5/13/08 Appointment update

Oh what a morning! We left in plenty of time, but there were accidents all over the place, I had to stop and go to the bathroom once, and because I was so flustered when we got there I left the notes in the car. I couldn’t go get them because I had it valet parked. I had enough time to call my mom and get the questions again, because they couldn’t find my chart. Kim had pulled it yesterday to look at something and she wasn’t there yet. Finally, around 8:50 (for an 8:15 appt) we saw Dr. Shepard.

It went really well I think. Things I learned:

- My insulin level was at 83 and my glucose was 103. At the point in the glucose tolerance test, normal for insulin would have been 6-50. Anything over 60 is considered insulin resistant. For the glucose, under 140 is what we wanted, although a truly normal response would be 110 or lower. Thankfully I fit into that range.

- The insulin resistance problem has probably been an issue all along. Even back when we first started trying my cycles were wonky, which indicates some ovulation issues. In the Fertility Diet book I was reading last night, they said that the increased insulin caused decreased “some big long phrase that I can’t remember” that is a protein that carries the sex hormones. Those would be estrogen, progesterone, and I’m not sure about LH and FSH but they are obviously closely related. If those aren’t traveling correctly, that obviously messes with ovulation. (For instance, in me – I had a large enough follicle on CD12, but my LH surge didn’t happen until CD18/19 (sometimes later) and by then the follicle was post mature. She didn’t go into this today, so this is all from my reading.) It also could explain why even when given 3 vials of the Lepori (which is a lot!) I only developed one follicle. They would have expected someone my age to produce a bunch then. She obviously can’t say for certain that it’s the only problem, but it’s enough of a problem that it’s what we’re going to focus on.

- I asked if my weight gain could have caused it and that was iffy. She said that it’s related, but whether or not it caused the weight gain or the weight gain caused it is up in the air. She was very surprised that I have no family history of diabetes though.

- I don’t need to go see any other doctors about it, although I obviously need to get it under control. If we weren’t trying to have a baby, they’d probably have me try diet/exercise for awhile first, but with TTC thrown in there they want me on the Metformin.

- It sounds like I will be on Metformin through a good chunk of a pregnancy. I have no other indicators of PCOS, but they have found that people with it have a slightly higher risk of miscarriage in the early part of the pregnancy. I will keep taking Metformin until they are sure that baby is burrowed nicely into the lining and will stick.

- As long as I keep my diet/exercise ok, I should be alright on the gestational diabetes. They’ll know to especially pay attention to that possibility, but I shouldn’t have any greater risk than anyone else.

Our plan for now:

- If AF shows this week then we’ll be taking another month of not really trying (although we don’t have to abstain either) while we wait for the metformin/diet/exercise to do its thing. Then we’ll move forward with the plan.

- If AF wait until at least next week, then she thinks that will be enough time for the Metformin to start working, so I’ll do a cycle of Clomid. I was concerned because my lining thinned out while on it, but we never watched it during the first two months, and I think it tends to get worse as you go along. We’ll try one month and see how it is. I’ll have an ultrasound on CD12 to check my lining and see how the follicles are developing. We may or may not get an HCG shot, and most likely won’t do IUI (that’s completely up to us.) I’ll probably have b/w done 7dpo to check P4 levels.

- If that doesn’t work, and especially if it thinned my lining, I’ll move to a drug called Letrozole. She doesn’t like to use it as often as Clomid (she thinks Clomid works so much better) but in some people who react poorly to in regards to lining, it can work better. Same protocol with u/s and b/w.

- If that doesn’t work then I’ll go back to the Lepori (the generic Repronex.) I have 14 vials left of that, so it makes sense to use them. That will involve more monitoring with u/s every few days. We’ll do the HCG trigger shot for sure and will also do IUI for that.

- After that if we’re still not PG, we’ll re-evaluate and see where we are.

Something we didn’t talk about:

- I’m not sure if they’re going to check my insulin again to see if it’s better or since I’ll be on metformin regardless into the PG they won’t bother.

- We also didn’t talk about IVF at all. I am happy that we’re starting back over, but that we’re only doing a month or so at each level. Once we get to injectables, we’ll still have to figure my response out before moving to IVF. It would make no sense to do that if I can’t seem to produce enough follicles. However, IF we do get to the point of IVF, I want to do it this calendar year. The office is SO good about coding everything so my insurance covers it and I’ve already met my deductible this year. If we waited until October/November then we’ll be in our 20th cycle or so, and I’m comfortable with that.

So that’s my update!
Laura