The bottom line

After writing that last post, I realized that I had omitted any sort of conclusion from all that data. I started to edit it to fix the problem, and then stopped – that post was too long anyway – and decided my “diagnosis” was deserving of its own post!

So what is my diagnosis? According to my online medical records at kp.org, it’s “female infertility” – not vague at all! Of course, Dr. Y. never actually said that to my face. He said something more like “low ovarian reserve” (i.e. reduced number of remaining eggs). When talking to close friends and family, I prefer the technical term “ovaries of a 45-year-old”.

All joking aside, I’m not really sure what the results of all those tests actually mean. And, frankly, I’m not sure experts know what those test results mean… Dr. Y. was very cautious in his choice of words, and from what I’ve been able to read about it, I can see why.

What I know (or, what I think I know, based on what I’ve read in infertility books and online):

  • My test results are atypical for 34-year old women who have taken these tests (that is, women with infertility). They are more typical of women in their 40s who have taken these tests.
  • Women with low ovarian reserve (i.e. with test results like mine) tend to respond poorly to ovarian stimulation drugs. This means that IVF patients with this condition are less likely to produce lots of eggs at once (a prerequisite for IVF), and thus have higher rates of cancellation, and lower success rates overall for IVF.

What I don’t know (and, from what I can tell, nobody really knows):

  • What impact does low ovarian reserve have on women trying to conceive naturally (who only need to drop one egg at a time)?
  • What are the ranges of test values for women in the general population (that is, not just women experiencing infertility, which currently seems to be the only people this data is available for)?
  • How many eggs do I actually have left? (Or, put differently, how many years do I have until menopause?)
  • What is the quality of my remaining eggs?

As far as we know, I could still get pregnant naturally – after all, it happened once! Then again, 45-year old women get pregnant sometimes too…

So, why am I pursuing treatment, especially given that my test results seem to suggest that I am not the best candidate for IVF?

Two reasons:

  1. IVF is the ‘gold standard’ infertility treatment, offering C. and me the greatest chance for a biological child (still true despite my low ovarian reserve).
  2. Every month that we delay treatment, our odds of success with IVF go down (especially true given my low ovarian reserve).

For me, these two facts are enough to propel me forward, ignoring such ‘helpful’ advice as: ‘It’s in God’s Hands’ (Of course it is, but so is cancer; should folks not seek treatment for that?); ‘Just Wait, It’ll Happen’ (Wait for what? Menopause?); ‘Try this Diet/Potion/Lube’ (The fact that it worked for your sister-in-law’s aunt’s cousin’s daughter is so much more compelling than scientific data!); and the classic ‘Just relax!’ (Oh, why didn’t I think of that? [snapping fingers] I’m relaxed now!)

Actually, I don’t mind the well-meaning advice (for the most part), but that’s where we stand!

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Test results

First, another update: I picked up C. in San Jose last weekend and flew home to San Diego with him yesterday. The flight was uneventful (a bit of turbulence, but smooth landing), but he was pretty tuckered out from the trip. Nice to have him home, though. The doggies and I missed him!

Back to the IF world. Now that I’m firmly in the two-week wait, I don’t actually have any news, but figured this would be a good time to fill in some of the holes in my earlier posts…starting with my pre-HSG test results.

I won’t share C.’s sperm test results, for the simple reason that I don’t have the values. (Due to HIPAA or whatever, I never got a copy of the results.) I will say (again) that I hear they were awesome. The best our IF nurse has seen, or so she claimed. C. is happy to believe her, and so am I.

So below are the results of my tests:

1) Antral follicle count. At my first visit with Dr. Y., he performed a transvaginal ultrasound and counted the number of antral follicles (maturing pre-eggs, visible under ultrasound). The idea here is that you can’t actually count the number of eggs a woman has left, so you assume that the number of partially-mature eggs your RE can see under ultrasound will give some indication of how many immature eggs (which your RE can’t see) are there. In general, more antral follicles = good, with ‘normal’ (in other words, ‘fertile’) levels being 16-30. My antral follicle count = 5.

The remaining three are all tests of blood hormone levels, determined from a blood draw on day 3 of my menstrual cycle. The structures of these hormones are shown below:

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Now, despite what my dad said in pretty much every Christmas letter throughout six years of grad school, I am not a biochemist. I’m an organic chemist, which means that I love to look at little chemical structures like the one of estradiol above. I start to get uncomfortable looking at any molecules bigger than about 1000 atomic mass units. Forget about proteins and nucleic acids! Both AMH and FSH (discussed in detail below) are protein hormones, which means that they are long chains of amino acids (AMH is composed of 560 amino acids; FSH is smaller*). If I tried to draw them using the same style of line drawing as estradiol, the drawings would be ridiculously large, indicipherable, or both. Instead, biochemists like to use other representations, such as the ribbon drawings above. The space-filling model is a compromise that makes me a little less uncomfortable, because I can at least see that there are carbons and hydrogens and oxygens, etc. Anyway, back to the tests:

2) Anti-Mullerian hormone (AMH). AMH is named for its role in preventing the ‘default’ development of female plumbing (“Mullerian ducts”…like uterus, vagina, and fallopian tubes) in male embryos. Its significance for infertility testing arises because AMH is released by egg-associated cells (“granulosa cells”) in the ovary, and – like antral follicles – is used as an indirect measurement of how many eggs are left. So, high AMH (>1 ng/mL) = good; low AMH = bad. My AMH = 0.17 ng/mL.

3) Follicle-stimulating hormone (FSH). As the name suggests, FSH stimulates the development of follicles (i.e. eggs) in the ovaries. My RE describes it as being like the gasoline that revs up the engine and gets your ovaries to develop and drop an egg. In young, nubile women, it doesn’t take much FSH (“gas”) to get the egg to drop. In women approaching menopause, you have to push the pedal to the floor to get enough gas for the egg to drop. In other words, low FSH (<9 mIU/mL) = good; high FSH = bad. My FSH = 13.7 mIU/mL.

4. Estradiol (a type of estrogen) is the main female sex hormone. In terms of predicting fertility, estradiol behaves a bit like FSH, in that your body may produce higher levels of estradiol (turning up the gas) as the number of remaining eggs decreases. Moreover, estradiol suppresses FSH production, so someone who has low FSH might actually still be in trouble if high levels of estradiol are ‘masking’ what would otherwise be high FSH. For this reason, REs like Dr. Y. typically order FSH and estradiol tests together… I can’t seem to find ‘normal’ values for estradiol, but since my high FSH levels already indicate very low fertility, I don’t think it matters! My estradiol = 24.6 pg/mL.

A side note about units:

As a scientist, I find it a little strange that every medical test seems to have its own units of measure. A cynical explanation is that perhaps physicians aren’t big fans of scientific notation, and prefer to choose a unit of measure for each test that gives normal ranges with values from 0.1-100 or so…even if it means learning dozens of different units. A more generous explanation is that maybe each of these molecules are being detected in different ways, and the units used might be determined by the detection method and sensitivity.

Regardless of the reason, here’s my guide to units for the tests above:

  • mIU/mL (milli-International Units per milliliter of blood). From what I can tell, the ‘International Unit’ is a biologist’s invention. (Is my bias showing?) It’s sort of like an ‘effective concentration’ that doesn’t translate to anything that a chemist would understand as concentration (like molarity, molalilty, normality, ppm, ppb, mg/mL, % by volume, etc.)
  • ng/mL (nanograms/milliliter of blood) For non-scientist types, a nanogram is one billionth of a gram.
  • pg/mL (picograms/milliliter of blood) A picogram is one trillionth of a gram, or one thousandth of a nanogram.

*For more about the structure of FSH, see: https://infertilechemist.wordpress.com/2013/04/16/injections/

Dr’s visit

Yesterday, I met with Dr. Y. for my HSG follow up visit. Highlights:

  • Dr. Y. expressed sincere concern for C.’s accident. (Love him!)
  • Dr. Y. expressed interest in seeing the image of my uterus from HSG that I have on my cell phone. (Even if he was faking, I don’t care. Still love him.)
  • Dr. Y. reassured me that while C.’s pain meds might reduce the odds of a pregnancy, in the event that I do get pregnant, there shouldn’t be any effect on the fetus. (One less thing to worry about.)
  • In the likely event that I don’t get pregnant, I need to call his office as soon as my period starts to schedule an ultrasound. (US has to happen within 3 days of my period start if I want to do IUI this cycle…one more thing to worry about!)
  • The rescheduled date for my menopur class (class to give myself hormone shots for medicated IUI) should hopefully happen before my period starts…if it doesn’t, then I won’t be able to do IUI this cycle. (Another thing to worry about!)

The try

First, an update: After 7 days in the hospital, C.’s risk of further internal bleeding was considered low enough to let him go home. The final tally (after hearing from a team of trauma surgeons, radiologists, and the like) was a bit worse than I said in my last post: 7 broken ribs, 3 broken vertebrae, class 4 lacerations on both liver and spleen, and a hemopneumothorax (blood and air in the chest cavity). Incredibly, he did not require surgery – just a few stitches on his knee, close monitoring for internal bleeding, and a $*#!load of painkillers (more on those later). Since he was in San Jose at the time of the accident, the ‘home’ that they released C. to is his parents’ house. Yesterday, I flew back to San Diego to return to work. The plan is for me to fly to San Jose again on Friday to pick up C. and bring him ‘home’ to San Diego…

But this blog is supposed to be about infertility. As I mentioned before, the timing of C.’s accident relative to my anticipated ovulation date made it unlikely that we would get to try this month. Well…I’ll spare you the details, but suffice it to say that there is at least the possibility (however remote) that I could get pregnant…(Nobody can accuse C. of not being dedicated to baby-making!)

Now whether that would be a good thing is another question entirely. In the past week, C. has been on a laundry-list of painkillers, most opiate narcotics. In the hospital, his drug of choice was hydromorphone (trade name Dilaudid), a fast-acting IV narcotic. Unfortunately, he couldn’t take that one home and had to settle for the ones that come in pill form, including time-release oxycodone (trade name OxyContin); a mixture of hydrocodone and paracetamol (trade name Norco); and ibuprofen (trade name Motrin). The narcotics are all derived from the natural products morphine and codeine, alkaloids produced by the opium poppy. For your viewing pleasure, I’ve pasted the chemical structures below.

If we do get pregnant this month, our baby might come out addicted to prescription painkillers!

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