Cheers!

Well, that's interesting. Up until last cycle, I've ovulated day 15 or 17.  During the first three or four cycles of TTC, I started using OPKs on CD10 and typically had a lot of negatives before I got something dark enough to consider it a positive. I don't ever get resounding positives, but I've learned what the maximum darkness I can expect is, and how that typically correlates with the temperature shift that signals ovulation.

In addition to OPKs, I track my basal body temperature and other fertility signs. The one challenge I have is extremely broken sleep. I'm up every two hours or so, and when gathering basal body temperatures for fertility purposes, it's ideal to have 4 to 5 hours of unbroken sleep. Hah! Wouldn't I love that? Still, most of the time I temp around 2:20 am (after a midnight wakeup, and before a 4:something wakeup), and I always see pre and post-ovulation patterns.

Anyhow, with CD15-17 ovulation, I decided it was a waste to start testing so early. I get a little neurotic wondering if I won't ovulate for some reason, and the early negatives make that worse. Thus, for the last two cycles, I didn't use an OPK until CD12. Last cycle, to my surprise, I ovulated on CD14. With the hysteroscopy last week, I expected that ovulation might be delayed this cycle, so again I waited until CD12 to use an OPK. It was about as dark as they ever get for me. This leaves me wondering: did I ovulate on CD 12/13?

You would think my temp could help answer this question, right? I say again, Hah! Yesterday I woke up at 1:00 and 3:30, instead of 2:20. My 1:00 am temperature was normal for pre-ovulation, my 3:30 am temperature was normal for post-ovulation. Only time will tell if it stays up and I ovulated or not, but I can't find any evidence of women having early ovulation after operative hysteroscopy, so I'm perplexed for now. What I wouldn't given for a moment-by-moment understanding of what's happening inside me!

Perhaps the explanation is that I did something this cycle that I almost never do. I had several glasses of wine. Since we are benched from surgery and I figured ovulation would be delayed, I had some of a really nice bottle of zin with a dinner out on Saturday, CD10. My Sunday morning temp was up at post-o levels, which is what happens when I drink. I didn't have anything to drink Monday night, so alcohol doesn't explain the high temp today. It does make me wonder if the alcohol impacted ovulation? Either way, it was worth it. That 2008 Rombauer Fiddletown was magnificent!

A Waiting Game

Patience has, quite frankly, never been my strong suit. I suspect much of this is the result of how I viewed the various stages of my life. Highschool was the thing you did so you could get good enough grades/work/volunteer experience to go to college. College was the thing you did so you could get good enough grades/research/work experience to go to grad school. Grad school was the thing you did so you could get that first job, which would eventually get you to a stellar career.

Every stage was an opportunity to work my ass off, excel, and therefore get what I wanted in the next stage. Every stage was something to be conquered before moving on to the next. Because the focus was always on the next stage, I spent a lot of my life ‘counting down’ – waiting for the end. I counted the days until the end of college semesters. I counted the days until the end of grad school semesters. My “coping” strategy for getting though a stage was to work harder, and that typically paid off with better outcomes in the next stage.

All of that is nice, and it’s left me in a really good place life and career-wise, but it hasn’t taught me how to cope when “work harder” isn’t an option that helps. When it comes to repeat pregnancy loss (RPL) no amount of work on my part is going to improve things. I already eat a good diet, maintain a healthy weight, and exercise a good amount. None of those things probably matter, but even if they do, there are no logical changes I can focus on working toward that might result in a better outcome. In other words, my normal coping strategy has failed me, and I have to revert to patience as a coping strategy.  

This is tough. Thursday, five days from now, will be my follow up appointment. It will also be when I find out my cycle day 3 test results. I expect that Thursday will be when I find out if we’re just dealing with RPL, or if we’re adding infertility into the mix, too. I’m worried. I’m 36, almost 37. Based on that alone, there’s a good chance I’ll be diagnosed as “diminished ovarian reserve.”  I understand that knowing my test results today won’t change anything when compared to knowing them on Thursday, but I’m still not finding it easy to wait patiently for Thursday. Or to wait patiently to ovulate and then get a period so I can start my next cycle. Or for any other waiting involved in this process of trying to conceive (TTC)!

It would probably be better for my mental health, physical health, and eventual success if I could wait out life patiently. I would say ‘that’s what I’m going to work on,’ but that sounds like my normal approach. So I’ll focus on alternate coping strategies (blogging, anyone?), appreciate how wonderful my day to day life is despite these heartbreaks, and keep moving toward Thursday. .  with my 5 day counter ticking down! J

It Went Well (Sorta)

Monday was hysteroscopy day. Surgery was scheduled for 1:50 pm, so I got to enjoy the fun of no food or liquid for most of the day, along with the anticipation of someone getting up close and personal with my reproductive system. Since Dr. S could only guess based on the ultrasound that I had scarring or fibroids, I was very interested in knowing what Dr. C (who performed the surgery) found. Thus, after surgery, I asked my husband what the doctor had told him. The only thing DH could remember was “it went well.” GAH!

On that front, it did go well. I was done and on my way home by 4:30, and other than a really sore throat, some mild cramping, a bit of bleeding, and the occasional shooting pain coming from the direction of my uterus, things are normal. Compared to the d&c in January, I was much more hungover from the anesthesia this time.

While DH didn't know much, Dr. C did, and he called me at home Tuesday night to check on me and follow up. He told me he found only minor scarring by one of my tubes and he took care of it. He doesn’t expect there to be any new scar tissue that forms, so he didn’t use a balloon catheter. He’s bumped up my follow up appointment to June 7, and we’ll talk about next steps then. The down side of “minor” scarring is that it’s unlikely to be an explanation for the repeated losses. So we’re not much farther along than where we started.

So, what’s ahead? I should be getting my cycle day (CD) 3 blood work back. That will tell me how close to diminished ovarian reserve I am. If the answer is that I’m very close, I lean toward more aggressive treatment now. If my numbers are ok for my age, hopefully we can try less costly and less aggressive options first. I’ll also be discussing my thin uterine lining with Dr. C. He said it’s probably not a factor, but a lining under 5 on the day before ovulation is not promising, and I have the research studies to back that up. So, we’ll see. Wish me luck?

What's Half of "I Told You So"?

Two Fridays ago, I had my saline sonogram. This entailed filling my uterine cavity with saline and then using ultrasound to determine if anything was amiss. It was scheduled for CD13 for me. Going in, I would have bet on two findings. Coming out, it turns out I would have been half correct.

Bet #1: Thin uterine lining. Result: Nailed that one. The ultrasound showed one beautiful 20mm follicle, ready to go in another day. My lining, however, was less than half the thickness it should have been. Outcome: To be confirmed, but I expect I’ll be getting some hormonal support in the future.

Bet #2: Everything else will look fine. Result: Nope. At first things looked picture-perfect, teardrop shaped. Then the ultrasound reached the top of my uterus and discovered something, that, after further inspection, appears to run the full length of the right side. It might be a fibroid or polyp, but it’s probably scar tissue from the January d&c. Research shows that nearly 20% of surgical abortions result in uterine adhesions and scar tissue. I should not be shocked to fall directly in the 20%. Whatever it is, it doesn’t belong. Outcome: I win surgery to remove it. The ultrasound photos below show the thing that doesn’t belong.

Overall, these two factors combined provide a logical explanation for the two chemical pregnancies. The extent of the whatever that’s in my uterus could easily disrupt implantation. I’d like to say that this gives me hope that maybe we’ve found the cause of these losses, can fix it, and will have no further trouble with getting and staying pregnant. I’d like to say that, but I really can’t. Three back to back losses have taught me that hope is not a good thing. Hope makes you hurt. So, for now, I’ll focus on next steps, not expect any better outcomes, and be positively thrilled if a sticky pregnancy arises from all of this.

Speaking of next steps, the plan is to do a surgical hysteroscopy, and use a morcellator to remove the whatever. If it’s scar tissue, they’ll leave a balloon catheter in place when they’re done, to prevent reformation of scar tissue. I go in for surgery on the 23rd. Post-op appointment is June 15, so I hope to be cleared at that time. In the meantime, I’ll keep up diet, supplements, and exercise. I don’t know if they make a difference, but this was the first cycle in my life that I’ve ovulated on day 14, and that was the first positive I’ve had in a while!

Diets, and Exercise, and Supplements, Oh My!

On the whole, I would describe myself as someone who likes to be in control. I want to have my own space, make my own decisions, and I’m ready to live with the consequences of those decisions. Studies have shown the probability of successful conception among women suffering fertility problems is higher with a “healthy” BMI and diet(Chavarro, et. al., 2012, Ferti Steril.). Other studies suggest that diet can play a role in fertility, especially caffeine and alcohol.

Thus, I find myself at a decision point: do I make changes that will be unpleasant in my daily life in order to improve the probability of getting the take home baby I want? And for me, the answer is that I have to at least try those changes. I may not succeed 100%, but I’ll feel I’ve let myself down if I don’t give it a shot. So, what am I doing, and why?

Exercise. A minimum of five days a week, 45 minutes a day of exercise. Most studies show a positive relationship between exercise and reduced miscarriage risk (e.g., Zhang, et. al., 2011; Latka, Kline, & Hatch, 1999; Clapp, 1998, AJOG). Further, exercising 3 or more times a week is associated with the most positive outcomes. I’ve seen one study that suggested that intense exercise can have a negative impact on fertility, via miscarriage, even in women with a “normal” BMI (Madsen, et. al., 2007, BJOG). As a result, I’ll drop the HIIT workouts I’d been doing, and focus on a goal to ride 2,000 miles on my bike this summer. That will mean daily exercise of at least 30 minutes, with longer sessions on the weekends, and it should correspond to a reduced probability of miscarriage.

Diet. I’ve been gluten-free for about five years and pescatarian for nearly 20. No reason to change that, but I also eat way too much sugar and processed crap: Udi’s bread, YogurtLab Fro-Yo, protein bars, TJ’s greek coconut yogurt, chocolate – I’m looking at you! Inflammation may play a role in repeat pregnancy loss (Comba, et. al., 2015, Fertil, Stil.), although it’s not well understood. I have a history of juvenile rheumatoid arthritis, thyroid issues, gluten intolerance, and other allergies, all of which suggest my immune system isn’t my best buddy. Based on that I’m going to adopt a hard-core, Mediterranean-focused, anti-inflammatory diet. This is supported by research on luteal phase disorder (Andrews et. al., 2015, Hum. Reprod.), as well as research on inflammation in general.
Sadly for my taste buds, the processed food in my diet is going out. More veggies (kale, broccoli, asparagus, and their friends) and more fruit are coming in. I’ll still stick with my staples of lentils, quinoa, black beans, and chickpeas, but I’ll drop as much dairy as possible. This falls under the category of ‘things that are going to be really hard to do,’ given my love for chocolate, sugar, and processed-carb happy snacks. Still, I keep reminding myself that getting another “I’m sorry” phone call from my doctor won’t be easy, either, and I’d rather feel I’ve tried everything I can if I reach that point. . . see my earlier note on control.

Supplements/Medications. This one is controversial and I’ve spent more time pouring through journal articles than I care to admit. I’m proceeding on the hypothesis that I probably have egg quality issues, since all other likely causes have been ruled out. I also know I have a short luteal phase (10 days) and light periods, so pending further testing, I seem to have lining issues. Thus, I’ve focused on diet and supplements for egg quality and lining. What are some of the options out there, and why might you consider using them?

Melatonin, 3mg, at bedtime. Several studies have shown that melatonin positively impacts pregnancy outcomes. A very small study out of Japan showed improved serum progesterone concentration (>10 ng/mL during the mid-luteal phase) in nine of 14 women (64.3%) receiving melatonin supplementation, whereas only two of 11 women (18.1%) showed normal serum progesterone levels in the control group (Taketni, et. al., 2011). In addition, for IVF patients with PCOS, implantation rates in a melatonin-supplemented group were higher than those of the non-supplemented control group. Pregnancy rates were also higher, although not significantly. The findings suggest that the addition of melatonin to IVM media may improve clinical outcomes. (Kim, et. al., 2013). There is also research correlating melatonin and premature labor, although I haven’t delved into that space. There are few, if any, studies suggesting harm from melatonin.

DHA – A number of studies link Omega-3 consumption to positive outcomes for pregnancy. I think this one is pretty well accepted, so I won’t bore you with citations!

Myo-insolitol 2g dissolved in water, 2x/day. Several studies have shown that myo-inositol can regulate ovulation, improve egg quality, and enhance embryo development (Carlomango, Nordio, Chiu, Unfer, 2011, Eur J Obstet Gynecol Reprod Bio; Kamenovz, et. al., 2015, Gyecol Endicrinol). While it’s probably most effective for women with PCOS, I can find no studies showing harm, and quite a few showing benefit.

Ubiquinol – 100 mg, 3x/day. A relatively small study out of Egypt (N=100) of women with PCOS who took CoQ10 daily showed higher follicle counts, thicker lining (8.82 ± 0.27 mm versus 7.03 ± 0.74 mm), and more regular ovulation (54/82 cycles (65.9%) vs. and 11/71 cycles (15.5%)), and higher clinical pregnancy rates ((19/51, 37.3%) vs. (3/50, 6.0%)) in comparison to women in a control group who did not take CoQ10 (Refaeey, Selem, Badawy, 2014). Ubiquinol is the more bio-available form of CoQ10.

L’agrinine – 1000 mg, 2x/day. This one’s controversial, so do your own research. A small study (N=34) out of Italy looked at poor responding women undergoing IVF. Half received L’arginine in addition to stims, the other half did not. The treatment group saw improved blood flow, improved number of eggs retrieved, higher numbers of embryos transferred, and 3 total pregnancies, compared to none in the control group (Battaglia, et., al., 1999. Hum Repro.).

Pycnogenol – While this supplement has been studied mostly in men, it’s also been shown to have positive impact on reducing endometriosis symptoms (Kohama, Herai, Inoue, 2007, J Reprod Med.). I am somewhat skeptical as the authors of most studies I can find are the same (vested financial interest, perhaps), and the one meta analysis I can locate showed only studies with small sample sizes (Schoonees, et. al., 2012).

Low dose aspirin – 81 mg 1/day. My OB suggested this as a ‘it can’t hurt’ measure. There’s also a bit of research to suggest it can reduce inflammatory processes and thereby help prevent RPL (Radin, et. al., 2015, J. Clin Invest).

There’s an interesting question around how long to sustain changes in diet and supplements to see results. I can’t find good answers in the literature, but for the changes I’m making, I’m going to aim for three months to start and see what happens. That will take me through all the rest of the medical testing I need, and will probably start me down some more invasive and expensive paths, given my age. Here’s to healthy eating and a healthy body!