Sunday, December 30, 2012

Erm, what is going on?!?!?

That, gentle readers, is not a question that is likely to be answered anytime soon, if ever. After my IVF, when things had looked super weird, my RE and I concurred that maybe following my AFC  for the next few months would be a good idea. I finally rolled off the procrastination wagon and took myself off to get an antral follicle count (AFC) done. The results floored me.

To recap the madness, mostly for my own records: 
  • August 2010: AFC = 34 (evenly distributed in both ovaries)
  • November 2010 (post 1 pregnancy and 1 loss): discover AMH is paradoxically low and am Vitamin D deficient, correct vitamin D deficiency
  • December 2010 ; AFC = 30 (evenly distributed in both ovaries) ; AMH = over 5 ng/ml
  • December 2010-April 2011- Take around 4000 IU vitamin D daily
  • April 2011: AFC = 16  (11 in one ovary and 5 in the other)
  • April 2011-Feb 2011: Add prenatal with extra vitamin D, so total is 5000/day, start taking calcium (50 % of RDA) daily as well.
  • Feb 2012: AFC = 16 (but now evenly distributed in both ovaries) AMH = 4.3.
  • March 2012: IUI# 3 results in failure
  • March-July 2012 - Drop vitamin D dosage to around 3000 IU/day
  • June-July 2012- 3rd pregnancy and loss, due to Trisomy 4.
  • August 2012-October 2012- drop Vitamin D dose 2500-3000 IU/day, continue calcium, however less regularly. Start Metformin
  • October 2012: AFC = 13 (more or less evenly distributed in both ovaries); AMH= 1.6, then 2.6 on retest
  • November2012-December 2011: Stop Metformin. Continue vitamin D at  2000 IU. Stop calcium almost completely.
  • December 29th 2012: AFC = 25 (evenly distributed in both ovaries)! AMH still pending.
With the drastic drop in my AFC (from 30-13 in 2 years), my RE was afraid that it  was because of drastic ovarian aging. I was less afraid of this, and felt that it was an unexplainable response to physiological changes induced by varying levels of vitamin D and *maybe* calcium in my system. I had hoped that after I dropped it to 2000 IU/day, with no added calcium, things would change as far as AFC went eventually, but this big jump back up surprised the crap out of me.  I don't know what to make of any of this- the changes in my Vitamin D intake alone are not that drastic, and there are no good explanations. 

I've played around a lot with vitamin D. Not supplementing at all, and just relying on sunlight and diet is a joke, its been proven time and again that this will leave me in the deficiency range.  What does deficiency do for me? I also lost a chromosmally normal child in this period, and my luteal phase used to be far too short on occasion. Its not so great from a physiological viewpoint- my health overall has subtly but definitely been improved by bringing me into the sufficiency range. However, how sufficient should I be

Deficiency of vitamin D is something that has been proven to be a contributor to infertility.  But a too high blood level may be equally bad, or worse, in my case.

4000-5000 IU with added calcium was something I felt great on, but *may* have had unanticipated, adverse effects on my reproductive system, which is not surprising in theory, because hey,  Vitamin D has been shown without doubt, to be a powerful modulator of this system.

Two thousand IU, the dose I am on now, is a fairly conservative, play-it-safe dose, given all the hot debate on the Vitamin D RDA. The IOM's  2010 recommendation of 600 RDA/day is pretty controversial and has not been well received at all. Other, seemingly saner voices advocate in the 1000-2000 range. The vitamin D council recommends over 4000/day, I believe. Experts at endocrinology are all of differing opinions.  In my revised opinion, everybody needs to keep their blood levels around 30 ng/ml, and its best not to go much higher. The amount you may need to get your blood level to 30 may vary from person to person, some trial and error might need to go into how much you need.

So I'll stick with 2000 IU/month for a while and see how I do, longterm. I'm now also going to start the CCRM regimen (melatonin, argenine, myo-insoitol, coQ10 etc) and see how my AFC fares with that. I'm only wondering whether I should wait one more month to start it, to confirm this rise in my AFC. However, I want to be on this atleast for 3 months before we attempt another IVF, which may be necessary very quickly if the transfer to the surrogate next month fails.

But, hey, on the bright side, my issue does not look like ovarian aging.  If only I can figure out what exactly it IS, though.  Bloody, bloody biology.

Updated: Much, much later, I figured out that the issue is that my RE (Dr. Malpani's) machine is older and has poorer resolution. At the point of my second IVF, we checked in two different machines: my AFC was 16 when using the much older 2D machine, and 24 when using a fancy 4D ultrasound machine. All the scans that showed a high AFC (25-30) were done using the 4D machine. Facepalm moment, for sure.


  1. Wouldn't the drop in your AFC be the expected result of taking Metformin? Conversely, one would anticipate that your AFC would increase in the absence of Metformin.

  2.  My AFC dropped from 30 to around 16 without any metformin- all I was taking during that period was 4000-5000 IU/day vitamin D

    After I started taking metformin( which, in total I only took for around 2 months) it maybe went from 16 to 13, with fits with the kind of drop in AFC metformin has induced in studies.

    It is hence not at all logical to assume that it went from 13 to 25 just because I stopped the metformin.

    If I have any candidate explanation, its that this increase is reflective of my system responding to a lower blood level of vitamin D, because of the gradual decrease in supplementation.  Maybe it is even my system reacting to IVF, who knows?

  3. Very interesting! Yes it's good to know what levels your system seems to prefer. Btw, my body did not like DHEA! At least at the recommended 75 per day dose. I'm considering going back on coq10 though. Look forward to hearing more about surrogate! Sending good thoughts. Happy New Year! -Kristina

  4. Dear Jay,

    Like every  good researcher knows, every time  you think you have found a solution, you find lots of new problems ! This is why doctors try to be conservative- there's just so much we do not understand . Sadly, we often do not acknowledge our areas of ignorance, either to our patients, or to ourselves !

  5. It is all very curious.

    I'm sure this is in your archives, but would you remind me why it is you're using a surrogate so early in the process?  I know you're dealing with RPL but from what I remember (and I'm sure I could be misremembering!!) those were mostly due to chromosomal problems, as opposed to clear uterine environment ones...??

    The whole thing, I know, is incredibly frustrating.  I ended up using an egg donor (at age 38) because I just wasn't getting pregnant, regardless of protocol.  Problem seemed to be "diminished ovarian reserve" but who really knows...  I still wonder what would have happened if I'd done IVF at a different clinic, but I'm glad I made the decision to stop being a fertility patient and move on to someone else's DNA...

  6. Sorry if I missed this, but how does your Dr interpret your AMH? Mine was undetectable from teh first test, so I don't know what range is ideal. I wish you a happy and healthy 2013!

  7. In my case, its difficult to make out whether it is a gestational or genetic problem, though its leaning towards genetic.

     BUT---My first pregnancy loss was that of a chromosomally normal male embryo. Add to this the fact that I'm heterozygous for MTHFR and PAI mutations, I'd be on lovenox throughout.

    Also...I'm just done with RPL. I really don't want to go through with it again, and if I can do anything to avoid it, I will.

    When you combine all of this with the fact that,  in India, surrogacy is not financially impossible, it does not even start to break the bank, then it seems like a viable idea.

  8. In the next post, I've provided the reference ranges used by my lab. Best of luck and Happy 2013 to you too!