It was a . . .

Back in the summer when we underwent genetic testing and met with a counselor to determine the specific chromosomal abnormalities that caused our miscarriage, I asked the counselor if the tests showed the sex of our lost fetus.  She indicated that information was available, and at our request sent us a copy of the results in a sealed envelope, in case we ever wanted to know that information.  At the time we received it, Hubby didn't want to open it.  I knew I wanted to know one day, but at that point my heart was still in a million broken pieces, so I wasn't sure the timing was right either.  So, we've kept the sealed envelope in a drawer, close at hand.

From time to time I'd think of the envelope, and at one point later in the summer I decided that I'd like to open the envelope around the time our baby was due, December 25th.  We were upstate with family for Christmas Eve & Christmas Day, so that timing wasn't appropriate -- I wanted to unseal the information in private.  I also didn't know how I'd react.  But, over the past couple weeks I made up my mind that I wanted to open it before the year ended.  I know there are so many things I have in my life to be thankful for, and I want to make a conscious effort to focus on those in 2014.  I thought by opening the envelope before the year ended, I could try to bring some closure to the situation, and try not to focus so hard on what we've lost.

* * *

Back in May, even before I miscarried, I had a strong feeling that our baby was a girl.  I can't recall what initially led me to believe I'd soon be carrying a bundle of pink in my arms, but I think it was a random dream.  Then, when we vacationed in the Dominican Republic for our anniversary and received a little parting gift from our hotel of a faceless girl figurine, my feelings became stronger.  When I first saw that little faceless girl, I was convinced it symbolized the baby growing inside of me.  And, after our miscarriage when I came home and saw the little faceless girl in a blue dress and hat, I just knew she represented the baby we'd never meet.

* * *

Well, it turns out I was completely wrong.  The little baby we lost back in June was a boy.  Our lost boy.  I'll never forget him, and always wonder what he could have grown up to be.  But the truth is, I'll never know.

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My Little Angel

I never got to hold you,

Or kiss your little head

Or watch you sleeping soundly,

All snuggled in your bed.

I can't count your tiny fingers,

Or you even smaller toes

I won't see your smile,

Or your cute little button nose.

I know you are in heaven,

Where there is no pain or tears.

You'll never get hurt or sick,

In heaven there are no fears

And though I'm sad you're not here right now

For us to hold today

I know we'll hold you in our arms

When we're in heaven with you someday

© April Westlake

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Obviously a part of me is still very sad, and I am sure I'll always wish for my angel baby.  But I am also grateful to have found out this information.  I have no idea why, but knowing this little tidbit of information, although it doesn't change a thing really, has brought me a tiny bit of closure.

Normal!

We finally got the much anticipated call from our Genetic Counselor, and we're normal!  {Chromosomally speaking anyway.}  Our karyotype results show that my husband and I each have 46 normal chromosomes, with no translocations.  That's good news.

It means the chromosomal abnormalities that caused our miscarriage were not inherited; they were "de novo" or new, likely due to errors during cell division.

It doesn't mean that they won't occur again; it's certainly not impossible, though from the research I've done so far, it seems improbable that we'll experience a chromosomal abnormality twice in a row.  As we've come to realize, there are no guarantees -- but I'll happily accept this prognosis.

This has been the longest 13 days of my life.  Who am I kidding... it's been the longest 53 days of my life.  Although hearing these results don't change or lessen in any way the loss of our first pregnancy, confirming that the miscarriage was not due to any inherited abnormalities does, finally, give me some sense of hope back.

We still have a few unanswered questions, I plan on doing some more research online, and we'll likely place a follow-up call to the Genetic Counselor to obtain more information; but for now I'm going to enjoy this small bit of relief.

Genetic Counseling Update

We met with a genetic counselor from NYU as scheduled on Thursday of last week.  She began the session by explaining that 1 out of 500 people in the general population have a balanced translocation, which predisposes them to conceptions with too much or too little information (i.e., an unbalanced translocation).  She then went on to state that although we were referred for genetic counseling due to the labs resulting from our miscarriage, she suspects it is highly unlikely that either my husband or I possess a translocation.  But, the genetic testing would definitively answer that question for us, and since more information is better than less, this is the reason my OB referred us for counseling even though this was "only" {I use that word begrudgingly here} our first loss.  I guess in many cases, due to either lack of insurance or lack of testable tissue samples, conclusive results are not often available for "first time" miscarriages.  I guess this means we should consider ourselves lucky that we have the opportunity to get more information about what caused our first loss?  I certainly don't feel that way.  I wish we we weren't in this position at all.  But I digress...

She sympathetically and astutely admitted that knowing the reason for the miscarriage or being tested ourselves wouldn't lessen the pain or sadness of our loss, and when she was done summarizing why we were sitting before her and how she could try to help us get information, she asked if we had any questions.  Of course the only question I could muster at that point was "May I have a tissue" since I was already crying, 5 minutes into the appointment.

Our counselor then summarized the lab report for us and explained that 20 cells were tested from our fetal tissue sample.

In 13 of the cells, there was a structural abnormality found known as a balanced Robertsonian Translocation of chromosomes 14 & 15.  A "translocation" is a form of structural abnormality where a portion of one chromosome is transferred to another chromosome.  There are two main types of translocations -- in a "Robertsonian" translocation, an entire chromosome has attached to another at the centromere.  Because this translocation was "balanced", all of the genetic information was present, but rearranged.

Source

Here is a good description if, like us, you're new to this topic {I've indicated with bold font the parts relevant to our fetal tissue results}:

Structural chromosomal anomalies consist of a defect in the structure of 1 or more chromosomes. Translocation is a type of structural abnormality in which parts of chromosomes end up in the wrong location.  Translocations may be reciprocal or Robertsonian. In a reciprocal translocation, pieces from 2 nonhomologous chromosomes have switched places with each other; in a Robertsonian translocation, 2 acrocentric chromosomes -- that is, chromosomes with essentially a single long arm rather than the more normally encountered long and short arms -- are fused together. The acrocentric chromosomes are 13, 14, 24, 15, 21, and 22. In a balanced structural chromosomal anomaly the amount of chromosomal material present is normal, but the configuration is abnormal. An individual carrying a balanced rearrangement would usually not have any phenotypic effect, except for the possibility of impaired fertility and reproduction. Structural chromosomal abnormalities occur in about 1 of 500 persons. These structural defects may be passed from parent to child; therefore, when a structural anomaly (balanced or unbalanced) is found in a fetus or in an individual, karyotype analysis of parents and possibly other relatives is indicated.

This explains why we were referred for karyotyping.  But, we did manage to have the wherewithal to ask the counselor whether Robertsonian translocations could be sporadic mutations (i.e., not inherited) and indeed they can be.  So, we're hoping that's what happened here and that we will not experience this abnormality in future pregnancies.  However, since all the proper genetic material is present in a balanced translocation, it would not cause a miscarriage.

***

In 7 of the cells, there was a numerical chromosomal abnormality found known as a "trisomy", which is the presence of extra chromosomes resulting from segregation errors during cell division.  In other words, there are three copies of a particular chromosome instead of the normal two.  In our case, our fetus had "Trisomy 14".  This is known as an "unbalanced" chromosomal arrangement because there is either too much or too little information present.  As with most trisomies and all unbalanced arrangements, this abnormality is not compatible with life.  Here is an example of what a trisomy looks like:

Source

The slightly reassuring news here is that numerical abnormalities are sporadic (i.e., not inherited), and they do not usually recur in subsequent pregnancies.  According to one source, "In the case of a numerical chromosomal anomaly in a fetus, parental chromosomes are usually normal, so karyotype analysis of the parents is not indicated. The recurrence risk for a chromosomal anomaly following the diagnosis of trisomy in a pregnancy is thought to be about 1%."  I hope this statistic holds true and we are not unlucky enough to experience this abnormality again in a future pregnancy.

***

After meeting with the counselor, we each had one vile of blood drawn and are now anxiously awaiting the results of the karyotyping, which should take approximately 2-4 weeks.

Please keep your fingers crossed for us...

Genetic Counseling

Since Tuesday's phone call, I've been trying to wrap my head around the idea of genetic counseling and testing.  Of course one of the first things I did after speaking with my husband is turn to a trusted online support group for help and information.  Luckily, I received some very good responses that helped me to stop assuming only worst-case scenarios (even if only momentarily), so I thought I'd share some of this helpful and wise advice:

Counseling

• Seeing a genetic counselor isn't the same as needing genetic testing. It's just talking with someone who knows more about this sort of thing than our OB, and can answer exactly the kinds of questions we have: What exactly was the genetic error in this case? How likely is it to happen again? What are the statistics for it being a random error? Should my husband and I be tested? 
• My OB might be required to send us to genetic counselor because we did tissue sample analysis of the miscarriage product and came back with a result indicating this abnormality.  (It may not necessarily be because we are in some path for persistent genetic defect.)
• Seeing a genetic counselor can be a good, reassuring experience because they can put things into perspective. (Seeing one doesn't always have to be a bad thing.)
• The genetic counselor will have had extensive training both in genetics and probability to really explain what is happening. There is a lot of genetics information on the internet but just enough to get one to the "shoulder of knowledge" where you know enough to scare yourself but not enough to fully understand the situation.
• Genetic counseling is not something to be afraid of.  Most doctors really do not know very much about genetics and genetic issues, but genetic counselors do!

Testing

• We'll need to decide if the information from the test would be useful to us. If we'd rather not know, or if we wouldn't do anything different based on the test results, then we might not want to get tested. If we would do something different, or if having the knowledge would help us even if we don't change any plans or actions, then we should get the testing done.
• With a translocation, it could be that the mutation happened in the embryo, or it could be that me or my husband have the mutation as well. Genetic testing can tell us which of those is the case.  If it turns out that neither of us has a translocation, then our odds are pretty much the same as average and we can proceed with future conceptions without a cloud of dread hanging over our heads.
• If the mutation did come from one of us, then any particular embryo could have about a 50-80% chance of having either too much or not enough genetic material. We'd still have a shot at a healthy pregnancy conceived on our own, but our risk of miscarriage or chromosome problems would be high. So, depending on the results of the genetic testing, we might decide to get IVF with pre-implantation genetic diagnosis, in order to attempt only getting implanted with embryos with good chromosomes. This would reduce any future miscarriage risk (but of course IVF has its own drawbacks).
• Just because we don't know of any inherited chromosomal abnormalities in our families doesn't mean they don't exist. The only way to know is to test, and knowing means that if we want to do prenatal testing for a future pregnancy we will know what to ask them to look for. (CVS/amnio does not test for "all" issues; only a handful of common ones are routinely tested unless there is reason to ask for specific additional testing.)

Bottom Line:  Step away from the internet searches for now, focus on meeting with a counselor and see what the testing results really say.

I'm still so sad and angry though that this happened in the first place.  Having to meet with the counselor makes it feel even more real when I'm having a hard time accepting what has happened.

I keep trying to remind myself that about 30% of known pregnancies end in miscarriage. While this was our first, it doesn't necessarily mean we won't ever go on to have a healthy baby.  Most miscarriages are due to a chromosomal abnormality and most are never even sent for genetic analysis, so we have information that many couples would not get, or wouldn't get unless they had several miscarriages.  I know I should be grateful for this information and the option to meet with a counselor after our first loss, but actually feeling that way is easier said than done.