Post-Op Questions (???)

It's been a week since my post-op appointment.  I brought with me a list of questions to ask Dr. Bachus.  I will now list the answers.

1. Endometriosis is a condition in which the tissue that behaves like the cells lining the uterus (endometrium) grows in other areas of the body, causing pain, irregular bleeding, and possible infertility.  The tissue growth (implant) typically occurs in the pelvic area, outside of the uterus, on the ovaries, bowel, rectum, bladder, and the delicate lining of the pelvis.

My Ovary - Pre-Endometriosis Removal

2. There is really no way to keep an eye on it.  It could grow back in 6 months, 10 years, or never.


3. Our Reproductive Endocrinologist, Dr. Bachus, will follow us during the first trimester of my next pregnancy to make sure that things are moving smoothly.  At that point, we will then move back over to our regular OBGYN.


4. The Septate Uterus answers why we miscarried at 6 weeks and 19 weeks because the embryo and baby did not have enough blood supply to help them grow.


5. The septum was more than 50% down the center of my uterus.

The bottom right photo is the best picture they could get of the Septum. 

6. I can start running again 2 weeks after the surgery! :) (More on this later.)


7. The endometriosis was removed by laser destruction (or diathermy).


8. We have an 85% - 95% chance of having a normal pregnancy on our next try.


9. I will need to take a Baby Aspirin every day during my next pregnancy as a way to prevent blood clotting.


10. I have as much of a chance as any "normal" pregnant woman to have a full-term vaginal delivery when the time comes.  And at this point in my life, it really doesn't matter how Baby arrives, just as long as Baby is healthy and crying loudly upon arrival.


11. A picture to prove that I was diagnosed with a Bicornuate Uterus and reminder that second and third opinions are so important to be able to finally reach a peace of mind.

12. A picture of my original HSG, which never would have been able to give us our true diagnosis of the Septate Uterus.  I'm so happy we had the laparoscopy/hysteroscopy! 

The End.

April 29, 2011

Mom & I Before I was Wheeled Into the Operating Room

Amongst all that is going on in the world from Bin Laden to the new Duke and Duchess... Joey and I finally have our own "new beginning."

On Friday, April 29th at 2:30pm, I went into the Surgery Center of Fort Collins and got ready for the biggest moment of my life, thus far.  I signed the necessary papers, put on my surgery gown, had the IV inserted into my hand and laid down on the hospital bed.  (After the IV was put in, the worst was over for me!)  Then my mom and Joey came to my bedside and sat with me while we waited for my surgeon to give me the okay to head back.

Our Surgeon/Reproductive Endocrinologist, Dr. Bachus, came to my bedside and explained that he would be performing the laparoscopy and from there he would decide what the best plan of action would be.  If he found a normal uterus or a bicornuate uterus, I would be in and out within 10 minutes because the procedure would only be diagnostic.  However, if he found a septum, he would then go ahead and remove it.  At this point, all we could do was just wait and see...

Around 5:30pm, I heard my name being called by the post-op nurse and realized I wasn't at work.  (I had previously been dreaming about case managing one of my clients.)  I looked around and realized that I had been under anesthesia for over 2 hours.  The nurse told me to take deep breaths and I laid there taking the best deep breaths that I could.  Thirty minutes later I was able to stand up, get dressed and go meet my Mom and Joey in the recovery room.  I began to sit down on the big comfy chair in the recovery room, when they walked in with sh*t eating grins from ear to ear.

"Did you hear the news?"
I had no clue.

"The doctor found a septum halfway down your uterus AND endometriosis.  He was able to get rid of it all.  You are as clean as a whistle inside!"

It would end up taking me another 24 hours to really let it sink in, but those were the best words I had ever heard.  I called it my "Christmas in April".  The surgery was over, the septum was identified and removed AND endometriosis was identified and removed before it caused me any more problems later on.

From here, I need to heal for 3 months, have one more MRI to make sure that my uterus healed properly, and then it is all in our hands.

It can really play with your mind when you go from a zero understanding of why you continue to miscarry and if you will ever be able to have a "normal" pregnancy, to having the world open up in front of you and the doctor telling you that you are healthy and good to go.  I'm still processing the whole situation in my head, and probably will be for a little while.  Luckily Joey and I start counseling next week with the same LCSW that helped us through the grief and loss of Baby.

Our journey to a family continues with cautious excitement and unexplainable relief.  I just can't thank the doctors, family and friends enough that have supported us to get to this point.

Our Answer! A Septate Uterus

The septate uterus is the most common müllerian anomaly, accounting for 3% of detected anomalies. It consists of a single uterus divided by a largely fibrous midline septum. If the septum extends to the internal opening (os) of the cervix or even further downward, it is considered a complete septum. If it does not, the uterus has a partial septum and is "subseptate." In addition, a septum may be broken up longitudinally, or segmented. The outside contour of the uterine dome (fundus) may or may not be indented, but the groove does not exceed 1.5 centimeters in depth.

In the female embryo, uterine development is usually complete by 22 weeks' gestation, with the two müllerian ducts fusing together to form a single uterus. In one of the final events of uterine formation, the wall where the ducts fused dissolves, forming a single endometrial cavity. It is the failure of this last process that produces a septate uterus with two endometrial canals, reflecting either a partial or complete failure of the duct walls to dissolve, depending on the extent of the septum. Although there is some evidence of a weak genetic factor at work, researchers still do not know the exact cause of the failure of a septum to resorb.

While a septum is not thought to decrease fertility, it does seem to affect the course of a pregnancy, either through miscarriage or pregnancy complications. Early miscarriage is common within the septate uterus, because the blood-starved median septum is covered by a poorer grade of endometrium than that of the blood-rich sidewalls. An embryo implanting in the septum frequently fails to thrive because of lack of nourishment, and an early miscarriage is the result. Late miscarriage is also common, and its likelihood increases along with the extent of the septum. Some studies suggest that in a completely septate uterus, the prognosis of a live birth is as low as 10%. In a late miscarriage, the pregnancy outgrows available space and the cervix may give way, typically midway in the pregnancy, before the fetus is mature enough to survive. Other complications include premature labor, premature birth, intrauterine growth retardation, and fetal malpresentation at birth. One caveat to keep in mind is that women diagnosed with uterine septa tend to be the ones with the most problems conceiving or carrying to term; cases of septa that do not affect reproduction are probably under-reported.

Unless the woman has a vaginal septum or double cervix, the septate uterus is usually not diagnosed until a woman has had some pregnancy failure. Typically, after failure to conceive or repeated miscarriage, hysterosalpingogram (HSG), in which dye is injected into the uterus and x-rays taken, reveals some degree of septation. Other tests which may reveal a septum are: magnetic resonance imaging (MRI), ultrasound, and hysteroscopy.

Each test has its own advantages and disadvantages. For instance HSG, which shows the inner contours of theuterine cavity and fallopian tubes, can not tell the difference between a septate uterus and a bicornuate uterus because it does not reveal the outer contour of the uterus. A spetate uterus looks normal or nearly normal on the outside, while a bicornuate uterus has some degree of outer division. Although some medical texts state that the angle between the horns may reveal the type of uterus, with an angle less than 75 degrees indicating a septate uterus, this is not reliable; some septa are very broad. MRI, on the other hand is increasingly thought to be more reliable, although sometimes it is difficult to see the uterus in the proper plane. While ultrasound may sometimes reveal the outer shape of the uterus, it is best used as an adjunct to a more definitive test. Hysteroscopy can frequently determine whether the septum is fibrous or muscular, and when used simultaneously with laparoscopy, can provide a very accurate diagnosis. Although a simultaneous hysteroscopy and laparoscopy is invasive, it can be done at the same time as a hysteroscopic metroplasty, if the latter is indicated to reduce a uterine septum.

One of the heartening aspects of having a septate uterus is that it can be repaired through a relatively simple surgery, giving the woman near-normal odds of carrying a subsequent pregnancy to term. Whether or not she needs a metroplasty depends on the extent of the septum, or whether or not she has lost previous pregnancies. Until the mid-1980s, surgery to reduce a septum, called a metroplasty, was done through an abdominal incision. Recent development of the hysteroscopic metroplasty (also known as "septoplasty") has rendered the former technique almost obsolete.


Information from: http://www.wegrokit.com/uterineanomalies/index.htm

Hope On The Horizon

I last left off at a very dark point our lives, where getting pregnant seemed like a crapshoot and our hope of actually having a child was slim to none.

Since that time, Joey and I have met with Dr. H, the doctor that delivered our little girl, and he gave us some news that we never even knew existed.  Apparently, with a condition like a Bicornuate Uterus, there is a procedure called a concurrent laparoscopy and hysteroscopy, which will look at my uterus from the inside and outside.  While the doctor is performing the procedure, he/she can perform a corrective hysteroscopic metroplasty, which essentially will detect the septum, snip it off and then sew up the uterus.

Now, I am sure I do not have all of the correct details, and there is always the possibility that something else could be wrong...but I have hope!  High hope!

This could be our chance to have a normal uterus, a normal pregnancy and a "normal" little addition to our family!

Dr. H and Dr. P referred us to Dr. B, who is a Reproductive Endocrinology and Infertility Specialist here in Fort Collins.  We have our first meeting with him on March 24th (after a 2 month wait) and I am really really hoping that he is our guy.  I have decided to put all of my faith into the possibility of fixing my uterus, and with that, hope has returned.  HOPE!

My Darkest Day

WARNING: This is the TRUE story of my pregnancy journey and the grief and loss that ensued. This is not for the faint of heart. 


I lost my first pregnancy on my mother's birthday, at 6 weeks. 

My husband, Joey, and I sent my mom a bouquet of flowers for her birthday.  The vase was a ceramic pair of baby booties with a beautiful bouquet and card inside.  “Happy Birthday!  You are going to be a Grana again!”  Two hours later, the blood began to flow and two hours after that, Joey and I were having our first ultrasound ever.  The Ultrasound Tech found the sac and we watched it bounce around the screen.  The baby did not have a heartbeat and I was miscarrying.  The grief began and we left the clinic in a fog.  I called my Mom and my best friend on the ride home and could only cry into the phone.

I thought that was bad, but I had no idea what I was in store for. 



*******************

Four months later, Joey and I found out we were pregnant again.  “This is it!”  I immediately told myself, "This baby is going to be born and it's going to be a boy!  I can feel it!"  (Self Realization: A feeling is not a promise.)



Skip ahead to 5 weeks pregnant and spots of blood began to appear.  The thought of miscarrying again sent shear terror throughout my body.  I called the clinic and was told, "If this is a threatened miscarriage, there is nothing we can do about it."  (Self Realization: The medical professionals are not perfect and cannot create miracles.)  

During the next 4 weeks, I spotted on and off and had a few ultrasounds in between.  At this time our midwife diagnosed me with a Bicornuate Uterus and Placenta Previa, and she warned me to NOT Google it.  She explained that there is a possibility that I could have preterm labor, a possible c-section if the baby is breech due to the little room available in the uterus, or in the worst-case scenario, second trimester miscarriage.

“Phew, that’s the worst case scenario… Oh man, I really hope I can still have a natural birth.”

(Self Realization: Ignorance is bliss.)

Meanwhile, Joey and I began to call our little being “Baby”.  We were entranced with Baby’s sonogram.  We secretly hoped that Baby was a little girl because we had the best name picked out for her.  It was perfect. 

I was prescribed Prometrium from 9 weeks to 13 weeks to raise my Progesterone levels.  I was a little bit nauseous, stopped spotting, and felt a little bump beginning to grow.  Those five weeks were pure pregnancy bliss.  If nothing else, I can always hold onto those 5 weeks.  (Self Realization: I would do anything to be riddled with morning sickness, knowing that in the end, my hard work would pay off.)


I finished taking the Prometrium on a Wednesday and that evening, after my prenatal yoga class, dark blood appeared on my underwear.  By this time, I had become so used to the spotting that I paid little attention to the blood.  However, by the following Sunday, I laid down on my side of the bed and immediately felt a stream of wet go down my leg.  "Oh shit!"  I ran into the bathroom...It was blood.  "This is it. It's all over."  It's all I could think about.  "This is it.  It's all over."  I decided not to go to the ER that night because in reality, I did not want to be miserable in the ER all night and end up leaving empty.  I decided that I could go to the clinic in the morning with a full night’s rest. 



The next morning Joey and I went to the clinic to check Baby’s heartbeat and it was as strong as ever.  Our midwife explained that, "It was just a small tear and it's good that the blood was released from the uterus because that could cause a blood clot."  If that's not foreshadowing, I don't know what is? 



The bleeding began to die down again for the next 5 weeks and we were back to bliss. 

*******************

From July 17th to July 23rd of 2010, I was 17 weeks pregnant and all of my immediate family came to Colorado to spend a week in a “log cabin” in Estes Park.  I quote “log cabin” because it was one of the fanciest cabins I have ever seen.  That week my family hiked Longs Peak, biked the Thompson Canyon, rode horses through Rocky Mountain National Park, and swam their hearts out while I sat back and watched.  I was perfectly content manning the house and relaxing as to not hurt Baby in any way.

On the fourth morning at the cabin, I woke up in bed and I noticed that my stomach felt flatter than it had and I immediately had a sinking feeling in my heart.  Something felt wrong.  

On the morning of my family’s final day in Colorado, I had an interview with a social work organization in Loveland.  After the interview, Joey and my parents picked me up in our Subaru and we began driving down I-25 to meet the rest of the family at the Denver Museum of Science.  Right after we had passed the Longmont exit I received a call on my phone that displayed “Unknown” and I immediately knew it was the women’s clinic.  “But why would they be calling me now?” 




“Melissa?” 


“Yes, this is she.” 


“This is Yada Yada from the clinic. Are you okay to talk right now?” 


“Yup.” 


“Okay Melissa, we got your results from your Quant blood test last week and the results came back. They show that your baby has a 1 in 5 chance of having Trisomy 18 or a Neural Tube Disorder. Now we are going to need to you come in, meet with the Genetic Counselor, and have a Level II ultrasound.” 



That was the conversation that pulled everything to a screeching halt.

I knew right then that Baby was not going to make it.  I knew my life was about to change forever.  I immediately began sobbing uncontrollably.  It was the kind of cry that only a few brave souls in this world must bare; brave souls that have lost pregnancies or children and have joined that exclusive and tragic Lost Child Club.  It’s a club full of lost dreams and future plans. 



As my Mom rubbed my back and consoled me as much as she could, she asked if we wanted to go home.  Joey and I both said yes and they dropped us off to be alone, while they continued the journey to Denver.

After a day spent at the museum and shopping in Denver, the whole family came back to our house in the late afternoon.  As Joey and I choked in our emotions and tears, we hugged my Mom, Dad, 2 Brothers, 2 Sister-in-laws, 2 nieces and nephew.  Joey and I did our best to put on our brave faces and we even laughed with everyone, but reality hung over our heads like a black cloud. 

*******************

The Level II Ultrasound was set for Tuesday, July 27^th.  We had to go see the Perinatologist; which is actually the scariest job title out there.  When Joey and I walked into the exam room, I sat down on the ultrasound chair while Joey took a seat on the stool next to me.  The ultrasound tech put the cold jelly on my belly and began examining the baby inside.  “Do you want to know what sex the baby is?”  Joey and I thought about it with some optimism and said, “Yes!”

“It’s a girl.” 



We soaked in the news.  “A girl!  That is just what we wanted!  Maybe she is going make it after all!” 



Shortly after, the Doctor (I’ll call him Dr. H) walked into the room to further exam Baby.  He introduced himself and explained that he was going to continue with the ultrasound to measure Baby and check for some markers.  After what seemed like an hour, Dr. H explained that he did not see any markers for a chromosomal problem; however, Baby was only measuring 15 weeks.  I was 18 weeks 1 day.

“I am so sorry but your baby is not going to make it.” 

After the words finally registered in my head, I sat back in shock.  It was all I could do.  Joey had to leave the room to get some air and I just sat in pure shock.  My shock turned into sobs and the Ultrasound Tech and Genetic Counselor held my hand and hugged me with the purist of empathy. 

Finally, Dr. H completed the amniocentesis and blood draw and the Genetic Counselor told us that the clinic would be calling soon to set up the induction.  Joey and I gathered every piece of strength in us, walked out of the clinic into the warm July sun, and drove home.

*******************

The next week was pure Hell wrapped up in a blanket of grief.  I cried, yelled, cleaned my house, walked the dogs, and did not talk to anyone.  Joey had to go to Las Vegas for a work commitment and only made it through one day.  His boss flew him home 3 days early after he found him crying uncontrollably in his hotel room. 

*******************

The induction was scheduled for August 2nd in Fort Collins, but a half an hour before we left for the hospital, we were informed that it would be put off until August 3rd and we had to go down to Denver instead. “WHAT?” We had to suck it up and re-prepare for August 3rd.

*******************

It was August 3rd, 2010 and Joey and I were in our Subaru, once again, heading down I-25 to the Swedish Hospital Labor and Delivery Floor.  We walked through the ER doors, took a right towards a locked door and showed our faces to the receptionist behind the glass window. This was the initial Labor and Delivery registration office and the receptionist looked at Joey and I like we had broken into Baby Disney World without a ticket.  I explained to her our situation and she looked back at us with sad eyes and apologized for our circumstance.  We then signed all of the obligatory papers, followed the dreaded black line all the way to the elevators, went up to the 3rd floor, and stepped out into a mosaic of beautiful, chunky, rolly polly baby pictures hung all over the walls.  (Self Realization: I hate the Labor and Delivery floor.) 



As we followed one of the nurses to our room, I noticed a white rose hanging on one of the doors to my left.  I thought to myself, “I bet their baby died too.”  I later found out that the woman was due that same day and when they got to the hospital, there was no heartbeat to be found.  Whether it’s good or not, I found comfort in the thought that she had it worse than me. 



Our nurse walked in as I was scolding Joey for playing with all of the buttons that he could find in the room.  She had kind eyes and gave us the “I’m so sorry” face, which immediately began to make me feel more comfortable.  She handed me a hospital gown and pair of cotton stretch underwear.  Great. 



Soon after, I changed into my gown, set up Joey’s cot next to me, and got comfortable in bed.  The nurse began to set up my IV.  “I’m super scared of needles so I am just going to look away.”  She took extra care and the fluids were dripping down my IV before I knew it. 



The nurse then started me on a cervical softening medication and gave me a sleeping pill.  When I woke up in the middle of the night in pain from the cramping, the nurse asked me if I wanted pain meds and I quickly said, "Yes!" 



(Self Realization: Back before my pregnancy innocence had been taken, I thought that I would have a natural birth, no drugs, in a lukewarm bath, in the middle of my bedroom.  Now...I want to be in no pain and welcome my baby while being on micro watch from the nurses and doctors.  I'll endure a cesarean...whatever it takes.) 

During the next 12 hours, Joey and I lived our worst nightmare and delivered our little girl around 8:00am on August 4, 2010.  I was 19 weeks 2 days pregnant.  She was so tiny.  I have never seen anything so tiny.  We took pictures with her, like the grief and loss experts suggest, and spent time saying goodbye.  We decided not to use the name we had picked out.  Instead, after talking to Joey’s mom, we decided to name her after his grandmother, Joely Christina.  Truthfully, she will always be “Baby” to us. 

After everything was said and done, the Doctor explained that I ended up having a blood clot inside my uterus that was bigger than the placenta.  He explained that an autopsy would be done on Baby and we might hopefully find out some answers from that.  

At 3:00pm on August 4th, Joey and I walked out of the ER doors of Swedish Hospital, alone, and with a hole in our hearts the size of our little girl. 

*******************

After The Storm

It has been a little over 6 months since that day.  From that time, I have encountered emotions and problems that I have never experienced in my life.  I have experienced panic attacks, heart flutters, anxiety, depression, loss of energy, loss of hope and the feeling of a deep hole in my womb.  In all honesty, it was the first time that the idea of ending my pain permanently popped into my head.  It was only for a second, but that second scared me more than anything and I knew I needed help.  As a Social Worker, I help my clients work through terrible situations in their lives, but this time I was the person reaching out for help.  I contacted a trauma and grief counselor 6 weeks after Baby’s birth, and Joey and I began attending a few days later.  It was the best thing we could have ever done.

If I’ve learned anything from the loss of my daughter, I’ve learned that I am a strong person and if I can get through that experience, I can get through anything.  I’ve learned and relearned that only time heals and as much as that time seems like centuries while you’re in it, you can look back and realize how far you have come.  I’ve realized that it’s true what they say, “You will never forget your loved one, but it will get easier to live as each day passes.”  I will never go through a day without thinking about her, but I can now think about her without wanting to break down.

I’ve realized that my husband is truly my best friend and my strongest ally.  I’ve learned that we can get through horrible times together and come out with a stronger relationship.  I’ve learned that the vows you state on your wedding day actually mean something.  “In good times and bad, in joy and sorrow.” 

As Joey and I begin to contemplate trying to conceive again, an explosion of emotion is beginning to erupt at the surface.  The ideas of being pregnant and possibly having a child are so exciting and we are so hopeful.  We sometimes day dream about what it would be like to actually get the chance to decorate a baby room, or ponder who will have to wake up in the middle of the night to feed the baby.  The future looks bright.  However, in the back of our minds, the black cloud looms.  Getting pregnant and bringing that pregnancy full-term is a crapshoot.  We will never know if we can definitely give birth to a thriving and breathing little baby until it happens.  Our specialists and doctors can only do so much.  In the end, getting pregnant is the biggest gamble we will ever make, but a gamble we are prepared to take.  

Definition

Definition of a Bicornuate Uterus:

A bicornuate uterus is a type of congenital uterine malformation (müllerian duct abnormality). A bicornuate uterus is heart-shaped with two joined cavities whereas a typical uterus has a single cavity.

Causes of a Bicornuate Uterus:

A bicornuate uterus results from the uterus not forming properly in a woman's early prenatal development. This can happen to women whose mothers took a medication called DES during pregnancy, or it can happen for unknown reasons.

Diagnosing Bicornuate Uterin:

Doctors can get an idea of whether a woman has a bicornuate uterus by using a hysterosalpingogram (HSG) or a hysteroscopy, but diagnosis should be confirmed with a three-dimensional ultrasound or laparoscopy (see below).

Bicornuate Uterus and Pregnancy Loss Risks:

Most studies find that the primary risk associated with a bicornuate uterus is of preterm labor and possible cervical insufficiency (not first-trimester miscarriages). Cervical insufficiency and preterm delivery could potentially cause a second-trimester miscarriage or loss at birth if the baby is born too prematurely, such as before 24 or 25 weeks of pregnancy (the point at which a premature baby can potentially survive).

However, many women with bicornuate uteri carry pregnancies to full term without any problems, so the risk may vary for each woman.

Treating a Bicornuate Uterus:

Some sources recommend reconstructive laparoscopic surgery of bicornuate uteri, but in most cases doctors do not suggest surgical treatment. Some women may need a cervical cerclage, a stitch placed in the cervix to stop premature dilation, which is what can cause premature delivery and possible late pregnancy loss. Treatment depends on the physician and the circumstances of each situation.

Why Confirming the Diagnosis May Be Important for Women With Miscarriages:

Particularly for women with recurrent miscarriages, it’s important to note that there is a documented trend that women who actually have septate uteri are sometimes misdiagnosed as having bicornuate uteri. The two congenital uterine malformations can look similar on imaging studies, such as HSG or ultrasound, but they differ in that a septate uterus is round on the top with a single cavity in the uterus and a bicornuate uterus dips on the top, forming a heart shape with two cavities.

Why is this important? For starters, the treatment is different –- a bicornuate uterus might not be treated at all except to watch for signs of cervical dilation. And if it is treated surgically, the treatment is a reconstruction via laparoscopy. Whereas a septate uterus is usually treated through a hysteroscopic surgery. In addition, a bicornuate uterus is often not considered a factor in recurrent miscarriages, whereas a septate uterus is known to increase miscarriage risks.

For these reasons, if you are having recurrent miscarriages and your doctor has diagnosed a bicornuate uterus through an imaging study, consider seeing a specialist for a second opinion to confirm the diagnosis and treatment plan.