Conflict (warning-dark)

Are you ever in the state that there are two absolutely opposing feelings vying for supremacy in your brain? Probably not, but its something I've been dealing with right now.

The first set of opposites are my reactions to the loss of my 2 babies. There is one part of me that almost instantly accepted these losses and came to terms with them.  This part of me is cool, rational and pragmatic.  It knows that from the beginning of time, thousands of billions of lives have flickered out before even completing organogenesis.  Miscarriage is one the truest cases of saying that the pain is only for the ones left behind. I'm aware that what has been a catastrophic event for me was an event that did not even register for my babies.  They were many months away from  anything resembling true awareness.  So they moved on without even know where they had been, or what had happened to them. I pray that they are in good places, wherever they went. But they are on their own journeys now, and it is one removed from mine.

Then there is that other emotional part of me. The part that still bursts into tears when I read about other people's stories of loss. The part that can't bear that my babies, the ones I never got to know, are gone.  Though I can write paragraphs about the rational side of me, I cannot even begin to address its emotional counterpart.

Thankfully, the rational part of me holds sway most of the time. After the initial spates of grief, this pragmatic part of me has prevailed mostly. But the emotional side unexpectedly has been dropping in the past few days, and I've been getting to see polar opposite sides of me in action, one rapidly following the other. Its been interesting, albeit exhausting.

The second set of conflicting feelings is now about pregnancy. There is a part of me that so badly wants to try immediately. Knowing that you have an excellent chance of getting pregnant within weeks is just heady. Sometimes I want it so badly I can taste it. But on the other hand, the thought of pregnancy just fills me with terror, for lack of a better word.  The other day, I was sitting and just thinking about the process...the positive pregnancy tests, your body changing instantly, your bladder immediately shrinking to pea-like proportions, waking up multiple times a night, those hunger pangs, and within 5 minutes, I was bawling. The first time I went through that, even the annoyances made me smile, the thought that life was growing inside me made everything ok, I'd be smiling as I was stumbling out of bed for the 4th time that night.

Now I just think that life will grow, all those amazing changes will happen, just to end in death again. I'm so very morbid I've been thinking about what to do in case I have to abort for the 3rd time. I do not want to have a 3rd  D&C because I'm worried about Asherman's syndrome. My Indian RE recommended misoprostol because he does not think repeat D&Cs are a good idea...the thought of going through the pain this pill induces makes me shudder. Although this thought would have seemed mindbogglingly weird a few months ago, I can say that D&Cs are relatively easy.  Somebody just sticks an IV in you, you wake up after,  physically its like nothing ever happened . I've gone through my 2 losses with only the emotional scars.  So yeah, I'm going to spend quite a bit of this year cringing at the thought of misoprostol.  I don't know what to do there, that is another giant area of confusion and conflict.

So for the next several months, I'm going to alternate between longing to be pregnant, cringing at the actuality of it, and hand-wringing while considering my alternatives in the worst case scenario. Goody.

The amazing thing about blog writing is that you can say all of this to yourself, it won't help you one bit. You come out here, you type out the crazy conversations you have been having with yourself, and just somehow, in some bizarre way, it helps.

Thank you all for reading. I know most of the people who pass through this blog never ever comment.  It would be nice, if for once, some of you delurked! Not the best post to ask you to do it, I know.

PCOS or not?!?!

On the medical front, I'm still ridiculously confused, I'm still pondering that million dollar question, do I really have PCOS? There are cases of PCOS that go undiagnosed for years because nobody runs the right tests. In my case, I've run all of them (sometimes in triplicate) and I'm still left scratching my head. This disease is COMPLICATED!!!

My San Diego RE( Dr. G) who first remarked that my ovaries looked polycystic, does not really think that I have PCOS. He thinks my ovaries look 'multi-cystic'. Translation- I have about a gzaliion follicles in each.

Courtesy of Google Images

My antral follicle count has consistently been in the 30s. My repeat AMH (because I never believe in just one test reading) was even higher, at 5.6 ng/ml.  You can look at these results from 2 different angles- from one angle I'm just blessed with a pretty abundant ovarian reserve, above average for age 30.  Look at it from another angle, and yeah, it looks like PCOS.

I've read some crazy complicated papers on how to diagnose PCOS.  There are 3 big players here-

• The ovarian parameters (high AMH and follicles) ---- big check mark here

• Ovulatory disturbances -----none. Ovulate beautifully, and in ridiculously reproducible patterns, every month.

•  Hyperandrogenism (greek for too much male hormone):  3 things to check here- DHEAS/ DHEA, testosterone and physical characteristic of hirsutism. 2 out of 3 qualifies you, I think.

Overall, you have to have at least 2 out of these 3 (ovarian parameters, inability to ovulate and hyperandrogenism) to qualify for a PCOS diagnosis. I have the first and definitely don't have the second. And as far as the 3rd goes......that is where I'm in limbo, awaiting a decision.

About hyperandrogenism:
I don't have high testosterone. I've tested this 6 ways to Sunday- conclusion- my testosterone is at the lowest end of the normal range.
I DO have high DHEAS (over 200 in 2 seperate tests)
The tie breaker is......hirsuteness. That is the condition where you are hairy like a man.  I'm sure everybody has seen somebody suffering from a really bad case of it one time or the other and knows what I'm talking about.  I'm NOT like that, not by a long shot, so if you had asked me a year ago whether I was hirsute, it would have been an absolute no-brainer to say no.

However, I recently came across this way to 'score' if you are clinically hirsute. Its called the Ferriman-Gallway score and it looks at body hair patterns not just on the face, but all over your body.

A picture speaks a 1000 words, so go here to see what it is all about. 

The papers say that if you have a Ferriman-Gallway score above 6, you might be considered hirsute. If you are above 8, you most definitely ARE hirsute. I looked at my own body hair patterns and I was like gee, I might just be in the 6-8 range, or maybe even higher but its really hard to evaluate one's self. If this comes through then we can conclude, yes, I just may have PCOS.

But right now, I'm waiting to pick an insurance, and then just find a doctor who will help me determine if I qualify for hirsutism. I usually get rid of body hair on a very regular basis, now I'm forced to keep it till I see a doc. UGH.

Quite a few medical professionals (including Dr. G) have asked me: how does it matter even if I DO have the mildest form of PCOS in the world, since its clearly not affecting my ability to conceive??? Well, because even in its mildest form, it CAN potentially be deadly.  It can stick a foot out and hamper fertility in MANY different ways.  PCOS can not only interfere with your ability to conceive, but can mess things up well after conception- ridiculously complicated post on that will be written one day in the future.

I'm a bad blogger, but...

Hope at Invisible mother, Jenny at Try, Try again and Randi at Fervently Wishing have very kindly nominated me for a few blog awards. Thank you ladies!!! I've done this blog award deal a couple of times so I've done the describe myself bit before- its here.

I wish I had the enthusiasm to find the blogs to nominate. I've been trying to find it for a few days but sadly, its just not coming..

But seriously... everybody out here writing, who have faced or are facing adversity,challenge and pain and growing from it, who are sharing their experiences and reaching out to other people in pain deserve these all of these awards. The one thing all of you REALLY deserve is squealing bundles of joy that enthusiastically create the most smelly diapers in the world. I give you all these awards and more than that, a prayer that all your quests are soon fulfilled.

In other news

• Completed my first week in NYC- wake up everyday with legs bitterly protesting all the walking I made them do- but loving it!

• Had 7 whole days of high fertility( measured with the ClearBlue Fertility Monitor) before ovulation- what ever was broken with the 2 cycles after my first loss (too few days of high fertility), its fixed now!

• Science related: I've updated my 'Science of infertility' page- I was flabbergasted to read that Vitamin D can actually fix insulin resistance in some people.. maybe this is the link of this vitamin to PCOS(caused by insulin resistance), one of the most common causes of infertility other than advanced maternal age or structural problems?

In New York.......

I moved!!  Here I am, staring at a beautiful 19th floor view of the Empire State Building. In other words, pretty darned nice digs and my commute to work is an elevator ride, so no complaints there.

But the transition is not easy. There is the freezing weather issue and the fact that I'm feeling sorry for myself because I don't know a soul in the city.

So many things I can do to meet people- sign up on eharmony (dating provided me sufficient social activity for nearly 6 months after I moved to San Diego and didn't know a soul, so I can always try that here),  join local societies,  find out when the local SMC chapter meets up...but here I am, not doing ANY of those things and just moping while staring at this incredible view. Of course, it takes months to truly settle into a city and I've been here two days and I'm feeling sorry for myself because of the lack of instant gratification.

This blog is so totally my version of cheap therapy..every time I'm stressed/upset about something, just putting it out here makes me feel better and realize what an idiot I'm being--love you guys!

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.

On the universe that does not give a damn and the resolution of loss

Horrible things have happened to me this year, and equally bad, or worse things have happened to other people I know. Chemical pregnancies. Miscarriages. Still births. I know of a couple whose two year old baby died, apparently, of SIDS. When such things happen, a lot of people can start losing another really important thing they possess, faith in a benevolent god. Luckily or unluckily, I've never had this to lose.

I regard religion as an institution created by man. Though I'll always be unsure as to whether 'god' exists or more to the point, how to define 'god',  I've always firmly rejected the view that such a supreme power is somebody made in man's image, who thinks like a man and hence experiences the same spectrum of same emotions we do.  I can say that I believe, confidently, that whatever 'god' is,  that entity is above emotions like benevolence or the opposite. Good things happen to people, bad-to-horrific-to-unimaginable things happen to a few and the wheel of life keeps spinning with universe/god not stopping to consider either the miracles or the tragedies. Entire species live and die, wars happen, genocide happens, people fall in love, heroic acts of selflessness occur, serial killers practice their craft, all while 'god' just lets the wheel spin.

But even if one is in agreement with such a philosophy (most people are not), how do you reconcile yourself to personal tragedy?  A line from a book I recently read stuck in my brain and is the inspiration for this post-- It went something like this 'Given enough time, does not every act of destruction ultimately turn into an act of creation?' Although this was a justification offered by the chief bad guy in the book, if you zoom out and look at chains of events over long periods of time, this could, in many cases, be true.

The horrible things that happen to us, like everything else, have butterfly effects- they set in motion a new chain of events, and if you wait long enough, something good might emerge from that new train of being. Then when you look at the good thing that happened to you (or somebody else), and weigh it against the tragedy that occurred before, what can you say?

Let me give the illustration of something I am personally involved with. I love my donor. He is open ID, and when you listen to his audio interview, you know that unlike the average sperm donor, he genuinely cares for any resulting children. His message to them is so darned nice and heartfelt. In his audio interview he states that he is a donor because of his wife- she cannot have children because she was in a car accident that damaged her ovaries and uterus.  He decided to donate because they could not have children, and today 3 children and 2 more on the way exist because of those donations. I've always been so struck by the fact that had that horrific, life-altering accident not happened to that poor woman, none of these babies would be. What can you say, really?

I've lost 2 babies, 2  precious promises that were never realized.  Even now, sometimes I wake up and cannot believe what has happened to me.  Other days I cannot  believe that I am so cursed so as to have to live through this while 95% of the population blithely sails through this process. Although I'm coping pretty well,  the sadness never goes away completely. But already, I can see the ripple effects of what happened to me starting up. God knows where they will lead, I'm just sitting here waiting. So yes, creation can be born from destruction, but when the destruction happens, words cannot begin to describe how awful it is.

I read something this morning that made me burst into tears and I'm so sad and angry...go here to express sympathy.

Meeting with the Genetics Counsellor

This meeting ended like my consults with doctors usually do-- with them telling me that I've already thought of every possibility and managed to test it all by myself. He looked at my 'normal' karyotype and said we could rerun it if I wanted (because one X chromosome looked a little shorter than the other) but most likely its nothing and such findings are common because of the way they do the tests.

But the one staggering thing to come out the meeting-- he told me that the fault was more likely to be the donors. My baby had Turners syndrome, one sex chromosome was missing. I had assumed that it was most likely that it had been the egg that came missing a chromosome. He informed me that in cases of Turner's syndrome, its more likely that it was the the sperm lacking the chromosome.

They assume this because a sperm lacking a chromosome is lighter, so it can swim faster than anybody else there and get to the egg first . So by this theory, monosomy is more likely to be a sperm error, while trisomy is more likely to be an egg error. If it really was a crappy sperm that  jumped my egg, then its just sheer, horrible, bloody bad luck.

People have often asked me whether my losses are happening because I'm doing IUI with frozen donor sperm and my answer has always been a very indignant negative. But now I have to wonder.

What is the advantage with natural conceptions? In a way, it is that the timing is often off. Intercourse may occur well before ovulation, and only the fittest sperm are still left swimming by the time the egg makes its appearance. In a perfectly timed IUI (where you just inject the sperm into the uterus instead of making them swim their way through a hostile vagina and through the cervix and then make them hang around waiting for the egg)  you are removing a lot of the negative selection process that allows only the fittest to survive, and just sometimes, you might end up paying for it

Still, this stuff is completely inconclusive. It very well might have been the egg (I was informed that with an X monosomy, 70% of the time its the sperm, 30% of the time its the egg).  It could still be PCOS messing up my eggs (likely explanation for both losses), it could have been thyroid issues responsible for my first loss and sheer bad luck the second time. OR--- it could be that both the thyroid and the turners are red herrings, that I have more than one big problem and there is another stealthy culprit we have no idea about just yet.

I wonder if I really have PCOS and should be on metformin.  I wonder if it would be a good idea to actually mess up the timing of the IUI a bit,  that is, inseminate the day I see surge and not 24 hours later, when ovulation is likely to occur?Or should I do an ICI? Worth the risk of a BFN? I wonder if I should be changing donors, though at this point there is no logical indication for that.

I have no idea what is the best route to take.  Despite the science and all the information I have (far, far more than the average person would in this position), the path forward is still unclear. I'm horribly aware that I'll have to take another leap of faith, knowing that another crash landing is highly possible. 

ARGH!!!!!!!!!!!!!!!!!