TTC Update 8/28/08

I had an appointment with Dr. M this morning. He is my OB/Gyn. He is a mild mannered, soft spoken, practical and easy to talk to Dr. Despite the fact that he is male (which normally means I won't even see a male Dr.) he is very compassionate and understanding. I really like him and I really like his approach to prenatal care as well as other gyno issues.

When I received my diagnosis of PCOS with Insulin resistance (IR) I was actually diagnosed by my Endocrinologist, Dr.L. Now Dr. L does not normally deal with women of child bearing age. He primarily deals with thyroid issues and diabetes in older adults. So I am not his normal clientele nor am I his area of expertise. But he was covered on our Ins and he is a good thyroid Dr which is my main reason for seeing him. But when I was diagnosed with PCOS, I was somewhat hesitant to believe whole heartily in that diagnosis. I honestly thought the reason I was not accepting of the diagnosis was because I was in DENIAL! LOL! But now that I have seen Dr. M I am thinking that maybe I wasn't so far off the mark.

Dr. M reviewed the lab results that Dr. L had made his PCOS diagnosis from and came to a different conclusion. Dr. M's basic feeling on "pcos" (every time he said PCOS he held his hands up and made quotation marks. LOL!) was that Drs use that as a label for women with unexplained infertility. Basically he thinks of PCOS as a dumping ground diagnosis. He thinks that IR can cause infertility. He thinks that cyst on your Ovaries can cause infertility but you can have one or both of those conditions and not have the "typical PCOS". About 1/2 way through the conversation he just stopped calling my infertility PCOS and just said to deal with the symptoms and see where we are at.

He explained it to me like this: Due to diet or actual IR the cells in your body can become resistance to insulin. Your body needs insulin to convert glucose into energy. So if your cells are resisting the insulin then your pancreas has to produce extra insulin to force the cells to covert glucose into energy. With the excess glucose not converted to energy it gets stored as fat in your body. Which is why IR folks are typically overweight. IR effects fertility because with the extra Insulin coming from your pancreas, your pituitary it tells your ovaries to produce more androgens and then your body turns androgens into testosterone which suppresses the estrogen and without estrogen your ovaries do not produce follicle to ovulate. Without Ovulation, no pregnancy.

So even without the whole cysts on your ovaries thing which is the primary symptom of PCOS you can still be infertile due to the IR and that can be called PCOS. What I DON'T have that is typical with PCOS is annovulatory cycles, male pattern hair growth, or excess androgens. I do have mild case of IR which the Metformin is treating.

I also asked Dr. M about my cycles and if he thought I was actually Ovulating. He asked me some questions about my cycle. I told him I have the normal thermal shifts, normal cervical mucous patterns, typical cervical positions, normal luteal phase length, normal cycle length, Periods that arrive on time, the bloating, breast tenderness etc of typical PMS symptoms. He said that given the obvious hormonal changes (evident by my symptoms per cycle) that there is a 95-98% chance that I AM ovulating. He felt that giving us some more time to try to conceive will most likely result in a pregnancy.

I asked about Clomid. He said that he feels strongly that I AM ovulating. He felt that using Clomid would NOT improve my chance of actually conceiving but WOULD improve my chances of conceiving a LITTER of children. He said in women that are ovulating, (which is where he feels I fall) that using clomid increases your chances of twins or triplets to 30%. That is NOT a risk Tim and I are willing to take.

Now if I fall into the 3-5% that have hormonal changes but still don't ovulate then there are 2 tests that he would like to do. The first being an Ultrasound study that looks at my ovaries before Ovulation to measure the follicles and determine which is the dominate follicle and then again an ultrasound after ovulation to see if the dominate follicle was actually released. If my ovaries are releasing the egg and I am STILL not pregnant then they would have to look at a few things. They might do a semen analysis on Tim's swimmers and also check my fallopian tubes. They would like to do a procedure (i can't think of the name right now) that involves them injecting dye into my uterus and tubes and then taking pictures to make sure the tubes are clear and no blockages are present. If that test comes back clear then they would probably want to take the next step in fertility drugs, which we would decline. In actuality we would probably not do the semen analysis or the dye test either. The Dye test is WAY to invasive for my taste. And if there is a problem with sperm mobility or my tubes the only answer/treatment is high tech (read $$$$) Intrauterine insemination or straight IVF. We would not spend the money on either of these procedures, so we would most likely decline the test as well.

Now the U/S might be something we would consider. The treatment for ovulation failure would be a low tech medication like progesterone trigger or clomid. In the case that I am NOT ovulating then the risk of twins or more when taking Clomid is only 10-12%. So we would consider that as a possibility.

I also got my questions answered about taking Prozac and Metformin when you are pregnant. He refilled my script for Prozac and we talked about the risks and benefits for Metformin during pregnancy. He also gave me a script for progesterone suppositories that are less expensive (albeit more messy) than the progesterone pill I was on. The suppositories are less expensive and covered by most Insurance. We will see how that goes. I have to use them twice a day. So that means MESSY all day. I could handle it if it was just at night cause I could shower in the morning. But twice a day means Messy all day! So we shall see.

Anyway, Bless you if you actually read this whole thing. I wrote all the details out for you to read but also for me to have a record of my appointment. I sometimes forget things and so I wanted to write this out while it was fresh in my mind so that I could re-read it when I forget what Dr. M said in a week!

So for now Tim & I will just be trying and trying.... and lets face it, that is the funnest part of the whole journey!