IUI day

My surge (judged by OPK) was close to full strength by around 7 pm last night, and this morning the line had darkened several shades. I went in for the ultrasound and blood draws this morning just because I want the numbers. The doctor who walked in did not even want to do the ultrasound, but reluctantly complied  on my insisting that it be done. She was so eager to be out of there (overall, I really cannot say good things about the practice I'm with now), I did not want to pepper her for details so I did not ask what the lining was at at, but my follicle grew 2 mm to 19 mm. That made me happy because that is largest follicle I've ever had, they have been at 17 mm the last 2 tries.

Not that it should mean much: I've said this many times, follicle size and quantity can never properly translate to quality, these are very likely to be 2 completely separate entities. The only way to ever measure follicle/ egg quality is to:
a)see how well the eggs fertilize and divide as embryos
b) Study of follicular fluid content: I'd think this is an area that really needs to be explored, to understand infertility better. People harp about genetics being the main cause of early (in the first 14-21 days) losses, but, in my opinion, they are looking at it the wrong way.  The fluid in the egg, which provides all the nutrients for the embryo to survive and proliferate for around nearly 8-10 days on its own, is more of the driving force at this early point. There is no reason for the genetics to come into play, because the embryo is just dividing again and again, with very few genes being expressed. In other words, very early losses, probably upto 2 weeks after fertilization are probably are due to cytoplasmic issues, unless the gene missing or damaged is from the small handful involved in  blastocyst formation, hatching, implantation etc. However: there could be a correlation between the two things (cytoplasm and genetics) though- an egg having a crappy cytoplasm is also likely to have had a crappy genetic division with more chances of aneuploidies.

Anyway, away from scientific speculation and back to me--bloodwork just came in.
-Estrogen has plateaued at 235 pg/ml.
Last time, from right ovary, was 265. Question for anybody in the know: what is the estrogen range at peak per single mature follicle? I found one website which said 200-600 pg/ml which makes me very sad, buts most say 200-300 pg/ml
-LH is a whopping 46.2 pg/ml.
Super strong surge, stronger than the last time (that was 31 pg/ml)

IUI is set for 1 pm.Will be saying many prayers as I head, once more, into this very scary breach.

Part II: All about the hormones (updated at the end)

Again, it does not *look* like a super pretty cycle that I am trying in. Its CD15 today.  I'm coming up to a surge possibly tomorrow. I picked this cycle because my Clear Blue Easy fertility monitor(CBEFM) switched to 'high' fertility a possible 4 days before ovulation, which is not too shabby.  To try to understand what that meant, I read the original studies looking up how the monitor works: There are 3 forms of estrogen: estradiol (strongest), estrone (middle strength) and estriol (weakest). The CBEFM measures the levels of a Estrone metabolite, which correlates very well to blood estradiol levels.  At some point, when the estrone levels increase past a certain threshold, the monitor changes from 'low' to 'high' fertility.

The good news, I've had 'high' fertility for around 3 days now, but the bad news is I have not seen a peep of the egg white CM yet.Apparently, estradiol (the strongest estrogen) drives the cervical mucous production. So when that gets super high, you get all that goopy stuff. It should be straightforward (lots of estradiol = lots of CM), but I have to wonder. Here is a question for you IVF ladies: There are times your estradiol levels must have gone through the roof, given the multiple maturing follicles: Do you always see the fertile CM during this time?


Because I've seen no CM yet, I was hoping  that ovulation would be delayed a day past CD17, but no dice, I've been monitoring my LH for the past 2 days, its on the rise and I think I should be in full surge by tomorrow (CD16). Which means the IUI is dayafter. ULP.

I am going in for hormonal monitoring and a U/S tomorrow. I have a feeling my stats (hormone levels, follicle sizes etc) are going to be very similar to my last cycles, and are considered bang normal by any RE, so my nitpicking and worry, is really for nothing. Something I cannot put my finger on is the problem.

In the last cycle, which was a BFN, I had a lot more 'symptoms' in the luteal phase which could
a) have been the result of a hypersensitive, far too imaginative psyche because absolutely nothing happened
b) been indicative of an embryo that probably bounced around for a few days, produced a smidgeon of HCG, before dying out because it could not implant, either due to uterine issues or because it was itself crappy quality and ran out of steam. Yeah- this covers most bases.

CD16 Testing and monitoring update:
EWCM made its exuberant entrance this morning (It always makes me SO happy to see it, yeah, I'm a little nuts but I blame this process :-))
U/S Monitoring:  The action is all in the left ovary (UGH- I have a hate-hate relationship with the left side of my body, will explain why sometime). Lining = 8.6 mm and 'beautiful'; Follicle = 17 mm (almost exactly the same as the last 2 times, albeit those measurements were on the day of ovulation, not from the day before).
Estrogen = 221 pg/ml-- normal for a single follicle,  I'm hoping it will be up a little tomorrow.

LH test results:
9 am blood work shows LH = 13. ie, looks like the surge is starting, but not there yet. 
2 pm check by OPK: Surge still not underway,  test line lighter than control.
7 pm check by OPK: LH surge is here. Test line now as dark as control.

IUI will be tomorrow. While I can apparently take a lot of shit and keep on going with barely a hitch in my stride, here is hoping the universe hands me something good instead.

In which I share far too much information

I've told about 3 IRL friends (and my mom and my brother) about this blog. If you are not my friend M or my mom- stop reading or you will regret it.

So anyway, this post is about the symptom you mention in hushed tones while being forced to converse with your RE's office in a public place- breast tenderness.

In the past year, the only times I noticed I had breast tenderness was occasionally in my luteal phase, and of course, both the times I got pregnant, from about day 3 DPO. At this point, I have to remind my readers, my vitamin D levels, unbeknownst to me, were in the deficiency range- below 20 ng/ml.

In December, I found out I was deficient and started supplementation. I noticed this first in January, where my blood Vitamin D levels had just entered the normal range (around 35 ng/ml)- I had  breast tenderness well before ovulation.This thew me for a loop, who had ever heard of this?!?!

Anyway, it continued that entire cycle. Then, I increased my vitamin D dosage, from 4000 IU/day to 6000 IU/day.  My blood level increased to 60 ng/ml. A great many things changed (including the tenderness disappearing. All of these changes (which included decreased cervical mucous and delayed ovulation ) were collectively indicative of lower estrogen levels. Not liking the changes, I cut back my Vitamin D dosage, and within a month, everything went back to the way it was before I upped the dosage.

This is the second cycle with a lower blood level  (probably back to 30). And, predictably, when my blood levels of vitamin D are around this mark, the tenderness is back. It is pronounced. I have a cat who likes to walk all over me first thing in the morning- she steps on my chest, and oh my bloody god, my neighbors get to hear me screech.  The rest of the time, it feels like I have a couple of lead weights strapped to my chest. Not fun. I'm kind of nervous thinking about how bad it would get if I got knocked up again, if it is this bad now.

I cannot believe that I have this symptom, this strongly, well before ovulation. It has to be a refection of increased estrogen sensitivity- either my estrogen levels are up, or levels of estrogen receptors are up. Vitamin D can affect both these parameters, so its not entirely illogical that this is happening.

My question to anybody reading is- did you feel this as a symptom in the pre-ovulatory phase, with injectibles or while doing IVF, ie conditions designed to increase your estrogen levels? Just curious.

A rambly post

I go away to Philly this weekend, where my old group of friends is experiencing a baby boom. 2 people got pregnant around the same time and are now close to the end of the first trimester. It still amazes me that when most people dodge this bullet pretty easily, I was slammed by it twice.

I still can't comprehend it and the why of it all would make for one rambling post or three. 

Why did my first, apparently chromosomally normal baby die? Was it my anti-thyroid antibodies? My mom was probably positive for these when she had my youngest brother, and that was an easy, perfectly normal pregnancy. She developed over Hashimotos about 6-7 years later--- people are antibody positive for many years before thyroid function is deteriorates to the level that it starts producing clinical hypothyroidism.  Correction: we recently found out that while my mom has hypothyroidism, she does not have anti-thyroid antibodies. So the cause of her hypothyroidism is not autoimmune, it is not Hashimotos. So I in fact have a pregnancy-loss associated factor she did not have.

Who made the abnormal egg or sperm that made my second baby die? That is really a million dollar question that haunts me to this day---I know there will never be an answer, but that really stops nothing.

There are some things in life you thought you would have no problems with. I always thought baby making would one of these, just because I come from a family with amazingly good fertility, so much so that sometimes it can turn into a horror story. Despite every attempt available at that time for birth control, my grandma had 9 children and it exacerbated her diabetes and caused an untimely death at 55.   My aunt had 3 kids then decided to have her tubes tied. It worked as birth control for a few years, then , in a one in million case, something grew back, causing a tiny opening in the fallopian tubes, enough for a sperm to get in. She of course, got pregnant even with such odds, had an ectopic pregnancy that nobody diagnosed and nearly died, and it started a lifetime of medical problems resulting in a chronic pain syndrome. Sometimes, what is a boon for one person can turn into a curse for another.

So why me?I've got the same freaky good genes in this department (that I thank my stars for, and now, no longer take for granted), as far as getting pregnant goes.  Most REs categorically refuse to think there is anything wrong with me, that I need to get treated for. I get pregnant, all my tests check out, right now they are going with the 'shrug-your-shoulder' diagnosis to explain my losses. I've tried to hit them over the head with the PCOS, and they are like--- yeah, looks like you might have some presentation of it, but we would refuse to think that really of any detriment to you, because you ovulate and get pregnant easily.  Except my Indian RE, who immediately jumped on the PCOS diagnosis for me after just listening to my history of conception and loss. Interestingly, I did turn out to have that, and I hope he is right and metformin is all I need.

Anyway, there has been something I wanted to share for a while: Last year, after I started charting, I found my cycles fell into 2 clearly different patterns---

Pattern 1: High temps on day 3 (around 97.2-97.3), more egg-white cervical mucus (usually), surge starting on the morning on CD19, ovulation on CD20, and a 14 day luteal phase.

Pattern 2: Low temperatures (96.9 approx) on CD3,less evident egg white cervical mucus,  Surge starting afternoon of day 15, ovulation on day 16 and a shorter, 12 day luteal phase , though you can't see that in the picture below:)

 You could say that if progesterone (which determines length of luteal phase) and estrogen (which determines quality of quantity of cervical mucous) were indicators of egg quality,  this was my less stellar pattern.  Both my conceptions were in this cycle pattern. I had expressed concern to my doctors about this, and they pooh-poohed it.

Since my second loss (and subsequent increase in Vitamin D levels), my second short pattern with the day 16 ovulation has disappeared.  Last year, it was there for 3 out of the 6 cycles I had, and this year, in the 5 cycles I've had so far, it has not made its appearance even once.Undoubtedly, something has changed in my physiology to cause this effect-- I doubt it was the loss itself, simply because this pattern repeated after my first loss. The only other discernible change is vitamin D, a hormone that regulates a large number of processes in your body. Nonetheless, no matter what the cause, I find this change remarkable, we shall see if the trend continues.

My new, utterly unanswerable million dollar question (I have a lot of them): Was vitamin D deficiency contributing to my shorter, less pretty cycles, and possibly my losses?

I was talking to a friend the other day and I told her that one day in the future, I would look back at all of this and it might make sense, but it sure as hell does not now, from any standpoint.

Sorry for being MIA..

I rarely blog nowadays and the reason for that is twofold- first, there is nothing concrete to say and secondly, life is, in a word, frantic, with work during the week and a fairly hectic social life on the weekend.  The second part is surreal.  A year ago, I gave up my carefree existence to start TTC. I gave up drinking completely, I became a homebody, I completely lost interest in the opposite sex.  After my 2 losses and the move and having to shelve my TTC plans temporarily, I'm suddenly thrust into this 'Sex and the City' lifestyle which is all about having a good time and meeting new people.   Its just a completely different set of priorities. This change actually feels good. It feels weird thinking about giving all up to go to last years way of life,  but there would be no regrets. All of this is fun, but if I had to abandon this to stay home in sweats and watch TV while being pregnant, I would do it without a second thought, and with complete happiness. 

Things are changing so rapidly, I feel like Alice in Wonderland, not knowing what will happen next. I think its highly unlikely that I will meet somebody and abandon plan B, but at the same time, I have no idea how the future is going to unfold. I have just a feeling that this year has some tricks up its sleeve- I just hope they are ones that lift me up, not knock me down. But even if they are ones that knock me down, I have to say, what does not kill you only makes you stronger. Despite all my misgivings of whether I will be able to handle another catastrophe in the baby-making department, I know this- I have a far greater reserve of equanimity than when I first started out. I've started realize, and more importantly, accept that I have no power, so when life does not go my way, I  have a better chance at not fighting it and just accept and adjust to whatever comes along. There is nothing else to do.

Science stuff

My antral follicle counts- done twice last year, have been very high, in the 30s. At my appointment with Dr L, I was shocked to see that one ovary had 11 follicles (small decrease), while the other had only 4-5 (huge drop down), giving a total of about 15. My antral follicle count has decreased by half. I was flabbergasted. I don't know what it means.  As you all know, I tend to attribute everything to the change in my vitamin D levels (because that has been the only big change in my physiology). Metformin has been shown to decrease antral counts in women with PCOS,  but that data, as my SD RE put it, is not too good. It would be interesting if vitamin D could do this as well, because both things actually influence sugar metabolism, which is has mysterious, ill understood links to fertility and egg production.

I don't know if my decreased AFC is good for overall egg quality, we shall see. As my next TTC cycle will be completely unmedicated as well, the only thing I have to go on is quality of my natural cycle. This takes into account BBTs, length of luteal phase, number of days with egg white cervical mucus, number of days of high fertility, etc.  Following your fertility signs can tell you a lot about your own cycle- this doctor describes it well here. The problem is though, you are shooting in the dark. The last cycle I conceived in, was, in my own opinion, an absolutely crummy one. I was very concerned about egg quality. Nonetheless, the RE, looking at my uterus and ovaries the day of ovulation, thought things looked good and we proceeded. And it was all good enough to produce an embryo that implanted beautifully and thrived in the first 6 weeks even thought it had a gross chromosomal abnormality. What I would love to know is whether my egg was missing an X chromosome because it was produced in a cycle with less than one day of high fertility before the LH surge began, but I will never know, will I? And even though I understand my cycle far better than the average person, I haven't a hope of figuring out what works and what does not.

A fact and speculation filled science post

On Vitamin D supplementation : how much is enough?

Two weeks after my missed miscarriage discovery and subsequent D&C, almost by accident and as a decided afterthought, I ordered a vitamin D test on myself.

Much to my surprise, I was deficient---anything less than 20 ng/ml is considered 'deficient', while if your blood levels are below 10 ng/ml then you are reaa-aahllly in trouble. I know people who have had bouts of frozen shoulder and some other not-so-nice musculo-skeletal issues when in this state.

25(OH)D Blood test results
Vitamin D Status	ng/ml	nmol/L
Severely Deficient	0-10	0-25
Deficient	11-20	26-50
Low-normal	21-32	51-81
Normal	33-49	82-124
Optimum	50-65	125-163
High, but not toxic	66-100	164-250
Toxicity possible	above 100	above 250

Since then I've been on massive supplementation- 60,000 IU/week first for 2 weeks. Then I checked blood levels, and they had shot up to an impressive 70 ng/ml.  I then dropped my dose to 4000 IU/day for the next month. This is 10 times the recommended daily dose.  One month later, I checked vitamin D levels again, and I'm only at 35 ng/ml.  The lab report states that to be considered in the healthy state, you need to be above 32 ng/ml, with the range being 32-100.

Its shocking to me, that despite having taken so much Vitamin D --a grand total of  over 200,000 IU in about 5 weeks, over 15 times the daily recommended dose, I'm JUST over the threshold for being sufficient and am still on the low end of the normal spectrum!

On Vitamin D and estrogen

It is my theory that my first pregnancy probably sucked up quite a bit of my vitamin D reserve. Interestingly, in the cycles following the end of my first pregnancy, I noticed something new and alarming.

I use the ClearBlue easy fertility monitor, that examines two hormones, estrogen and luetinizing hormone(LH).  My usual pattern was that I had 3-5 days of 'high' fertility(= high estrogen) before going on to 'peak' fertility(= high estrogen accompanied by a LH surge).  The alarming part was that in the two cycles following the end of my first pregnancy,  my days of high fertility had dropped off sharply, from 3-5 days to a stingy one day.  This did not seem good; high estrogen before you surge is pretty important for optimum egg maturation, a good lining, etc. Usually, you could set your clock on the happenings in my reproductive system, they are that spookily similar from cycle to cycle, so any change, especially one so drastic was jaw-droppingly strange.

I'm in a new cycle now. I'm on CD14, putting me 6 days away from ovulation. I used the fertility monitor this morning- I'm already on 'high fertility ie my estrogen is already high. If I ovulate on the 20 day as usual, that would give me 6 days of high estrogen at least!

Has there been any big change in my physiology ? The only think I can think of is the drastic change in my vitamin D levels. I have no concrete thing linking the two. I did my usual literature search and I could fine one study suggesting that vitamin D is involved in estrogen biosynthesis, atleast in mice.

I have no idea if vitamin D deficiency can effect estrogen production-all I have to go on is that when my vitamin D levels possibly fell a little, my days of high estrogen decreased. When I increased my vitamin D blood levels, coincidentally my estrogen production has seemingly increased. Sure as hell not enough to make any sort of case about anything, but documenting it here cannot hurt.

Unlike this speculation about vitamin D and estrogen, one thing seems fairly certain though-  vitamin D could be involved in implantation. I've talked about it my 'Science of infertility' section and yesterday my RE just showed me another study backing this theory up. Everybody having issues in this department, or even suffering from general, unexplained infertility- please get this checked out. If your insurance does not cover it, it would be worth getting it tested out of pocket.