Wednesday, November 23, 2005

What next?

I overanalyze everything. So when this cycle came to a rather abrupt and unexpected end (how rude!) at first I had a day to deny that this was the end. I was holding out for whatever hope I could. Then, I was overwhelmed with grief. The next day - furious that if it had worked, the embryo wouldn't have had time to implant before it's enviornment started dissolving around it. Anger seethed from every pore in my body.

Now, I'm just sort of here. And I will be for some time as I won't be cycling this month due to the hyperstimulation.

So, while I realize that every woman is different, and that every cycle can be different - I have questions. I want to know what it is that I should be asking the doctor when I go back. (That's your cue). I was supposed to be baking pies last night - and I made two burboun pecan pies and key lime bars before I burned my hand on the oven and decided to say screw it and delve into the wild world of medical journals.

During the last cycle, I started Follistim on day 3, and took 150 iu each day through day 10 (that's 8 days). The HCG trigger shot (day 11) was followed by an IUI 36 hours later (day 13) we had sex again on the next day (day 14) and there were around four- five follicles or so released at ovulation. I started the prometrium (200 mg. in the morning, 200 mg. at bedtime) on day 14 and kept using it until I started bleeding heavily on day 23. On day 23, 8 days post ovulation, my serum progesterone levels were 33.9. Now, that should be high enough to sustain a pregnancy - but for some reason I started spotting that same afternoon.

I knew I had a progesterone deficiency before we started this cycle, and I had begged and pleaded with doctors to put me on progesterone supplementation for over a year. They pooh-poohed my concern, saying that it's just normal to spot before your period. I showed them charts - that I was routinely spotting 3-5 days before my period started, and I generally have an 11-12 day luteal phase while unmedicated. My current R.E. agreed that I obviously have a luteal phase defect and said that he would put me on progesterone supplementation - and he did, in the normal dosage (or even a little higher) for someone undergoing IUI.

For his IVF patients, however, he prescribes PIO. Why? Based on the reading I've done - instead of merely raising serum levels of P4, it is more swiftly absorbed into the uterus, where it's needed (as is crinone as well). With high levels of E2 prior to ovulation, as is often the case in IVF, where the patient is intentionally overstimulated - or in cases where a patient has mild OHSS, as I did - higher levels of progesterone are needed to counterbalance the artificially elevated E2 levels.

Other studies that I have read indicate that if you have had OHSS in the past you are at a much higher likelihood of having it recur with subsequent cycles (check). Being young (check), PCOS (news to me - but check), also greatly increases your risk of OHSS in a cycle.

So, while I can hope it will not be the case, the likelihood is that I will probably overstim again on my next cycle. Which seems to me that merely being on the oral progesterone is not going to be enough again.

The nurse said she's never heard of someone starting already after only 8 days on the progesterone. My question is - why do they use this to help potentially sustain a pregnancy if they also use it for anovulatory women to bring on a period?

So, am I overanalyzing here? What other questions would you ask the doctor?


At 12:41 PM, Blogger Dramalish said...

Hi April,

I think your questions about PIO v. prometrium are good ones. It never ever hurts to ask, anyway.

I was on prometrium for all my IUI's, but on a lower dose. And true to promise, my progesterone levels were always higher on the medicated cycles.

I'm so sorry this cycle didn't bring you success. I hope the time passes quickly so you can get that BFP soon.


At 12:52 PM, Blogger Emma B. said...

I'm really sorry to hear about the IUI.

As for your question about why progesterone is used to sustain a pregnancy and induce periods, the answer is that it isn't the progesterone which starts a period, it's the withdrawal of it. The protocol is that you'll take Provera/Prometrium for 10 days, or get a PIO shot, and then your body detects the *drop* in progesterone levels after it clears your system, starting a period in response. If you're using it for pregnancy support, though, you'll stay on it for 12 weeks or so, until the placenta can manufacture adequate progesterone itself.

I'm planning on doing progesterone with my upcoming IUI too, most likely PIO shots. I don't have a short luteal phase -- I don't have any luteal phase at all, just a bitchin' case of hypothalamic amenorrhea -- but I've been so unresponsive to hormones in general that my mom (the RE nurse) and my doctor both think that it's a good idea to take out some extra insurance. They both said that PIO is the gold standard, and that it's definitely the way to go unless I just cannot stand the shots.

At 1:24 PM, Anonymous thalia said...

Thanks, April, the discussion about progesterone is really helping me. It's one of the things on the agenda for my discussion with the doct next week. I'll (obviously) let you know what he says.

At 1:29 PM, Anonymous Jenn said...

Emma said exactly what I was going to about the drop in levels is what brings on a period. At my clinic they only do PIO shots for three days, then switch back to suppositories. I've also heard that suppositories are well absorbed since they are "closer to the source." But I really don't know. I'd ask why you started bleeding so much with such a high progesterone. That doesn't make sense to me.

At 2:21 PM, Blogger Lindy said...

Ditto what the other ladies said about progesterone. Suppositories would also be an option in lieu of PIO. They work better than the pills, but not quite as well as PIO. Some REs even use them for IVF. My RE tried to explain that the reason you need more progesterone supplementation for IVF than for IUI is that when they retrieve the eggs, they essentially destroy the corpus luteum and so there is no natural source of progesterone.

I don't know whether you've exhausted all possible semen analysis tests, but considering that your response was so good and you still didn't conceive (though the LP issues may be the explanation), I think it's certainly worth pursuing additional semen analysis if you haven't already. There are a number of tests (sperm penetration assay, antibody testing come to mind) that aren't generally done as part of a typical semen analysis. An internet friend of mine recently learned after four failed IUIs (in which she responded well, overstimming in two of them)that her husband is producing sperm antibodies and so the IUIs were essentially useless. She's now moving on to IVF.

Good luck, April.

Again, I'm so sorry that this cycle ended in such a devastating way.

At 3:17 PM, Blogger Blue said...

I would definitely ask about the level of progesterone you are getting. I have heard the oral form is not as good as suppository or PIO. So you might check into changing how you are taking it.

Also, for luteal phase defects (especially spotting pre-period) I have read that Vitamin B6 works miracles at extending the luteal phase and keeping the lining up where it should be. I always suffered from spotting, I knew within a few hours when my period would start based on when I first saw the spotting the day(s) before. Once I started B6, I didn't get the spotting. I was SURPRISED by my period!!! Never happened to me before in the 20 years I've been bleeding on a not-so-monthly basis. So check into the B6 as well. (No more than 100mg per day without doctor approval as more can be toxic.)

I am so sorry this didn't work for you. All you symptoms sounded SO promising but I guess it was the progesterone working its magic in the wrong way. Hopefully this cycle will at least bring you knowledge of how to face the next one.

At 3:27 PM, Anonymous wessel said...

Provera and Prometrium are not the same thing. Provera is a synthetic progesterone, which is not safe to take in pregnancy. It is given for 10 days or so, then abruptly stopped, and the withdrawal of the medicine is what causes your period to come. This is called a "withdrawal bleed" and is not considered a true menses in medical terms.

Prometrium is natural progesterone, and it is entirely safe to use in pregnancy, and is the form of progesterone used to sustain a luteal phase or a continuing pregnancy.

I cannot answer the question as to how you could have such a high serum progesterone level, but still bleed. That is a good question for the doctor.

For the PCOS, I would ask your doctor if you should be placed on Metformin, which is a drug that stabilizes blood sugar and insulin response. PCOS is characterised by unstable blood sugars/insulin. You will want to get that under good control, and you can accomplish a lot by making some important dietary changes. Basically, no refined sugars or refined carbs (white flour, white rice, white potatoes). There may also be an issue with cow's milk, but you should check on that further since I'm not sure. It can dramatically effect the way a PCOS patient responds to stimulation and the quality of the eggs she gets.

Also ask your doctor about IVM, which stands for in-vitro maturation. It is being used primarily for PCOS patients with very good results. PCOS patients tend to have a lot of immature antral follicles, which makes them very good candidates for IVM. Much less gonadotropin stimulation is given, and for only a couple of days or so, followed by a trigger shot early on. The eggs are retrieved in their immature state, and then allowed to mature in the laboratory. The risk of developing OHSS is virtually nil with IVM. Some are predicting that IVM is the wave of the future and that once perfected, it will replace traditional IVF altogether.

If your doctor does not do IVM, it would be worth your while to do some research and find out which clinics are perfecting this technique.

Good luck April. Again, I'm so sorry that this happened.

At 3:41 PM, Anonymous wessel said...

One more thing -- about oral progesterone. It seems like a lot of RE's have gotten away from oral progesterone, and prefer suppositories instead for IUI patients because it is absorbed closer to where it is needed. (Lindy is right about retrieval causing destruction of the corpus lutei and thereby preventing the body from producing its own progesterone, hence the need for PIO). Perhaps suppositories would have worked better for you, but you can't be sure. I have bled on both suppositories and PIO injections, though not as early as you.

There is something else that may be at work here too. Some of us have bodies that do not like artificial, exogenous hormones; our bodies will only respond to endogenous hormones, or, those hormones that we produce ourselves. I discovered this on my DE cycle. I had always had a normal lining, in every single cycle I ever did, EVER. Even the totally natural cycles. My DE cycle was the first time I took "supplemental estrogen" which is given for the sole purpose of building up the lining. Well, for me, for two months in a row, it had the opposite effect. It thinned my lining!!!! The first month, my RE pooh poohed that, because he didn't know me yet (I just flew in to do the cycle). He increased my estrogen the second month to an ungodly amount, and my lining didn't budge. That is when he was forced to admit that bit about some women needing to make their own hormones. For my FET, we will go totally natural. (and if my lining is still thin, then I will have to shoot myself).

Where is this leading -- perhaps you should check into ways that you could increase your own production of progesterone, in addition to taking suppositories or PIO. I am a big believer in naturopathy and acupuncture--everyone who knows me knows that. I know that Chaste Tree Berry (Vitex) increases progesterone production. It always works great for me, but some women have problems with it and it screws them up. You are not supposed to take it while stimulating, though. So that presents a problem for someone going through an IVF cycle. It would be great for someone doing an FET cycle, because then they wouldn't have to worry about stims interacting with the herb. There are probably other ways to stimulate your own progesterone, and acupuncture may help. Or, who knows, maybe progesterone in suppository form or PIO will do the trick for you.

It's frustrating but this whole process is really just trial and error. By the time I will have learned everything I need to know about how my body works, my eggs will be good and dead! (if they aren't already).

At 3:47 PM, Anonymous wessel said...

Ok, really, one last thing: if you do decide to try herbs, please don't do it on your own. Please put yourself under the care of a licensed naturopath or licensed TCM (traditional Chinese medicine doctor) who is also familiar with western medical treatments for IF. That's all. I'll shut up now.

At 3:51 PM, Anonymous Molly said...

Holy shit! Everyone's so smart!

Just wanted to wish you luck, whatever you decide.

At 7:00 PM, Blogger Toni said...

There's also another reason to be on the metformin if you have PCOS - it can reduce your chance of miscarriage when you do get pregnant. Definitely worth it.

As for the bleeding...I have no clue. But take this forced break to sit down with the doc and talk to him (or at least over the phone). If he's good, he'll come up with another way to do the next cycles.

PS I had the same problem - always having to take a break after a cycle b/c of over stim. Nothing you can do about it except rest. Sorry. :(

At 2:04 AM, Blogger Nico said...

I would definitely ask your RE about starting on a lower dose of stims. My first cycle they started me on 50U Repronex, then bumped up to 75, then 112.5 when I finally responded. They kept saying that they were going slowly so that I wouldn't overstim. On the one subsequent cycle when they started me at 112.5 I stimulated much too quickly, had too many follicles, and the cycle was totall effed. The other two cycles they started me at 75U, then went up from there after I didn't respond, but eventually got to a good place both in terms of # of eggs and lining. Based on that, I totally have to agree with them that it's better to take a little longer, and avoid having so many eggs. Given that you did stim so quickly and so much, and that it is a problem with PCOS just as with HA, it definitely seems like it would be better to start off with a lower dose.

I'm also so sorry that this didn't work. And that you have to sit out a cycle. It totally completely sucks to be sidelined when you don't want to.

At 12:47 PM, Anonymous T said...

Jebus - everyone has everything covered. I'm ditto'ing the lowered doses of stims, looking into getting eastern medicine (with a trained professional - preferably one with IF experience) involved and the corpus luteum for us ivf patients being the reason for PIO (or crinone or suppositories).

So I'll just say I'm sorry, sorry too for the forced break - hate that.

At 3:30 PM, Blogger Spanglish said...

Hi April. I have nothing to add to what everyone else has said, but I just wanted to let you know that you're on my mind.

At 11:05 AM, Blogger Calliope said...

B6 has been great for my LPD. I added at least a day to my LP.

At 2:26 AM, Blogger persephone said...

April, I didn't really want to say this while your cycle was still playing out -- but I got the scary higher order multiple speech on 2 out of my 4 IUI's, and each time all those follicles came to nothing. I have also started to bleed while on progesterone suppositories. I have a good idea of how this must feel, and I'm so sorry.

Hopefully all these questions will help you make a new, improved plan. Good luck.

At 1:15 PM, Anonymous mm said...

Oh April, I'm so, so sorry for how this cycle turned out. (Just catching up on my blog reading here.) Definitely ask your RE about switching to PIO. My clinic uses the shots for both IVF and IUIs. Hang in there.

At 6:02 PM, Anonymous Anonymous said...

I also start spotting at 9 days post transfer even when on pessaries/suppositories. It's happen for 4 IVF cycles. This cycle I'm monitoring it with blood tests. 5 days post transfer my progesterone was 500 extremely high. But 7 days post transfer my progesterone has dropped to 350. Day 9 is when I usually start to spot which is tomorrow and I can already start to feel a little cramping.

At 5:21 PM, Anonymous LMW said...

My RE prescribed the oral prometrium (200mg) for my IUI cycles. However, he suggested that I insert them vaginally because it was more effective. Not sure why he didn't give me a suppository or PIO. Just wanted to mention it. Good luck, you'll be in my thoughts.


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