The NT scan

This Tuesday last week I was anxiously counting down the hours until my NT test. I was a bundle of nerves, and had to break down the activity into tiny steps so that I could get through it (get dressed, leave house, get to hospital, walk through front doors, etc). My doppler still hasn’t arrived, so I had no idea if the foetus was even alive.

I arrived 30 minutes early and impatiently waited for my husband to arrive, as he left it to the last minute and only arrived 5 minutes early. Twenty minutes after that, they called us in. My first transabdominal ultrasound, I didn’t even have to take off my pants.

The technician pressed down on my belly and a grainy picture appeared. At first glance, it didn’t look that different from the scan three weeks ago, and my heart froze. But she pointed out the heartbeat and I started to relax. I thought that I had been a responsible patient by drinking a litre of water an hour beforehand, but the technician said that all I was doing was forcing my uterus further towards my spine. She sent me to the bathroom to empty my bladder, and then got down to business.

Everything looked great. The foetus was measuring 6.5 cm (12w6d) at 12w0d with a femur length of 0.68 cm and a NT thickness of 1.49mm (photo of the fetus with a hand on its nose here). I was so relieved when I saw that NT measurement. Then the technician went on to check all the organs, pointing them out as she went along: brain, stomach, kidneys, spine, fingers, feet, even the four chambers of the heart. Due to the position of my uterus, she switched to a transvaginal probe for some of the measurements, so I got a visit from my old friend too. All in all, she concluded “it is a good baby”.

The foetus waved its hands in front of its head, occasionally wiggling and kicking. Although the print outs were a bit poor, seeing the live-action movement on the screen was incredible. With my husband by my side, holding my hand and smiling at me, we could have watched that little thing for hours.

After she had finished, the supervising doctor came in to double-check the measurements. I was a little concerned that the heart rate was a little low (151 bpm) – (the mean rate is 159 +/- 3 bpm at 13 weeks). She did something where she did four different types of doppler heartbeat measurements and said that everything looked fine.

My urine, weight, and blood pressure looked good, so they printed out an official certificate of pregnancy that I need for my work and for securing a childcare position. A few days later I heard that my combined trisomy risk is 1:11 600 for T13 and 1:20 000 for the others.

So, there we are. So far, things look good. Now another three weeks until my next check-up, and another seven weeks until the big anomaly scan.

11w3d: Exhausted

In exactly four days time I will be making my way to the hospital for my NT scan. I am scared of all the things that can go wrong, and excited about what a milestone it will be if everything looks good.

So in order to get me into the spirit of the occasion, I have been doing what any good scientist would do, and reading through the literature surrounding the tests that will be conducted at this appointment, mainly, the NT scan and the blood tests.

The nuchal translucency (NT) test measures the thickness of the sack of fluid behind the neck of the fetus. In general, a fetus with a trisomy (three copies of a chromosome, rather than two) has a thicker NT than a chromosomally normal fetus.

The first figure below illustrates this observation. Each black dot represents two measurements (the crown-rump length and the NT thickness) of a single fetus that was subsequently found to have trisomy 21 (Down's Syndrome). The dark grey rainbow is the distribution of 90% of chromosomally normal fetuses. As you can see, in normal fetuses the NT thickness gradually gets thicker as the fetus gets larger. However, in trisomy 21 fetuses, the thickness remains relatively constant during this gestational period, with a mean thickness of 3.4 mm.

(from Kagan, et al., Ultrasound Obstet Gynecol 2008; 31: 618-624)

The second test is a blood test of the mother to measure our old friend beta-human chorionic gonadotropin (beta-hCG) as well as pregnancy-associated plasma protein-A (PAPP-A). The values on the axis are multiples of the median (MoM), that is, by how many-fold does a result differ from the median value from all normal women. By definition, the median beta-hCG for unaffected pregnancies is 1.0, and the median PAPP-A for unaffected pregnancies is also 1.0.

This second figure below shows how the blood tests from women with trisomy 21 fetuses varies from women with chromasomally normal fetuses. Each dot represents the values from a single patient with a trisomy 21 fetus. The unfilled oval represents the lab values of 90% of women with chromasomally normal fetuses. The median beta-hCG values were 2-fold higher and the the PAPP-A values were 2-fold lower in women with trisomy 21 fetuses.

(from Kagan, et. al., 2008, Ultrasound Obstet Gynecol, 31: 618-624)

So here's hoping that all my dots fall in the normal range, and I can pass this test and start to look forward to moving into the second trimester. It is still feeling unreal, so I hope that seeing a wiggling little fetus on the ultrasound next Tuesday will put some of my anxiety to rest.

References:

Kagan, K.O., Wright, D., Baker, A., Sahota., D., & Nicolaides, K.H. 2008. Screening for trisomy 21 by maternal age, fetal nuchal translucency thickness, free beta-human chorionic gonadotropin and pregnancy-associated plasma protein-A. Ultrasound Obstet Gynecol., 31: 618-624

10w2d Anxious

It is a long slow wait until my next ultrasound in mid-January. I have ordered a doppler, but it seems to be making its way to my home on foot, and is not due here for another week. Although the queasiness, fatigue, back-pain, and swollen breasts continue, it is not the concrete proof that I would like that everything is progressing well with this pregnancy.

My husband, on the other side, seems to have accepted the fact that our family will welcome another member in August next year. He is busy reading "First Time Parent" and making a long list of all the tasks that must be completed before then. He wants to start painting the nursery and buying furniture. The other day he started asking me questions like if we should alternate bottle with breast at night to allow me to get more sleep, and if we should use a crib in the nursery rather than a co-sleeper in our bedroom.

I responded to his thoughtful questions by bursting into tears. For me, it is all I can do to get through the next two weeks until the Week 12 scan. For him, he figures I've got the pregnancy handled, and his job starts in August. I am thinking fetus, and he is thinking newborn. I am so thankful that he realises that he is an equal partner in the upbringing of our child, but sometimes his go-go attitude is a little intimidating, especially when I can barely muster the energy to get off the couch.

9w2d: Happy

Today was supposed to be the day of my post-failure consultation with my RE. We were going to discuss strategies to improve my endometrium thickness during the next round of stimulation. I was going to be leaving today with a cooler full of medication, ready to start my suppression injections.

Instead, here I am, pregnant, and less than three weeks away from my week 12 scan. I don't know how one can be in shock for more than a month, but I still feel blown away by our luck.

On Tuesday we had our first appointment with an obstetrician. I had expected just a quick interview with a few routine questions, but they were very thorough. Full medical history, weight, height, blood pressure, urine test, and six vials of blood. They tested for anti-RBC Abs, STIs (syphilis, HIV, hepatitis, chlamydia ), infections (rubella, toxoplasmosis, CMV), blood type, hormones (TSF), and did a full RBC and WBC. I smiled as she said that since it had been over three months since my last SDI screen at the fertility clinic, they had better run it again. I guess they figure I must have gotten pregnant somehow.

Best of all, before she started the consultation, she gave us a quick peak at the embryo with an ultrasound. I whipped off my pants before she had time to realise that we had already had a scan last week, and we were greeted with a happy looking blob on the screen. I was a bit worried at first, as I couldn't see the heart beating and it looked the same size as last week. However, she she pointed out the heartbeat and measuring the embryo as measuring 9w3d, three days ahead of schedule.

Ultrasound and belly photos here.

Overall, I am feeling fantastic. I feel nauseous unless I am constantly nibbling on simple carbohydrates, which might explain the 4 kg increase in weight over the past two months. I however like to think that I am just growing the most comfortable womb ever. I have back pain if I twist or bend down, and heart palpitations keep me awake during the night. I am always thirsty, and I love pineapple and orange juice. My breasts are larger and slightly sore.

I love being pregnant. I was never convinced that this would happen for me, and I love every day that this little embryo grows inside me.

8w0d Everything looks perfect

We walked into the shiny new ultrasound department of the hospital, just unveiled a few weeks ago. Lots of space, new machines, and they even called us in 5 minutes early. The doctor was great. She quickly went through our history and confirmed that I had previously miscarried, and then moved immediately to the ultrasound. She delicately stated that at this stage, they get better resolutions with a vaginal scan, and I told her that wasn't a problem, I was used to those.

Pants off and then I was sitting up in the chair, watching my uterus pop up on the TV screen on the wall. A few seconds in, and she said "and there is the heartbeat", and I saw a cute little bean in a gestational sac, with a flicker inside. My poor husband was just confused, I guess he hasn't been watching as many ultrasound YouTube videos as I have, so it took him a bit longer to understand what he was seeing. At one stage he thought he saw whiskers.

She then spent a while measuring everything and checking my ovaries for cysts. She measured the heartbeat at 140 bpm, and told us that they switch the sound on the machine after about 10 weeks. The estimated gestational age was 8w1d, one day ahead. Photo can be found here.

She went away to check the measurements with her supervisor, then came back and said everything looks fine. She said congratulations, enjoy your pregnancy. I said Thank-you. Then we went and made an appointment with a gynecologist for next week, and for a NT scan at 12 weeks.

Afterwards I sat outside in the waiting area with my husband in shock. What a surprise. I am supposed to be starting my Gonal-F injections next week, yet somehow I am already half-way through the first trimester. I am so, so, thankful that we received such wonderful news today.

7w6d Tomorrow

I have seen a lot of scans of my uterus over the past few years. I even have a few photos from my laparoscopy. Yet I have no idea what I will see tomorrow.

One one hand, the queasiness, fatigue, sore breasts and lower back pain suggests that I might be gestating something. On the other hand, these symptoms are all psychosomatic, and I know of plenty of women who have received terrible news at their first ultrasound scan.

Seeing a heartbeat tomorrow is both imaginable and completely impossible.

Tomorrow, we open Schrodinger's box, and hope he didn't share it with Pandora.

7w0d Waiting

Today marks my seventh week of pregnancy, if indeed that is what I am. My husband likes to remind me that I can only claim five weeks of this as the true post-conception period. It has been three weeks since I saw those two pink lines. One more week until our first ultrasound.

During our last pregnancy, we had our ultrasound at seven weeks and received the news that I had already miscarried, like we suspected. This time around, I am feeling a little more hopeful. My betas were strong and doubling, I am feeling constantly queasy and tired, and I have not even had a single spot of spotting.

I am trying not to think about what any of this means until after the ultrasound. I keep imagining alternative scenarios - will we see a thriving little bouncing bean, or will we see nothing but a still and silent sorrow?

Seven days to go.

Grateful

Thank-you all for your excited comments and congratulations. There were over 100 exclamation points in your replies. I was really moved to read such excitement, especially as many of you have been through so much more than we have, and you are still waiting for your own good news.

Many of you asked why I didn't announce this sooner. There were two main reasons.

1. I wanted to wait for my husband to come back home so that I could share this news with him in person.

2. I am still skeptical that this all means what everyone think it means. Sure, I have an exponentially increasing amount of hCG in my serum, and I feel a little queasy and tired, and I haven't seen my period for over 6 weeks, but still, I don't know.

I look at those pictures of month-old fish-like embryos and read phrases like "the neural tube closes" and "small buds will soon become arms" and "heart contractions start", and they all sound preposterous. I bought a pregnancy book but then put it away because it seemed completely irrelevant.

I find myself remembering all over again 100 times a day, and every time it surprises me. I have spent so many years day-dreaming about getting pregnant that this feels like just another fantasy.

As I said before, pregnancy is what happens to other people. Not me. And especially not without an embryologist.

Twelve days until my first ultrasound. I hope to see some wonderful sights that day that change my mind.

Unbelievable

-1 dpo (days post ovulation)
I have my final Menopur injection, and a Pregnyl shot to trigger the release from a single 16.1 mm follicle. It is on my right ovary, the one with the partly blocked tube. My endometrium is a very thin 6.7 mm. It looks gloomy.

0 dpo
I have a romantic evening with my husband.

2 dpo
I get a call from the clinic telling me that our frozen embryo didn't make it, and our FET is cancelled. They tell me they can't book me in for a follow-up consultation for another seven weeks.

9 dpo
My husband leaves for a conference in a developing country with no phone contact and sporadic dial-up internet.

14 dpo
I am alone in the house. I figure there's no one there to laugh at me when I pee on a stick. This way it won't be such a shock when I get my period today. However, I look down, and I see the strangest thing:

A spectacular positive test. I had to blink several times, I was sure I was dreaming or hallucinating. No squinting, no colour correction (unlike all the other times). Two very strong lines. Then I remember the 5,000 U Pregnyl trigger 14 days ago. Is it just the trigger? No, it's too strong, and a 10,000 U Pregnyl shot was out of my system by 12 days during my last IVF. So then it must be real.

My husband doesn't respond to any of my text messages. I email a picture to him, but it is a long eight hours until I get his excited reply. He tells me that he secretly had his hopes up for this cycle.

I should make an appointment to get a blood test, but it feels too surreal. I tell myself I'll test again tomorrow and see how that looks.

15 dpo
Well, there's no mistaking this test for anything else:

It still doesn't seem real, and it takes me nine hours to psych myself up to call up the fertility clinic and tell them the news. I was sure that they were going to yell at me for being delusional and making up stories, but instead I hear a smile in her voice as she books me in for a blood test.

16 dpo
I go in for my blood test, so nervous as I watch my blood fill the tube. It looks like the same old blood that I've always had. I can't see any hCG antigens floating around. I make the poor nurse check three times that the tube has my name on it and that they are going to check for hCG, not just LH and FSH.

The clinic surprises me by calling at 11:13 AM. I didn't even have time to get nervous. She tells me that I have a beta of:

1,097

I am in shock. Last time I was pregnant we had a beta of 477 at 20 dpo. A beta of 1097 falls in the top 4% of singleton betas at 16 days post ovulation. My progestrone is great at 31.0. She books me in for another test in a week.

19 dpo
I am tired and sleepy, but then again I am always tired and sleepy. No spotting, no sore breasts, no nausea. Apart from the lack of a period, I do not feel any different. I suspect this is some sort of trickery. I take another pregnancy test at 2 weeks, 5 days post ovulation. I believe it for about 5 minutes.




23 dpo
I go in for my blood test, and again make the nurse triple-check that the label is correct on my tube is blood. I work from home because I can't imagine taking this call in an open office, plus I am too nervous to concentrate properly on anything else. By 12:30 they still haven't called. The later they call in the day, the worse the news, right? At 12:37 my phone rings. I pick it up with shaking hands.

Calmly the nurse tells me that everything looks good, and I am graduating from the clinic. I need to make an appointment with gynecology for an 8 week scan. I am in shock. I ask her for my beta number. "The gynecology number?", she asks. No, the hCG number. She tells me it is:

13,843

Which works out to a very respectable doubling time of 45.93 hours. My progesterone still looks good at 31.4. I beg her to let me pop in for a quick search for a heartbeat, but she says that their work is done.

After sharing the news with my husband, I sit and stare at the screen for about an hour. Then I pick up the phone and ring the gynecology department and book an 8 week scan like any other normal woman would.

28 dpo
Today. I still don't know what to think. I always thought that pregnancy was what happened to other women. I still don't quite understand how we got this fortunate. The embryo failed to thaw. The follicle was on the wrong side. My endometrium was too thin. This is just so unbelievable.

So how do I feel? Tremendously excited. Hopeful. Thankful. Lucky. Worried. Happy.

(If you somehow know me in real life, please keep this information to yourself).

6w4d Miscarriage

For the first week after my beta, I was very optimistic – looking at dopplers and imagining how to tell my mum. Thinking about a January birth, signing us up for a pregnancy information evening.

From 5 weeks 6 days, the brown spotting became heavier. My husband would look at me and call me his “beautiful pregnant wife”, but I asked him to stop. I still don’t feel comfortable saying that word out loud. Every day was a mixture of hope and anxiety. The days ticked slowly past.

By 6 weeks 3 days, there was tissue, and by 6 weeks 4 days, there was a great deal of bright red blood. I didn’t feel any pain, but I knew that this was not a very good sign.

Today was the day of my scan, and I woke up today a bundle of nerves, pushing my husband out of the house so that we ended up arriving at the hospital half an hour early. They had me down for a 12 week NT scan, and as I corrected the receptionist, I felt like such a sham. I hated hearing myself say “I am seven weeks pregnant”. We turned the corner to the waiting room, and I was confronted with a long line of baby bumps. That was really hard for me, watching them walk out with smiles and little print outs of hands and feet. The wait was excruciating, but eventually my name was called.

I dumped my coat and bag on the floor in the corner, and the nurse chastised me, telling me to hang up my beautiful coat. Seriously, my coat. I threw it on a chair, anxious to just get to the scan. They asked me to pop up on the chair fully clothed, like I was getting an abdominal scan. I tried to tell them that I needed an internal scan, but first they started firing all these questions at me. Last menstrual period. 17th April, ovulation 9 days after that. Name of my family doctor? I told them that I don’t have one. Name of my gynaecologist? I told them that I don’t have one. “But you need one!”, the nurse explained “Who is going to follow you through this pregnancy?” This is when I lost it.

With my eyes full of tears, I said to them “There has been a lot of bleeding, let’s just make sure that there is a pregnancy first, then I can answer these questions”. I could barely stand or speak after that, and my husband gently took over, telling them about our reproductive history. They asked me to take my pants off, and I sat on the table half naked and shaking.

My uterus came into focus, and it was the same as I have always seen it – tight as a clam. The doctor was called quickly. They interrogated me – what made me think I was pregnant? Just a urine test at home? No, I told them, I had a blood test of 477 at 21 days post ovulation. I am so glad I got that blood test. I am glad that the system has some sort of concrete record that I was pregnant, that I wasn’t just mad.

The doctor was quite kind, gently explaining that she could not see anything in the uterus, and now her job was to search for something outside the uterus. She carefully looked along my ovaries and checked for extra fluid in my abdomen. There were no signs of an ectopic pregnancy. She tried to tell me that “at least you can get pregnant”, but I told her that after two years of trying, a miscarriage isn’t that much comfort.

They sent me off to get a blood test to completely rule out an ectopic, and told me they would send a copy of everything to the fertility centre for their records.

I then walked down the hall to the fertility centre to make another IVF intake appointment, and I was glad to hear that they can fit me in next week.

So how am I now?

I am comforted that I don’t have an ectopic, and I am reassured that I should be able to start my IVF cycle with my next cycle.

I am relieved that the worrying and anxiety are over.

I am thankful that I have a wonderful husband who held my hand through the whole ordeal, and who manages to make me smile every day.

But I am very sad that I am no longer pregnant.

I am so disappointed that we will never have a January 2011 baby.

I am worried that even if I manage to get pregnant again, I will not stay that way.

I am bitter than two pink lines will never mean the same thing again.

I am exhausted.

6w2d: Waiting to see the heartbeat

If I am pregnant, then I am 6 weeks and 2 days today. The brown spotting seems to have gone away for the moment, which is great. Five days until the ultrasound. My husband keeps on reminding me that I must still be pregnant because I haven't had my period. But what if I had my period without noticing, or it's ectopic, or I reabsorbed it like a rabbit?

The ultrasound is scheduled for Tuesday. My IVF intake appointment is scheduled for Monday. I still haven't cancelled my IVF intake appointment. I will do this today, and hope that it doesn't jinx me.

My stomach is churning this morning. Morning sickness or anxiety?

5w4d: Not not pregnant?

Still another ten days to go until the ultrasound. I really do not feel pregnant at all. I know a lot of women feel like this around this stage, but I also know that a lot of non-pregnant women feel non-pregnant, too. I like to think that my breasts are a little sore and my appetite is a little off, but that might all be psychosomatic. A few days ago my abdomen felt like I had done too many sit-ups, but that sensation has also disappeared.

Still, no red spotting and no cramping. I'm going to take this as a good sign.

I am so impatient to see the scan. Is there something inside me, or is this just going to be a sad little line on my history bar?

If it were up to me, I would be measuring my blood hCG daily and searching for a gestational sac. I am not very good at not-knowing how things are going inside of me.

Zwanger

Yesterday afternoon, I picked up a digital pregnancy test, or a "test de grossesse / zwangerschapstest"" as they are known here in Belgium. Sixteen euros. Sheesh. Luckily, instead of trying to fit "enciente/ pas enciente; zwanger / niet zwanger; gravid / ikke er gravid" into the tiny window, there is simply a plus or a minus. So I come home, and use the fancy test. The hour glass flashes, and I put it down to wait. Three minutes later, I return, and I think that I catch a glimpse of a minus sign. Yep, I think, that's more like it.

But then I pick it up, and this is what I see:



It still feels very academic to me. Like this stick that I'm holding is referring to someone else. I still don't feel any difference - just some very mild pre-period cramping.

Still, I know I have to tell my husband. Maybe that will make it real. I pop out to a local baby store. It takes me a long time to walk in. Once in, I feel as if everyone is looking at me. After a long deliberation, I pick up a cute bear onsie for newborns. It looks disturbingly large. I come home, wrap it up, write a note, and order pizza.

Over dinner, my husband tells me about his day. I am terrified of telling him. I still don't feel like it's true, and that I am jumping the gun or making it up. So I give him the gift, and a card that says "I am pregnant. I am due on the 9th of May, 2010. I love you". He looks at me with wonder and amazement, and pulls me over to the couch. "Wow", he says, as we touch noses. I can't stop holding the positive pregnancy test. It is the only evidence that anything is difference. We spend the rest of the evening discussing wills and life insurance and maternity leave and childcare. It still doesn't seem real.

Pale pink line

So, this cycle I ovulated sometime after cycle day 13. I had a positive luteinizing hormone rise at day 12, but no temperature rise until day 18. If I did ovulate at day 13, then today I am 18 days into my luteal phase. I took a pregnancy test 14 days past my LH surge, when my period was due, but it was completely negative, as usual. I also noticed I had some spotting and cramping, and thus had a few glasses of wine and a cup of coffee, and waited for my period to show up. Today, four days later, it still isn't here. My pregnancy tests will expire in two months, so I figured, why not use another one, even though my temperature is falling.

I remember reading that usually the second line shows up straight away. But mine, as usual, fades to white. I put it down, but then a few minutes pick it back up again. If I look very, very carefully, there appears to be an extremely faint second line. So faint, I must be hallucinating. I pull up the Fertility Friend gallery of very faint positive pregnancy tests, and they all look darker than mine. I pull it out again. It's more than a shadow than a line. The test strip cost a dollar from the internet, is over a year old, and has been shipped over two continents. It's probably not very accurate.

I have had no other signs. No nausea or sore breasts or anything. I feel completely normal.

If it is positive and I had a healthy pregnancy, I would give birth on the 9th of May 2010. That is far too soon and too real and too scary. My hands shake at the thought. It's all too soon. I'm not ready.

So I will test again this afternoon, and we shall see then. But I might pick up the strip and look at it again.

Hmmm...