Expect the Unexpected

By Dr. Avanthi Vellala

She was 40. Thirteen years of marriage. Three failed IUIs, two IVF cycles, four failed embryo transfers. And then a spontaneous conception. Her daughter is now eight years old, active and healthy.

She came to me wanting to try for a second child.

AMH of 0.01. Follicle count of barely one. Decreased ovarian reserve at 40. She wanted to try with her own eggs.

I didn’t deny her. How could I with her history? She had conceived spontaneously before when everyone including the biology was working against her. I owed her honesty, not a closed door.

I told her exactly what we were working with. At her age I need 12 to 14 mature eggs to get one euploid blastocyst. With her reserve, we would need multiple stimulation rounds. Risk of cycle cancellation at every step. Poor stimulation, empty follicles, poor quality eggs, no blastocysts. She understood all of it.

We stimulated for ten days. No response.

I recommended donor eggs. They took their time. And then they came back.

She is sweet. And tired. That was clear the moment she walked back in.

She wasn’t keen on another pregnancy. She was exhausted from years of treatment. But she wanted a sibling for her daughter. And I understood that. We don’t always want a second child purely for ourselves. Sometimes it’s for the first one. The “two kids completes a family” idea that gets woven into us so early we don’t question it. Sometimes the pressure is real and quiet and it drives decisions that look like they come from want but actually come from somewhere more complicated.

I’m not judging her. She found the courage to try again after four failed transfers and years of treatments. That takes something most people don’t have.

We went ahead with donor egg, PGT and ERA. The donor stimulation was excellent four blastocysts biopsied, all four came back euploid. That doesn’t happen every time. I was quietly pleased.

The ERA cycle was planned alongside a hysteroscopy. On the day of the hysteroscopy she was still questioning whether she actually needed it. Was it necessary? Could we skip it?

I gave her the choice. But I told her what I thought. She’s 40. Perimenopausal uterus. I wanted to see the cavity before transferring anything. She agreed half-heartedly. We did it.

She took a break the following cycle. Then we did a PGT and ERA based FET with strong luteal phase support.

I kept preparing her for failure. I told her even PGT ERA based FETs can fail. She wasn’t expecting a result in the first go not after everything she’d been through.

Beta HCG of 2083. Positive. First attempt.

On the day of the pregnancy test, I found her quiet

Overwhelmed. I asked my nursing staff what was wrong. My nursing staff said she was worried about the long journey of pregnancy ahead.

I sat with that for a moment.

A positive pregnancy test the thing that so many people in my clinic have cried and prayed and waited years for. And she was sad. Not because the result was wrong. But because she was already tired before the journey had even started.

This is something we don’t talk about enough. The second pregnancy that happens not out of joy but out of a quiet social pressure that nobody named and nobody questioned. The exhaustion of a body and a mind that has been through so much and is now being asked to do it all over again.

I admire her. Genuinely. She came back after four failed transfers. She said yes when everything in her was probably saying no. That kind of courage is quiet and it doesn’t announce itself. But it’s real.

Wishing her a safe, happy and healthy pregnancy. And some rest. She’s earned it.