Waiting and Dilemmas.

So my pregnancy test last night was very light, faint, even. Tonight or tomorrow night, I expect a negative test.

Which means the mandatory wait cycle will have finally, officially have begun.

Most people who miscarry are told to wait a cycle (ie, until after their next period) to begin trying again. There are exceptions to this, of course - I was specifically told I did not need to wait after Chickadee as I had not had surgery. Some people are told to wait longer, because of infections or retained tissue or to let the lining build up enough. There are a lot of reasons for this. People who are treated for ectopics with methotrexate are told to wait too, but it's a bit more serious.

There are two reasons for this. One, the drug metabolizes quickly, but can potentially be stored for awhile longer in your kidneys or liver. The drug itself is contraindicated for pregnancy, as it can stop a pregnancy from developing and has been linked to birth defects. It is a teratogen, and as such, you really, really shouldn't try to conceive too near having received the drug as treatment for anything. Two, it inhibits folic acid and strips the body of folic acid reserves. And of course, most of us who are trying to conceive know how important folic acid is in the prevention of (and lessening the severity of) neural tube defects. So the prenatal vitamin may not be enough folic acid on its own (which also increases the risk of miscarriage, btw).

Two very good reasons to wait until you are cleared to begin trying to conceive another child, right?

Absolutely. For what I'm about to say next - remember that.

The problem I'm encountering is when I am actually cleared to ttc again. The OB said I was fine after 1 cycle, except for wanting me to wait a full year and drop 100 pounds. A fair number of others have been told the same thing - a full cycle and then you can try again. However, a larger number of women are told to wait 3 months before trying again. And conventional wisdom and the majority on the internet seem to agree with that (though again - there is plenty of talk about just 1 cycle).

So . . . 1 cycle or 3 months? And what is the difference? Well, it's already taken over 3 weeks for my hcg to drop to levels where my reproductive cycle could start functioning again. Next week will be 1 month post-treatment, so one down before my wait cycle is anywhere near over. Assuming I resume normal-for-me ovulatory function (which - that is an assumption. anytime after a miscarriage, ectopic or otherwise, your body can go wonky for awhile. it can take awhile to start functioning again, it can have an anovulatory cycle or two, it can have strange-for-you cycles), I would ovulate around 14-20 days after my period ended. Let's take that as when my hcg hits 0 for grins and say that happens around 2/18 for an example date- that would put ovulation between 3/4 and 3/10 - we'll split the difference and say it happens around 3/7. My next period would come about 12 days later, around 3/19. I would then expect to ovulate around cd 23 or April 15. That is a little under 2 weeks shy of the 3 months post-shot mark. And that is assuming things go normally. If it was later than that - that would be ok. I would be near enough to 3 months not to care.

But what if it happens earlier? What if I ovulate on, say, Feb 25? Then I can expect to ovulate again at the end of March. Which . . . is just over 2 months post treatment.

And that leads me to where I am right now. More than 10 weeks post treatment (or a mid-April ovulation), I am pretty comfortable with that. I've read enough to believe the drug is in fact gone from your system pretty darn quickly. And that anything retained in the kidneys or liver is gone too. After all, we are given very low doses to treat ectopics. One woman consulted a geneticist because she had to do another round of IVF two months post treatment or it would be entirely out of pocket. The geneticist said she was fine - the geneticist herself said that 1 month was more than enough to be out of any danger zone when it came to potential birth defects.

So where does the 3 month wait come from? Apparently, methotrexate isn't FDA approved for use in stopping pregnancies (though it is the standard and recommended course of action, recognized by ACOG and AMA and other sorts of pretentious initials). The point is that because of that - there haven't actually been a lot of studies about when it would be safe to try again. The studies that have been done have focused on women who received continuous, high dose treatment (like chemotherapy or treatment for arthritis). They are recommended to wait 6 months to ttc, but some don't or end up pregnant anyhow, and those that were 3 months post treatment seem to be just fine. So . . . that's why it's recommended that a woman wait 3 months, far as I can tell from my research. Even though the scenarios are completely different, given that a single low dose is metabolized within days, if not hours.

But since there are proven risks, and there are some studies saying 3 months is fine, general wisdom and ever-present threat of malpractice have combined to make that the standard.

So it's not clear at all - 1 cycle or 3 months.

Normally, I'm all about trusting your caregiver. They are the people with the education, the folks with the most complete picture of your health and who are the best qualified to make a judgement. But . . . obviously, I have some trust issues with my treating physician, and I certainly am disregarding his advice to wait until I've lost 100 lbs to ttc. As someone pointed out to me earlier when I posed this dilemma to friends and sought their opinions in a WWYD scenario - it is possible the doc didn't proscribe ttc for 3 months because he assumed I'd do it anyway while I lost weight.

And speaking of - every.single.person I asked said they personally would wait to ttc until 3 months had passed. My mother agrees. All because of that very slight possibility of birth defects. The what-ifs and the fear of the crushing guilt were something to happen. And believe me - it's on my mind. Hence - why I asked.

I worry about that too. I worry about another miscarriage and it being my fault, I worry about repeat loss testing being delayed or undermined by that. I worry about birth defects caught too late to consider termination. I worry about lots of things.

But I also know that the thought of not trying to conceive chokes me. The thought of voluntarily waiting another cycle to be safe - even though the doc said it was ok and even though there is research to support that pronouncement- it makes me panicky. I have been doing not so hot with this waiting business. Do I want to put a potential child at risk because I am impatient? Absolutely not.

But I'm not convinced that I am merely impatient or that it would irresponsible to go ahead after a full cycle. It's so muddy right now, and I'm not sure what the best options are. It's easy for someone who has not been told to wait (or has not gone through the hell have trying to get my baby - the one who sticks and grows and is born) to say it's just another month or so, what's the big deal? One of my friends who has had trouble ttc summed it up really well when she said - "In this situation, I'd wait. But if my doc told me to wait 3 months, I'd have to go on meds. I would go insane. I wouldn't deal well with it." She understands where I'm coming from.

It was odd - nearly everyone who expressed an opinion apologized for it, because they knew it wasn't what I wanted to hear - which is funny, because I didn't want to hear any particular thing, just get an outside perspective. I'm not seeking permission or validation, just trying to sort through it all. I thank my friends for being honest and giving me more to consider and for hearing me out as I work through this. And I trust they know we won't do anything that we are not 100% comfortable with and that we will only go ahead if we believe the risks of doing so are very minimal.

Dh and I have talked about it and we agreed that we'd wait to make any sort of decision until after my period comes. We know we won't be trying before then, so may as well see when I ovulate and what happens after that. If it's late enough - as in the first scenario - I ovulate in early to mid March and my period comes in late March or early April - well, that puts me past the 10 week post-shot mark that I am comfortable trying in. If not, well, we have hard decisions ahead of us.