Thursday, November 24, 2011

The day before Thanksgiving

I've told the story of an astrologer's spooky prediction before, but have to recount it again here.My parents, being pretty darned eager to get me hitched, and being Indian, have consulted with multiple astrologers about my matrimonial prospects. I usually wave whatever they say away, but one person did get my attention. He said its a good thing I have not been married yet, because until November 23rd of this year, I should not get pregnant, because if I do, there is a strong chance either I will die, or my baby will die. Afterwards apparently, is smooth sailing.

Although I've known about this prediction for months, but the significance of the date hit me today. On November 24th 2010, the day before thanksgiving last year,  I discovered my baby no longer had a heartbeat.  And now, on the day before thanksgiving, one year later, I get the celestial green light to attempt conception again? Of all the bloody days in the calendar, the astrologer names this one momentous date. This makes me clutch my head...what DOES it mean?!?!!?

Cosmic weirdness aside, I should also be thankful. I went though a lot of crap last year. My first pregnancy loss had me lost and groping. I was fixated on making this process work and I'd forgotten how to live life, long before that loss. I'd have thought a second blow would have toppled me completely. Instead, that second loss reset me, it made me stronger.  I've written a post before about how the only way I could cope was the hope that something good would come out of the bad that had happened with me. In a way that still amazes me, positive things have happened, only because my second child did not make it.  I discovered my Vitamin D deficiency only after that miscarriage. If I had stayed pregnant, I don't think it would have come to light, and it strikes me that I was at risk for a number of  pregnancy complications in that state.  Lets just say that far worse scenarios could have unfolded.

A lot of women have come by my blog and have discovered that they too had the same issue. Some of them have had (or are going towards) their happy endings. I don't think anybody can say whether their correcting their deficiency was the cause, but it remains a probability. If that is so, then its kind of amazing and emphasizes the point that even an event that appears wholly negative, may indeed not be so. There is a lot to be said for that butterfly effect.

I also got a cat this year. She is over 5 years old and I rescued her from the ASPCA. I do not know whether she would have found a good home, but she looked pretty wretched when I got her. Now, she is happy and fat and whole, and I'm just so glad I did it. If I had had a baby, there is no way I'd have got her.

We cannot control what happens. All we can do its try to find some comfort in our new reality, and I'm happy to say I'm finding plenty in mine today.  One year ago today, I was a horrified, confused mess. Today, I'm happy, healed and ready for whatever life brings.  I'm very thankful.

Wednesday, November 23, 2011

Investigating miscarriage

This is a response to another comment left on my 'Science of Infertility' page

Hi, my husband and I have been ttc for almost 2 years. I've had 2 m/c in the past year and am desperate to figure out bloodwork came back normal and now i'm scheduled to have an hsg test in the next week or 2. I had to beg my gynecologist to put an order through for my Vitamin D levels. Finally she did and they are low (18L). Do you think this could be why I've been miscarrying? Should I still do the HSG testing?? Thanks for any help/advice! 

This is an impossible question to concretely answer. Most doctors would shrug and say, who knows? Me, I try to wildly speculate. But you need an incredibly detailed medical history to speculate and I do not have it for the commenter.

I can only offer my first miscarriage (the one that is still a complete mystery) try to speculate if vitamin D had a contributing roles.

This is a basic checklist one goes through, of examining risk factors for pregnancy loss. All issues were not tested, the full RPL panel covers more ground.

1) Was the embryo chromosomally normal? --Yes (no issue of mixup as was male)
2) Was there a structural uterine abnormality (determined by Ultrasound/hysteroscopy. I'm not sure if an HSG can contribute) -- No
3) Was diminished ovarian reserve a contributing factor miscarriage risk -- No, lots of eggs left
4) MTHFR mutations? -- unlikely, My homocysteine level was super low.
5)Autoimmune issues
Lupus anti-coagulant-No
Anti-phopsholipid antibodies- borderline positive then repeat negative so unlikely
Thyroid autoimmunity-yes
6)Progesterone Issues:  No, levels were excellent
7)Luteal phase defect:  borderline...11 day luteal phase in similar cycles.
8) PCOS:  Yes.

I do not know why my baby died, but I do know that a vitamin D deficiency is a risk factor for PCOS, all autoimmunity(including thyroid) as well as luteal phase defect. After becoming vitamin D replete, my ovaries are no longer poly/multicystic (My antral follicle count came down from 30-34 to around 16-18). More importantly, I consistently have a 14-16 day luteal phase.

Based on what was 'wrong' with me, do I think my D3 deficiency possibly contributed to my miscarriage? Yes. Can I be certain? Hell no. There is no way to know anything for certain.

About whether a HSG is useful: It can only be useful if it helps reveal anything about your uterus (not so sure about this) and tubes. So if you have not had this investigated, do so, because it is something off the checklist that must be crossed off.  

Also, this is by no means infallible or a comprehensive list,  but this is what I would suspect was a more likely cause depending on WHEN pregnancy loss happens.

Very early pregnancy loss risk factors: Bad egg quality (hindering growth of the embryo),  and immune factors that hinder implantation such as activated NK cells and T cells.

Mid-late first Trimester loss risk factors: Chromosomal/genetic abnormalities, anti-thyroid antibodies, and god knows what else.

Second trimester loss: autoimmune issues, anti-phospholipid antibodies, clotting issues.

Thursday, November 3, 2011

Low AMH: Diminished ovarian reserve or a Vit D deficiency?

I received this email a few days ago. This post is to address this question and as well as the many people  who have come across my blog doing Google searches for "low AMH" or "AMH and Vitamin D."

"I came upon your blog while googling for information about low AMH levels, which I'm sure you know, is very difficult to find.  I'm curious whether you've found any other information about increasing AMH levels other than Vitamin D.  I was diagnosed with low AMH (all else normal) and my RE told me there is no way for it to increase and that it would only decrease.  He was pretty doom and gloom about everything.  I'm currently using royal jelly, acupuncture, Chinese herbs, sprirullina, and a general prenatal multi-vitamin.  I haven't had my Vitamin D level checked yet but am considering doing that and asking about DHEA next time I go to the doctor as I'm hesitant to add anything else to the mix right now.  Thanks for sharing your story online."

In addressing the question asked of me, I have to point out one important fact that I think falls between the cracks with most people.

AMH is a surrogate marker. Why it is considered a good indicator of your ovarian reserve is because it tells you how many antral follicles are present in your ovaries each cycle. The antral follicles actually make your AMH. So more the antral follicles you have, the more your AMH, or at least, that is the logical stream of thought. Women with a failing or low ovarian reserve have very few follicles left, so their AMH is low. In other words, the problem is not that their AMH is low, but it is that they have few follicles left.

The question is, can your AMH be falsely low? To find this out, you must have an antral follicle count done. AMH alone, or AMH + FSH/E2 cannot give you the full picture.

If you have a low AMH and very few follicles left, then the probability, sadly, is indeed that you do have a case of diminished ovarian reserve.However, if your antral follicle count is normal/good/high and your AMH is too low, then something may be wrong.

One of two possibilities may account for this:

1) The lab messed the test up
2) The tantalizing Vitamin D theory: Now----I came up with the theory only based on the finding that the AMH gene is turned on by Vitamin D. This is solid, irrefutable science here.  What is still unclear is whether a vitamin D deficiency leads to suboptimal AMH production in the antral follicles. My findings imply that it did, but we cannot rule out that the first lab really messed up my AMH test. It needs to be studied clinically.
Updated 2 years later: Yes, this has been studied, and it is now fairly certain that your vitamin D level affects your AMH level. If your AMH level is too low when compared with your AFC, Vitamin D may be the culprit.

Overall, if you have a low AMH, then your plan of action must be to test for both vitamin D and your antral follicle count.

If your vitamin D is normal and your antral follicle count is low, then that just means you do have few eggs left.  DHEA seems to have some little success at improving the success rate in cases of diminished ovarian reserve, but its horribly unclear as to what is happening. Is it increasing recruitment of antral follicles from the diminished supply left? Is it improving egg quality as well? There was a study which actually showed that DHEA decreases the rate of aneuploidy. I don't know how solid the data is, but that is tantalizing if it is indeed so.

When you truly have DOR, then it is what it is. There is no way to fix it. You can, however, improve your chances with supplements (look for the CCRM cocktail).

I'll end on this note, and this is purely an informed opinion on my part: If  you want to have a baby, it is folly not to investigate your vitamin D3 levels. Its not just to treat infertility, but it is also proving to be very relevant in preventing pregnancy-related complications stemming from infection, autoimmunity, or pre-eclampsia. Just taking supplements is not the best way to go, because you don't know how much to take: you could end up taking too little, or in rare cases, too much.