Well, fuck!

That’s what I said when I read my most recent email from Dr. Y’s nurse:

“YOU DAY 3 LAB WORK CAME BACK AND THE RESULTS SHOW AND ELEVATED FSH AND THE AMH IS LESS THATN 0.03. IT WOULD BE BEST IF YOU CAME IN AND HAD AN APPOINTMENT WITH DR Y. I WILL NOT HAVE ANY APPOINTMENTS UNTIL AFTER YOU RETURN FROM EUROPE. PLEASE CALL ME AT xxx-xxx–xxxx SO THAT WE CAN SCHEDULE AN APPOINTMENT”

Yes, she writes her emails all in caps like that, as if I needed any more reason to feel alarmed.

My AMH is less than 0.03. I didn’t know the test measured amounts that low.

In what feels like another lifetime, I once wrote a long post about what AMH (and FSH and estradiol) mean for fertility.

Here’s a summary of my results the four times I’ve taken these tests. Prior to yesterday, 0.17 ng/mL was the lowest AMH of anyone I know in real life (including my Resolve support group).

  1/26/13 5/4/13 4/24/15 10/8/16
estradiol (E2) 24.6 pg/mL 27.2 pg/mL 23 pg/mL 20 pg/mL
follicle stimulating hormone (FSH) 13.7 mIU/mL 13.5 mIU/mL 9.7 mIU/mL 17.7 mIU/mL
anti-Mullerian hormone (AMH) 0.17 ng/mL 0.22 ng/mL 0.31 ng/mL <0.03 ng/mL

 

I’m feeling pretty hopeless at the moment.

At least I get to go to Rome on Sunday.

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:

Image

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/