IUI day

My surge (judged by OPK) was close to full strength by around 7 pm last night, and this morning the line had darkened several shades. I went in for the ultrasound and blood draws this morning just because I want the numbers. The doctor who walked in did not even want to do the ultrasound, but reluctantly complied  on my insisting that it be done. She was so eager to be out of there (overall, I really cannot say good things about the practice I'm with now), I did not want to pepper her for details so I did not ask what the lining was at at, but my follicle grew 2 mm to 19 mm. That made me happy because that is largest follicle I've ever had, they have been at 17 mm the last 2 tries.

Not that it should mean much: I've said this many times, follicle size and quantity can never properly translate to quality, these are very likely to be 2 completely separate entities. The only way to ever measure follicle/ egg quality is to:
a)see how well the eggs fertilize and divide as embryos
b) Study of follicular fluid content: I'd think this is an area that really needs to be explored, to understand infertility better. People harp about genetics being the main cause of early (in the first 14-21 days) losses, but, in my opinion, they are looking at it the wrong way.  The fluid in the egg, which provides all the nutrients for the embryo to survive and proliferate for around nearly 8-10 days on its own, is more of the driving force at this early point. There is no reason for the genetics to come into play, because the embryo is just dividing again and again, with very few genes being expressed. In other words, very early losses, probably upto 2 weeks after fertilization are probably are due to cytoplasmic issues, unless the gene missing or damaged is from the small handful involved in  blastocyst formation, hatching, implantation etc. However: there could be a correlation between the two things (cytoplasm and genetics) though- an egg having a crappy cytoplasm is also likely to have had a crappy genetic division with more chances of aneuploidies.

Anyway, away from scientific speculation and back to me--bloodwork just came in.
-Estrogen has plateaued at 235 pg/ml.
Last time, from right ovary, was 265. Question for anybody in the know: what is the estrogen range at peak per single mature follicle? I found one website which said 200-600 pg/ml which makes me very sad, buts most say 200-300 pg/ml
-LH is a whopping 46.2 pg/ml.
Super strong surge, stronger than the last time (that was 31 pg/ml)

IUI is set for 1 pm.Will be saying many prayers as I head, once more, into this very scary breach.

Part II: All about the hormones (updated at the end)

Again, it does not *look* like a super pretty cycle that I am trying in. Its CD15 today.  I'm coming up to a surge possibly tomorrow. I picked this cycle because my Clear Blue Easy fertility monitor(CBEFM) switched to 'high' fertility a possible 4 days before ovulation, which is not too shabby.  To try to understand what that meant, I read the original studies looking up how the monitor works: There are 3 forms of estrogen: estradiol (strongest), estrone (middle strength) and estriol (weakest). The CBEFM measures the levels of a Estrone metabolite, which correlates very well to blood estradiol levels.  At some point, when the estrone levels increase past a certain threshold, the monitor changes from 'low' to 'high' fertility.

The good news, I've had 'high' fertility for around 3 days now, but the bad news is I have not seen a peep of the egg white CM yet.Apparently, estradiol (the strongest estrogen) drives the cervical mucous production. So when that gets super high, you get all that goopy stuff. It should be straightforward (lots of estradiol = lots of CM), but I have to wonder. Here is a question for you IVF ladies: There are times your estradiol levels must have gone through the roof, given the multiple maturing follicles: Do you always see the fertile CM during this time?


Because I've seen no CM yet, I was hoping  that ovulation would be delayed a day past CD17, but no dice, I've been monitoring my LH for the past 2 days, its on the rise and I think I should be in full surge by tomorrow (CD16). Which means the IUI is dayafter. ULP.

I am going in for hormonal monitoring and a U/S tomorrow. I have a feeling my stats (hormone levels, follicle sizes etc) are going to be very similar to my last cycles, and are considered bang normal by any RE, so my nitpicking and worry, is really for nothing. Something I cannot put my finger on is the problem.

In the last cycle, which was a BFN, I had a lot more 'symptoms' in the luteal phase which could
a) have been the result of a hypersensitive, far too imaginative psyche because absolutely nothing happened
b) been indicative of an embryo that probably bounced around for a few days, produced a smidgeon of HCG, before dying out because it could not implant, either due to uterine issues or because it was itself crappy quality and ran out of steam. Yeah- this covers most bases.

CD16 Testing and monitoring update:
EWCM made its exuberant entrance this morning (It always makes me SO happy to see it, yeah, I'm a little nuts but I blame this process :-))
U/S Monitoring:  The action is all in the left ovary (UGH- I have a hate-hate relationship with the left side of my body, will explain why sometime). Lining = 8.6 mm and 'beautiful'; Follicle = 17 mm (almost exactly the same as the last 2 times, albeit those measurements were on the day of ovulation, not from the day before).
Estrogen = 221 pg/ml-- normal for a single follicle,  I'm hoping it will be up a little tomorrow.

LH test results:
9 am blood work shows LH = 13. ie, looks like the surge is starting, but not there yet. 
2 pm check by OPK: Surge still not underway,  test line lighter than control.
7 pm check by OPK: LH surge is here. Test line now as dark as control.

IUI will be tomorrow. While I can apparently take a lot of shit and keep on going with barely a hitch in my stride, here is hoping the universe hands me something good instead.

Update

I CAN have an IUI today. Its scheduled for 2:30 in the afternoon, I went in this morning to draw blood for E2 and LH, and to take a quick look-see at my uterus. My stats look practically identical to the last time where I TTCed where I 'felt' I'd barely had much of an estrogen  peak- 17 mm dominant follicle, and a "nice, thick" lining of 8.5. I groaned when the doctor told me that, he was completely taken aback-- but it scares me that it looks like the last time. Which is not rational at all.  I got pregnant, with a beautiful-looking, albeit short-lived embryo that just happened to have one chromosome missing. That genetic abnormality cannot be correlated in any which way to the size of the follicle or the thickness of the lining. One could imagine a correlation to the E2 level, but that is ridiculous hand-waving at best. But as we all are well aware, fear and rationality go in completely opposite directions.

I just got a call for my blood work, and its not too illuminating since I have not had serial blood tests, and have no idea how this measures compared to my super-pretty cycles, but feel free to weigh in. From all accounts, I will ovulate at some point today.

Estradiol= 262 pg/ml (I have only one dominant follicle, on my right, so this is in normal range)
LH= 31 (Definitely in the surge. Apparently anything above 9 is considered one)

While trying to understand how this can be used to interpret egg quality, this was the most useful resource- wish I had read this earlier, I would have gone in happily for multiple tests. If I ever do this again, I'm going to monitor myself.

The one piece of good news- I'm ovulating from my right ovary. The last try came from the left. For good reason, I think the left side of my body just has more health issues- I have limb-length discrepancy, my right side is an entire inch longer than my left, which means I need to have correctional shoes (GRR).  When I did facial electrolysis years ago,  the hair on right side never grew back, but that on the left kept coming and is still there. Overall, I think the left side has crappier metabolism and is more prone to PCOS, so I'm happy its not in play here.

I had another acupuncture session. I'm taking wheatgrass pills--based on the aroma, I thank god I got those, not the juice. IUI set for this afternoon.

I've yo-yoed between feeling reassured and irrationally terrified that I'm letting history repeat itself. People keep stressing the importance of doing this with a 'positive' outlook--well screw that. Telling you that is counterproductive- you only get nervous that you are not positive enough, just adding to the stress levels. Babies have been conceived in times in incredible stress and negativity- take rape victims for example. Plus, I'm sure a lot of people at the end of an infertility slog, who are in the cycle that, unknown to them, is going to give them that take-home baby, are anything but positive and non-stressed. So if you are one of those folks, please speak up, I could use the reassurance. Any feedback on the estrogen level would be welcome as well, this is the first time I've done one of these tests.

A rambly post

I go away to Philly this weekend, where my old group of friends is experiencing a baby boom. 2 people got pregnant around the same time and are now close to the end of the first trimester. It still amazes me that when most people dodge this bullet pretty easily, I was slammed by it twice.

I still can't comprehend it and the why of it all would make for one rambling post or three. 

Why did my first, apparently chromosomally normal baby die? Was it my anti-thyroid antibodies? My mom was probably positive for these when she had my youngest brother, and that was an easy, perfectly normal pregnancy. She developed over Hashimotos about 6-7 years later--- people are antibody positive for many years before thyroid function is deteriorates to the level that it starts producing clinical hypothyroidism.  Correction: we recently found out that while my mom has hypothyroidism, she does not have anti-thyroid antibodies. So the cause of her hypothyroidism is not autoimmune, it is not Hashimotos. So I in fact have a pregnancy-loss associated factor she did not have.

Who made the abnormal egg or sperm that made my second baby die? That is really a million dollar question that haunts me to this day---I know there will never be an answer, but that really stops nothing.

There are some things in life you thought you would have no problems with. I always thought baby making would one of these, just because I come from a family with amazingly good fertility, so much so that sometimes it can turn into a horror story. Despite every attempt available at that time for birth control, my grandma had 9 children and it exacerbated her diabetes and caused an untimely death at 55.   My aunt had 3 kids then decided to have her tubes tied. It worked as birth control for a few years, then , in a one in million case, something grew back, causing a tiny opening in the fallopian tubes, enough for a sperm to get in. She of course, got pregnant even with such odds, had an ectopic pregnancy that nobody diagnosed and nearly died, and it started a lifetime of medical problems resulting in a chronic pain syndrome. Sometimes, what is a boon for one person can turn into a curse for another.

So why me?I've got the same freaky good genes in this department (that I thank my stars for, and now, no longer take for granted), as far as getting pregnant goes.  Most REs categorically refuse to think there is anything wrong with me, that I need to get treated for. I get pregnant, all my tests check out, right now they are going with the 'shrug-your-shoulder' diagnosis to explain my losses. I've tried to hit them over the head with the PCOS, and they are like--- yeah, looks like you might have some presentation of it, but we would refuse to think that really of any detriment to you, because you ovulate and get pregnant easily.  Except my Indian RE, who immediately jumped on the PCOS diagnosis for me after just listening to my history of conception and loss. Interestingly, I did turn out to have that, and I hope he is right and metformin is all I need.

Anyway, there has been something I wanted to share for a while: Last year, after I started charting, I found my cycles fell into 2 clearly different patterns---

Pattern 1: High temps on day 3 (around 97.2-97.3), more egg-white cervical mucus (usually), surge starting on the morning on CD19, ovulation on CD20, and a 14 day luteal phase.

Pattern 2: Low temperatures (96.9 approx) on CD3,less evident egg white cervical mucus,  Surge starting afternoon of day 15, ovulation on day 16 and a shorter, 12 day luteal phase , though you can't see that in the picture below:)

 You could say that if progesterone (which determines length of luteal phase) and estrogen (which determines quality of quantity of cervical mucous) were indicators of egg quality,  this was my less stellar pattern.  Both my conceptions were in this cycle pattern. I had expressed concern to my doctors about this, and they pooh-poohed it.

Since my second loss (and subsequent increase in Vitamin D levels), my second short pattern with the day 16 ovulation has disappeared.  Last year, it was there for 3 out of the 6 cycles I had, and this year, in the 5 cycles I've had so far, it has not made its appearance even once.Undoubtedly, something has changed in my physiology to cause this effect-- I doubt it was the loss itself, simply because this pattern repeated after my first loss. The only other discernible change is vitamin D, a hormone that regulates a large number of processes in your body. Nonetheless, no matter what the cause, I find this change remarkable, we shall see if the trend continues.

My new, utterly unanswerable million dollar question (I have a lot of them): Was vitamin D deficiency contributing to my shorter, less pretty cycles, and possibly my losses?

I was talking to a friend the other day and I told her that one day in the future, I would look back at all of this and it might make sense, but it sure as hell does not now, from any standpoint.

Sorry for being MIA..

I rarely blog nowadays and the reason for that is twofold- first, there is nothing concrete to say and secondly, life is, in a word, frantic, with work during the week and a fairly hectic social life on the weekend.  The second part is surreal.  A year ago, I gave up my carefree existence to start TTC. I gave up drinking completely, I became a homebody, I completely lost interest in the opposite sex.  After my 2 losses and the move and having to shelve my TTC plans temporarily, I'm suddenly thrust into this 'Sex and the City' lifestyle which is all about having a good time and meeting new people.   Its just a completely different set of priorities. This change actually feels good. It feels weird thinking about giving all up to go to last years way of life,  but there would be no regrets. All of this is fun, but if I had to abandon this to stay home in sweats and watch TV while being pregnant, I would do it without a second thought, and with complete happiness. 

Things are changing so rapidly, I feel like Alice in Wonderland, not knowing what will happen next. I think its highly unlikely that I will meet somebody and abandon plan B, but at the same time, I have no idea how the future is going to unfold. I have just a feeling that this year has some tricks up its sleeve- I just hope they are ones that lift me up, not knock me down. But even if they are ones that knock me down, I have to say, what does not kill you only makes you stronger. Despite all my misgivings of whether I will be able to handle another catastrophe in the baby-making department, I know this- I have a far greater reserve of equanimity than when I first started out. I've started realize, and more importantly, accept that I have no power, so when life does not go my way, I  have a better chance at not fighting it and just accept and adjust to whatever comes along. There is nothing else to do.

Science stuff

My antral follicle counts- done twice last year, have been very high, in the 30s. At my appointment with Dr L, I was shocked to see that one ovary had 11 follicles (small decrease), while the other had only 4-5 (huge drop down), giving a total of about 15. My antral follicle count has decreased by half. I was flabbergasted. I don't know what it means.  As you all know, I tend to attribute everything to the change in my vitamin D levels (because that has been the only big change in my physiology). Metformin has been shown to decrease antral counts in women with PCOS,  but that data, as my SD RE put it, is not too good. It would be interesting if vitamin D could do this as well, because both things actually influence sugar metabolism, which is has mysterious, ill understood links to fertility and egg production.

I don't know if my decreased AFC is good for overall egg quality, we shall see. As my next TTC cycle will be completely unmedicated as well, the only thing I have to go on is quality of my natural cycle. This takes into account BBTs, length of luteal phase, number of days with egg white cervical mucus, number of days of high fertility, etc.  Following your fertility signs can tell you a lot about your own cycle- this doctor describes it well here. The problem is though, you are shooting in the dark. The last cycle I conceived in, was, in my own opinion, an absolutely crummy one. I was very concerned about egg quality. Nonetheless, the RE, looking at my uterus and ovaries the day of ovulation, thought things looked good and we proceeded. And it was all good enough to produce an embryo that implanted beautifully and thrived in the first 6 weeks even thought it had a gross chromosomal abnormality. What I would love to know is whether my egg was missing an X chromosome because it was produced in a cycle with less than one day of high fertility before the LH surge began, but I will never know, will I? And even though I understand my cycle far better than the average person, I haven't a hope of figuring out what works and what does not.

On vitamin D

I came across two things which I beleive I should share. The first was a news report about a finding presented at a fertility conference. This group at Yale tested blood levels of Vitamin D in 67 'infertile' women. 93% of women had levels that were low or clinically deficient. That is pretty amazing, IMO.

The second is this recently published study, where they basically found that higher the vitamin D levels in your follicular fluid, the higher your chances were of achieving pregnancy in IVF.

My advice to everybody struggling to get or stay pregnant- do a blood test for this vitamin. Its not the most expensive thing and seems like a reasonable thing to check out.  Testing your levels before taking vitamin D supplementation would be prudent because you would have to tailor your dosage to your blood level.  I was clinically deficient. Granted I had taken my last vitamin D supplement 2 weeks before this blood test, but while I was pregnant, I was consuming around 1500 IU/day, which is about 6 times the daily recommended dosage, and my levels 2 weeks later were still abysmal.

Switching gears now.  In my last post I had said none of my theories have been right.  I just realized that was not true, I have been proven right in the most horrible way. As my second IUI rolled around, I had become really scared as I had looked at my cycle and realized that it was one with fewest days of peak estrogen ever and I was nervous that egg quality might be compromised. (Prophetic blogpost here) 

I went ahead with the insemination because on ultrasound, everything looked decent and nobody knows what parameter really determines egg quality. I did conceive but it was my worst fear realized- a genetically abnormal egg. Its been only a month since that horrible ultrasound, that awful day.  I'm doing very well though, all things considered. I guess I should thank god for small mercies.

Shattering my preconceived notions (karyotyping results)

I got the karyotyping results back and they were what I had been praying for since I heard my child's heart had just  stopped- a chromosomal abnormality, Turners syndrome (45 X0).   It does not seem that way, but I actually got lucky. Turners is a genetic condition with wide variation. In the least severe cases,  the child can survive, but have some serious physical issues, including heart defects and sterility.  Chances are, had this loss not occurred, I would have detected it in  the 5 month ultrasound and would have been faced with the agonizing decision whether to terminate or not. I thank god, the universe, whatever, that it did not take me to that place.

I would put this down to really crappy luck, except, though, as an effort to determine the PCOS diagnosis, we finally tested my AMH.  To my absolute amazement, it came back  on the low end, at 1.1 ng/ml. The reference range for the testing lab is 1.23- 8 ng/ml. AMH is touted to be the most accurate predictor of your ovarian reserve. The lower it is, the fewer eggs you have and the closer you are to menopause. My value, while not abysmally low, indicates that my ovarian reserve may not be as good as I thought it to be.

What this has told me- don't have preconceived notions about your own biology. I always thought that I had plenty of good reproductive years left. My grandma gave birth to my dad, her 9th child, at 45.  My cousin conceived her one and only child (a perfectly healthy boy) at the age of 43!  My mom got pregnant every time she wanted to, and produced 3 healthy children. Reproduction is NOT an issue with my family. When I had confessed my plans to that cousin who reproduced  (by accident) at 43, she tore into me for not waiting any longer, because according to her, I could have have done this comfortably even when I was skimming 40, given our history. At that point, I thought I could too. Now I don;t know anything anymore.

We have not yet confirmed that its a failing reserve we are dealing with here.  Overall, my test results can be summed up in one word- confounding. I'm baffled, nothing seems to add up.Adding weight to the PCOS diagnosis,  I have high-ish male hormones (though still within normal reference ranges). PCOS is associated with insulin resistance, with fits with my family history of type 2 diabetes. Because the universe has decreed that nothing should ever add up, I have the opposite,  insulin sensitivity- low insulin, normal sugar in fasting levels. With respect to ovarian reserve too I'm scratching my head.  At the last test around 4 months ago, the other good indicator of ovarian reserve, antral follicle count came back ridiculously high at 34. So we don't have the full picture yet, we need to determine if I have PCOS, or a close-to-failing reserve. Of the two problems, I'd pick PCOS I think, though its choosing between the devil and the deep sea.

Sometimes, things happen that really make you wonder if there is a gran plan to things, even if  a particularly perverse, slightly evil one. The day Turbulence was conceived, something told me it was a girl. After the loss,I've been praying it was a boy because then I thought, for some weird reason it would not hurt so much. It also it takes the guesswork out- if your karyotyping results are a chromosomally normal female, you will always be left a little in doubt, it might have been your cells they examined by mistake. But all in all, I was really anticipating an answer that would definitively give me the gender of my child. I've even been very mildly obsessive about this point.  When I got this result, I started laughing (the alternative was to cry). With an XO genotype, my child was essentially genderless.  Talk about the universe telling you, in a creative, slightly evil way of course, that sometimes, there are no answers.

Grand plans

I met with this RE in India who came up with an interesting potential cause for my losses: PCOS that was affecting egg quality.  My regular RE had thought my ovaries looked slightly polycystic (~17 antral follicles in each ovary), and he had checked DHEAS and testosterone. DHEAS was in PCOS range (over 200) but testosterone was low, so the PCOS diagnosis had fallen by the wayside. This new guy now wants to recheck antral follicles and also LH and AMH (both of which are elevated in PCOS, and have never been examined in my case).  This offers a possible answer and the fix would be metformin both before and during pregnancy.

I know that there is still a higher than normal risk for miscarriage with the next pregnancy. This is, after all, only an emperical treatment. On suggesting gestational surrogacy, he flatly refused. He told me by all accounts, that I had a healthy uterus, and using surrogates just because I could would be premature and wrong at this point. In all fairness, I have to agree with him. But, I'm not ready to face the prospect of another short lived pregnancy and loss, while back in the States and alone.  I need a good support system and I can get this only if I  a) magically find Mr. Right and get hitched or b) come back to India and try here while being with family. All in all, I've reached the end of my tether as far as going-it-alone is concerned.

Setting the stage for short term return to India will take one year.  I'm willing to put off babymaking for that long. I''ll be only 32 at that point, and by all indicators, would have plenty of eggs left. The only real hurry has always been in my own head. To stay sane, I need plans with contingencies upon contingencies, so here goes.

The Plan 

1)Check genetics (mine and babies) and run every RPL test under the sun. If all is normal, then do nothing for 1 year. Enjoy life and return to the the person I used to be before pregnancy loss.

2) Return to India, start TTCing with unmedicated IUIs after 3 months on metformin.

3) If a loss occurs, then do IVF using 2 different donors ( including my original, who I just don't want to give up on yet) and THEN (with  this RE's blessing),  go to gestational surrogates. This is the part which can be repeated again and again, if need be. 3 losses would be when I'd stop using myself a s a guinea pig, its just too much. With surrogates and a shitload of dough though, its a different thing. I'm really lucky to have these options,.

4) If multiple tries here fail too, then that implies the issue is genetic and with my eggs.  At this point, go to donor embryos and use my body to carry them (hoping that all parts are still functional at the end of this and the issue was never with my uterus in the first place)

5) if this fails too-adoption in India. 

I can deal with the prospect of short-lived pregnancies and more losses, but I need to choose my battleground wisely. Having lived through the last few days mostly easily, I know being at home will do it.  But importantly, finding real peace requires preparing myself  for the final 2 options which involve letting go of a biological child. Once I become ok with this concept (its going to take work) then who cares how long it takes to get there? Life is making me work for a child, I have faith that it has something good (even if its not what I originally envisaged) waiting for me.

And its a green light!

My doctor looked at my insides this morning, and my lining was what he described as 'great' at just over 9 mm. Its also triple stripe. Since I've had a lining of 14 mm at 2 DPO in a similar cycle, I was initially not as enthusiastic, but I'm definitely bowing to his superior judgment. Also I'm not sure if the lining continues to thicken for the next few days- anybody know the answer to this one, holler!

Usually I've gotten the impression that my right ovary produces the dominant follicle. This time, its the left one in play with a 17 mm follicle.  The right had one at 14 mm.  So all of this looks adequate, even if developed under less than stellar conditions (by my usual standards).

The swimmers are thawing as we speak. I could not sleep last night when confronted with the enormity of what I am about to do.  I'm not half as afraid of a BFN as I am of going through another loss, this time because of a 'bad' egg.  As somebody pointed out, it is an utter fool's errand to try to micromanage this process, and waiting for that perfect cycle seems pointless because no matter what, you CANNOT accurately calculate the odds of something even the experts barely understand.

So, although I'm agnostic, I'm praying very hard as we speak!

UPDATE: The deed is done!  Let the egg pillage begin!  I feel so much more relaxed with things now once the die is cast.

Note: Lesson learned from comparing this insemination to the last- make sure your RE rewashed your sperm even if it is already 'IUI-ready'! The last time I was curled up in a fetal position cramping horribly after my IUI , and I suspected that was because the sperm still had trace amounts of semen components such as prostaglandins in them because my lazy ass RE did not bother rewashing. With my new RE, of course it was re-washed and I'm utterly comfortable. What a difference a good RE makes!

A less than perfect egg??

First, I have to apologize for this is a horribly technical post.

I can safely say that I'm very attuned to my cycles, so much so that I've recognized that they fall into one of two patterns (ovulation either on day 16 or day 20) based on my day 3 temperatures. Based on which pattern is in play, I will know  what day ovulation will happen, what day post-surge my temperature will rise, I can even somewhat predict what my BBT will be on any particular day, its that spookily accurate.

What is important for egg maturation? Well, lots and lots of estrogen. Now, in addition to charting temperatures and monitoring cervical mucous like the KGB, I also use the clear blue easy fertility monitor. Once you switch to high fertility, it means your estrogen levels have shot into the stratosphere.

So the point of this post is: I started my surge today, and based on a) cervical mucous and b) estrogen levels (from the clear blue easy fertility monitor) that this is a a cycle where I've had the least days of high fertility( ie high estrogen) ever.

If you compare this cycle to the last time I had this cycle pattern, I had 4 more days of high fertility + 2 days of peak fertility. In this one, I've gone directly to peak, and this is scaring the crap out of me.

I explained all of this to my nurse, who actually understood what I was talking about right away. So I asked to have an ultrasound tommorow to see how things look, and if that is good, ONLY then thaw the sperm. We put this plan to my RE and he agreed that it was the most sensible thing to do.

This is such a huge gamble. This has to be MY worst cycle, but if you compare it to the average woman's, its probably still decent. God only knows what determines egg quality, and how these things differ among different people.  I feel like a poker player going all in on a substandard hand, but its just too hard to wait any more.