Getting Pregnant with POF / DOR / Low FSH

Supplements anyone? I recently got rid of these and gave away my remaining OPKs, which felt really, really good.

I'll never forget the moment when I found out I have premature ovarian failure / diminished ovarian reserve. My OB ran a few "routine" blood tests after I told her I was having short cycles after coming off of birth control (24-25 days).  I didn't even know for what she was checking, but I was sitting at my desk at work when she said "Your AMH level was undetectable and your FSH very high.  You may have a very narrow window in which you can have your own children.  But don't worry, you can always use donor eggs."  Those three sentences completely upturned my world and everything I thought about building a family (not to mention that I had no idea what AMH was and what, exactly, she meant by donor eggs.

After the initial shock wore off and I scheduled an appointment with CCRM, I fell down the rabbit hole that is Google and started to learn everything I could about high FSH, low AMH, DOR, POF, etc.  In a situation where I felt like I had no control, I wanted to arm myself with any information I could and to do whatever was in my control to become pregnant.  I scoured the internet for success stories, read every book available on the subject, and had consults with three Denver fertility clinics, including CCRM (where I was handed a packet of information on donor eggs and told I wasn't really a candidate for IVF).  

I found great hope in posts I read online from women who beat the odds and got pregnant despite depressing statistics and seemingly insurmountable odds (see My Bum Ovaries and Torthúil as examples) and I promised myself that if I had success, I would share my story and what I learned with others.  I've been wanting to write this post for ages, but I knew I couldn't do it until Baby C was safely in my arms.   

I live in Colorado, so I've included local resources that I utilized and liked.

Background

• Diagnosed at age 32 with DOR/POF. AMH less than 0.15 (undetectable) and day 3 FSH of 17.3
• My FSH has since been as low as 7 and as high as 59 (immediately following my first miscarriage).  My AMH has been as high as 0.23.
• I have mild hypothyroidism and low Vitamin D
• Day 3 ultrasound shows only two follicles on one ovary and one follicle on the other
• I have been pregnant 5 times:
• Spontaneous (unassisted) pregnancy 8/2013, which ended in the stillbirth of our daughter at 26 weeks (unrelated to fertility)
• Spontaneous (unassisted) pregnancy 5/2014, which ended in the birth of Baby B
• Spontaneous (unassisted) pregnancy 3/2016, which ended in miscarriage at 6 weeks
• Pregnancy while taking Clomid 12/2016, which ended in miscarriage at 6 weeks
• Spontaneous (unassisted) pregnancy 8/2017, which ended in the birth of Baby C
• I have tried IUI once and have tried 2 cycles on Clomid.  I have planned to do IVF cycles 3 times but had a spontaneous pregnancy before each planned IVF cycle.
• My husband has no issues with sperm count or quality.
• I am otherwise quite healthy, eat well, exercise regularly (marathon runner and triathlete), drink only in moderation, don't do drugs, and have never smoked.  

Books I Read

• It Starts with the Egg by Rebecca Fett (I can't recommend this one enough)
• Taking Charge of Your Fertility
• Real Food for Mother and Baby: The Fertility Diet, Eatingfor Two, and Baby's First Foods by Nina Planck
• The Hormone Cure by Sara Gottfried
• The Fertile Female

What I tried

• Acupuncture (Jane at Acupuncture Denver and Gina at Insight Acupuncture)
• Hypnotherapy (Eastburn Hypnotherapy Center)
• Mayan Uterine Massage (Artemisia & Rue - Shelley is incredible)
• OPKs
• Less exercise
• Eliminating BPA and phthalates
• Changes in diet, restricting caffeine, and eliminating alcohol 
• Charting / AVA Fertility Monitor
• Supplements & Vitamins
• Vitamin D 2,000 IU D2 (2/day)
• Prenatal Vitamin (1/day)
• Fish Oil EPA/DHA - 2,000 mg/day with food
• COQ10 (300 mg, 2x day) - taken in the a.m. with protein (purchased from a compound pharmacy with a prescription)
• Inositol (2 scoops, 2x day) - 4g day total
• OPCs (1 capsule daily) (http://umm.edu/health/medical/altmed/herb/grape-seed) 
• DHEA - 75 mg (taken in 2 half doses and purchased from a compound pharmacy with a prescription)
• Amazing Grass Green Super Food (650 mg x 5)
• Amazing Grass Organic Wheat Grass (1000 mg x 5) 
• Life Extension PQQ (Pyrroloquinoline Quinone) (10 mg)
• Therapy
• Regulating Thyroid 
• Regulating Vitamin D
• Baby Aspirin
• Tracking cervical mucus
• Tracking fertility (I like the Ovia app)

What I think worked

• OPKs - While I found that tracking my cervical mucus was the best indicator of ovulation, I heavily relied on OPKs to confirm ovulation and to identify potentially fertile days in otherwise wacky cycles (for example, when I'd have egg white cervical mucus (EWCM) but not other signs of ovulation, or EWCM was oddly early or late in a cycle).  I purchased the Clearblue Fertility Monitor at some point, but far preferred the basic Clearblue Digital Ovulation Tests and the Clearblue Advanced Ovulation Tests.  In some cycles, I used both (can you sense my desperation?).  For me, it was critical to have confirmation of peak fertility or to identify that my cervical mucus might otherwise be off. 
• Tracking cervical mucus - This was the easiest way for me to tell when I was ovulating.  There are many primers online and I found this to be an extremely accurate way of knowing when I was ovulating.
• Acupuncture - Acupuncture helped me to regulate my cycles and generally to improve my mental health throughout the challenges of the last 5 years.  I can't say whether it directly impacted fertility because I did acupuncture in conjunction with taking supplements, etc., but it made me feel better emotionally and my cycles did regulate.  When I was having perimenopausal symptoms, it helped to diminish those as well. 
• Trying to stay positive / mental health / exercise / therapy - This isn't specific, but for me trying to stay positive, even in the depths of overwhelming sadness after losing Baby L, was really what kept me going.  Hand in hand with keeping a positive attitude for me exercising, not eating a super restrictive diet, having a drink here and there, and finding things to do that I still enjoyed that were unrelated to baby-making.  Vague, I know, but it is all too easy to become completely engulfed in the world of infertility and to lose sight of everything else going on around you.  I saw a therapist after Baby L died and throughout my pregnancy with Baby B, which helped immensely.  
• Supplements & Vitamins - Generally speaking, I felt that taking supplements absolutely helped me feel better.  The two that the research shows help the most are DHEA and COQ10.  At various times, I took all of the supplements listed above, but sometimes the sheer number was overwhelming so I dropped to just taking the DHEA and COQ10. 
• Regulating Thyroid and Vitamin D - Research shows that having a TSH level (thyroid function) in a normal range, as well as normal Vitamin D levels both have an impact on fertility.  Both can be checked with a simple blood test and easily regulated if they are out of whack.  These are simple and inexpensive areas to "fix" if there is an issue.
• Tracking Fertility - I used the Ovia app to track my cycles, cervical mucus, intercourse, OPKs, etc.  You could certainly do this on a calendar, but the app makes it easy and offers insights regarding your cycle. I have found it helpful to be able to scroll back through the past few years to see what my cycles looked like when I did get pregnant, etc.

What may have helped and that I didn't mind doing

• Eliminating BPA and phthalates from our home - I got rid of plastic, checked all of my toiletries, changed up household cleaners to a certain extent, etc. I go into more specifics here if you want to know more.  I have no idea whether this impacted my fertility, but it seemed like something I ought to be doing regardless.
• Mayan Uterine Massage - I had only had one session when I found out I was pregnant with Baby C, so I have no idea whether this helped, but I continued working with the same masseuse through my pregnancy and found it helped with stress, anxiety, mental health, and preventing back pain and soreness in pregnancy.  
• Eliminating Caffeine - I periodically have eliminated caffeine entirely and generally drink decaffeinated coffee or a half caf (which is what we make at home).  I like the taste of coffee and I don't mind drinking decaf, so this wasn't a big deal for me to do.
• Baby Aspirin - Because I have a history of clotting in pregnancy, I take a baby aspirin when pregnant.  There is some evidence that taking a baby aspirin can assist with getting pregnant, so I have taken one when we were trying.  

What didn't work for me

• Restricting food, exercise, and alcohol  - I tried removing gluten from my diet, giving up running, only drinking decaffeinated beverages, and entirely giving up alcohol, but it turns out I am someone who prefers to moderate than to abstain.  I am a very healthy eater, and do not drink excessively.  My evidence is anecdotal, but I was not eating or drinking in any sort of limited way when I became pregnant and I find it is a huge drain on me emotionally.  Exercise was the hardest of these for me because I find running to be therapeutic and essential for my mental health.  Again, for each of my pregnancies that didn't end in early miscarriage, I was running quite a bit and feeling strong and fit.  One caveat to this is that I would have strictly adhered to it leading up to and during an IVF cycle, which is recommended.
• Hypnotherapy - I was glad I tried this once, but I didn't feel compelled to go back. Interestingly, the woman who ran the session told me I'd have two living children, a girl and a boy.
• Charting / Basal Body Temperature - Call me lazy, but I could never get the hang of taking my BBT each morning.  The thermometers always beep (which my husband hated), I often forgot to take my temperature before I got out of bed, etc.  I even bought the Ava bracelet, which is supposed to do this for you, but it always fell off and didn't seem to be all that accurate.  I found that monitoring cervical mucus and using OPKs were more effective for me.

Reminiscing

One of my New Year's Resolutions is to finish all of our photo books from our travels. I was pretty good about keeping up with them while we were on the road, but I'm determined to be completely caught up before this baby arrives in mid-April.  I ordered two last week, so progress is being made.

I was sorting through photos and came across two that I took in our cabin in the Archipelago of Sweden (this place, seriously one of the best airbnbs of our entire trip).  The cabin was full of charming details, but I was most struck by two pieces of art that made me think so much of being pregnant -- so much so that I took photos of each in an optimistic gesture that perhaps I'd get pregnant while we were there.  That didn't happen, but I did shortly thereafter.

I was struck by how the woman in the top picture looks quite pregnant and the one in the bottom appears to be holding a baby.  The translation of the bottom cross-stitch is "she comes down the fields."  There isn't a real point in sharing this, but in stumbling upon these, I was reminded how even in the midst of feeling pretty despondent about our situation and still grieving over the two miscarriages, I had hope that I might get pregnant again.  

I still feel great disbelief about the size of my growing belly, the wonderful movements I'm feeling, and the fact that my c-section will be scheduled for 10 weeks from now.  TEN WEEKS.  It doesn't seem possible.

Next week I'll be in my third trimester, I'll have another ultrasound and my glucose screen and I'll post another update.  For now, I'm embracing the positivity, am thrilled to be past 26 weeks, which is when we lost Quinn, and generally trying to just stay calm. 

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An Update from the Southern Hemisphere

Wow, I've been terrible about blogging.  I have been writing on my other blog, but I've been preoccupied with traveling and having fun.

Mercifully, the day after my doctor's appointment, my body started to miscarry on its own (I started bleeding).  It was as if my body had known for weeks but my mind was clinging to the pregnancy. Once I let go of it in my head, my body followed.  I took Cytotec anyway and it was a pretty easy process albeit uncomfortable as many of you unfortunately know.

5 weeks later, I have just had my first cycle since the miscarriage.  I haven't had any menopausal symptoms this time around for which I am eternally grateful and I haven't fallen into a depression like I did last spring.   Part of it is certainly that I have learned to manage my expectations a bit but more so I think it is just that I refuse to let this ruin our trip.  We had an incredible time in Hawaii, fell in love with Sydney, and are having the best time exploring New Zealand.  My health is good all things considered and I love spending time with R & B.  Am I incredibly sad and disappointed?  Of course.  But I won't let it swallow me whole this time around.

So, that's the update from here.  My OB did write me another prescription for Clomid before I left Hawaii and I filled it, but I don't plan on taking it right away.  I'm going to see what happens the next few cycles and try not to focus too much on trying to get pregnant.   I feel more resigned than ever to not having another baby.

I did read a fascinating NY Times article today about stillbirth and three tests that can help determine the cause in many cases: placental examination, fetal autopsy, and genetic testing.  We had all three of these done on Q and the placental examination did tell us what happened to her although we still don't know why.  In any event, an interesting read for those of us who have experienced stillbirth (at least I find myself wanting to read and know everything about it).

You all are still very much in my thoughts, I'm just not at a computer very often (which is the whole point of this trip).

Another Day, Another Miscarriage

I'm right back where I was last spring, just four weeks farther along than last time.  Yesterday we saw an OB in Kauai and the baby hadn't grown since six weeks and three days and there was no longer a heartbeat.  R & B were there with and just looking over at them and seeing B smile at me and give me a big hug made the whole situation survivable, but I'd be lying if I said I wasn't devastated, disappointed, sad, and, frankly, really f-ing angry.  I would just rather not repeatedly get pregnant only to find out the pregnancy isn't viable, and this one feels worse because we saw a heartbeat and I'm now 10+ weeks with *no* signs of miscarriage.  In fact, my HCG yesterday was 25,000 so clearly my body has not yet caught on.

Given how high my HCG is, the OB here wants me to come back in for a scan with their radiology department (better equipment) to confirm it isn't a molar pregnancy.  My Colorado OB (with whom I've spoken several times) thinks this is highly unlikely, but of course I'm going to go in to confirm.

Most of all, I feel foolish.  Foolish for getting my hopes up, foolish for thinking this was our second rainbow baby, imagining flying home mid-summer instead of next winter so that I could have this baby at home, worrying about the logistics of getting meds, etc.  None of it matters and why haven't I learned my lesson about thinking things will work out?

I am, of course, already thinking about what is next.  I'll take misoprostol again to induce bleeding so that everything can be "take care of" before we leave the U.S. (on February 12th).  And then what?  I know in my heart I'm not done - I want to have another baby.  But I am beginning to wonder if that is wise.  I'm 36 years old.  I have POF.  I now have a history of recurrent miscarriages, presumably due to chromosomal abnormalities.  I have complicated pregnancies.  I keep thinking: "Fool me once, shame on you; fool me twice, shame on me."

One silver lining to all of this is that, so far, I feel much better emotionally than I did last spring.  Even with getting my hopes up, I knew better than to tell many people, make plans, or really give this pregnancy much credence.  I don't know if that is helping or the fact that I'm with my family in Hawaii but I don't feel the darkness overwhelming me like I did last spring.  Who knows?  It's too soon to tell how I'll feel in a few days, but I'm trying to keep perspective and stay as positive as possible.

So that's the (depressing, frustrating, infuriating, disappointing) update from here.

Grieving

A double rainbow with my rainbow baby beneath.  I'm choosing to see this as a good sign.

We have a lot going on over the past two weeks, much of it wonderful.  We celebrated Christmas (it's difficult to believe that was just two weeks ago), B's birthday, and the New Year, we packed up our house and moved out, moved our cat to my parent's, and left the mainland for Hawaii.  In the midst of all of the good, there is the anxiety that comes with early pregnancy and all of the thoughts that are always in the back of my mind but are front of mind this time of year on the anniversary of Q's death and the day I gave birth to her (Was she "born"? What is the the right word?).  I thought constantly about Q over the past few weeks and reflected a lot on everything that has happened since December 2013.  We didn't have the opportunity to do anything in particular to memorialize the day other than to light a candle and talk about her and what happened (and to think about how lucky we are to have B), but I feel the heaviness of the season even here in Hawaii.

"The Japanese Art of Grieving a Miscarriage" appeared in the NY Times this week and I love that the culture embraces and encourages publicly honoring babies who are never born.  I'm going to keep my eyes open for a Jizo when we are in Japan and try to bring one home to honor both Q and the little baby we lost this spring.  There is something so comforting about an object -- when Q died, the hospital gave us a box and inside was a tiny bear.  It isn't anything special, but I have slept with it every night since we left the hospital.

I've been particularly upset this week about some favorite bloggers (who I do not know personally) who just lost their son who was born prematurely.  Their grief and sadness and loss is so palpable in the photos and how courageous of them to share something so personal.  For whatever reason -- this time of year, being pregnant and emotional, or just the fact that their situation is heartbreaking -- I find what they are going through so upsetting and I wish I could reach out to them.  I have no idea what I'd say, but I just want them to know they aren't alone.

All of this just serves to remind me that, three years out from losing Q, I still acutely feel her absence and it is front of mind, more so in December and January than is typical.  And even in the midst of an exciting adventure and the possibility of another life, I'm grieving.  Still.

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I did find an OB in Kauai and have an appointment at the end of the month.  They have no perinatologist or MFM on the island and they don't do "level 2" ultrasounds as they called it (e.g., the 12-week anatomy scan) so I'm going around 10 weeks for another ultrasound and the Progenity chromosomal test.  If I need additional monitoring or testing, we'll spend a night on Oahu before we head to Sydney.  At this stage with Baby B, I had weekly ultrasounds (for my peace of mind). I'm trying my best to be Zen about this -- what will be, will be.

The "M" Word

I've known this day was coming since my dreaded diagnosis in early 2013 of premature ovarian failure / diminished ovarian reserve.  I'm 10 weeks out from my miscarriage and still no sign of my period.  I gave in and had a blood test run last week to check Estradiol levels and FSH.  Given the recent hot flashes I've been experiencing, the results are not surprising:

Estradiol: undetectable
FSH: 59

I'm officially in perimenopause.

How I can go from being pregnant to menopause in one cycle is completely baffling (especially since I'd had 3 normal cycles prior to the pregnancy).  But I have.  As explained by my OB, this doesn't mean I won't have cycles again as hormone levels tend to fluctuate, but I should assume that my baby-making days are over.  I'm going to start hormone replacement therapy.

Menopause.  This is something that my Mom talks about.  That women in their 50s deal with. How am I here?

Nevertheless, I am.  Please don't think for one second that I don't count myself lucky every time I look at Blythe, think about Blythe, kiss her cheeks, hug my husband, etc.  Over the past three years we have faced infertility, failed infertility treatments, a stillborn daughter, me almost dying from a blood clot in pregnancy, a miscarriage, a myriad of health concerns, and, most importantly, the birth of our living daughter.  She is a miracle and I count my lucky stars every day for her life.

But does that change the fact that I dream of having another living child?  Not at all.

I'm an only child and I loved my childhood. I think we can give B a wonderful upbringing on her own. But I really would have liked her status as our solo living little one to have been our choice.  I'm resenting the fact that this decision has been made for me, and frankly in such a cruel way.

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I have the impression that most of my readers are here because we share the common experience of losing a baby, but if any of you out there have experience with POF/DOR. I'd love to hear your thoughts/experiences.  Have you had wild fluctuations in hormone levels?  Any advice/guidance?

Crickets

I've been quiet over here for the last six weeks.  April was a very hard month for me.  I foolishly thought I would just bounce back from the miscarriage and feel like myself again right away, which proved to be the exact opposite of what happened.  Despite doing everything I could think of for self care (running, pilates, sleep, acupuncture, a weekend away), for the first time I felt like I was truly depressed.  After we lost Q, I wasn't depressed - I was devastated and grieving and angry.  I'm sure under all of those emotions, I was depressed, but this felt different.  It was just like there was a dark cloud hanging over my head that I couldn't push away no matter what.

To make matters worse, I've been having hot flashes.

A likely outcome of having premature ovarian failure and diminished ovarian reserve is that I will go through menopause much earlier than most women.  Thus, the hot flashes have been absolutely freaking me out.  I have been scared to tell anyone because I sometimes feel (even though it is nonsensical and absurd) that if I say out loud "I am having hot flashes" it somehow will make it more true than the physical discomfort of heat creeping up my body.  Ha. 

I finally went to my OB last week.  I told her about the hot flashes and about how I've been feeling. She prescribed Zoloft (more on that later) and we discussed the hot flashes.  They could mean I am in perimenopause or they could be related to my hormones being out of whack post-miscarriage.  I still haven't had a period following the miscarriage (8 weeks), so I'm taking Provera to force my body to have one.  

Needless to say, I'm feeling totally unlike myself and like things are totally out of control as it relates to my body and fertility.  That said, just having the Zoloft at home has made me feel better - like knowing I could take it has made me feel better.  I've felt more like myself this week than I have in ages.

As part of trying to feel better, I dialed it back on blogging and reading blogs.  I have relied on this community so much in the past few years, but sometimes I go down the rabbit hole of re-reading people's stories of loss and infertility and it just sucks me in.  And when I'm already feeling so overwhelmingly sad and gloomy, I've been trying to avoid making it worse.  

Thanks to those of you who are still reading and many of you who I know understand.

Spring

I had an ultrasound on Tuesday that confirmed the Cytotec worked and I don't need a D&C.  Now that  I've officially miscarried, I feel some closure and am trying to put this behind me and get back to feeling happy and positive.  Suffice it to say that this hasn't been as easy as I hoped it would be.  I've found myself a bit of an emotional disaster the past week.  I'm happy one minute and sad the next and my anxiety is through the roof.  My OB prescribed some Xanax (unsolicited - she just thought I might want it), which I've never taken before but am very tempted to try.

I keep reminding myself that my HCG is probably only just back to 0 and so I'm sure my hormones are all out of whack.  Plus, last week was Baby L's due date.  That date doesn't weigh on me as much as the anniversary of her birth, but I do find myself thinking "L would be 2 this week" and other related thoughts.    

Anyway... most of you know how the emotions go after a miscarriage (unfortunately), so I won't drone on, but I don't yet feel like myself.  I can be happy all day and the come crashing into a terrible mood and a total funk where I am upset with R and just want to cry and/or be grouchy for no obvious reason.  Please let this pass quickly.

I did sign up for a marathon in June (my version of therapy), I've started going to acupuncture again because I find it incredibly relaxing, and I've been having so much fun with B when I'm not at work, especially since we've been having amazing spring weather and she loves to roam the neighborhood with me looking at flowers and leaves.  Photo below of her scoping out our neighbor's bush that has beautiful yellow flowers (at least until this weekend when we are supposed to be hit with a massive snowstorm).  B has finally learned how to smell something rather than always trying to put everything in her mouth.  

This miscarriage has made me think a lot about how much we are willing to go through to have a second child.  Of course it is what we both WANT, but given my AMH level, FSH, follicle count, etc., everything suggests that my egg quality is low, which means a higher risk of miscarriage and chromosomal abnormalities.  IF I even get pregnant again, the odds are higher than normal that this could happen again.  As of right now, I still want to continue trying to get pregnant, but I don't know how many miscarriages I can handle.  I know many of you out there have been through this many times, but after losing L and given what we know about my fertility situation, I think there may be a point when we decide that B is a healthy, happy, fun, joyful little girl, we are thrilled to have her, and having one living little one is enough. 

We also booked a trip to Cabo for the first weekend in May.  A little vacation with beach time should help.

It's Official

At our ultrasound on Monday, we learned that the baby hadn't grown at all.  It was the news I was expecting, but it didn't make it any easier to swallow.  We talked through options (wait to miscarry naturally, take Cytotec at home, or have a D&C) and I kept everything together at my doctor's office.

B and I had her first swimming lesson of the new session that afternoon and had so much fun.  She loves the water and it was just what I needed for us to play together and laugh and for me to be reminded of everything I do have.  

I didn't lose it until I was putting B to bed.  We always read in the glider and then I rock her while she has milk and I sing.  And man, are there any lullabies that aren't sad to begin with and even worse when you are struggling and emotional?  I basically sobbed my way through her bedtime and for the following hour... and then I swallowed 4 Cytotec and the waiting began.

Unfortunately, the Cytotec hasn't worked at all, so I stayed home from work and wore a bulky pad (ha) all day for nothing. I'm starting round #2 tonight and I really hope it works this time.  My OB would really like for me to avoid having a D&C and I really would rather not as well.

Now that we have a path forward, I feel much better about the state of things.  I obviously wished the outcome was different, but I know that something was wrong and am relieved that any difficult decisions that could have arisen weeks from now are out of my hands.

So, that's my update.  Life goes on.  I'm scheduling fun activities and a date night for the weekend and hoping that I've made some progress by then.  Thank you all for your support, it means so much.

So Much for Luck

We went for a 6-week ultrasound today.  We could see a gestational sac but no yolk sac or fetal pole or heartbeat.  Either my timing is off (unlikely) in terms of date count or I am going to have a miscarriage.  I'm sure it is the latter -- I'm pretty positive on ovulation date and I know that what we saw today is not good news.  I know the u/s tech very well and she was very sweet about it and reminded me that 33% of pregnancies end in miscarriage and that what this likely means is that something is/was wrong.

I am crushed.  This is not how I felt when we lost Q, of course. But I'd be lying if I hadn't already been thinking about this baby and what he/she would be like, how different our lives would be come November, etc.  Even though I told myself not to, I'd been making plans.

Don't I know better by know?

Everything does feel different with B at home. I snuggled her extra long this morning before the appointment and I'm going to head home early to see her tonight.  I know how lucky we are to have her and how much joy she brings to us.

Nevertheless, I'm quite sad.

We'll do a repeat ultrasound next Monday unless I start bleeding between now and then and decide next steps then.