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I’ve been on a little hiatus since my last post, taking a very rare moment between appointments and work to go visit my family on the east coast of Canada. Living so far away from where I was born is both a blessing and a curse. It often means going through this stuff alone, but it also means I don’t get unsolicited opinions about how we’re going about things. It makes the infertility community I’ve surrounded myself with that much more important and valuable (so thanks for being here and listening). 

In September 1st my period came again and we started with a wonderful new clinic. I was nervous to make the switch. It meant new blood work, scans and building a new relationship with a new team (let’s be real though, there wasn’t much of one at the last clinic). I’m not sure I would have had the energy to keep going with the first one anyhow. It’s like kicking a relationship until it’s last breath. It felt like it was just time to call it. I felt like I deserved better. 

I called the clinic on cycle day one and we discussed then and there what our next steps would/should be. Did I want to forge ahead with a retrieval and get moving asap? Absolutely! But we decided before we made any more attempts that it would be smarter to do some further testing. 

We started with my AMH levels, last tested in April of 2022. My initial levels were 9.6 pmol/L, but now in September 2023 they had dropped significantly to 5.1 (for those on the ng/mL scale, it went from about 1.34 to .78). This officially put me in DOR (diminished ovarian reserve) territory. Scary stuff. Your AMH can fluctuate but I took this seriously. Going ahead, and looking back, it was becoming harder to get quality eggs and embryos. Our time was running out and the embryos we could get were becoming rare and precious. 

We decided with our new doctor (who is wonderful BTW) to do a mock cycle before doing another retrieval. This would delay our retrieval by 2-4 months but it would be instrumental in ruling out and identifying any barriers to carrying a healthy pregnancy.

Mock cycles are often debated in the fertility community. Some doctors are all for them, and the myriad of biopsies that can go alongside them. There is mixed evidence, or maybe just not enough evidence to convince all doctors of the value of these tests, but I wanted to take the kitchen sink approach. We were still very much in unexplained infertility territory, so anything that could explain what was happening was welcome.(I’ll link to some relevant studies below in case you want to read them)

Four endometrial biopsy tests were recommended as options with one strongly urged over the others. I decided to do all of them. 

EndomeTrio (3 tests)

ERA (Endometrial Receptivity Analysis)

The ERA test checks the receptivity of the uterine lining to find out if it is lining is receptive to embryo implantation at the time of a normal transfer. The test could indicate a different amount of progesterone in preparation for future embryo transfers. (The ERA test resulted in a 73% pregnancy rate in patients with implantation failure) 



ALICE (Analysis of Infectious Chronic Endometritis) 

ALICE detects the bacteria causing chronic endometritis (CE) and identifies the most common bacteria causing it and helps clinicians to recommend appropriate antibiotic and probiotic treatments.


EMMA (Endometrial Microbiome Metagenomic Analysis) 

EMMA evaluates the uterine environment at the microbiological level by analyzing it’s  microbiome. It can indicate whether the uterus has the optimal microbiome for embryo implantation.

UTIMPRO (strongly encouraged by our doctor)

UtimPro is a biopsy that analyzes the immune profile of your uterine environment and response to foreign cells (embryos, etc). It tests for natural killer cells and it can indicate a very specific customized protocol for individual patients. 

To do a mock cycle, you basically proceed as if you’re planning on doing a frozen embryo transfer. I started on Estradiol on day one, and similar to a FET, my lining was monitored throughout my cycle. I did 5 appointments with my friend Wanda, and it took a little while to get to the needed 7.5mm minimum uterine lining thickness required for the biopsy. I introduced progesterone on day 28 (pretty normal for me as I struggle with thin lining issues) – both as suppositories and intramuscular injections. My biopsy finally took place 6 days later on October 3rd. 

I’ll stop here to say, by this time I had met with my actual doctor either on zoom or in person 5 times in one month. He was also the one to personally do my scans and my biopsy. Seeing that smiling familiar face made all the difference. Technically the appointments were the same, but patient care was worlds ahead with the new clinic. From the receptionists and nurses to the clinic itself and their professionalism and timeliness. It made the experience better many times over. 

The biopsy was…. Not fun. Not going to sugar coat it. Because of the things being tested, the biopsy only allows you to take Tylenol as a pain killer and is fully unmedicated otherwise. I managed to convince them to give me a Ativan to take as I tend to have a sensitive cervix. The procedure requires them to use the speculum, and sometimes a cervical clamp, and insert a tool into the uterus to scrape the lining. It’s as gross as it sounds. The doctor told me it would hurt and I prepared myself. He told me I could swear at him if I needed to, that it would last 10-15 seconds and I’d have some severe cramping. The nurse offered to hold my hand.

They went in with the pipette (the tool for the biopsy scrape), and I was surprised it didn’t hurt more to be honest. It did suck, very much. But I tolerated it and they applauded me for handling it better than most do. Once the procedure ended, the cramping stopped. It turned to mild tenderness, and I spotted a tiny bit following the procedure. After that, I was good to go.

The test results take 2-3 weeks on average for the EndomeTRIO and 4-6 weeks for the UTIMPRO.

The doctor put me on Estradiol again for 5 days, but I began bleeding 3 days later for my next period. All in all, I think it was worthwhile. The overall cost was around $3400 CAD including meds, the time it took was 33 days for the cycle, and the recovery was almost immediate.

Now, we wait for those juicy results.


Studies on the above mentioned tests:

The Uterine Immune Profile May Help Women With Repeated Unexplained Embryo Implantation Failure After In Vitro Fertilization (2016)

Comparison of the Effectiveness of Endometrial Receptivity Analysis (ERA) to Guide Personalized Embryo Transfer with Conventional Frozen Embryo Transfer in 281 Chinese Women with Recurrent Implantation Failure

Is Endometrial Receptivity Assay (ERA) Useful in Patients with
Repeated Implantation Failure Undergoing Single, Autologous Euploid
Embryo Transfer?

The Endometrial Microbiome and Its Impact on Human Conception

Characterization of the Endometrial Microbiome in Patients with Recurrent Implantation Failure

The diagnosis of chronic endometritis in infertile asymptomatic women: a comparative study of histology, microbial cultures, hysteroscopy, and molecular microbiology

The effect of chronic endometritis and treatment on patients with unexplained infertility

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