I’ve been quiet lately, and that’s not without reason.
After preparing for nearly a year, my husband and I went through IVF again, this time to have a second child. This was my first cycle in this second round, and my third cycle/transfer total. If you follow me on social media, then you know this cycle failed. I experienced pregnancy symptoms very shortly after my FET, and through the day before my beta. What likely occurred was that our tiny embryosowski implanted, and then failed to grow. 15 days after transfer, I lost our baby boy.
I was devastated. Although I’d had a failed transfer before my daughter, the impact now felt much greater. The grief struck me in ways I hadn’t expected, and I had to sit with those feelings as I learned to process them.
Our follow up (WTF) appointment with the RE was about a week after our negative test, and that timing gave me some space to feel, and then to strategize. I was torn between taking a break and jumping back into another cycle, and I wanted her advice. I needed a plan. To walk out of that meeting knowing what my next steps were.
One common question I get asked by clients is “What questions should we ask after a failed cycle/failed transfer/cancelled cycle/miscarriage/loss?” and I wanted to talk today about what I asked, and why, and how that impacted my next steps.
Do you have any idea what happened? Did any of my labs, scans, embryo grading, transfer procedure, etc. give you indication that this might not become a sustainable pregnancy?
Unfortunately, both often and in my case, the answer to this question is usually a very frustrating no. With IVF, and an ideally thick uterine lining, and a well graded embryo embryo, there's at best a 60% chance of success. This is both heartbreaking and hopeful, depending on who you ask and when. It was important to me to ask this question though, so I could put away the thoughts of “i did something wrong, or i could’ve done something better” and help myself to move forward.
How can I heal my body?
In my case, time was the only answer. I had to let my estrogen and progesterone levels come down to normal, and then I had to essentially miscarry our embryo. With other situations, there may be more helpful notes and suggestions from your provider, so I always suggest asking this question.
When should I expect to bleed? For how long?
This again, unfortunately, is not always a straightforward answer. It may be fairly instant in some cases, and more delayed in others. Bleeding after a failed cycle or early miscarriage usually occurs anywhere from 1-14 days after a negative test/ultrasound, and can last anywhere from 3-14 days (usually similar to your period, but often more intense in blood quantity and cramping, and brighter in color)
I stopped all of my medications after the negative test. What comes next? When can i start again?
My clinic wanted me to call on the first day of my bleeding to set up another baseline ultrasound and labs. I am incredibly lucky that I have one remaining frozen embryo, so if I chose to go into another cycle, I could begin FET prep again after clearance from my clinic. Many clinics consider a ‘back to back’ cycle to be one cycle apart - meaning rather than baseline during your bleeding of the failed transfer, you baseline at the next cycle, typically about 3-6 weeks later.
Can we do any testing for more information?
I wanted to know first if there was anything diagnostic we could do to look for reasons for failure, or anything else I could try to give my next transfer the best chance for success possible. I was presented with two options:
An ERA (or Endometrial Receptivity Analysis) is a procedure done (outpatient) during a “mock cycle” on the same day that your embryo transfer would normally be completed. In my clinic, this is 6 days after starting Progesterone. “The biopsy taken from your endometrial lining evaluates over 200 genes that play a role in the endometrium becoming receptive for embryo implantation, and the test predicts your personal ideal window for implantation, hopefully determining the “best” day in your cycle for the embryo transfer and decreasing the likelihood of implantation failure.” **
A Endometrial Biopsy/Uterine Scratch, done during my FET prep, which would only alter the timing of my cycle if it came back with notable results. This procedure is uncomfortable, but quick, and requires no preparation. During a regular vaginal exam with a speculum, a small amount of tissue is removed from your uterine lining to be tested. This primarily would indicate if there was inflammation (endometritis) or other uterine abnormalities that could interfere with successful embryo transfer.
Because I’d only had one failure this cycle, I decided that I was not ready to do an ERA. Also to note - this conversation occurred in mid-October, and I was told that based on my clinic's calendar, there was not time left to complete a cycle for an ERA and then a FET cycle before the year ended. My husband and I decided that we will complete an ERA cycle if we experience a second, and therefore back to back, failure.
We did go ahead and agree to the Endometrial Biopsy. We figured if nothing else, it would help us either discover or rule out any possibly identifiable causes for our failed transfer.
Should we use the same protocol again? Should we do something different?
This was by and large my most important question, and the one I hear from clients most often. The protocol I used during this last cycle was the exact same one that I used in 2018 for the successful transfer of my daughter, so I still had some faith left in it. My doctor actually recommended that typically, when patients have a failed conventional cycle (medicated, like mine) that they try a natural, or modified natural cycle. Here’s what I learned about our options:
A Natural FET cycle uses moderating to follow your natural menstrual cycle (instead of medication to create an ideal cycle), and schedules the embryo transfer around the time that an embryo would implant if you’d gotten pregnant when you ovulated. This type of cycle requires additional monitoring visits at the fertility clinic so your hormone levels can be monitored via labs as closely as possible, and so routine ultrasounds near the time of ovulation can measure the thickness of your uterine lining.
Pros: For me, this would mean no oral estrogen or progesterone in oil injections - not just in preparation for the FET, but even after a hopefully successful transfer. My body would just take over the preparation on it’s own to house a baby, since the cycle had been natural, it just replaced spontaneous pregnancy with a pre-formed (and PGS tested) embryo.
Cons: The additional required clinic visits didn’t feel ideal to me based on COVID-19 and trying to limit our exposure, as well as the time and distance required to get to our clinic. Additionally, because this method involves a lot of careful tracking, it is possible to miss the ovulation window/ideal timing for a transfer, and to have to start again with the following cycle. I was not a fan of this.
A Modified Natural FET cycle is similar to a natural cycle, but hCG “trigger shot” is used to force ovulation, and then embryo transfer is scheduled for 5 days after.
Pros & Cons, for me, were the same as listed above.
A Conventional/Medicated FET cycle - this is what I’d known previously - taking oral estrogen (4mg 2x/day) for 10-14 days from baseline to mid-cycle, then adding PIO injections 2x a day, and continuing these medications through 10 weeks gestation after a hopefully successful pregnancy is confirmed.
Pros: I’d already done this protocol 3 times, and was comfortable with it (as comfortable as one could get when dealing with hormones and 1.5 inch needles). It was also the protocol that gave us our daughter, so I knew it had worked for me before.
Cons: This protocol had just failed us, leaving me confused and frustrated and full of grief, and I was afraid of trusting it again.
After some serious discussion with my husband and our doctor, we decided to give another try to the conventional/medicated FET cycle. Honestly, the main reasoning for me was that my gut told me not to abandon it since it has been successful for me in the past.
As I began to prepare for my next cycle, I thought a lot about my advice to clients and friends who struggle with starting again after IVF failure. Here’s what I want to recommend:
Advocate for yourself. This may feel incredibly hard, awkward, new and challenging, but it’s critical. You know your body best, and if there are things you’re confused about, or wanting to probe, or even to try, you have to ask. I always suggest walking into an appointment (in person or telehealth) with a list - of questions, concerns, thoughts, feelings - anything on your mind that you want to share with the doctor. If you feel like having moral support might be helpful, see if your partner or doula or family member or friend can accompany you to your appointment, or help you prepare for it.
Give yourself grace to feel your feelings. IVF is a lot, for anyone. Dealing with the aftermath of a failed cycle or any type of loss along the way is really difficult, and absolutely impacts how you mentally and physically strategize for your next steps.
Fill up your cup - find support where it feels good for you - whether through hashtags on Instagram, in online support groups or forums, in friends or family members, in infertility doulas and coaches - let other people help build you back up and cheer you on along the way.
If any of this resonates with you, and you’d like to talk more about your own journey, decisions and next steps, let’s chat! You can click here to schedule a complimentary consultation with me.