Nyoni, Umoja, Frank, and I got up bright and early Friday morning and headed into downtown Atlanta for our consult with Dr. One. Call me judgmental, but I tend to be highly critical of people whose fingers I know will come to find their way around my vag. So thankfully, I was pleased to find that I like Dr. One as much as I thought I would. Though this screening phase is far more time-consuming (and therefore more nerve-wracking) than any others I have ever been through, I appreciate the fact that she is being so thorough. This will help ensure that all of us – herself, Nyoni & Umoja, and Frank & me – all make a sound and educated collective decision about proceeding onward with me as a surrogate. Sure, the process analyzes to the nth degree all the ways in which my body is screwed up, but never before has a doctor been so careful to check out each and every little thing to maximize success and minimize risk. Before being fully approved, Dr. One has established three additional hurdles to get over that I've not had to jump before:
- Full PCOS work-up to determine if I do, indeed, actually have PCOS. This one threw me for a little bit of a loop, because I've been living for six years with the knowledge that the cause of my infertility was PCOS. As a refresher, the short run-down of my history is that I tried for 2.5 years to get pregnant naturally and it never happened. When I finally relented and went to get help, I went to an OB who specialized in minor fertility issues. He looked at my BBT charts and determined that I was anovulatory, but he never gave a specific underlying cause of the anovulation. He prescribed Clomid, and 2 cycles later I was packing the Twinz. I conceived Jordan with Clomid when Kyra and Jaiden were 5 months old, still without a diagnosis. It wasn't until I was being screened for my first surrogacy attempt in 2004 that the RE diagnosed me with PCOS. She used my prior (sub)fertility history, appearance of polycystic ovaries on ultrasound, and a fasting blood sugar test which revealed mild insulin resistance as criteria to diagnose the PCOS. Though I knew something wasn't right with my lady bits, it was unnerving, but also a bit of a relief to have a real diagnosis for it. Everything made sense; my symptoms seemed to match the diagnosis and I didn't feel like such a walking mystery any longer. However, on Friday Dr. One was a bit surprised to hear that in all these years of working with three other REs before her, not one of them has ever run a full PCOS panel to conclusively diagnose the PCOS. It is possible to have several symptoms of PCOS without actually having it, so other causes have to be ruled out before you can definitely call it PCOS. It sounds strange for me to say that I hope I have PCOS, but I do. It's a strange bedfellow, one I've lived with knowingly for six years and it feels better to stick with the demon I know rather than one I don't. Anyway, I was able to get the PCOS work-up knocked out of the way while at the clinic on Friday. I had an ultrasound which did reveal polycystic ovaries, and I also had TWELVE tubes of blood drained from my arm. I felt a bit woozy afterwards, especially given the fact that I was also fasting for a 2-hour glucose tolerance test. We should have the results by the end of this week.
- HSG – I've had a few endometrial biopsies and several saline sonograms, but I've never had a full HSG to check if my tubes were open. I've always known that in the presence of a hydrosalpinx (fluid in the tubes), the fluid can backflow into the uterus and create a hostile environment for embryos. It would make sense if HSGs were regularly scheduled as part of a surrogate's screening, but once again, Dr. One is the only one who has suggested it. For this, I have to call on my next CD 1 to schedule the exam. Dr. One gave us the option of having my local monitoring RE – our old friend Dr. Dead Fish – do the procedure to save me from having to take another 4-hour hike up to Atlanta, but Ny, Mo, and I ultimately decided that we felt more comfortable letting Dr. One do it herself, that way nothing about the geography of my girly bits is left open to interpretation.
- Consult with an MFM about the risks associated with my having a pregnancy after four prior c-sections — Dr. Sleepy explained all of the risks to Mia and Urs in 2008 and again to Chance and Apollo in 2009, but Dr. One really stressed the risks. She went all Grim Reaper on us: "YOU COULD DIE and leave your children without a mom and your husband without a wife. SHE MIGHT DIE, and then you'll have to live with that the rest of your lives, Ny and Mo, if SHE DIES trying to help you have a baby, and there's also potential risk to the baby. SHE MIGHT DIE, Frank, and you'd be left without your partner. I can't quote numbers since I'm not a high risk OB, so I'd like for you all to sit down with a perinatologist who does know the numbers of your chance of DYING so that we can make sure you don't DIE if it's not a risk you're willing to take. Of y'know – DYING!" Perhaps I'm exaggerating a bit, but it was still sobering, especially for Ny & Mo.
The main risk is of the variations of placenta accreta, which is when the placenta abnormally attaches and actually digs into or beyond the uterine wall, possibly adhering to surrounding internal organs. Complications arise because placenta is densely vascular; if it spreads and grows beyond where it's supposed to, there is a risk of bleeding out during delivery due to the increased blood flow. The chance of placenta accreta (or the more severe instances of increta and percreta) increases with each successive c-section. A diagnosis of placenta accreta almost certainly means delivery by c-section at 34-36 weeks and a hysterectomy (in about 80-85% of cases). Around 60% of women will need to receive a blood transfusion during the procedure. 15% of accreta cases grow to the extreme of percreta, which is when the placenta attaches to other organs, usually the bladder. In those cases, reconstructive surgeries must also be performed during or soon after delivery. In the rarest of cases, there is maternal and or/fetal demise. So yes – all things being true – I COULD DIE, and there is also potential risk to the potential baby. It would be stupid for any of us to brush it off lightly and not recognize that undeniable truth. Still, even with 4 prior c-sections, the odds of developing placenta accreta are relatively slim. Less than 1% of women in their first pregnancies develop it, and by the fifth pregnancy after four c-sections, the likelihood increases to just 3-4%. Now, all of the above stats were given to me by Dr. Google. I went home and researched the hell out of it 2.5 years ago when Dr. Sleepy first mentioned it, and I did the same again after Dr. One's Grim Reaper speech. The most recent studies that I could find pretty much said the same thing. But, we all know Dr. Google – sometimes he's full of Good Things to Know, and other times he's a doctor who's fingers you'd rather not have in your vag. So, I think having the MFM consult is a wise move. I have some questions that I'd like to have answered and even though I feel like proceeding with surrogacy is a gamble I'm willing to take given the slim chance of placenta accreta developing, I'd still like to hear the stats from an actual doctor. Ny and Mo I'm sure have their own list of questions, and even though I'd be willing to take the risk, they may not. I ultimately want them to make the best decision for them and I'll support them 100%, even if it means they decide that my body's too much of a risk and they choose to find another carrier. They need the opportunity to get information so that they, too, can make an informed decision. Ny and Mo will come down to Savannah and the four of us (Frank included), will discuss get the information that we need.
So, long story short – tomorrow morning I'll gas up the van again and make the 1-hour drive to Savannah for an appointment with my OB, which was needed as a preliminary step before they can write the referral to the MFM. The MFM's office has consult appointments only every other Tuesday and Wednesday. Hopefully there won't be too long of a long wait before we can get that crossed off of our list.
Those are the main three things that we have to get accomplished before we can even begin to think about getting calendars and cycling. We still have to work in the psychological consult (a 4-hour appointment in Atlanta) and the contract phase (which won't start until I've cleared screening and we're 100% certain that we're continuing forward), but those two are the least of my concerns. I think if we're lucky, we can have all necessary screening appointments finished by the middle/end of September and possibly transfer by the end of October/early November.* It seems like a long way off, but I was conservative in my estimates and rounded up the timing. I hope that we'll be able to move along a bit more quickly than I anticipate.
*Someone please slap some sense into my head, because my mind just registered how perfect a pregnancy at that point would be because I'd deliver over the summer. As cautiously hopeful as I am, I'm supposed to be too jaded for skippy-dippy forward thinking thoughts like that.