#era test

ok so, the 1st ERA was done in Nov 2017, the result being that my uterus is most receptible on 6 DPO, which is one day later than normal. Now, three failed 6-DPO transfers later, the doc wanted to repeat the ERA test, also because the transfer that lead to my son being born was done on 4 DPO in 2015.

So a new biopsy was taken on 6 DPO last cycle, and the results came last Friday. The results said my uterus was pre-receptive, i.e. not yet receptive, and that another ERA test should be taken 2 days later, on 8 DPO in the next cycle. It also said that this result can be due to my body not reacting correctly to the trigger shot, which should cause ovulation and thus ”set off the clock”, as ovulation day is DPO 0. If the shot works only partly, the time calculation is wrong. What should be 6 DPO is maybe only 4 DPO or 5 DPO, which of course means the transfer is done on the wrong day.

What’s strange is having two different results. And how and why has my responsiveness to the trigger shot changed, if it has? It shouldn’t. This is a rare phenomenon and my doc is perplexed, and is also doing this round of treatment pro bono because he says he’s getting valuable research knowledge on the ERA test. So now we’re repeating the ERA test, but rather than doing it 2 days later. we’re using estrogen to stop follicle growth altogether in order to stop my natural ovulation signal from interfering, and will not use the trigger shot but take a high dose of progesterone orally. The biopsy for the 3rd ERA test will be taken next week.

The good news is, my doc is motivated and genuinely interested in figuring this out. The bad news is, this problem with responsiveness to progesterone could mean the timing is off again in later cycles, even if we managed to get it right for the ERA test cycle. Of course, the same regimen will be repeated in the transfer cycle, but the inconsistency in the ERA test results means that there’s no guarantees how my body works.

I had the second biopsy for my third ERA test taken today. I’m a little nervous of what the result will be, and I’m guessing that my doctor is, too. we’ll know in two weeks, I hope.

The plan for the next cycle, i.e. for transfer cycle 4, is to follow the same regimen as in this cycle: estrogen patches to stop follicle growth and thus the natural ovulation signal, and progesterone tablets instead of a trigger shot.

My doc finally phoned me on Fri to let me know that the ERA lab in the US had recommended that a biopsy be taken on Monday (tomorrow), which is 5 DPO AND Wednesday, 7 DPO, which will then allow them to find out the most receptive time.

in other news, T’s having his first stomach flu, and it’s no joke. I’ll have to take him to the doctor’s tomorrow, nothing stays in for very long. Of course M, who travels for work max once a year, is leaving tomorrow for a 3-day trip to London.

I phoned the doc again because I really wanted to know the answer to my 2 questions. Now that I got them, they seem simple but I'm glad the doc said: "These are good questions, the kind we ponder on ourselves."

Question 1: The ERA test showed my uterus is most receptive on day 6, meaning the embryo transfer should be done one day later than usual. Why was the last FET, done on day 4, successful then?

Reply: It's likely that, even though ovulation was induced with a hormone shot, my brain had already started to give a signal for ovulation earlier, because the follicle size was already big (around 19-20mm) as seen on ultrasound. This means ovulation had in a sense, started before the shot, making the actual transfer date not 4 days after ovulation but closer to six.

Another option is having a wider implantation window than normal but the doc didn't think it likely.

Question 2: If my uterus is most receptive on day 6, can we do a fresh transfer or should it be a frozen one?

Answer: Depends on the embryo development: if it reaches the blastocyst stage on day 5, it cannot wait until day 6 for the transfer which means it will have to be frozen and transferred in another cycle. If it developes slower and only reaches the blastocyst stage on day 6, then of course, the transfer is done on day 6 as a fresh transfer.

The result was supposed to arrive in about 2 weeks and it's been almost 4 so I phoned and asked. I didn't reach the doc and then he tried to phone me but being an idiot, I didn't reply (I was at the cashier at the grocery shop), but he texted me saying the result was mailed to me more than a week ago, which is weird. And that the result was that my uterus is most receptive 6 days after ovulation, which means the transfer should be done one day later than usually. This raises two questions: last time, the FET was done on day 4 and it was successful. What does that mean? That the embryo was so SUPERB that it decided to implant even though the window was a bit off? And a second question: if the uterus is ready on day 6, can we do a fresh transfer or should it be a frozen one? In other words, do fresh embryos go bad after day 5? Does anyone know?

So yesterday was our long-awaited visit to the fertility clinic. We basically went in there to hear what they had to say, whether they thought it would be a very bad idea for us to have a go. And also to hear if there was anything new invented that could guarantee a baby for us (you know, I’m kidding, right). But really, our clinic is absolutely top notch, they follow up on the latest research and no doubt contribute to it, so if there was anything new, they’d know about it.

My husband isn’t one to beat about the bush, so he pretty bluntly just asked if there has been any advances in technology since the last time we were there, as if we had expected there to be something really major of the type, ‘yes, these days we can guarantee a baby for all of our patients’. The doc was a bit puzzled at first but then he went on to explain that actually there is something that wasn’t done as much a few years ago, but that they are considering making a standard practice, which is the ERA test or the endometrial receptivity analysis. Essentially it’s a test to determine the correct time for embryo transfer, or the window of implantation. On average, the uterus is most receptive for implantation 5 -7 days after ovulation, which is why embryo (blastocyst) transfers are done on day five. Recent studies have shown, however, that some cases, particularly in cases of unexplained fertility, the window of implantation may be somewhat different, or in rare cases, radically different from the average one. This of course means, that if the uterus is not receptive at the time of the embryo transfer, you might as well have thrown the embryo to the bin and got the the same results. He went on to explain that they have had people come to their clinic with several unsuccessful treatments in the past or pregnancies that have repeatedly ended in early miscarriage  ( = chemical pregnancies). They have made it a practice to do the ERA test particularly in those cases and have found that the window of implantation has been very different from the assumed one. So some of these have got successfully pregnant once they have adjusted the day of transfer to meet the window of implantation. 

In our case, we didn’t do the ERA test last time, and they didn’t talk about it at the time to my memory, but our successful transfer was done on day 4 instead of day 5, because he already mentioned a possibility for the window of implantation being different. This time, he suggested that we could, if we wanted, to do the ERA test, although he did mention that our last treatment already indicated that it might be wisest to do the transfer on day 4 (that is if we get anything that could be transferred). But he said he does feel tempted to do the ERA if we want, because last time we only got 2 embryos, so it’s not like we have plenty to waste.

We agreed. It’s expensive (EUR 700), but whatever. They whole thing will cost us so much more than we can afford anyway. Since the timing is convenient, we’ll be doing the test next week. It involves a biopsy, similar to a PAP smear. To this end, I was instructed to test for ovulation and if it was negative, induce ovulation yesterday by an injection between 6 and 8 pm. I’ll go in for the ERA test next Monday. They’ll take the biopsy and then analyse it to see if my uterus was receptive at the time as it should be, if my window of implantation is at the average time. Have any of you with experience of infertility heard of or done the ERA?

I was working from home so I thought it would be convenient to go buy the ovulation test and do it sometime during the day and then the injection in the evening. Not quite. I was sort of busy with work so I didn’t bother going to buy the test, I thought we could go after I pick up T around 4 pm. Well, the weather was awful so I thought I’d rather wait for M to get home and have him give me a ride to the pharmacy. He came home at about 6.30 and called his Mom about something and before I knew it, it was 7.15 before we left the house. So I had 45 minutes to go buy the test and injection, do the test and inject the hormone. By that time, I was pretty certain I wasn’t going to make it back home before the 8 pm deadline, so off I go to the pharmacy, get the meds plus antibacterial wipes, grab a disposable cup from the pharmacy, run to the shopping centre toilet, that one’s taken, run to another one, pee into the cup (I’m a master at that by now), do the test, wait for what seems like forever for the result and prep the injection while waiting, get the result (negative) and inject at 7.55 pm.

A nice and smooth start for the second round of infertility treatments. I guess we’re doing this. If we’re paying all this money for the ERA, I guess we’re really doing this. Wish us luck.

So about this ERA test. Maybe it’s obvious, at least to fellow IVFers, but if the implantation window turns out to be something other than normal, it will mean that we will have to do a frozen embryo transfer rather than a fresh one, because we want to transfer a day-5 embryo, and if my uterus is at its best on day 4 or day 6 or even 7, of course that equation is impossible during a single cycle because the embryo and my uterus are not in sync. So in that case, we would retrieve during the first cycle and then do a FET during the following, on the optimal day indicated by the ERA test. 

I must emphasise, as the doc did, that in the vast majority of cases, the uterus and the embryo are ready within the same implantation window because that’s the way the female body was designed to work. But of course, when you’re dealing with infertility, it is more likely that your body is not doing what it should when it should, and when there have been many failed treatments, this offers an additional route to explore, and it has already, at their clinic, brought good results in some cases that have seemed to be unexplained.

I also forgot to mention that when the doc asked about my cycle and I said ovulation is around the corner, he said we could do the ERA test in this cycle and he could do an ultrasound to see where we stand at the moment. I then said: “I’ll check my fertility app to see if I remember right.” To which he said: “I suggest we do the ultrasound instead.” I was so embarrassed because I think he may have thought I honestly meant that we could skip the ultrasound and just check my app, but of course it wasn’t what I meant. I don’t know what I meant. Anyway, that was a bit funny but also embarrassing. I tried to save my face by saying that I should probably adjust the app based on the ultrasound. The ultrasound showed that I was right, and also that there has not been radical changes in the ovaries: the number of follicles looks similar to last time. He mentioned that for some people, there is a notable decrease at around 37 years of age, but that apparently for me that wasn’t the case. So that’s something.

Of course, all this has got me thinking that round two is going to be a walk in the park. And it will not.