All about CGH microarray- part II

A continuation from my previous post, this discusses the pros and cons of CGH microarray. If there is anything I have missed out, please bring it up here.

2 kinds of embryo biopsies:
First a little background, and its going to get technical. You can biopsy a developing embryo at 2 points- around day 3, where you pull out a single blastomere, and on day 5-6, after the blastocyst has begun hatching- here you can get out multiple cells. The latter is called a trophectoderm biopsy.

A blastomere biopsy on day 3 is more harmful to the embryo, because "removal of one or two cells from a six- to eight-cell embryo on day 3 depletes the embryonic mass by 12.5%–25% or more, risking the inadvertent removal of critical cells from the embryo, especially if attempting to improve diagnostic certainty by taking more than one cell for testing." Also, with a single cell biopsy on day 3, you have a significant chance on missing out on mosaicism, a condition where chromosomal errors can be introduced during cell division after fertilization, at any point. The earlier the mosaicism is introduced, obviously, the greater impact it would have.  

A trophectoderm biopsy on day 6 appears to have 2 advantages over a blastomere biopsy on day 3-- a) it is potentially less damaging to the embryo (you remove a much lower percentage of the total number of cells, and one lab, who had done this a gazillion times and were now expert at this, clearly, reported that "after allowing for blastocele reconstitution" the majority of their embryos survived their freeze-thaw) and b) It has a  much higher chance (but is not a 100% reliable obviously), of catching out on mosaicism.

Ok- those technicalities being explained,  my RE wisely chose a trophectoderm biopsy, so lets move on to the pros and cons of that, with CGH micrroarray thrown in.

Cons

Damage to the embryo during biopsy: The more the lack of experience of the tech doing this, the higher the possibility of damage, or so i think--correct me if I'm wrong, it does not seem like a simple procedure, no idea what the learning curve is like. Additionally, there are different options of herniating the zona pellucida(?) prior to biopsy, and some may be safer than others, it depends on available technology.

Obviously, as stated above a trophoectoderm biopsy is better than a blastomere biopsy, because you take less from the embryo. But the risk remains that you can damage the embryo, worst case, none of your chromosomal normals might survive the thaw. Or they might be able to survive, but might have a lower chance of implanting. My mother had a unique worry: that there would be flawed development of the baby due to embryo biopsy.  Nothing I've read shows any indication of abnormalities in any children resulting from biopsy (there have been 700 children born from blastomere biopsy worldwide in 2005, apparently). There are plenty of logical reasons to think it decreases your chances of having viable embryos in itself, and based on the hardiness of the embryo and the skill/experience of the tech doing this delicate procedure, may even result in your IVF cycle producing zero clinical pregnancies. That, I think is the worst case scenario, and its one I've considered.I think my final decision will be made after considering the experience my clinic has had with this procedure. If I'm one the first people they try it with, I'll be aware before I decide, one way or the other. 

It does not eliminate the possibility of mosaicism: Obviously, a trophectoderm biopsy is your best chance of detecting this, while it is not foolproof. Again, it comes down to the luck of the draw and about overall risk reduction of pregnancy loss. My goal is to eliminate as many aneuploids as possible. I know that I may not be able to get them all.

Limitations of the technique itself:  My RE bought this one up- its a new-ish procedure, with limitations. In the very best hands with the very best luck, its limits of detection are possibly microdeletions/microinsertions. Still room for things to go wrong. But right now, I'm considering it only for its core ability- the ability to detect gross aneuploidy. Good enough for me.

Practical issues: I'm doing this in India, where CGH microarray is not offered as a procedure (I hope some enterprising individual comes across this and decides to start this as a business venture, sometime soon, though its not going to happen for me). So we are doing it in a clinic where this is not usually done (and I am deeply and utterly grateful for their willingness to take this on), then will be attempting to ship DNA across continents (So much can go wrong there), then I have to find a lab willing to do this, who accepts extracted, amplified DNA from another country as raw material for this procedure (anybody who has had this done, can you tell me the name of your lab?) CCRM girls, this is done in house (right?)
Right now, I just know of  24suretest (in England) and CCRM.

Pros:

It would definitely improve the chances of success. One study reported that after taking into account aneuploidy and mosaicism, over 50 % of the generated embryos of 'young women'  were chromosomally abnormal.  Clearly, age does not protect you fully.  And I'm young (in that I appear to have plenty of eggs left, with excellent FSH, AMH, estradiol and AFC--similar to that of any egg donor), and I make eggs capable of fertilization and implantation, and 2 out of my 3 eggs may have been chromosomally abnormal.

If 40 % of the embryos generated through IVF are aneuploid (and embryo grade is not much of an indicator of whether am embryo is euploid or not!) then I would need some serious luck to avoid having a surrogate go through loss. Both my RE and my mother were of the thought process that, if my surrogate went through one loss, or more, it would be something easily borne, because it is not me going through the pregnancy. I think everybody was startled when I burst into tears at the very thought of my surrogate losing the pregnancy--and the 20 week amnio time point was under discussion here. I think women who have lost babies will completely understand my horrified reaction, while others would think--- its not your body, so what is the matter? To that, I'm going to say, its still your child. So you will be devastated each and every time it happens, especially if you get to the point of 20 weeks, where your hopes have really been built up. For people having gone through the process of using a surrogate, if you could address how you felt at the thought of anything happening to the surrogate pregnancy in the comments section, that would be very useful.

It would potentially decrease time required for success: Lets start with the assumption that around 40% of my embryos will be aneuploid. I line up one surrogate. Transfer one embryo (I refuse to do multiple embryo transfers to one surrogate).  If its aneuploid, best case, we lose around 3 months.Worst case, its something that we don't detect for 20 weeks (again, bloody scary prospect for the mother, while the general audience thinks this is not a big deal). Then, we repeat the process again. If we get unlucky, it would really be a while before we hit on a winning combination. I want to stay in India around 3-4 years maximally. I also want any children I have to spend atleast the first formative 2 years of their lives around my family---which means, for my 2 plans to mesh, this has to work quickly. While IVF with PGS does not guarantee this---I could totally lose a chromosomally normal embryo, at 5 months, for multiple reasons, it reduces the overall risk of pregnancy loss.

A valuable learning experience: If we embark on this road, everybody involved could learn a lot, even if no pregnancy results from this IVF cycle.  I could learn more about the nature of my embryos. The person doing this should get valuable laboratory experience at this technique. If this entire IVF fails, the only commodity that would be definitively lost is money and time. The time would smart, but the money? We spend money on so many things, so many of them relatively inconsequential that I'm not going to feel bad about spending money on this, even if it fails utterly. My mom wants to get me a diamond set worth around a million rupees for the wedding. The possibility of a baby is definitely something priceless, and this venture may set us back around 1/5th of that price, so I'm not going to quibble about it.

This is a post utterly open to lively comment and debate. I hope there is some of that, and more importantly feedback on available facilities (in the US, or anywhere else) that do this routinely and are willing to accept samples and my $$$.  I know a lot of people, from everywhere, read this blog. I hope that will come in useful here!

All about CGH microarray---part 1

I had my visit with my RE yesterday, with my parents in tow. Coming back to India, with the difficult choices to be made, I had expected no step of this process to be easy, and that was proven right with a vengeance yesterday. And its not even a process that should be easy, these are extremely difficult decisions, with a great deal of grey area and a lot of room for arguing pros and cons for any particular fork in the road. Unexpectedly, the point I had expected to be the sticking one, surrogacy, was more easily settled, but another point provided a great deal of debate-- that of genetically testing the IVF-generated embryos.

First, lets segue to another point, that of treatment choice in itself. Both my RE and the MFM specialist I saw in the US gave me the impression that of all the treatment options they would offer as the first choice, an IUI conception (probably with ovulation-inducing drugs thrown in) would be a top choice, and possibly, many of you reading would also agree. This stems from the finding that even women who have had 5 losses have a good chance (is it 50%?) of carrying to term in the next round. This is where the patient and the doctor part ways I think. The patient looks at a 50% risk of going through the hell they went through previously, and may balk, for good reason, I should add. Nobody who has not experienced that reason, personally, (being a truly empathetic audience is not good enough), will  understand why.

I personally, am invested in making the risk of miscarrying/late loss lower. That is all I'm about. I'd love to eliminate that risk entirely, but I know all I can do is make the risk as low as practically and economically possible (and everybody's capabilities here are different), but I can never, ever, despite the best laid plans and all the plotting, planning, testing and novel approaches (IVF, PGS and surrogacy included), can I make that risk go away. Despite all you account for, things can go wrong in yet another way, I am so blindingly, painfully aware of that, far more so now, than 2 years ago.

My doctor proposed a novel  exercise, and its one that is pretty useful and logical- consider and write out the 'cons' of pre-genetic screening of embryos.  I'm doing that, but more for my parent's benefit (they need to understand why I'm proposing this, instead of following the doctor's advice), I'm also going to write a 'Pros' list. This list of pros and cons should be useful for anybody who is at the cusp of this difficult decision. This is coming up in the next post...stay tuned.

Meiotic non-disjunction strikes again

After a great deal of haranguing, I got the results.  Meiotic non-disjunction (which, in English means, the chromosomes did not separate properly during the process of making an egg or sperm) has happened again.

During my second pregnancy, it happened in the form of a monsomy of the X chromosome, which means either the egg or sperm had one less X chromosome that it should have. Monosomies are considered to be more likely a sperm error (a sperm that is missing a chromosome is lighter, can swim faster, yada, yada).

This time, it was most likely to be an egg error- a Trisomy, of chromosome 4. And it was a girl.

On googling, my blood ran cold- trisomy 4 appears be one of the rarer ones, and more often its a partial trisomy, (you have a 3rd copy of only one half of that chromosome) and the child can make it to birth, but obviously, with major, major issues. Thank god  my baby and I was spared that. Often, miscarriage is not about nature being cruel, its about nature being kind, and nature was kind here, but only AFTER the bloody trisomy had resulted. Bloody nature.

I'd had a bad feeling about this pregnancy from the time that the first beta and progesterone values had come in, because they were both far lower than my levels for the first 2 pregnancies (though, in normal range for the population) and the progesterone fell sharply by the 7th-8th week period-this was all in keeping  with the observation that some (but not all aneuploidies) can have lower progesterone and beta-HCG levels. Its fascinating, apparently trisomy 21 has higher HCG levels, but Trisomies 13 and 18 have lower progesterone and beta-HCG levels---wow, this suggests that complex mechanisms behind aneuploidy of different chromosomes, just because we don't understand it in the slightest, does not necessarily mean that its completely random. Chromosome 4 aneuploidy has not been studied, because its too rare, but my scenario also points to reduced hormone levels with this one.

What next? IVF with PGD obviously, but I'm trying to end up with a method more accurate than FISH, which does not analyze all the chromosomes, and would (probably?) have not caught this one.  The goal is to get microarray done with IVF in India-- this one has several logistical issues, lets see how they can get worked out. 

But as for now, I'm so very glad to have an answer. The point where we get grateful for small mercies is a sad one indeed.

The ability to cry

When I'm sad, or when I'm stressed and something gives out,  I cry.  Tears work in different ways for people. Some cry copiously, and feel no better. Others lack the ability to shed tears, and keep hoarding their negative emotions. In my case, crying works in precisely the way evolution probably intended it, as an exquisitely-designed mechanism to physically shed emotion and become free of it.

The most sensitive emotional barometer I possess is how much I've cried in any given situation. I cried copiously after my first loss, for days on end, for long periods of time. My second loss bought about far less frequent tears, I went to the numb and 'I'm ok' bits much more quickly. With this 3rd loss, while I cried infrequently through the pregnancy to expend the stress that was building, and plenty on the day of the loss, but afterwards, my tears just dried up.  They came maybe four times that coming week, in very short (like 1-3 min) durations, and afterwards, not all all. I also felt like life was almost normal, I was not even numb, most of the time, I just felt fine. That was bewildering in itself, I have to say.

There has also been very little grief with the loss of this particular life, and there is a little part of me that feels profoundly guilty about it. I never felt like this pregnancy was real, because my psyche, for whatever reason, solidly blocked it. There was no grief that I could identify over the loss of THIS life, this child. I felt sad that the pregnancy has failed. I cried because I'm so scared about the future, and that things were so hard for me.  But I never cried because this particular life was gone. And to this day, I wonder why it was. The easy and simple answer is, its a coping mechanism that my sub-conscious developed, after the back-to-back whacks of 2 pregnancy losses. But still, I'm not wholly satisfied with that explanation.

I want the results of my karyotyping back for multiple reasons-- one part is, that I want this lost pregnancy to become more real for me. I want to know what I had, so it finally becomes more tangible. Its been 21 days post D&C. When I left the country (17 days post-surgery), the results were not back yet. I called today, the receptionist was distinctly unhelpful. She would not inform me of the availability of results via email, she had no idea when they would become available, and her advice was to keep calling back until a) the results came back and b) a nurse practitioner was available to relay them to me. Yikes. That is a lot of international calls. And honestly, I'm just dying to know.

After talking to that woman, the dam finally cracked. I cried again, and I desperately needed to. Grief or the lack of it non-withstanding, these past few weeks have been enormously stressful. Like an idiot, I scheduled my flight out of the country 2 days after I had finished work. I decided the timing the day of the loss, on a day I should have been making no decisions, on a day that my primary priority was to run home to family. Two weeks after, when I was emotionally back to a completely even keel, when I was stressed and overworked with the burden of wrapping up my handover and packing to leave in a ridiculously short time, I seriously regretted it.  I managed it, finished everything I had to do and I'm back in India, but not without some serious stress and cost to myself. Its been rough. And I finally cried today, because of a rude receptionist. I just pray I get my results soon, and they don't end up tell me that they managed to lose all samples or the lab messed it up or something. Though my badly needed R&R has begun, I'm stretched very thin right now.  C'mon universe, tell me what I had.  

So, so boggy

During my pregnancy, I had a dream that I lost the baby. I remember being utterly unsurprised in my dream state and thinking, well, this had the lowest progesterone and HCG of any of my pregnancies, so yeah, this is no shocker that its over. I woke up, had a moment of disquiet, and dismissed the dream to my fears manifesting in my subconscious. After all, these 2 readings have proven to be very imperfect in predicting the fate of a pregnancy.

But my dream reasoning was probably dead on. Of all 3 of my pregnancies,this is has been the worst looking one and it ended the earliest too. 2 weeks have passed, and I still have no concrete idea why. I had them run a progesterone test after they discovered the loss, and it was interesting, my progesterone had dropped like a stone. It was around 25 ng/ml in the 15-21 DPO period. On the day of my loss, it was 11 ng/ml(!!), while my HCG was over 40,000.  You have to wonder, what came first, the chicken or the egg? Was my progesterone low because it was a bad. ie genetically abnormal pregnancy (those tend to have lower progesterone, though the correlation is not very good) or did my pregnancy end (partly) because of low progesterone?

I'm still waiting on the chromosmal analysis. Right now, my biggest fear is that they lose the sample, or can't test it. As long as I get an answer of what the embryo was, I'll be satisfied with that. Any day now, the doctor should call me.

I also got my bloodwork of my RPL panel in my hand, and I pored over every result, and I'm very glad I analysed it myself, because the doctor who was looking at it (who I had an RPL consultation with), was really not detail-oriented. AAARGGHH.

The doctor I spoke (not the one I consulted with) to said I had issues with 3 genes related to clotting issues. Not actually true-- i have semi issues with 2 of them.
This is how it goes
I'm actually normal for the anti-thrombin gene (very good news, the mutant variant confers pretty strong risk for various issues)
I'm heterozygous (ie have one copy) for the MTHFR C677T gene
I'm heterozygous for the PAI4G mutation- I'm 4G/5G (where 5G, I think, is the normal variant)

The immunological bloodwork should be taken with a giant grain of salt because yeah, the did not send to the best testing lab. Arghhhh. I asked my doctor why that was and he said, it was because 'the others are expensive'. At that point, I wanted to find a nice wall to bang my head against, I mean, why bother testing if you cannot trust the results?

So---I'm in grey zone territory for thrombophilias. This doctor (who according to his practice was 'aces' at treating RPL) gave the following verdict- I should try again,  preferably with clomid to improve egg quality (why do docs love clomid, and not femara, which has fewer side effects??) and once I got pregnant, add asprin, lovenox, Prednisone (10 mg, 2X/day) and progesterone to the mix. Basically, throw the empirical, basic RPL cocktail at me and see what happens.

Errm. Moving on from what that doctor (he was SUCH a name dropper, he just kept talking about his famous patients) thought- here is my biggest fear. There are 2 flavors of thrombophilias which can interfere with pregnancy-- maternal and fetal. If  both me and my donor are heterozygous(ie only one copy) for a bad version of the MTHFR or the PAI gene, any baby has a higher risk than either of us, because it could  get the bad copy from both of us and end up with much higher risk for developing clots. I asked the doctor when he thought fetal thrombophilias play out, and he thought it has a role in later (second and third trimester) pregnancy loss. Interestingly, all my losses have occurred after the fetus has developed a rudimentary blood circulation---so theoretically, fetal thrompbophilia could be in play. This issue would not, in theory, be fixed by using a surrogate, unless the surrogate was given lovenox as well.

To have a better idea of what is happening, I really want to talk to an RPL expert, even if just to brainstorm. Some of the best minds in the RPL field, are, as Adele pointed out in the comments section,  are in England, at St Marys. I can't go to England unfortunately. But ANY of you coming by this blog get to talk to anybody who is expert with RPL- can you ask about fetal thrombophilias-- when they think they play out? Btw, if any of you are heterozygous(ie, one copy) for thrombophilia-predisposing mutations(such as MTHFR C677T),  testing your husband for the same is a very good idea. Nobody wants to have a child that is homozygous (ie, 2 copies) for these mutations, that could predispose to a lot of health issues later. I wish I could frogmarch my donor to give some blood, but that, sadly is not an option. The only option I have is to test the embryos.

I know what I want to do- I want to do IVF. Then after we biospy that one blastomere, I want to expand the DNA so I can do a lot of testing with it, including running genetic tests for the MTHFR, PAI and anti-thrombin genes. This is going to be extremely technically and logistically challenging and is going to need a lot of money and initiative, but thankfully, money is the one commodity I do have to throw at this problem. After that-- I want to do surrogacy. There is a part of me that shudders at the thought of being pregnant again, I just don't ever want to go through a pregnancy, for so many reasons, though I most definitely want to be a mother. I don't trust my body anymore. I don't know if its immune issues or clotting issues, right now, its fair to say that with my history I AM higher risk for all the later term complications, such as placental abruption and IUGR and all that other good stuff. I can't keep gambling like this, not when I have an out. Even with this preset idea of what I want to do, its going to be an uphill task to figure out what I should do and to find a plan that everybody involved can make a degree of peace with.

In other news, I got done with work, I'm packing up to move back to India, and I'm really, shockingly fine, from a mental standpoint. There is a lot more to say there, but as of now, time is a commodity of which I am very short of.

Recovery

I had my D&C yesterday, and it was a huge releif to get that done. They did it under ultrasound guidance and the doctor assured me he was going to be 'very gentle' and he reiterated, after surgery that he had been and that everything looked fine. No doctor actually wants to give their patient Asherman's syndrome--so fingers crossed.

Emotionally, I'm recovering at warp speed from what happened. I measure how I'm feeling by 2 yardsticks- 1) how much time I spend crying, and 2) What my zest/enthusiasm for life in general is. In the past 5 days, if you added up all the time I had been truly emotionally upset or cried, I doubt it would be for more than a 15 minute period, which is amazing. My enthusiasm for life is well and truely there,I'm enjoying the olympics, I want to go out and shop, I'm eager to tick off items off my New York Bucket list,  this feels *almost*  like a normal week in my life. I'm gobsmacked by how well I'm doing, all in all.

But---I've definitely not gotten away scot- free from what happened, that is impossible. The thought of being pregnant again almost makes me feel ill. If I go the pregnancy route again, I think it would likely trigger feelings akin to PTSD. A number of you cautioned me to go easy on myself, not to blame myself for what happened.

The thing is, I definitely don't think anything I did caused the loss. It was not the cup of coffee I drank daily, it was not the beer I had 3 days past ovulation (baby not implanted yet, that was my rationale:)), It was not my 6 hour walks across Manhattan- Nothing I did caused it. But most certainly, something that I am  that is responsible for my 3 losses. I'm not really angry with myself for that , but its more like a deep embarrassment, that I'm failing where most people succeed without trying. As I've said, that comes down to ego. I've always enjoyed perfect health and a body that works well, and when you are used to thinking of yourself a certain way, learning otherwise is going to sting. There is also a little teeny tiny nugget of rage at everybody who has succeeded here. The first step to recovery is awareness, I've really been talking out how I feel with my mom, which helps.

I got a call from my doctor this morning- they got the results of my RPL panel back. No immunological issues whatsoever, which is nice, because that is the mildly harder thing  to fix, and also given that my Vitamin D levels were nice and high, I expected my immune system to be bitch slapped into submission. And yeah, it was.

But--3 flags on genes linked to coagulopathy. MTHFR (I have 1 copy of the 'bad' gene), Something with the thrombin gene, and something with  PAI4G.  I asked my doctor to email me the actual lab reports, since these are complicated, and you need the details to figure out what is going on.  Then, I'm going to read up on all of this myself, so I can asses risk independent of my doctor.  True risk aside, the treatment is simple, lovenox.

All in all, I have 4 factors that *might* elevate risk for RPL, anti-thyroid antibodies, and the 3 genetic risk factors for thrombotic abnormalities. Uhh, there is  a little smoke, and there has definitely been a fire. Are they related?

Einstein famously said insanity is doing the same thing again and again and expecting different results. Its not a 100 % true for infertility, sometimes, the 10th try may actually work. But I don't like such odds at all, and I refuse to keep gambling with them.  The next try is definitely going to be IVF, with PGD for all generated embryos. I"m seriously mulling adding surrogacy to the mix, for many, many reasons. Its around 20,000 $ in India- its very,very affordable.

But for now, I'm very, very ok.