. Or less. Or maybe a little bit more. There are a lot of moving parts to consider, even though we're committed to giving O a sibling - or at least trying our hardest to do so. We've been so blessed to have him, and I hope and pray that our luck continues!

And Then There Was One (Complication)

Up until now, my Maternal-Fetal Medicine appointments have fit into one of two categories:

1.) Establishing that my existing complications are still going on
2.) Finding that a complication might be resolving, but discovering a new one

I am thrilled to announce that last week, I discovered that there was a third category:

3.) Learning that my complications have continued to resolve, not finding any others, and getting bumped down closer and closer to "normal pregnant woman" status!

Seriously, the visit couldn't have gone better. My placenta previa, which we already knew had technically resolved by a small amount thanks to a scan at 21 weeks after my last bleed, has moved farther and farther away from my cervix. It was barely 1 cm away at 21 weeks and at 26 weeks it was between 1.5-2 cm depending on how they measured it. The doctors said that they expect it will keep moving (though they were careful to make sure that I understood it's not the placenta that moves, it's the uterus that grows, and as the uterus grows the placenta stays put so it keeps "moving" farther away. Got it, guys. Trust me, I've looked up how placentas work by now!) Oh, and my cervix is holding strong at 3.7 cm.

The other good news is that there continues to be no new bleeding, either that I've noticed or internally. So the sub-chorionic hemorrhages from my first trimester appear to be well and truly gone (oh please, please, please let that be the case!) Perhaps the 21-week bleed was the last hurrah? Man, if I had known that, I would have thrown a party to celebrate rather than lying on the couch all weekend in terror!

So for those of you keeping track at home, we've now gone from three potentially disastrous complications to one. That one is, of course, the Lovenox I'm still taking after my deep vein thrombosis very early in the pregnancy - and it won't go away because I will be at risk for additional clots and need to stay on blood thinners right through 6 weeks after delivery. But with this in mind, my MFM doctor recommended that we change my labor and delivery plan slightly from "induce no later than 38 weeks" to "induce no later than 40 weeks." I now feel like less of a fraud when people ask my my due date and I respond "October 18th!" Inwardly, for the past few months I've been cringing inside as I said it, knowing that the babe was medically indicated to come out no later than Oct. 4th, and quite possibly earlier than that. Now he has a shot at truly, genuinely, just-as-nature-intended making it to term. I hope he does, even if it means I need to wait a bit longer to meet him!

Of course, all of this "you're a normal pregnant woman and can possibly anticipate a normal delivery" has me a bit freaked out. Which brings me to my next topic... CHILDBIRTH CLASS. I'll save that for another post, but highlights include forgetting to bring our pillows, learning to give a massage under dim lights in a room full of strangers, and me getting all high and mighty about patient consent. Fun!

MFM Appointment: Legitimately Good News

Despite a super-long wait, my Maternal-Fetal Medicine appointment yielded a host of good news. There continues to be no new bleeding, I'm not contracting, the baby is very active, etc. Here were the main talking points:

- The baby's fine, looking ever-so-slightly larger than average in most measurements, which is good because if he does have to come early we want him to be as big as possible.

- My cervix is still long and closed. They were baffled that I was worried about a measurement of 35mm and said that there was absolutely no reason to be concerned.

- There are still no placental abruptions or sub-chorionic hemorrhages. Thank goodness!

- They did a fetal echocardiogram just for funsies and it was very normal and very boring.

- Are you sitting down? :::pause::: How about now? Okay, so get this: on their very detailed ultrasound machine, looking transvaginally for the most accurate view possible, my placenta is 1 cm away from my cervix. That means it's not a previa anymore.

Whoohoo! Break out the sparkling cider, everybody! Except that means we don't have a good reason for the bleed anymore. I was really leaning toward my OB's guess that it was just the usual previa complication and staying as quiet as possible would help avoid it happening again, but now we're back to square one in terms of unraveling the mystery. My MFM doctor said that he would bet it was somehow related to the original hemorrhage, but also said that there are a million reasons that women bleed in pregnancy and the important thing is that we don't see anything worrisome on the scan right now. This doesn't mean I can start doing back handsprings in celebration (ha! Back handsprings, that's a good one. I think the last time I did a cartwheel was in 1996, and I didn't exactly stick the landing) but it's all good news. It also means that I'm back on the lowest dose possible of Lovenox effective tomorrow morning, yippee.

One more thing. You know how I had unexpectedly lost five pounds as of Monday? On MFM's scale, I had actually only lost two. The nurse said that it was probably just normal variation and I should keep doing what I'm doing. In other words, perhaps I shouldn't have made this Mocha Icebox Cake yesterday? Oh well. I make no apologies. It's delicious!

OB Appointment: Still Hanging On

Yesterday's OB appointment went about as well as expected. Overall, I'm not experiencing any new bleeding, my cervix remains long and closed, I am not contracting, and the baby (yes, everyone needs to say this as soon as they start the ultrasound) is "very active." My OB's best guess about what happened is that it was related to the placenta previa - after all, painless bright red bleeding is the classic presentation and in the pre-ultrasound days it was evidently how they found out about previas. She thinks that the placenta probably bled a few days ago internally, it formed a clot, and then the clot made its dramatic escape on Friday night. She also said that stopping the Lovenox was the best thing I could have done right now.

So it was a good report, overall. However, there were still some things that were ever-so-slightly worrisome:

- Finally, someone did a transvaginal ultrasound to measure my cervical length. They could see it pretty well transabdominally, but I knew it wasn't an accurate measurement, and even though I have no risk factors for Incompetent Cervix, of course I'm worried about it. The good news is that the transvaginal ultrasound confirmed that my cervix is "long and closed." The bad news, according to this chart, is that my 35mm long cervix is still below the 10th percentile for singleton pregnancies at 21 weeks. I know, I know, it could be so much worse. And it seems like most OBs consider anything above 25mm to be fine. But now I've got that on my mind, too.

- The transvaginal ultrasound, even though it was as gentle and noninvasive as possible, dislodged enough of the bleed that it started up again. (That's why you apparently never want to touch a cervix with placenta previa - even a small amount of activity can disrupt the fragile blood vessels right above it.) It was pinkish-brown and I actually showed some of it to a nurse on a tissue after they told me to clean myself off and she said it was nothing to worry about. Still, for the rest of the day, every time I went to the bathroom, there it was. The mental torture of seeing more blood was the worst part of yesterday, because I just kept waiting for it to turn into a full-on hemorrhage... even though it didn't.

- Finally, here's one for you to puzzle over. Yesterday the intake nurse who did my blood pressure and my weight (and obviously hadn't looked at my chart) said "Oh, looks like you've lost five pounds since your last visit, congratulations!" To which I replied, "Um, I'm actually pregnant... aren't I supposed to be gaining weight?" Awkward pause. I then had two separate nurses as well as my doctor ask me, all polite concern, "Are you eating?" And my response was yes! Yes, I am eating! I had a burger for dinner last night! I haven't had any morning sickness in weeks! I'm lying around on the couch all the time doing as little exercise as possible! My bottom should be the size of Brazil! How entirely bizarre. I mean, at any other time in my life, my reaction would have been - unexpected weight loss, score! But now I'm just baffled more than anything. Why on earth would I be losing weight? My doctor didn't seem terribly worried and said that it was more important to just watch the trend, and Dr. Google doesn't seem to have many resources on this particular problem. I mean, I want to gain weight in the healthiest way possible, so noshing on a tube of chocolate chip cookie dough seems like rather an immature response, but I will admit it's tempting. How often am I going to have this opportunity, really?

That's all for now - hopefully today will be quiet, and then tomorrow it's off to see the Maternal-Fetal Medicine doctor. There's no Yellow Brick Road leading the way there, but fingers crossed for at least one wizard who can make all of this better.

Another Bleed, Another Midnight Trip to the Hospital

Headline: I am okay and the baby is okay. For now.

So there I was, minding my own business, lying in bed wasting time on the Internet when I should have been making progress on my book club assignment, the cat curled up next to me, and it occurred to me that before I nodded off to sleep I should use the bathroom. I'd had a huge glass of water earlier, and who likes to wake up an hour after they fall asleep to go pee? I went, and I looked at the toilet paper, and... no. NO!!! Red blood. A goodly amount of it. And, a moment later, a clot about 1/2" across.

I walked back into the bedroom and was about to look up my OB's number when I realized I knew it by heart. The answering service took down my name and information and put me in touch with a very nice doctor in their practice who I'd never met before. I was oddly, supernaturally calm as I explained what was going on and gave her the ten-second history of this pregnancy: G1P0, 21w1d, tubes blocked from endometriosis, subsequent IVF, DVT at 5 weeks, SCH at 9 weeks, complete placenta previa, red blood and a clot, blood seems to be slowing down, should I go to the Emergency Room? No, she said. You should go to Labor and Delivery.

I'll pause for a second to let you take that in. Labor and Delivery. At 21 weeks. As I drove to the hospital, hating every song the radio station played because I knew I'd forever associate it with this moment, I got ready to hear: There's nothing we can do for you. We've made a certificate with the baby's footprints for you to take home. Would you like to speak with the Chaplain?

Harry met me at Labor & Delivery and, mercifully, led me right back to the triage unit where they were expecting me. They led me to a little room with a whole bunch of monitoring equipment that I could just tell was meant for a much larger bump than the one I sported. A nurse came in with a Doppler and tried to find the baby's heartbeat - over and over, putting it on different spots on my belly, and distinctly not hearing the familiar thumpthumpthump that my OB has always been able to find on the first try. Harry and I were quiet, me thinking silently "But I can feel the baby moving, he can't be dead! Oh G-d, maybe this is what early labor feels like! Or maybe I've been wrong the whole time and that's not fetal movement at all!" Finally I said out loud, "Is there any way we can check with the ultrasound? The suspense is killing me." She agreed and brought in the ultrasound, which was turned off so we all sat there as the machine booted up. Seriously, I guess it runs off Windows because it was going through all the screens and hourglasses and everything, and I have never hated a computer more than I did at that moment.

The ultrasound showed within seconds that the baby was fine. His heartbeat sounded strong and regular, he was just curled up against the top of my uterus. Oh, now he's moving around and his heartbeat can be heard over here. Wait, now he's over here, try this spot. By this time two separate doctors had seen him on the ultrasound and they both remarked that he was a very active baby! Sigh of relief #1. They also saw, wonder of wonders and miracle of miracles, that there was no placental abruption and my cervix was long and closed. I wasn't contracting (I hadn't felt any pain the entire time, which obviously was a good thing) and the bleeding appeared to have stopped. Sigh of relief #2.

The final doctor who examined me was the OB I had called earlier that night from my practice. She did a speculum exam (don't want to irritate that cervix further by rooting around in there!) and said that everything looked okay although there was still a small amount of blood visible. It could have been any number of things that caused the bleed, ranging from a random event aggravated by the Lovenox to a final clot coming down from the original sub-chorionic hemorrhage to the classic problem of placenta previa: painless bleeding caused by the cervix dilating slightly. Basically, there's no good answer. I didn't bring it on by doing anything (for heaven's sake, I was lying around reading blogs and watching YouTube videos, about as sedentary as it gets) and the only thing they could recommend was that I take it very, very easy over the weekend. I'm off the Lovenox for now so nobody was willing to actually say the words "bedrest," and they emphasized moving around my legs as much as possible without using my abdominal muscles or exerting myself in any way. And, just like that, I got to go home. Total time door-to-door: 2 hours.

I left Labor & Delivery with my baby still alive inside me and an appointment with my OB on Monday. Not a bad outcome given what I was steeling myself to face earlier that night, but who are we kidding, this was not a good thing. Do I need to tell you that bleeding in two different trimesters significantly raises my risk of any number of other complications, including preterm delivery? Do I need to mention the statistics surrounding complete previa when the first bleed appears at 21 weeks? Should I cite the research about infant survival at a gestational age of 24 weeks (my new so-close-yet-so-far-away, crossed-fingers-and-toes goal)? Probably not.

This entire experience has been such a rollercoaster. I didn't know that my infertility blog would turn into a complicated-pregnancy blog, and I'm trying to prepare for the possibility that it'll turn into a pregnancy loss blog in the next few days or weeks. We had about five weeks recently where things were stable and we started seriously thinking about having a baby come fall - planning a shower, signing up for a birth/parenting class, actually buying a onesie. I was beginning to visualize myself with a giant belly, fantasizing about holding our son for the first time, wondering if the previa might clear so I'd have a shot at a vaginal delivery. Now my best-case scenario involves CPAP, an NG tube, surgery for ROP, cerebral palsy. And my worst-case scenario, well, I can't even bring myself to type it. I really, really don't know which way this will go. But I'll let you know as things unfold.

Other News of the Moment

Obviously, we are beyond thrilled that our anatomy scan went so well. Finding out that we have a normal-looking baby, and that he's got some little-boy parts, was wonderful. But... what about all the other crazy things I've been diagnosed with over the past few months? How is that stuff going?

Sub-Chorionic Hemorrhage This is the best news we got: it looks like both SCHs are gone, all gone! The tech hadn't seen me for any of my earlier ultrasounds and didn't even know this had been a problem for me until I told her. Happily, in an hour of moving the wand all over my belly, she saw no evidence of any hemorrhages or placental abruptions. I'd like to give a shout-out to the very first OB I talked to on the night of my big bleed, who said that these things often didn't fully resolve until 18 weeks. At the time that seemed unimaginably far away, but true to form, it did clear up sometime between 15 and 20 weeks!

DVT and Clotting Issues My leg hasn't bothered me since February, even though they insist on checking it at every appointment, and knock on wood I have had nothing to suggest another clot at all. However, when they test my Lovenox levels - which involves making an appointment at the lab exactly 4 hours after I inject myself and then skipping the line of irritated waiting people who didn't know they could make appointments and who then give me the hairy eyeball - they have consistently come up higher than would be optimal. We're adjusting my dose, which right now means that I have to squirt a little Lovenox into the sink and hope that I'm getting something close to 30 mg. I should also mention that the bruises have almost entirely subsided, so injecting myself doesn't make me anywhere near as depressed as it did in the past. We'll keep testing this.

Placenta Previa This could still go either way. The good news is that most of my placenta is now over on the left side of my uterus, which also explains why I haven't been feeling much kicking on that side. If it's now a side placenta, could it keep pulling away from my cervix as my uterus grows, thus resolving the problem? Maybe. Maybe not. Right now it's still covering the cervix entirely, so I'm on the same restrictions for complete placenta previa that I've been on since April. However, I'm considerably more optimistic about it becoming a partial previa or even just a low-lying placenta than I was after April's gloom & doom diagnosis.

Everything else is going pretty much according to plan. My cervix is long and closed, though they didn't bother with an internal ultrasound to measure it precisely; they could see enough transabdominally that they weren't at all worried. With the exception of a few bad moments in May (I think I threw up three times?), my morning sickness has disappeared. I get round ligament pains just about every day, on both sides, but if I sit or lie down for a few minutes they ease up. My belly is growing and I'm keeping up with the cocoa butter in a vain effort to avoid stretch marks - none yet, but I'd be shocked if I avoid them entirely. And our unborn son would like to add to this list: he says, and I quote, "KICK! Kick kick kick! [pause] Kick kick KICK!" I'll leave you to interpret that however you want.

You've Got to Ac-Cen-Tchu-Ate... Oh, Shut Up.

I'm not feeling so great today.

I mean, I'm fine physically. My morning sickness is diminishing every day to the point where I routinely get hungry before I get nauseous. I'm tired, but no more so than usual. In terms of aches and pains, the biggest thing I have to complain about is a totally unrelated blister on my foot (darn you, cute shoes!) Honestly, if it weren't for the belly that's getting harder to cover up every day - and which I keep spilling soup on - it would be possible to actually forget that I'm pregnant. In fact, these past few days have been downright boring, symptom-wise. And boring is good, because boring is normal, normal is not traumatic, and not constantly experiencing traumatic events means that I have a fighting chance of getting back to the person I was before this whole crazy mess started.

Yesterday was a different story. It was far from the worst-case scenario, but the news of my placenta previa just kicked me right to the curb again. The pattern of my behavior is roughly: feel happy ---> see doctor/find out something is wrong with my body ---> plunge into crippling depression ---> over a long period of time, start gradually feeling better ---> feel happy ---> see doctor/find out something is wrong with my body ---> etc. This problem was greatly compounded during my IVF cycle by a negative experience with my egg retrieval procedure, which made me feel like the medical staff who were telling me all these bad things about my malfunctioning body were not in fact kind people who were doing their best to help me, but rather judgmental, heartless cogs in a reproductive endocrinology assembly line that was processing patients with approximately the same level of care that Henry Ford used on his Model Ts. (Okay, that was harsh. What I mean to say is, Henry Ford used way more care on his precious horseless carriages than I felt my RE's office did during my retrieval. I'm still really pissed that they took what was already a bad situation and made it worse, and no, obviously I have not gotten past it yet.) Everyone I interacted with yesterday was very kind, thorough, and optimistic that we will ultimately have a good outcome. That's wonderful, of course, although it also makes things a little harder to wrap my head around because when I look back at the totality of my experience since my diagnosis, there's no one villain that I can point to and say "You! This is your fault!" There's no mustache-twirling Giver of Infertility who I can fantasize about punching in the face. There's just bad luck, and good luck, and I have no way of predicting which one will finally tip the scale.

Anyway. I could start linking to a bunch of research I did yesterday about complete placenta previa and why I'm slightly mystified that my doctors are so pessimistic that mine won't clear up before delivery (many do! really! and they are quantified in peer-reviewed studies that are published in major medical journals!), but I think I'll save that for another day. My guess is that I'll start to feel better slowly over the next few days and weeks, right up until my next appointment can tell me that the baby is eating my lungs or shaped like a dragon or something else equally unpredictable and horrifying. We'll have to see.

Coming soon: My contribution to NIAW! Telling friends I'm pregnant! Maternity pants deliberately worn to a burger place for maximum food consumption!

Placenta Previa

Okay. Another appointment this morning yielded a ton of information. In the good column we have:

•  The baby is alive! 
•  And huge! Measuring 8 days farther along than average. 
•  S/he still has a terrifying face. 
•  One of the sub-chorionic hemorrhages is gone, and the other appears to be resolving. 

And, as always, the bad:

• The placenta is covering the cervical opening entirely (known as placenta previa), which will require close monitoring for second- and third-trimester bleeding, and probable early delivery.
• There's a small chance the placenta previa could resolve, but it's very unlikely in my case. 
• Even if I make it to term - or close to it - I'm definitely looking at a C-section delivery.

So, to sum it up, my message to the universe this morning is: what the f*cking f*ck. One step forward, two steps back. Oh, and in case you were wondering, it's a complete previa, meaning that the placenta is entirely covering the cervix and very unlikely to resolve as the uterus grows. (Often, women will be diagnosed with a partial placenta previa and as things get bigger, the placenta is naturally pulled upwards and away from the cervical opening so the problem is resolved. This is emphatically not what is happening in my uterus; near as we can tell - and yes, Mr. Wandy helped make this diagnosis so there were a total of two ultrasound angles and two MDs involved - my cervix is pretty much smack-dab in the middle of my placenta. Worst place it could be.) Now I'm wondering if the sub-chorionic hemorrhages and the placenta previa were all ultimately related to the problem the RE had with the angle of my uterus and finding the right catheter during the transfer, and the embryo implanting lower than it should have. And I'm also wondering if, by some miracle we do have a healthy baby at the end of all this, I'll have difficulty getting a sibling to implant in the future now that I'm almost certainly going to have a big ol' scar right across my uterus. Oh, and did I mention that placenta previa is associated with placenta accreta, where it grows too deeply into your uterus and they can't take it out and then you have to have a hysterectomy?!?


Anyway. Breathe. I probably should have waited to post this until I was a little calmer; the Maternal-Fetal Medicine doctor could tell that Harry and I were starting to lose it a little bit and he said at the end of our visit, "You're doing really well, you still get an A today." I appreciate his optimism, I really do. But there are days I just feel like taking to my bed (how convenient, since bedrest could easily be involved at some point in the not-so-distant future) and this is one of them. Still, let's focus on something positive: I will probably never hear somebody say "Well, Charlotte, it looks like you have a fourth-degree perineal tear from pushing this giant baby through your vagina!" And for that, and our healthy growing fetus, I am very grateful indeed.