TTCAL ETIQUETTE IN A NUTSHELL

Please read the detailed TTCAL Etiquette page here

1. TTCAL is an established support network for ladies who’ve lived the unimaginable. Please post an intro so we can get to know you better.

2. Do not ask us if you might be pregnant. We have no way of knowing.

3. If you are fortunate enough to get a BFP please read this before posting a BFP thread on TTCAL. BFP posts are reserved for long-term members who have shown support on a consistent basis for six or more months.

4. Discussing living children on TTCAL is inappropriate. If you want to discuss your living children please head straight to Parenting after a Loss.

5. Images of young children and toddlers are discouraged in signature. TTCAL is a safe space for ladies with and without living children as a result these photos cause hurt feelings. Read more about that here.

6. Loss warnings are NOT needed in thread titles. This is a loss board and we are aware that most threads relate or discuss loss in some way.

 

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AMH {Information and TTCAL user experiences}

Anti-Mullerian Hormone (AMH) is a substance produced by granulosa cells in ovarian follicles. It is produced by primary follicles and is highest in follicles that are in the preantral and small antral stage (less than 4mm in diameter). Because AMH is produced only in small follicles, it is believed to be a measure of the remaining egg supply.
Finding out your AMH level is low (0.5 – 1.0 ng/ml) is devastating for most women. It is believed that you can do nothing to improve your AMH levels. It is used, along with other hormone levels, to determine if you are an IVF candidate. Finding out that your AMH level is low or very low (less than .5 ng/ml) is hope crushing. You feel like the window on your fertility is closing or that it may have already closed.

I have been on TTCAL long enough to see many of our ladies who have low and very low AMH go on to PgAL and PAL. Some of these ladies conceived via IVF, some with donor eggs, some with their own, and some naturally. I asked our grads to share their stories to help remind our ladies with low AMH that it is just one test and it does not mean that you cannot get pregnant with a healthy pregnancy. Thank you to all of our graduates who replied with their stories and agreed to share them with you.

I would like to give special thanks to MsAmandaPants who provided me with a copy of her well thought out and researched reply that she gives to ladies who post about receiving low AMH results. I have included it in its entirety.

A special note on supplements: many of our grads used supplements while they were still TTC and credit those with helping them conceive. If you would like to take any of these supplements, please talk with your doctor first.
buggirl72, AMH .17

From MsAmandaPants – AMH is an indicator of ovarian reserve–how many eggs you have left. Low AMH itself won’t cause a miscarriage, but it might (but not necessarily) point to egg issues that could have contributed to it. Most research suggests that AMH has more to do with the quantity of your remaining eggs. There are different opinions on whether it is also an indicator of quality. While it does not necessarily indicate poor quality eggs, there are some that think that the eggs that remain at the end of your reserve may not be the highest quality, that higher quality eggs are selectively ovulated first, but there are differing opinions. AMH is also used as a predictor of how well you might respond to fertility drugs; low AMH is often correlated to poor response (but not necessarily so– I have shitty AMH and had a decent response).

It is important to keep in mind that AMH is only one marker of ovarian reserve and should always be considered in the context of your entire medical history, appropriate CD 3 blood work (estradiol, LH, FSH), and an antral follicle count. These are all critical parts of a whole that make up your entire fertility outlook.
Age naturally plays a role in decreasing AMH since egg reserves decrease with age; older women would be expected to have a naturally lower AMH range. While a lower normal range would be expected in AMA women, there is a threshold at which your AMH might be deemed irregularly low for your age. AMA + abnormally low AMH is a bit more worrisome because you are naturally dealing with older eggs and the quality issues that come with that, as well as a decreased reserve of quantity. There are some studies that show that low AMH in younger women is less of an issue because they typically have younger, higher quality eggs, in which case it is likely merely an issue of quantity/remaining eggs.

Other factors can artificially influence AMH readings and, again, it is important to understand it in context of our your entire fertility picture. This also means understanding factors that can influence and skew CD 3 blood work. For example, high estradiol can falsely suppress FSH. High FSH, particularly when combined with a low AMH could be indicative of diminished ovarian reserve. Low vitamin D can also artificially suppress AMH. Anyone that gets a low AMH reading, particularly if not AMA, should have their vitamin D checked to determine if it could be falsely lowering your score. Finally, from what I have read, the AMH test itself is fairly difficult to run/process and can be prone to errors. If you get a low initial AMH reading and don’t show any risk factors or corroborating blood work/antral follicle count, etc., I would encourage a recheck before resigning yourself to a dx of low or diminished ovarian reserve.

There are a lot of conflicting reports about whether you can improve your AMH through supplementation. DHEA, CoQ10 (or, even better, ubiquinol the more readily available for absorption version of CoQ10) to support your egg health, have been linked to possibly improved AMH readings. This is fairly controversial and without significant acceptance in the larger medical community. Talk to your doctor about whether supplementations might be helpful in your specific case. Do not start any supplements without consulting with your RE. There are significant drug interactions and supplementation can also do more harm than good. DHEA, in particular, is a hormone that can have negative consequences if taken without appropriate need and monitoring.

Take heart, whether AMA or not, a low AMH does not necessarily mean that you are going to run out of eggs next month. It may, however, mean that your window to conceive is shorter than the average person and that you may need to consider more aggressive treatment under the direction of your RE. Low AMH does NOT, repeat NOT, mean that you can not get pregnant and stay pregnant.

  • MsAmandaPants – February 2012: 1st pregnancy: natural BFP after one month of trying. Ended in MMC and D&C.
    • April-October 2012: trying on our own with no success, despite temping, OPKs confirming ovulation, good timing, etc.
    • November 2012: 2nd pregnancy: natural BFP after 6 or 7 cycles of trying with no luck, ultimately determined to be complete molar pregnancy
    • December 2012: RPL/AMA testing, including AMH. AMH comes back at .53. Crushing. Diagnosed with low AMH, DOR, and complete molar pregnancy. Benched until August for molar pregnancy.
    • August 2013: Recheck of AMH to determine how much it had decreased during mandatory bench time. It came back at .29. Devastating.
    • August-October 2013: Started fertility treatments in August because of worsening AMH. 3 IUIs using Femara and injects (Menopur) and Ovidrel trigger. All failed, although I had a decent response to fertility drugs, 3, 4, 6 mature follicles, respectively).
    • December 2013: We were told we would have to move to IVF. Recheck of AMH to see if ubiquinol was helping and to determine how much worse it had gotten before moving to IVF. It came back at .54, showing some improvement.
    • A few days later in December 2013: Learned I was pregnant. I had been told that I had to move to IVF and was letting my body and brain rest from treatments for a couple of months before jumping into that. I got pregnant on my own, on a treatment break.

During my molar pregnancy mandatory bench time, I was exercising very heavily (training for half marathons) and I was also regularly taking between 200 and 300 of ubiquinol (the more bio-available version of coQ10) daily. I can’t say for certain that it was the result of my efforts, but my AMH did show improvement during this time. I also took high quality prenatals throughout the period I was TTC.

Grateful&Thankful AMH was .23 & my first RE told me there was no way to increase it. I took 2tsp daily of Royal Jelly & 300 mg of CoQ10 2x a day for 3 months. After retesting my AMH was .77

I don’t have any tubes so IVF was my only option any way. I got pregnant via IVF after taking those supplements for about 2.5 months. I miscarried due to a SCH. I’m currently pregnant again after IVF 5.5

I wanted to add that I’ve heard RJ can make fibroids grow so if you have trouble with fibroids, you may want to tone down your dosage.
2MomsinCA – Hi! Low AMH was devastating. I did a full work up with the RE before even attempting to ttc so I found out I had an AMH of .8 early on. My paperwork at every RE appt from then on said my diagnosis was “diminished ovarian reserve.” Ouch.

I took ubiquinol coq10, L-arginine, and pure royal jelly daily for about 4 months during the ttc process. I also practiced yoga and abdominal massage through the whole process. We did a total of 6 IUI’s and 2 ICI’s over the course of 10 months. The 2nd through 5th IUI were medicated with clomid, trigger shot, and progesterone suppositories. My 6th, final and sticky IUI was medicated with injectable menopur, trigger, and progesterone suppositories. My 2nd, 4th, and 6th IUIs resulted in BFPs. I lost the first two by 6 weeks. I was very good about taking my supplements for the 2 months prior to starting the injectable cycle and once I started menopur I stopped all supplements, did not do any vigorous exercise, and ate plenty of protein.
Emma2370 – In June ’13 my AMH came back at .39 July ’13 BFP naturally mmc at 8 weeks, November ’13 BFP ended in chemical pregnancy. December.’13 natural BFP healthy baby girl. I took my prenatal and royal jelly supplements. We had no issues getting pregnant staying pregnant with a healthy viable pregnancy was the issue. My DH has an chromosomal inversion which could have contributed to our losses. We did make an appointment with a RE just before our BFP.

2RedTulips – My OB ordered my bloodwork in July 2013, and that’s when my AMH came back at 0.2. I was devastated. We had already suffered one miscarriage and had been trying again for eight months at that point.

With those results, OB sent me to an RE, and we did a full work-up. In addition to my low AMH (tested at 0.8 at the RE’s), DH had poor morph, and we were given a less than 2 percent chance of conceiving naturally. Devastation #2. The one piece of good news I received during that time was that I had 12 resting follicles, which was a big shock.

We both started a slew of supplements per the RE. I also started a low-gluten diet, acupuncture and baby aspirin.

We were gearing up for a first round of IUI (certain we’d have to do IVF after a cycle or two) when I got a BFP. So, I call this baby our “2 percent baby,” because he ducked in under the wire.

So, from the time we received the low AMH results to conception was four months.

ETA: I am 39, by the way. I also took all the supplements with the RE’s blessing (L-Arginine, DHEA (prescription compound only), DHA, Inositol, Vitamin C, Vitamin E, CoQ-10 and Melatonin)

Eliz77 – My AMH was tested twice under two different REs and came back at 0.27 both times-tested in August 2013 and January 2014. Both REs recommended we try naturally for two cycles and if no success, move on to letrozole and IUI. We did get pregnant both times one 2nd cycle, 1st time ended in natural MC at 7 weeks. This one is far from a success story, but doing better than previous.

However, neither RE felt the low AMH was reason for losses or cause of concern. It was explained to me as having a lower egg reserve due to AMA, not necessary an indicator of quality since all other results came back normal.

Due to 2nd RE’s discovery of two copies of the MTHFR c77t gene, I was put on low dose aspirin, folate and started lovenox and calcium once an intrauterine pregnancy was determined. I know opinion vary on whether this is reason alone for losses, but since it was the only thing found amiss, RE decided to be proactive in his treatment plan just in case.

If we lose this pregnancy, my RE has already said he would like to move to IVF with PGD.

Daisy19782011 – Age 35, AMH .16
Did a back to back IUI with injections (gonal F) and a trigger. Got pregnant on 1st cycle. I lost that baby at 19 weeks, unrelated to IF, and did the same protocol 3 months later and got pregannat again. All of my other numbers are OK though, and we have not MFI.
BootsOrHearts –
I am trying to remember my AMH number from way back, I think it was 0.25 I’ll have to ask my doctor as the online records don’t go back that far.
Jan 2012: AMH 0.25 (?) @ 38 years old, diagnosed with DOR, told we are unlikely to get pregnant except via IVF or donor eggs.
Later that month. . . . natural BFP! Loss at 18 weeks, unrelated to DOR diagnosis
Started taking DHEA, one pill/day
2012/early 2013 Lots o’ failed fertility treatments, but good response to IVF, estrogen priming protocol: 7 retrieved, 7 mature, 5 fertilized (with ICSI) and 4 available for transfer, 2 implanted (resulted in C/P) and 2 frozen
April 2013. . . natural BFP @39 years old. Isaac, a.k.a. Baby Boots born 11/23/13.

egsquared –
I had 4 early losses between September 2011-August 2012. In October of 2012, my AMH was .18 at 36 years old. All my other results were normal, and two different RE’s recommended IVF. We had to wait until January 2013 to do an IVF cycle (switched to DH’s insurance). I had 9 eggs retrieved (which I thought was a low number), 5 fertilized with ICSI and two available for a 3 day transfer. we implanted both and got pregnant that cycle. DS was born 4 weeks early in September 2013.

In the months leading up to our IVF cycle, I took DHEA, CoQ10 and myoinositol.

The RE explained that with low AMH, you have a higher percentage of abnormal eggs left, so I was probably having bad luck and getting BFP’s on the cycles where my body released a bad egg. He said we could just keep trying naturally and we could get lucky and get a ‘good’ egg and a BFP, whereas with IVF we would be picking the best looking embryo(s) out of the group. We chose to go the IVF route to hopefully avoid any additional losses and because age/time was not on my side.

rslh10 – 28 years old, DX of .58 AMH in March 2014. Started Clomid CD 3-7 with trigger on CD 15, BFP the first try, but ended up ectopic @ 5w6d.
I was taking prenate minis, vitamin D, and biotin. Also my FSH was 7.5, and all the other blood work that had been drawn has been normal. HTH

Etiquette for posting a BFP on TTCAL

Thank you to Buggirl72 for this awesome contribution!

It has been two years since Petra wrote out the etiquette for BFP posts that laid out the rules.

https://ttcalblog.wordpress.com/2011/11/29/rules-aka-etiquette-for-bfp-posting/.

The board has evolved over those two years and I have been asked to update the BFP etiquette to reflect the current board policy and to clarify some of the earlier rules.

We all know that the goal of every woman on this board is to have their rainbow, and, rationally, that means with the large numbers of women on this board who are actively trying to conceive, BFPs happen. The question for many is “Do I post my BFP on TTCAL?” This is probably one of the most difficult areas on TTCAL and one with the most potential for causing the maximum amount of pain for the ladies on the board. You may be asking how the one thing we are all striving for is painful to others. Aren’t we all trying to get a BFP? Shouldn’t we celebrate/support everyone regardless of how long they have been on the board?

This is the time to remember your audience. TTCAL is a safe place. We have fought hard to make it a safe place, one that is safe from people asking if they are pregnant and one that is safe from BFPs. Does it hurt you IRL to find out someone is pregnant? If the answer is no, you are fortunate because for the vast majority of women after a loss, the answer is yes. Be mindful of those women who will be hurt by your BFP. We have women on our board who have been trying for many cycles and are on CD1 or just got a BFN. Seeing your BFP is a cruel reminder that they are not pregnant. We have women who have been on TTCAL for way too long, years in some cases. How do you think a BFP makes them feel? We also have graduates who have returned to us because they suffered another loss. TTCAL is their home and is full of the women who love and support them and they love and support back. A BFP is especially painful for those women. Again, if you are even considering posting your BFP, remember your audience.

Keep in mind, that most of these rules are assuming that you have been an active member. An active member is one that offers support to others, participates in TTCAL as a member of the community, and is a regular contributor. Look at your post history. Are all or most of your posts in the last several months on TTCAL? Are the majority of those under replies and where those replies in support of others, not just vents, complaints, or AW type responses? If you can answer yes to both of those, you are probably an active member. If all you do is read posts, rarely respond, or respond only to check-ins, you are not an active member.

The “rules”:

1) Your first cycle on TTCAL. It is never okay to post your BFP. That is the short and simple answer for you if you fall in that category. You are new to the board and for anyone that has been on the board for more than a few months, your BFP will just remind them that they have been left behind again. You do not give us hope. You depress us. Go straight to PgAL and intro over there. If you post anyways – you will be flamed.

2) You are a “newbie”. Still not okay to post your BFP. Like the person posting that they got a BFP after their first cycle, your BFP is a painful reminder to the vast majority of the women on the board that they have been left behind. The majority of the board has not had very much time to get to know you (trust me, two/three months in not that long). Even if you post what you think of as a lot, have made friends, and are active in check-ins – you are still considered a newbie. Go to PgAL and post an intro. Those who lurk on PgAL will offer you congrats. If you are a member of a check-in that includes BFP announcements, send a PM to your check-in leader and they will announce your BFP in your check-in for you.

3) Your are an “inbetweener”. This is a very, very gray area. You might be asking what an inbetweener is. An “inbetweener” is someone who has been on the board long enough to not be a newbie but they have not been here so long as to be considered an oldie. See, even your definition is muddy. Essentially, you have been on TTCAL for three, four, five, or six cycles. You are realizing that you are not going to graduate quickly but you are still able to offer support to all the newbies who intro (and there is a lot – you are really just noticing how many!), you probably lurk on PgAL and recognize some people over there You also understand why drive-by BFPs are painful and are making strong connections with people on the board.

The reason that this is a gray area is, for the oldies, you are still newish. Even if you offer tons of support and are incredibly active on the board, and have been for many months, your BFP is going to be hard for the oldies to take. This is where the board has evolved in the last two years and the original rule (that you could freely post your BFP after three months) do not apply.

If you have been on the board for only 3 or 4 months, you probably should just intro on PgAL without posting your BFP on TTCAL. Let your check-in leader announce for you.

If you have been an active member of the board for 5 or 6 months then do some soul searching before your post. If you truly are an active member, your BFP will probably be well received.

4) You are an “oldie”. You can post your BFP without reservation (assuming that you are an active member of the board) because you have provided support to generations of TTCALers. If you are a member of TTCAL+6 you should have zero worries. But you will worry, which is why we love you. The fact that you are concerned that your BFP will cause anyone pain shows how much of a valued member of this community you are. Just remember, we want to celebrate for you and we love to see BFPs from those who have Ellie dancing in their signatures.

Special Snowflake – because there is always one. Maybe you introduced on the board over six months ago but never posted again; you feel like your BFP will bring people hope; you are an active check-in poster but only post to your check-in; you think these rules are silly and we should SQUEEEEE all over the place for you. We don’t care. We don’t know you. You are not special. Do not post your BFP.

Ask yourself a lot of questions on why you want to post your BFP on TTCAL. If you do decide to post your BFP, make sure your post has “BFP warning” in the title. This way those who are not up to reading about a BFP can avoid your post.

If you are a check-in leader for a check-in that includes BFP announcements please make sure that “BFP warning” is in the title of your check-in post when announcing someone else’s BFP. If you are announcing your BFP in your check-in, please have “BFP warning/mine” included in the check-in title.

If you are not a check-in leader, do not announce someone else’s BFP. It’s not your place to do that. PM them your congratulations. With the new updated Bump, you do not need to page someone that you are PMing them. You also should not page a graduate on TTCAL. It’s not necessary and TTCAL is no longer their home board.

A final note. If you are fortunate enough to get a BFP, please wait to update your siggy with a ticker. If you were an active member then you are going to still have posts on active threads. If you slam a ticker in your siggy right away, people on TTCAL will see it with no warning in your old posts. Please hold off for a week or so to let any active threads you contributed to role back to the third or fourth page. For those who chart on FF – remove your chart and any links to your chart from your siggy. I found out the hard way just how many people stalked me with my last BFP. People were hurt by it. On the same note, once you get your BFP, you need to step away from TTCAL . Even if you think you are going to have another loss, you need to go to PgAL and wait there. It is hard, especially when you have had multiple losses, but remember that TTCAL is a safe place for many women not just for you.

Please do not think that I am saying that graduates are not welcome to participate on TTCAL. Remember to look for the “PgAL/PAL” warning in the OP’s signature and include a siggy warning in your replies. We love our graduates and want to know they have not forgotten us.

As I wrote this post, I am trying to remember the last BFP announcement that I have seen on the board (not including drive-bys). The graduate is now over 20 weeks and had been a very active and well-loved member of the board for over a year. Several other “oldies” graduated around the same time – they did not post a BFP on TTCAL, even though their BFPs would have been well received. If you ask any of them they would tell you they did not post their BFP out of the worry that it would cause pain to even one woman on the board. Please reflect on that while you think about whether you should post your BFP.

Incompetent Cervix Facts

Thanks to rlajambe for writing this very informative and helpful blog post!!!

What is incompetent Cervix (IC)?
Incompetent cervix (IC) is essential a weak cervix.  Mainly occurring in the 2nd trimester, the weight of the baby causes the cervix to dilate prematurely and this can result in premature labour (PTL).  IC is characterized by dilation in the absence of contractions.
What is cervical insufficiency?
Cervical insufficiency is having little to no cervix.  Some women are born with little to no cervix due to a congenital anomaly.  Surgery can also be a main reason for cervical insufficiency.  A cone biopsy or a cervical surgery for cancer can result in part of the cervix being compromised and cervical insufficiency.
How is it diagnosed?
Unfortunately, unless dilation is detected during a routine ultrasound, IC is very hard to diagnose.  Some women lose multiple babies in the 2nd trimester without a reason.  Generally, three losses in the 2nd trimester with premature labour are deemed to be IC.  However, doctors have started to perform more cervical monitoring for women with suspected IC.
What treatment options are there for IC?
Cervical cerclage (aka cervical stitches) – stitches are placed to hold the cervix closed and prevent cervical shortening.  There are two main types:
Preventative cerclage – placed at around the 12-13th week of gestation.  When a diagnosis of IC has been made during a previous pregnancy, your OB will likely recommend a cerclage at the end of the 1st trimester.  The success rate is about 90-95%.
Emergent cerclage – placed during the 2nd trimester after dilation has already started.  This type is usually due to the discovery of IC that was not known.  The success rate is lower (40-60%) than the preventative cerclage, but many women are successful with this technique.  Also, most doctors will not perform an emergent cerclage after 23 weeks due to the risk of premature rupture of membranes and possible infection.
Bed rest – By placing the women on bed rest, the baby’s weight is taken off the cervix and the cervix is less likely to dilate.  The bed rest period will vary from one women to another usually depending on cervical length through the course of the pregnancy.
Progesterone –Some women experience contractions even after the cerclage is placed. Progesterone gels or P17 injections (17 alpha-hydroxyprogesterone caproate) are intended to prevent the onset of PTL.  
Cervical length monitoring – The length of the cervix will be measured and examined to check for shortening and/or funneling.  Transvaginal ultrasound generally gives more reliable measurements than transabdominal ultrasound.
Your doctor may recommend one or all of these treatments depending on your specific situation.   
Dr. Google told me that there are different methods of cerclage.  What is the difference between them?
There are two main methods of cerclage.  Each has advantages and disadvantages.
Transvaginal Cerclage (TVC) – This method is the most common.  It is essentially placing sutures onto the cervix to hold it closed.  There are several techniques of how the stitches are placed (McDonald’s, Shiradkor, etc.); however, all have approximately the same success rate.  Different doctors have preferences for specific techniques.
Advantages 
  • the sutures can removed from the cervix and allow for a vaginal delivery
  • no incisions are needed as the sutures are placed through the vaginal opening
Disadvantages 
  • not suitable for women with cervical insufficiency
Transabdominal Cerclage (TAC)- This method is usually reserved for women with a failed transvaginal cerclage or those with cerclage insufficiency.  Sutures and surgical mesh are placed internally (inside the abdomen) to close the cervical opening.
Advantages 
  • higher success rate than transvaginal
Disadvantages 
  • makes vaginal delivery impossible, you must have a C-section
  • requires laproscopic surgeries during pregnancy to be placed
  • often not available unless a TVC has already failed
Why doesn’t my OB place the cerclage as soon as I get a BFP?
Viability.  You OB will want to ensure that the pregnancy is viable before placing the cerclage.  Otherwise, they will have to perform two surgeries (placement and removal).  Unfortunately, women with IC still have same risk of a 1st trimester loss as any other woman does.
I had IC with my twins. Will it happen again with another pregnancy?
Not necessarily.  Some women who have IC with multiples go on to have normal pregnancies with singletons.  However, there is no way to know for sure.  Some doctors will take the “wait and see” approach, but this can be risky.  Finding a doctor that will perform the cerclage preventatively can be difficult, but is highly recommended.
What can I do while we’re TTC?
Get the right doctor – The right OB will make all the difference in having a successful pregnancy.  Find an OB with experience with IC and cerclage.  You will need to have your doctor in place before you get pregnant, as you will need to start your appointments sooner than most women.  Discuss your plan with your OB before you get pregnant.  Be clear about what restrictions will be in place during the pregnancy.  
For those who live in more rural areas, you may have look to a major city to find the right doctor.  You want someone who performs cerclages on at least a semi-regular basis, not the OB that does one cerclage a year or less.
Get the right insurance and get your finances in order – You know that you will be high-risk next time out, make sure you have the financial resources to cover all the possible expenses that may arise.  Bed rest (with no income) and extra doctor visits are not cheap.  
Get in shape physically – You can’t make your cervix any stronger, but you can get everything else stronger.  Being in shape physically will help to prevent any other complications, like gestational diabetes or high blood pressure.  You have enough to manage with IC.
Consider talking to a therapist – Your loss can be very difficult to process.  Therapy can help you work through all the emotional issues of your loss and a subsequent pregnancy.  

Recurrent Pregnancy Loss (RPL) Testing

       Pregnancy loss alone is devastating. Not knowing why it occurs even once is heartbreaking. To continue to experience loss after loss causes anxiety, depression and fear. Recurrent pregnancy loss is typically defined as 3+ consecutive losses, while some practitioners may Dx RPL as 2 consecutive losses.
       One thing I ran into personally, was I had two early miscarriages and then an ectopic- some doctors may not consider this RPL because ectopics are either flukes or caused by tubal factors, not necessarily in the same department as another type of loss. My old OB did not feel as though I need RPL testing, whereas my current OB and RE did.  Depending on the types of losses you’ve had, your doctor may order a couple, a handful or all of the testing listed below.
       Bottom line is you need to advocate for what you feel is right. RPL testing can be very expensive (I’ve listed prices my insurance was billed FYI, but obviously prices and benefits will vary), emotionally exhausting and may still not provide you with answers. Below are some tests you may request or discuss with your medical practitioner. I decided not to include normal lab values because one lab’s ‘normal’ may be another lab’s ‘abnormal’.

  • Hormonal Factors Tests (prices may vary from $50-300 per test): This includes prolactin, thyroid and progesterone. Other hormones that may be checked (as part of an IF work-up, some tests may be cycle day sensitive) are estradiol, testosterone, LH and FSH. 
    •  An imbalance with one or more hormone may warrant treatment depending on the Dx. Depending on hormonal imbalance an ultrasound may also be ordered to make a firm Dx (PCOS, DOR)  
  • Blood Clotting Disorders- typically treated with some type of blood thinner (baby aspirin, heparin, lovenox)
    • homocysteine/MTHFR
    • Prothrombin gene
    • Protein C&S
    • Antithrombin III
    • Factor V Leiden
    • Fibrinogen
    • PT/PTT (INR)
  • Structural Factors Tests: These tests are conducted to determine the size and shape of your uterus as well as checking the uterine wall in hopes it is free of scarring, polyps, fibroids or a septum- all of which can affect implantation. Tests to check the integrity of your tubes may also be ordered if one or more of your losses were ectopic, or if you are at higher risk for one. 
    • SHG (sonohysterogram) ($300-ish): This test is conducted by inserting a catheter through your cervix to push saline into the uterine cavity. Simultaneously, your doctor will also be performing a transvaginal ultrasound to get a visual of your uterus. This test can identify if there’s abnormalities in your uterus (listed above). If there are concerns about the uterus, a hysteroscopy or laparoscopy may be performed to fix and further Dx the issue.
    • HSG (hysterosalpingogram) ($500-ish): This test is typically performed in your local hospital’s X-ray lab by an X-ray tech, and sometimes your doctor depending on how their practice handles this procedure. Similar to an SHG, a catheter is inserted through your cervix, except this test requires dye to get an adequate picture of your tubes. Sometimes, simply performing this test may unblock tubes if there’s a blockage while other situations may require surgery. 
  •  Uterine Lining Test/ Endometrial Biopsy: While this test is considered obsolete by some in the medical community (results may vary from tech to tech reading doing the biopsy, which may not give accurate results), it can still be an important piece of the puzzle, especially if you’re dealing with possible luteal phase defect (LPD) or spotting for more than a couple days during your LP. 
    •  This test is typically performed in the office after CD 21 (be SURE you have ovulated, as this test is checking your uterine lining for implantation). To get an accurate and reliable reading, it is typically recommended for this test to be performed two cycles for comparison to make a firm Dx. 
    •  If the uterine lining is ‘out of phase’ (2+ days… meaning you’re 7dpo and your biopsy is showing 9dpo, your body may not be adequately using hormones to build your uterine lining) treatments of clomid/femara, hCG trigger and/or booster and progesterone supplementation may be used for Tx. 
    •  I do want to mention that if the endo biopsy does leave you with a LPD Dx, to ask your doctor about what type of defect it is. Click HERE to read more about the different types and causes.  LPD is a controversial Dx in the medical community, about 50/50- if you are concerned about your LP and your doctor does not believe it’s an issue, seek a second opinion.
  •  Tests for Chromosomal Causes
    • Pathology from D&C/D&E ($480- pathology only): this will show if the cause of your loss was from a chromosomal abnormality or not. Most chromosomal abnormalities found are not typical to repeat in the future. 
    • Genetic testing (saliva testing $960 for MH and I) on one or both partners- This may consist of blood or saliva tests. Some cultural groups may be at higher risk/genetic carriers for certain chromosomal defects. 
    • Karyotyping ($2300 for MH and I): Blood test to be performed on you and your partner to check for translocations (normal number of genes, but are joined together abnormally) Tests for 
  • Immunologic Causes: This is one area that seems to not have as much research on all areas of testing, some are controversial and some are routine- and that I admittedly do not know much about. If you have more information I can add to this section, please feel free to leave a comment, message me on the bump or page me on TTCAL
    •  Anti cardiolipin antibodies (ACA) 
    • Anti-nuclear antibodies (ANA) 
    • Anti-thyroid antibodies (ATA) 
    • Anti-Ovarian Antibodies (AOA) 
    • Anti-Sperm Antibodies (ASA) 
    • Anti-phospholipid antibodies (APA) 
    • Leukocyte Antibody Detection (LAD) 
    • Lupus anticoagulant (LAC) 
    • Embryo Toxic Factor (ETF) 
    • NK activation assay (NKa) 
    • reproductive immuno-phenotype (RIP)

The Scoop on Ectopic Pregnancies

Looking back over the blog I realized that we have not posted anything about Ectopic Pregnancies yet we have quite a few ladies on the board that have experienced them. So let’s go over what a Ectopic Pregnancy is and sign and symptoms to look for. I personally have not experienced one so if any of the ladies that have would like to chime in on anything please get a hold of me.

What is a ectopic pregnancy?

An ectopic pregnancy, or eccysis, is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the mother, since internal haemorrhage is a life threatening complication. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. An ectopic pregnancy is a potential medical emergency, and, if not treated properly, can lead to death.

About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes.

In a typical ectopic pregnancy, the embryo adheres to the lining of the fallopian tube and burrows into the tubal lining. Most commonly this invades vessels and will cause bleeding. This intratubal bleeding hematosalpinx expels the implantation out of the tubal end and is a common type of miscarriage. There is no inflammation of the tube in ectopic pregnancy. The pain is caused by prostaglandins released at the implantation site, and by free blood in the peritoneal cavity, which is a local irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube (just before it enters the uterus), it may invade into the nearby Sampson artery, causing heavy bleeding earlier than usual.

If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal miscarriages. The advent of methotrexate* treatment for ectopic pregnancy has reduced the need for surgery; however, surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. This intervention may be laparoscopic or through a larger incision, known as a laparotomy.

*Methotrexate, abbreviated MTX and formerly known as amethopterin, is an antimetabolite and antifolate drug. It is used in treatment of cancer, autoimmune diseases, and ectopic pregnancy.

I’ve suffered an ectopic pregnancy, but my hCG keeps rising.. what could be going on?

There is a chance that you are still retaining tissue from your loss, you may be going through what is called a heterotopic pregnancy, or you may be going through a persstent ectopic pregnancy, either way you should be in contact with you doctor about your concerns for testing and monitoring.

Heterotopic pregnancy

In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a heterotopic pregnancy. Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies. Since ectopic pregnancies are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound.

Although rare, heterotopic pregnancies are becoming more common, likely due to increased use of IVF. The survival rate of the uterine fetus of an ectopic pregnancy is around 70%.

Successful pregnancies have been reported from ruptured tubal pregnancy continuing by the placenta implanting on abdominal organs or on the outside of the uterus.

Persistent ectopic pregnancy

A persistent ectopic pregnancy refers to the continuation of trophoplastic growth after a surgical intervention to remove an ectopic pregnancy. After a conservative procedure that attempts to preserve the affected fallopian tube such as a salpingotomy, in about 15-20% the major portion of the ectopic growth may have been removed, but some trophoblastic tissue, perhaps deeply embedded, has escaped removal and continues to grow, generating a new rise in hCG levels. After weeks this may lead to new clinical symptoms including bleeding. For this reason hCG levels may have to be monitored after removal of an ectopic to assure their decline, also methotrexate can be given at the time of surgery prophylactically.

What are some signs and symptoms I should be looking for if I do become pregnant?

Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability.
Early signs include:

  • Pain in the lower abdomen, and inflammation (pain may be confused with a strong stomach pain, it may also feel like a strong cramp).
  • Pain while urinating.
  • Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms.
  • Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. This can be indistinguishable from an early miscarriage or the ‘implantation bleed’ of a normal early pregnancy.
  • Pain while having a bowel movement.

Patients with a late ectopic pregnancy typically experience pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms:

  • External bleeding is due to the falling progesterone levels.
  • Internal bleeding is due to hemorrhage from the affected tube.

The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and early normal pregnancy. The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an active pelvic inflammatory disease (PID). The most common misdiagnosis assigned to early ectopic pregnancy is PID.

More severe internal bleeding may cause:

  • Lower back, abdominal, or pelvic pain.
  • Shoulder pain. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an ominous sign.
  • There may be cramping or even tenderness on one side of the pelvis.
  • The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse.

Ectopic pregnancy can mimic symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynaecologic problems.

What causes Ectopic Pregnancies?

There are a number of risk factors for ectopic pregnancies. However, in as many as one third to one half of ectopic pregnancies, no risk factors can be identified. Risk factors include: pelvic inflammatory disease, infertility, use of an intrauterine device (IUD), tubal surgery, intrauterine surgery (e.g. D&C), smoking, previous ectopic pregnancy, and tubal ligation.

Will experiencing an Ectopic Pregnancy lead to fertility problems in the future?

Fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior history of infertility. The treatment choice, whether surgical or nonsurgical, also plays a role. For example, the rate of intrauterine pregnancy may be higher following methotrexate compared to surgical treatment.

*** All this information was obtained by certified sources on Wikipedia.org

Interesting Article

Pressure to Father Child
Please take some time to read this article.

Short version: Timed sex can lead to issues with men’s libido and the researchers don’t recommend more than a few months of timed sex. Some men also are more prone to erectile disfunction and straying after prolonged timed sex. 
 ____________________________________________________________________________
Long version: 
 “Any couple trying for a baby is told that timing is everything. But pressure to perform when their partner is at her most fertile drives men away, according to research. 
One in ten men has had an affair because of the pressure of rigorously timed sessions, while four out of ten claimed it made them impotent.
More than 400 men took part in the study, which found the pressure to conceive a baby caused men acute stress.
Fertility experts routinely tell couples to time intercourse to coincide with the window when a woman is ovulating. There are even highly sensitive devices designed to help couples work out – down to the minute – when she is at her most fertile.
But as the number of timed sex sessions increased so did the men’s level of stress, according to the research carried out in South Korea. None of the men in the study had ever had sexual problems. 
    The finding supports several previous studies showing that men who are under stress produce less testosterone, which has an effect on their libido.The authors suggested couples should be made aware of these risks and attempt timed sessions for no longer than three months at a time, with breaks for a few months in between. 
    Timed intercourse seems to impose a substantial degree of stress on male partners, inducing erectile dysfunction and, in some cases, causing them to seek extramarital sex,’ they wrote in the Journal Of Andrology. Andrology is the branch of medicine concerned with diseases in men, especially the reproductive organs.
    They added: ‘It is clear that the greater instances of timed intercourse trials, the more incidences of erectile dysfunction and extramarital sex and the greater the desire to avoid sex with the intended partner.’ All the couples in the study had been trying to conceive naturally for a year.
    The authors noted that having to sleep with their partner at a specific time ‘becomes a burden and is carried out as a job to be done, which imposes further stress’. They believe that higher levels of cortisol, the stress hormone, being produced by the body was to blame for lower testosterone. 


    Professor Allan Pacey, a senior lecturer in andrology at the University of Sheffield, said: ‘I’m glad someone has studied this, as the single biggest concern for men – usually when their partner is not in the room – is that they really find it a struggle when their partners are obsessed with timing.
    ‘While it is useful for couples to be aware of the fertile window, obsessing about it is not helpful at all. Men are being phoned up at three in the afternoon and told that the green light is on and they have to come home immediately.’
    Professor Pacey, also chairman of the British Fertility Society, added: ‘If couples are having regular sex two or three times a week, they will hit the fertile window.’
    In the UK the age limit for free IVF treatment is to be raised to
    42. Currently only women up to 39 are allowed three free rounds of NHS fertility treatment. Draft guidelines being put out for consultation by the rationing body Nice could allow 8,000 more women in their early 40s to benefit. At present they have to pay up to £5,000 per treatment.”


    Summary taken from this post on the Infertility board on thebump.com