Pregnancy Loss and the Role of PGT

Our son was born through gestational surrogacy in the USA. This was after a six-year infertility journey. During that time, we suffered three heart breaking pregnancy losses.

It’s estimated that 15 per cent of confirmed pregnancies end in miscarriage. Yet from talking to my friends, I would say the number is higher. And whether the pregnancy happened naturally or through fertility treatment, after a month of trying to conceive or after years, or whether the baby passed at 5 weeks or 12 weeks, it really doesn’t matter. A loss is a loss. In my experience, it’s a suffering that doesn’t compare to anything else. It rips you open and leaves you feeling devastated, confused, and sometimes even guilty. You can feel at peace with it one day and then without any warning, feel a tidal wave of grief the next.

Our first pregnancy loss was due to an ectopic pregnancy. Our second loss was a missed miscarriage. And our third miscarriage was with our surrogate Leigha and was due to a sub chronic haematoma. I remember after our second loss, I was consumed with trying to work out what had happened. The first thing I learned is that it’s not your fault. I once read an inspiring Instagram post by the actor James Van Der Beek (Dawson’s Creek). He was honest and vulnerable about the multiple miscarriages he and his wife had endured. But what really stood out was his refreshing take on the word miscarriage itself. He wrote, “First off—we need a new word for it. ‘Miscarriage’, in an insidious way, suggests fault of the mother—as if she dropped something, or failed to ‘carry’. From what I’ve learned, in all but the most obvious, extreme cases, it has nothing to do with anything the mother did or didn’t do. So, let’s wipe all blame off the table before we even start”. Spot on.

The second thing I learned is that most miscarriages are due to genetic abnormalities. And this is where Preimplantation Genetic Testing (PGT) is invaluable. PGT tests if your embryos are genetically normal. There are different types of PGT, but the most common test is PGT-A. This test screens embryos to ensure they have the correct number and order of chromosomes—this includes twenty-three pairs of chromosomes. If a chromosome is missing or duplicated, an embryo won’t implant. Or if it does implant, you will miscarry. Given chromosome abnormalities are the cause of most miscarriages, PGT-A is said to decrease the miscarriage rate by a staggering fifty per cent. Also, a pregnancy rate on a PGT-A cycle is estimated to be sixty to seventy per cent, compared to approximately thirty per cent for a cycle without it.

There’s also an added benefit of PGT-A, it can screen for gender. If an embryo has XX sex chromosomes, it’s a female. If it has XY chromosomes, it’s a male. For us, this wasn’t an option. Even though our surrogacy transfers were in the USA, our embryos were created and genetically tested in Australia where it’s illegal to know the gender. But in the USA, it’s legal.

Prior to PGT, embryologists would assess an embryo’s quality through the ABC grading system. Many IVF clinics still use both methods in conjunction with one another. But this grading system alone is not reliable as it only assesses how an embryo looks on the outside. During our treatment, one of our embryologists compared the grading system to a book. A book can look perfect on the outside but once you open it, there could be a page or section missing. Or a page doubled up. This means the story is interrupted and doesn’t make sense to the reader. Or, in the case of an embryo, a chromosome is missing or duplicated and therefore it won’t be a viable pregnancy.

As mentioned, there are different types of PGT. To learn more about PGT, you can read the article:  Understanding Preimplantation Genetic Testing (PGT): Insights from Dr. Minoos Hosseinzadeh.

Your First IVF Cycle

When you first start IVF, it can be daunting. I remember feeling excited and hopeful but also overwhelmed. Some weeks fertility treatment felt like a full-time job. Today I want to share what a typical IVF cycle looks like. 

1. Paperwork. Police checks, child protection checks, consent forms and payment forms. 

2. Mandatory couple’s counselling.

3. Blood and urine tests. This includes testing for infectious diseases and checking your hormone levels.

4. Pelvic ultrasound. To assess your uterus and check for any abnormalities, e.g., cysts.

5. Semen analysis. To measure the number of sperm and their ability to move. About 40 per cent of infertility is attributed to sperm. 

6. The Anti-Mullerian Hormone (AMH) blood test. A hormone secreted by cells in developing egg sacs (follicles). The level of AMH in your blood helps predict roughly how many eggs you have left. 

   
   

   Day 1-11

   • The first day of my IVF cycle was day one of my period.

   • I took a 75 daily dose of the Gonal-f injection (a moderate dose because I had several follicles). The nurse was quick to point out that I needed to inject myself at the same time every night for it to work. Gonal-f helps to stimulate your ovaries to over produce eggs.

   Day 6 -12

   • Every two days, I would visit the hospital before work for an ultrasound and blood test to monitor my follicles and to check my hormone levels (progesterone and oestrogen).

   Day 9-13

   • Towards the end of my egg stimulation phase, I started to take the Orgalutran injection. This is used to prevent you from ovulating too early.

   Day 14

   • Ovidrel injection, the ‘trigger’ shot. The injection to make you ovulate. The timing of this injection is crucial as it needs to be taken at precisely 36 hours before your egg retrieval.

   Day 16

   • Egg retrieval surgery. This is a day procedure where the eggs are collected from your ovaries. Under general anaesthetic, an ultrasound probe is inserted into your vaginal wall to identify follicles and then a needle is guided through. The needle goes into each of the ovarian follicles and gentle suction is used to pull out the fluid and the egg that comes with it.

   • It only takes about 30 minutes, but I was in hospital for half the day with pre surgery checks, paperwork, and a couple of hours in recovery. For two to three days after, I experienced cramping, and bloating

   • Once the eggs are collected, they are fertilised. We fertilised our eggs using Intra Cytoplasmic Sperm Injection (ICSI). This is where a single sperm is injected into each egg. It is often considered your best chance of fertilisation because there is no risk of the sperm swimming aimlessly in the petri dish unable to find an egg.

     
     

   My results

   • Eleven eggs collected, a good result. In later egg collections, with a higher dose of Gonal-f, I collected 15-20 eggs.

   • The next day, the nurse called to say that out of eleven eggs, nine had fertilised. On average, around 60-70 per cent off mature eggs will fertilise.

   • On day five, she called again to say five embryos had made it to blastocyst stage and were being frozen.

   • A blastocyst embryo is an advanced stage of development. Blastocyst embryos are graded – A, B, and C. Simply put, A and B are the best; they have well defined and smooth cells. In contrast, C embryos have irregular and dark cells and few of them. The only true way to measure the quality of an embryo though is through Pre-Genetic Screening (PGS) testing.

   • Before they’re frozen, the embryos also undergo assisted hatching. A laser is used to gently thin the outer shell of the egg (the zona). If the embryo can hatch out of the shell more easily, there’s a higher chance of implantation.

   Day 17-35

   • From three days after Ovidreal injection until the pregnancy blood test on day 35, twice daily I inserted vaginal progesterone pessaries. Given progesterone is usually produced during a women’s natural cycle, the pessaries are needed to maintain progesterone levels during early pregnancy.

   • If you receive a positive pregnancy result, you continue the progesterone pessaries throughout the first trimester.

   Transfer day – Day 22

   • I had my transfer in the morning and I was in at work an hour later. For the transfer, an embryologist prepares your embryo by placing it in a catheter. Under guided ultrasound, the fertility specialist then threads the catheter up through your cervix and into your uterus. It only takes about 10 minutes. The most uncomfortable part is having a half full bladder

   • On the day of the transfer, the embryo is thawed about an hour beforehand. For blastocyst embryos, we were told that approximately 90 per cent of embryos survive the thaw.

   Day 35 – The pregnancy blood test

   • Two weeks after my embryo transfer, I had a blood test to measure my hCG, THE pregnancy hormone.

     
     
   
   

IVF: What to expect

When we first started trying, I assumed it would happen quickly and easily. We were in our early thirties and had no fertility issues (that I was aware of then) so it never occurred to me that we would struggle to fall pregnant. But a year on, and still not pregnant, I was becoming increasingly upset and frustrated. We decided to see a fertility specialist. She checked my egg quality and count and my husband’s sperm, and she did an ultrasound of my uterus. Everything came back ‘normal’. But to ensure I was ovulating regularly, she prescribed Clomid. Three months later, no pregnancy.

It was then some friends mentioned IVF. They told us that if we were having trouble conceiving, we could “just do IVF.” Problem solved. And I believed them. But it didn’t just magically happen for us. In fact, it took us six years to have our beautiful son, born through gestational surrogacy.  

Reflecting back, here’s some things I wish I had known before starting IVF.

It’s a marathon, not a sprint

I assumed that IVF would guarantee a baby, and the first IVF transfer would work. I think many of us assume this. But sadly, for many people, it takes multiple transfers. I think if you go into IVF with those expectations in mind, it will make it a bit easier if it doesn’t work right away.

It’s a waiting game

There’s lots of waiting when you’re in the throes of fertility treatment. Waiting for an appointment, waiting to get started, waiting for the right time to transfer, and of course, the dreaded Two Week Wait. Waiting can be tortuous. Especially the Two Week Wait, in my opinion. I always found it useful to keep busy, distract myself and do things that made me happy. Often that meant going for walks, catching up with friends, having a weekend away or binging a TV series. 

Self-care is crucial

There’s no sugar coating it, infertility is tough. It’s an emotional roller coaster. It can be emotionally and physically draining so be kind to yourself and put yourself first. Whether that means setting boundaries and saying no to certain things (i.e., baby showers, gender reveal parties) or doing something just for you.

The medication side effects can also be brutal. Everyone is different so you may have mild side effects, or you may experience a truck load. If it’s a lot, self-care is vital. Finally, I found therapy helpful. I first started seeing a therapist – who also did hypnosis – after our second pregnancy loss and she was instrumental in helping me heal and navigate the next chapter. 

Be your own advocate

It took me a while to advocate for myself but once I did, it was invaluable. Come to your appointments prepared with questions, do your research, talk to others going through IVF and get a second opinion if you feel you need it. You can read more in our article on advocating for yourself during fertility treatment.

Some people will get it, others won’t

I was shocked that so many people – who weren’t medical specialists – had an opinion. You may get tonnes of unsolicited advice from “You just need to relax” to “It will happen when you stop trying.” Comments like these are hurtful and ridiculous. Infertility is a reproductive disease that affects 1 in 6 couples worldwide. “Just relax” is not a medical cure.

Connect with others

Talking to someone who is also going through IVF can help you feel less alone. You may also learn about different treatment options. Wish for a Baby Australia is a great way to meet others going through the same journey as you and to also meet all the fertility specialists under the one roof.