Sunday, September 11, 2011

Indecision 2011

Boy, you do not fully appreciate how relatively stress-free your existence is until you decide to jump back in the gladiator ring of TTCing again. I'm sitting here with this gigantic decision to make- to start metformin or not???

I talked to my Indian RE about it.  What he told me took me back to my first thought about this: he deals with a different ethnic group than REs in America and PCOS figures very heavily there.  Its not terribly surprising, you cannot throw a stone in India without hitting somebody with Type 2 diabetes- its really, really common. PCOS is related to Type II diabetes. Its all logical.

He reiterated he does not really know if metformin works. His reasoning is its cheap and safe- so why not? I'm not so sure its safe though. My body functions perfectly, medication-free right now. I'm really nervous about upsetting that cart.

The other reason I'm hesitating is that if you lined up all the possible causes of my 2 miscarriages, examining each and every detail , I'd say the highest probability is that it was the vitamin D deficiency, which *probably* made for crappier eggs more likely to have genetic defects. Its also possible that my second loss was not even my fault- It could have been the universe really not wanted me to have a kid at that point and letting the one sperm with a missing chromosome impregnate my poor egg.

For the millionth time, I'm going to discuss all the changes that have come about, when my vitamin D3 blood levels are in the 30-40 ng/ml range, as opposed to the deficiency range I was in (17 ng/ml) just post miscarriage # 2.

My bbt patterns have changed.  My temperature used to vary from maybe 97.4-96.7 in the preovulatory phase- now it flatlines at 97.3. And when I say flatline, I mean it. Maybe for one day, every 3rd cycle, a really strong estrogen surge will push my temperature down to 97.1, but that is it. Nothing can be made of it, but I think its very interesting.

Breast tenderness- nearly constant - ie- more progesterone and estrogen, overall. That is good :-)

My luteal phase has gotten longer. MUCH longer. This has to be the most startling, and clear indicator that things have changed. The two cycles I conceived in had an early day 16 ovulation, with a luteal phase of 11-12 days. If I ovulated at day 20, my luteal phase would be 13-14 days. Now, almost all my ovulations have been at day 20 or later.  The luteal phase in such cycles is now increased to 14-16 days, with average being 15. 

Luteal phase defect (9-10 days or less) has been implicated as a miscarriage risk factor, which again, is logical. Shorter luteal phases are indicative of less effective progesterone mechanisms, which is in turn indicative of poorer quality eggs, which of course means you have a lower chance of seeing that pregnancy succeed. Though to qualify for LPD, you have to have a really short luteal phase, maybe for somebody like me, a 11 day LP was probably indicative of an issue- who knows?

So basically, I really think that it was highly likely that my problems were tied, principally, to a vitamin D deficiency, that has now been fixed. What makes it even more interesting is that a lot of women with PCOS are vitamin D deficient, and I think its likely that some part of the PCOS presentation can stem from vitamin D deficiency. So- I do not know if I need metformin, and I'm really don't want to take it, but I don't want to end up regretting that I did not do it.

In less scientific matters- I'm going on a cruise in December! I am so excited and I really, really wanted to go snorkel in some really blue waters- but I calculated ahead because some dreaded instinct told me this may be an issue.... Going with my current cycle patterns, bloody AF is going to show up on the day we dock at the Bahamas! My frustration knows no bounds...Eff You Universe!


  1. I remember when I went on a cruise, AF showed the very first day and lasted all seven days of it. But how nice to get in a vacation and take in some sunshine in December, I bet it will be fun whether AF shows or not.
    I'm sorry I can't give you any advice on taking or not taking Metformin but I find the link between Vit D and PCOS to be interesting. I hope that boosting your Vit D levels will help when you do try again.

  2. I'm glad you're thinking about trying again and forming a strategy. 
    How does AF always know when the special occasions are?  Vacations, New Year's Eve, birthdays....she's always there.   Grrr....    Enjoy yourself anyway!

  3. I have a couple of thoughts here. First is that, while most women with PCOS have a vitamin D deficiency, so does pretty much everyone period. So that's not really indicative of much aside from women with PCOS live and work indoors like everyone else. Not to say your vitamin D deficiency wasn't a problem - just that it's possible tie to PCOS is pretty shaky, given that most of the population is D deficient, whether they are PCOS or not.

    My second thought is that I never, ever want to take a medication that isn't necessary. If I'm remembering correctly, you don't have insulin or glucose problems, correct? In that case, I would definitely not take metformin. It's got some pretty nasty-sounding side effects, and if your body is already using insulin efficiently, what would the metformin be doing besides giving you diarrhea? I think a much wiser decision would be to follow a paleo/primal/South Beach/low-carb style diet. THe medication seems like overkill, since you don't seem to be having insulin problems, so instead of meds I'd tackle it with diet. Plus, eating loads and loads of fresh, healthy foods can only help for TTC anyway.

    And lastly, have fun on the cruise! And hopefully this next ride on the TTC crazy train will be short and successful.

  4. I'm completely in agreement with you on the first point, that a large % of PCOS women are also vitamin D deficient in itself is inconclusive- I read an article from the medical community that basically thinks about a billion people are deficient(!!).

    The second bit is where it gets murky. Yep, I do not have any overt issues metabolizing glucose, but the GTT is NOT the best test for insulin resistance, I'm not even sure if the euglycemic clamp test (which is considered the current gold standard) is good enough. Our understanding of this whole process is completely rudimentary, so even after running all the tests, we could still legitimately be in the dark as to whether there is a link between glucose metabolism and my so-very-mild-PCOS presentation.    

    I don't even know if I need to 'fix' anything by way of diet- PCOS is not actually interfering in any way, with either weight or ovulation with me. I break out a little too often, but that is about the only PCOS-related 'problem' I have, other than having 2 pregnancy losses.

    Sigh....thanks for the feedback though. Question for you- were you ever diagnosed as vitamin D deficient? Did you take supplementation? If you did, what is the timeline between you fixing the deficiency and your getting pregnant?

  5. I never had my D tested before I began supplementing, so I don't know what my baseline levels were. However, my first D test (after about a year of supplementing, and after 3 m/c) was 49. Then, at that D level, I had 2 more miscarriages and the wholly underwhelming IVF. I had my D levels tested in 1st tri with this pregnancy when I had my thyroid b/w done, and it's at 55 now, so about the same.

  6. Thanks for the explanation- a blood level of around 50 is actually pretty darned good, so it looks like this probably might never have been that much of a contributing factor to whatever the problem was!

    Just going back to our earlier conversation: I read a study today that looked at the question they way I wanted them to look at it:  they examined the frequency of vitamin D deficiency in healthy controls and women with  PCOS- 11 % of healthy controls were deficient, as opposed to 44% of the PCOS patients, so it does look like it is more common in PCOS groups.....maybe.

    Its hard to make sense of all this:(

  7. Ahh, ok, phrasing it like that does make it make more sense.

  8. Jay, thanks for your post this morning.  It's nice to have some fellow New Yorkers to commiserate with!  Your blog is very interesting - I think it's great that you're applying some of your scientific knowledge in unlocking the puzzle of your IF.  Biology is so complex and mysterious in it's workings - would be fascinating to me if I didn't have so much emotional investment in this!
    Have a wonderful time on your cruise - some sun and sea always does wonders for the soul.  

  9. I am interested in your vit D info as I was diagnosed PCOS, put on metformin, had the ovarian drilling, and then found out two years later that I've actually got low ovarian reserve and am on the verge of menopause.  When we started IVF we were expecting me to over-stim due to PCOS and ended up getting only a handful of eggs each try.  I don't know what my vit D situation is, although after reading your writing about it earlier I've added extra supplements to my daily drug-fest just in case.  Perhaps I also had vit D deficiency and was wrongly diagnosed PCOS.  Regardless, I'm still on the metformin (a slow release version 2x a day rather than the normal 3x a day as it was upsetting my stomach) two years later as my OB thinks it's cheap and can't hurt and may even help me to avoid gestational diabetes (and it seems to be working so far).  I guess this is all just a long-winded way of saying that I'm taking it on the basis of 'it can't hurt and might help' and so far so good.  For what it's worth.  Good luck with your decision and wow - a cruise, I'm jealous!  You'll have a wonderful time I'm sure, and you deserve it!

  10. Huh. That is interesting, that you were first diagnosed with PCOS and then with diminished ovarian reserve- I've actually read of a condition where both are possible, where women first present as PCOS and then have a very rapid depletion of ovarian reserve, and its linked to this gene called FMR1,  but its a ridiculously complicated, murky area

    I just want to say, even if you did have a vitamin D deficiency, that cannot cause a false PCOS diagnosis, the two are entirely separate. Vitamin D deficiency is more common in women with PCOS, yes, and I have speculated whether it is one of the causative factors for PCOS, but its entirely impossible to know for sure.

    How were you diagnosed with low ovarian reserve? If it was only by AMH, then I do not think that that is confirmatory. If it is by antral follicle count +/- elevated FSH, then I'm afraid it is.

    Also, be careful with Vitamin D- I do not at all advocate at all that people should take large doses of this without getting their blood levels checked. This is a fat soluble vitamin, if you had good blood levels to start with and start taking it, you can head for toxicity. Also, taking small doses does little good if you are truely deficient- I was taking almost 1500 IU/day during my second failed pregnancy, over 3 times the daily recommended dose (400 IU/day), and I STILL turned out to be deficient. Only when I started taking truly massive amounts (4000 IU/day) was my deficiency corrected. BUT- taking such large doses without a blood test is definitely not advisable. I really recommend getting your vitamin D3 levels checked and tailoring your dose to your blood level.

    Anyway, it sounds like you are pregnant now, since you are talking about gestational diabetes? I hope you are!!