Merde!!

Which is french for SHIT!! I was expecting my surge to start tomorrow morning. I've been monitoring for its arrival  like a KGB agent. I checked thrice yesterday, morning, afternoon and midnight, and this morning, where my test line was still lighter than my control line, and this just now.

See to the right the results- the test line was lighter than the control line at 11 am this morning, but by 5 it had visibly darkened, being as dark as the control line.


This means my surge began this afternoon. I have not scheduled an IUI for tomorrow- I called in the evening, but everybody was gone. I'm with NYU fertility, I wonder what they do in situations like this.

Its also an irregular cycle for me, but is it bad irregular? Who the hell knows? I have had around 1 full day (atleast) of high estrogen before my surge began.  My CM has only been creamy till yesterday, but today it changed to eggwhite. I've definitely had better natural cycles, though this is not the worst either. If my surge had begun tomorrow I'd have had far fewer worries.

I'm probably going to go in tomorrow for an IUI (if they'll let me, given the late hour). Sigh. When I wanted to do this again, I wanted things to look extremely reassuring. They never seem to be, not when I actually want them to be. But its bloody hard to wait- I wish to god I had gone the last time things look good, last month. But when you hunker down and wait for that 'perfect' cycle to show, its like waiting for the kettle to boil, its not going to happen on your watch.

So the games may begin again- will update when PUPO, assuming they let me go tomorrow.

It looks like things may proceed as planned.....

Since my last attempt at conception, where I tried in what I thought was an awful cycle, got pregnant, and lost it to a chromosomal abnormality, I've decided that the next time I conceive I was I want it to be in a *very* good looking cycle.

The cycle before this was like.....Chris Pine. Crazy pretty-looking, in the pre-ovulatory phase.  This cycle is kind of like... Ewan Mcgregor. Its solid, its kind of nice-looking, but cannot compare to the few Godzilla-like fertile cycles I've had, wherein, even in the days I was blissfully unaware of anything fertility-related, I would have noticed that something was brewing below. Unfortunately, those cycles have shitty timing.
 
I've been having just the creamy CM for days, just enough to let me know that the estrogen rise is happening, but not hitting me on the head with it, like in the last cycle. EWCM is not here yet, and I'm atleast 72 hours (hopefully) away from ovulation. Today, I used my Clearblue fertility monitor for the first time this cycle- I was so expecting to see the 'Low fertility' (= low estrogen), instead I got 'High Fertility' (= high estrogen). A happy dance happened :)

 The reason I had utterly hated the last cycle I conceived in was that I went directly from 'Low fertility' to 'Peak fertility'(= high estrogen + LH surge) --- there were no days of high fertility, where your uterus and ovaries bathe in estrogen before the surge begins. This cycle, I have that, hopefully for 2 full days of that before my surge begins. If my OPK gets positive later today or even tomorrow, I'll have to bench myself, though I'd be on the fence about tomorrow.

Onto bloodwork results:  I had gone to see an endocrinologist 1 week ago, who is awesome and definitely gets a review written up in the 'good doctors section'. He ordered every test I wanted, and a few extras, and we got the results back.

The salient points:

• I should have been taking my own advice of getting Vitamin D levels regularly tested when you supplement. To be fair, I had tested twice and it looked like 4000 IU/day was kept my levels at around 35-40 ng/ml,which was just about prefect IMO. Maybe there is an accumulatory effect over time, and quite likely, the 8 days I mostly spend bikini-clad on a ship (slathered in sunblock, but still managing to tan meaning UV rays WERE getting through) had an effect too- my D3 (1,25 hydroxy version) was 86. Ack!!!! WAY too high. I'm going to cut down now and start retaking the same dose once pregnancy establishes.
•  TSH is nice and super-duper low at 0.65 mIU/DL, and my T4 levels were just over the high end of the normal range. Perfect for conception.
•  Anti-TPO antibody titer is slightly down, from 107 around 16 months ago to 90 now. I've been taking selenium (80 mcg/day), plus a nearly equivalent amount in my prenatal. Many studies show that which is supposed to lower Anti-TPO levels. This is an excellent link for anybody who has thyroid issues, I urge you to visit it.
•  AMH is down a bit, from 5.6 to 4.3. I had expected this, because my AFC has gone down in half, from 30 + to around 16 ish, so its logical that AMH (that is made by the follicles) would go down too.  I'm happy with just this slight drop.
•   DHEAS is still high, and has gone up to 331 from around 250 in the last tests. This is the only part I cannot understand.

Interpretation: My thyroid function is now as well behaved as it ever is going to be. I believe that becoming vitamin D replete- see above link- as well as the selenium intake had much to do with this slight change.  Over 1 year ago, the following tests suggested PCOS (High AFC (30+), High AMH (5+), high DHEAS). Now, the only thing that is left is the high DHEAS, which, in itself may not be a bad thing necessarily.  Also, I used to get annoying skin breakouts, which is a PCOS-related issue, every now and then. Interestingly, for the past few months (hammering on wood), my skin has looked as good as it ever has- no breakouts for months. Praying that typing this out here does not bring them back, just to prove me wrong.

Things look good. Right now, its a go for early next week.

I had my first acupuncture session- thank you everybody who came up with recommendations- I went to the first name suggested, and so far, so good. Liz Carlson (of Clarity point Healthcare) was very nice. Its too soon to say if it has worked, but hey, I did wake up to high estrogen today. I have another appointment on Monday, just to play it safe.

She also suggested that I take wheatgrass. I've been reading up on this and so far it seems like a good idea- I really like the fact that its supposed to help detoxify heavy metals from your body. I need advice- pills or juice shots? How disgusting do the shots taste? I kind of like pills because you don't have to go looking for a juice bar or a farmers market on a regular basis. For any of you who took wheatgrass,  what form did you take it in, and how regularly did you take it?  Plus, did any of you continue to take it into pregnancy?

I'd also promised a writeup on Thyroid and fertility/pregnancy, I'll add that directly to the 'Science of Infertility section'.

I noticed commenting is a little wonky today, it takes a while for comments posted to become listed- are people also having issues using Disqus?

Acupuncture in NYC?

I'm just about a week shy of my IUI.  It looked like my CM was starting to build --not the super fertile but the pre-fertile variety that signals the rise of estrogen. Two days into this I'm all relaxed and happy, and ominously, it starts looking like it is going down, don't see anything for 24 hours. Instantly cue in stress. Honestly, at times like this., I actually see the value in the usually craptastic 'just relax' advice that gets doled out on a regular basis. Work is very demanding right now-- I'm kind of  happy that today has been so frantic,its been 12 hours since I even spared a thought for my lady parts, and not dwelling on this is about the most healthy thing I can do right now.

I'm doing a unmedicated cycle, same as the last  time-- all I do is monitor my surge and have the IUI. During my minor freak out, I decided that if I can do it at this really late hour, throwing in acupuncture may not be a bad idea. But I'm literally 1 week away from IUI. Being absolutely clueless about fertility acupuncture, I had a few questions---Is there any hope of getting a last minute session with anybody good? Is getting about one session worth it? Does anybody local have recommendations? 

ICLW (quite a bit late)

Well, I’ve been meaning to write a post welcoming whoever came over for ICLW for the past 4 days, but my schedule has been nothing short of insane so nothing got written and worse, ICLW commenting did not get done.  I’ve had a lot of people who just jumped in there with the last disjointed, introduction-less entry and commented, I thank you for it.

Still, better late than never: To sum up my blog, I’m somebody who thought she would have absolutely no issues in the baby making department.  2 pregnancy losses later, I’m one hell of a lot tougher, and I think a whole lot wiser too.  Since I’m a scientist that studies how the body works for a living anyway, I’ve come a good way in understanding reproductive biology, and I’ve tried my best to share that knowledge with everybody.  I discovered I was Vitamin D deficient after my second loss, and intense reading on the subject of deficiency of this hormone in various disease states, including infertility has made me a very vocal advocate on the topic of testing for this, and making sure you have normal range blood levels, with a large portion of my blog being dedicated to this subject.

Sharing of knowledge aside, I’m awed at what a source of emotional support the blogsphere has proven to be. While nobody else in real life wants to spend more than 15 minutes listening to you, here, you have a network of people from all over the world, genuinely invested in everybody’s journey and willing to spend hours cheering others on, or crying with them in the horrible times.  Women going through infertility just a scant 10 years ago did not have this resource, yet, we today, do.  When we think about the unfair hands we are dealt, that is something to remember.

In other news, I'm gearing up for the next try. I finally got my act together and went to an endocrinologist.  I was lucky to find one at NYU with really good reviews, and thankfully, he more than lived up to them. He listened to me,  he was well versed on the topic of anti-thyroid antibodies and their potential role in pregnancy loss, as well as the studies (not terribly convincing, but still plausible) looking at correlations of higher levels of TSH during pregnancy and IQ of the resulting children. He was willing to re-test everything, which included the PCOS hormones (Testosterone, DHEAS, AMH, and LH), the thyroid hormones (TSH T4, T3) and the Anti-TPO/anti-thyro-globulin antibodies. I had a whopping 10 vials drawn, and I'm eager to find out what it will show. 

Detailed post on the PCOS + thyroid condition coming , but I have to say again what I will reiterate there- when you get your thryoid tests done, look at that TSH value.  The old normal range for TSH was about 0.4-4 mIU/ml, now  it seems to have been revised  to 0.3-3 mIU/ml, with studies suggesting being over 2.5 is bad in pregnancy.  If TSH  over 2.5 (but still in the normal range),  demand a test for anti-thyroid antibodies. Anybody who is TTC, with infertility issues, is best off maintaining their TSH at  around 1-1.5. 

Its a simple no-risk treatment that only asks that you take some amount of thyroid hormone (which is perfectly safe as long as you do not take too much) and get frequent monitoring done, and it *may* fix an issue which is kind of an ill-understood and murky threat.  I am of this opinion, my current RE is not, but thankfully, this endocrinologist definitely is.  My thyroid during pregnancy will be in good hands.

Meh

For the last year, I've taken immense comfort in the fact that my luteal phase (LP), which was teetering on the edge of being classified as LPD, in both my cycles of conception, had changed greatly after I became Vitamin D replete.  It used to be a short 11 day one, and after I got my  D3 levels up and above 30 ng/ml, it has been a healthy average of 15 days, over 13 or so cycles.

Since Vitamin D increases both estrogen and progesterone and has been shown to regulate the menstrual cycle, its a logical thing to assume that taking vitamin D was responsible for this change.  Heads up on this link, it also talks about a subject I've long neglected in this blog, the effects of Vitamin D on male infertility. Its really something to take into consideration, for all affected parties.

Then, just as I'm about to start a cycle where I AM planning to TTC, I get my period 2 whole days early, giving me a 13 day LP. Occasionally something happens that seems entirely counter intuitive, and this is one of them. This past cycle seemed glorious looking. Lots of estrogen evidenced by crazy amounts of fertile CM, really high progesterone, evidenced by really high BBTs and crazy breast tenderness. Then why on earth did my endometrium give up the ghost 2 days early?  Ironically, based on the 2 progesterone symptoms (BBT and breast tenderness), I think my progesterone did not drop fully till day 16, but my period began 2 days early anyway.

Ugh, Ugh, Ugh. The next time I wanted to TTC, I wanted it to be in a very pretty-looking natural cycle with no issues, since that is all I have to go on. Now I kind of feel like I'm at the mercy of a celestial prankster, determined to mess with my head.

Anyways, if this cycle does not look like sh.it, I should be having an IUI on March 6th or the 7th, if nothing changes.  God, the thought of something changing and me having to make a decision whether to go with a crappy cycle or not is making me nervous already-- all the Should Is/Should'nt Is are starting up.

Adding to the pressure, I got really good news, but it makes when I conceive important-  My brother is getting engaged (!!!) and his fiancee wants to get married in December. Uhmmmm...also my due month, if I do get knocked up now. I definitely cannot attend a wedding when I'm nearly full term, not in India anyway. My parents are looking to pushing the wedding to late January,  which would be just on the edge of ok if all goes well, and as planned, but if not, its going to be a a bit of a pickle.  I did not forsee having to attend a wedding with a baby in tow---I really wanted to keep human contact to a minimum for the first few months of my child's life- that was going to be the best part of doing this in India, wherein no daycare would be needed. To have to attend a wedding, which in India is a 2 day long, giant communal affair, with 100s of germ-laden individuals running around the place and to try to devise a way that only 10 or so people get to handle/be in the same room as my baby...whee.  The thing with plans, you never see the potholes coming.

But...really, this is small stuff. Should remember not to sweat it All issues can be surmounted, you just roll up your sleeves and do what is necessary.   My brother is getting married---that is the part to celebrate!

Psychologists are no fun

Most REs have a policy that anybody using donor sperm has to go see a psychologist first.  My REs in CA had the same policy, but I skillfully (and forcefully) wiggled out in each case, there was no way I was going to spend 300 bucks out of pocket for an issue I had already researched by myself.

No dice with NYU's practice, I had to go see one. So I went, plonked down 350 dollars, but was given a reimbursement form and was told I'd get my money back.  So no pain there, but cannot say the same for the actual visit.

You definitely get your money's worth, I nearly spent 2 hours with her.  Every time I really have a conversation about using donor sperm, about doing this by such a non-traditional route, I start crying. But then, I also cry everytime I read that page in Love Story when Jennifer tells Oliver she has cancer,  and I cry everytime I see that animal shelter ad when they play that song, "In the arms of the angels" and all the animals look at you with those melting eyes. Just remembering that ad can make me cry. To sum up, any emotion (sorrow, empathy, anger, just any strong feeling) instantly triggers my lacrimal glands.

As a result, what was expected to be an easy conversation with rational and had depth, stayed a  conversation with rationality and depth, except I cried for about 30 % of it, intermittently and sporadically. The emotional response does not piss me off, but the tears do.  It pisses me off that I had to redo my eye makeup. It pisses me off that I had to take painkillers and sinus decongestants just to ensure that I did not have a blinding headache for the rest of the day. Argh.  Among the things I wish I could change about myself, this is in the top 5.  When you are in the midst of making a strong argument, you want to appear cool and collected. If  the topic under discussion pushes my emotional buttons, I'm usually bawling while trying to make a point.  Its SUCH a liability. My brother once accused me of turning on the waterworks as a way to get the upper hand, but that is not true- I have the opposite issue, I cannot figure out a way to turn them off.

Anyway, the psychologist covered a few interesting points about donor sperm and having THE conversation with your kid and all that fun jazz. I'd talk about it now, but it has to wait for later because I'm going to watch a pretty silly movie with two smoking hot men (Tom Hardy and Chris Pine)---the perfect end to a day like this! Update: The movie (This means war) is deeply silly and abandons logic at many points, but I recommend it none the less, the eye candy more than delivers, and its also very funny in multiple bits.Successfully took my mind off my afternoon, yay.

Another post on AMH, AFC and Vitamin D

Biology is complicated.  X sets off Y which sets off Z. Z  can positively or negatively regulate X or Y and any or all of them can be regulated by A, B C or D.  Its a crazy, multilayed, mind-boggling system in other words. Yet, when perfectly balanced,  perfect health results.

Trying to understand it is like trying to untangle a Texas-sized jumble of wool, yet we solider gamely on to do exactly that. After I took Vitamin D, a number of things changed- my antral follicle count went down and  my luteal phase got longer.  In this post I wanted to talk about certain studies which may offer explanations for the first, the second will be tackled in another post. 

After my second miscarriage, it came to light that I may have certain presentations of PCOS, primarily, a very high antral follicle count, or AFC and  high levels of the hormone, DHEAS.  My AFC was 30 and 34, when measured by 2 independent operators, over 3 months apart.  Between these two counts, we also found out that paradoxically, my AMH was low. I realized that this might be because I was Vitamin D deficient, and indeed, after increasing my Vitamin D, my AMH also went up 4-fold.

One of the things that concerned me from the getgo was my high AFC. Another TTCer (Tiara), who had 1 pregnancy loss, also presented with a high AFC. Her doctor, in what may have been a very prudent move, put her on metformin, which is supposed to combat insulin resistance.  She was alarmed that, the next cycle, her follicle count dropped sharply, but that IUI resulted in a healthy, beautiful baby girl.  Interestingly, her anecdotal finding of decrease in AFC after start of metformin correlates with this study, which also showed a drop in both AFC and AMH, after start of metformin.  Nobody knows how metformin accomplishes this,  but its main mode of action appears to be combating insulin resistance.

Vitamin D also helps to correct insulin resistance, although a lot of studies seem to think it mainly helps that subset of women who are overweight because of PCOS (I don't belong to this subgroup).  Nonetheless, because Vitamin D and metformin share this property, I was hoping my AFC would go down. The conversation I had where I tried to explain this to my nurse, so I could just have an AFC recount ordered, was kind of funny, although, on the whole, a firmly closed mind does not amuse me in the slightest. 

Anyway, I turned out to be right in predicting the result, though I think I was wrong in the mechanism behind it. My AFC went down from 32 (average of 2 cycles) to around 16 ish (average of 2 cycles).  People have said that AFC can vary with different cycles,  and this is true, but in my case the variation, if nothing has changed, is less than +/- 5.

For the longest time I presumed my drop in AFC was *probably* because vitamin D did something similar to metformin. Recently, somebody left a comment on Dr. Malpani's blogpost on AMH , that gave a really smart, and plausible alternate explanation. Apparently, AMH has this really interesting property- it inhibits recruitment of primordial follicles into the pool of developing (or antral follicles). This property of AMH provides an explanation why women with PCOS, who usually have higher AMH levels, may hit menopause later, because the recruitment of primordial follicles is lower , and hence their ovarian reserve lasts longer.


Coming back to my case, in addition to a *maybe* case of PCOS,  I had an additional confounding factor of Vitamin D deficiency (though this is also shared by around 40 % of women with PCOS). If everything in the previous paragraphs is considered correct, the broad possible explanation is this- when I was vitamin D deficient, my AMH was low because this gene needs to be 'turned on' by Vitamin D.  Once my Vitamin D levels went up, my AMH level went up. Over time, that increased AMH decreased the recruitment  of primordial follicles, so my AFC went down.

My numbers are still respectable, my total AFC is now around 16. God knows what this means but 16 is a reassuring number. However, even if you do have PCOS and your AFC goes to a number you don't like, I would hold off the alarm. One should remember this: quantity does not necessarily equal quality. This is best exemplified by women with PCOS who make a TON of eggs in an IVF cycle, and the majority are not good quality. So, on the whole, for women with PCOS,  the moral of the story is, both metformin and vitamin D have a good chance of helping you. I had the option to take metformin, but I chose not to do it, thinking that just Vitamin D would be enough.  It looks like I may be right, I hope the facts bear it out eventually.

I'll end on this note- while the role of vitamin D in pregnancy is open-shut good, its role in fertility itself is a bit murky. Overall, being deficient is bad for you.  But a few studies show that going too high may also be non-optimal, especially if you have endometriosis....you can read an entire review on the role of Vitamin D in female reproductive states here.   I'd say, while trying to get pregnant, maintaining your blood levels at around 30 ng/ml seems like the best course. After you get pregnant, your vitamin D requirements are going to rise- making sure you are taking enough to maintain around 40 ng/ml  may be best.