The short list of things to rule out

Still working on taking my break. Aside from marking down my period on my charting program and taking my first temp of the cycle (just to make sure it dropped appropriately) I haven't been charting or temping this cycle. Feels a little liberating.

I was talking to my partner the other day, and I told him that I feel as though there is something fundamentally wrong with our fertility -- though I don't know what it is. I see gals with fibroids getting pregnant on enough boards to know that fibroids alone aren't necessarily the only thing that causes infertility, though I know enough post myo gals to know that lots of them are having similar experiences to mine as well.

I've probably done this before but here's my list of things that might be possibly impacting our fertility without going out on too much of a tangent.

FEMALE	MALE
Anemia - low ferritin Low Progesterone	SCSA - sperm DNA fragmentation Repeat semen analysis (#8?)

I don't want to go in for a consult right now as that would make me cry and I'm trying to not put myself in situations like that right now. I called over to my favorite assistant at the RE's office and asked her to see about my getting my ferritin rechecked (since all evidence I've found online indicates that a level less than 40 can impair fertility) and a pooled progesterone test.

I can get the ferritin done at a lab, totally innocuous and generic place that I've been to before -- I think that will be less emotionally loaded for me. As it turns out the lab is way faster than the hospital lab was the last time I had it checked. I've heard that you can get your blood work done whereever -- and particularly for standard tests, as many hospitals and clinics are sending their lab work out of state because it's better for them, you as the patient might want to intervene and make sure that those cost-savings are yours or at least you are getting the benefit of the quick local turn-around. My ferritin test in July took about 3 weeks to get back. This lab can get it within a day or so -- they run the ferritin tests daily.

Then the pooled progesterone test, the assistant told me that my RE said that she didn't think that a pooled progesterone test was indicated by our infertility but that if I wanted to do it she would order it. I explained to the assistant that I had seen other REs, specifically as my first RE left the state, and that one RE in particular thought that I would need progesterone support on any cycle I was to conceive and that all of my progesterone tests had been on the low side. She said that was why working with more than one RE was difficult as they would of course have differing opinions. Still, I was welcome to do it if I felt like it would be helpful to me -- and evidently the other RE working in the same practice as my RE does do them frequently. I told the assistant that I would probably wait until the new year but at least I've gotten that sorted out.

So, I've got an RE not on the up and up with progesterone -- or rather definately not in the progesterone camp. Is that enough to consider working with someone else? Or should I just stick with her and just demand the care that would make me feel more secure -- particularly if I get pregnant again -- such as weekly progesterone draws until I'm out of the danger zone? Why does it have to be this difficult?

Then for all my spinning of wheels, it might not be me, it could still be the poor sperm morphology that's challenging things. Ugh, but with all that blood loss last June from the last miscarriage and how awful I felt subsequently, plus a couple of cycles that don't make sense (did something happen but not take hold?) I should at least rule out the impact my anemia might be having.

More about Progesterone Testing and the Value of Pooled Progesterone Testing for Luteal Phase Defect

"Single or multiple pooled serum progesterone values have been used between 21-24 days into the menstrual cycle. A progesterone level greater than 10 ng/mL may represent adequate progesterone support from the corpus luteum. Most authors now agree that a single mid luteal phase progesterone level is not sufficient to evaluate the adequacy of the luteal phase."
From: Lutenizing Hormone Deficiency

"Among women who present with a history of infertility, approximately 3-5% of those with infertility have a true luteal phase defect, with repeated cycles lacking adequate luteal support. The incidence of luteinizing hormone deficiency is higher (10-15%) in subsets of patients who are infertile and have had [repeated miscarriages]."
From: Lutenizing Hormone Deficiency

"As with many hormones, progesterone levels fluctuate hour to hour and day to day, so that a single level is not always an accurate reflection of ovarian function. Also, it is important that progesterone levels are sufficiently elevated for an adequate number of days after ovulation. For these reasons, it is ideal to check more than one blood progesterone level during the time in your cycle when progesterone levels are the highest, approximately 5 to 9 days after the LH surge. In the pooled progesterone test, blood is drawn on three days between the 5th and 9th days of the luteal phase. Blood samples will be "pooled" together, and a single progesterone level will be determined, representing an average of your progesterone levels."
From Pooled Progesterone Test (PDF)

"The results suggest that the most sensitive and specific prediction of low integrated progesterone (and therefore of LPD) was a value of <30 ng/mL for the sum of three (midluteal) serum progesterone measurements (100% sensitivity, 80% specificity).

Even a single (midluteal) progesterone result of <10 ng/mL was highly predictive of LPD (84% sensitivity, 82% specificity). However, a diagnosis based on a single progesterone determination continues to be controversial. Progesterone is secreted in a pulsatile manner, and serial samples obtained over a 24-hour period can range from 2.3 to 40 ng/mL.3 Such fluctuations raise questions about the reliability of a single progesterone determination for the differential diagnosis of LPD. The pulsatile secretion of progesterone argues for either assaying multiple specimens separately or pooling multiple specimens for processing in a single assay."
From: Progesterone: Physiology and Clinical Utility (PDF)

With a pooled progesterone test you should do it fasting, on any three days during your mid-luteal phase -- 5-9 dpo.

I've also read that luteal phase dysfunction is best tested in tandem with an endometrial biopsy and basal charting.

I've researched progesterone a lot and I've used both a topical cream and Rx vaginal suppositories. My progesterone level was low when I had my 7dpo test last October, and I have other small symptoms of low progesterone as well. My mother had low progesterone prior to conceiving my brother, after 3 miscarriages -- although she is allergic to iodine and has thyroid trouble.

My P4 at 19 dpo was 18.4 which is low I know. I used NPC (natural progesterone cream) for 4 days (19dpo-22dpo) and then the vag. suppositories (V.S.), 50 mg twice daily starting a week after that (there was a problem with the Rx so hence the delay.

My early pregnancy was full of queasiness (like motion sickness -- I recall it now from physical memory like being on a roller coaster -- which I hate!!!). My breasts were huge and sore, I felt like I was surrounded by cotton -- I couldn't think clearly. And my mood! I was like Attila the Hun there, snapping and losing it at the drop of a hat.

When I found out about my blighted ovum I stopped taking the progesterone and magically I felt 100 times better. I had no idea when I was taking it that it was the progesterone that was jerking me around so much. Now that I've finally kicked the bugger out (d&c yesterday) and I'm preparing myself for my next try (in a few weeks or so) I feel just so confused about the progesterone. It seems like it caused some fibroid growth, made me feel like HELL and hardly functional at all. I'm feeling reluctant to take it, at least in that high dosage the next time.

I didn't have any bloodwork done when I was on the V.S. so I don't know if my body is super killer at processing progesterone or if I'm absolutely horrible at metabolizing it so it just builds up to unbearable degrees. I guess I'll have to talk to my doc.

Back from RE#2

I've just gotten back from a visit with the RE and guess what my pooled progesterone test showed....I have low progesterone. (I feel like I have a twisted mind because I'm glad they actually found something off in my endocrine system). The doctor said that they would have to supplement me during the second half of my cycle when I was trying to conceive (um, wasn't that what I was already doing?). My progesterone is 9.4 and I found mention of it on a site that said "A level above 15 ng/dl is desirable".

I brought up the desire to have UAE with him and he said he could tell I was extremely knowledgeble on the subject -- thanks of course to the ladies on the NUFF group and on the embo list. He wasn't aware that there was anyone doing the procedure at that medical center (and the RE is the head of the fertility clinic) so my research and consultations with the IR may help other women as well. He did mention that he was understanding my willingness to be a guinea pig (which I am), since there isn't that much information (no randomized studies) on the affects of embolization on fertility.

He told me that I should continue taking iron supplementation ongoing due to my heavier periods. I know this to be true even though my menorrhagia (heavy periods) are nothing compared to the flooding some other women have reported in the NUFF group. FYI my period lasts a full 7 days, it is a little heavier now than when I was younger (I'm now 33) but not dramatically so. I do have some clotting and I do also double up on protection since a bad episode with flooding when I was in high school.

He said that there wasn't a link between hypothyroidism and low progesterone (although Dr Lee mentioned that low progesterone may mimic mild hypothyroidism).

I have a referral/Rx for the MRI now so I can schedule that and get more info.

So, it wasn't that bad and we didn't get into any arguments. He's going to consult with the IR next week.

Stay tuned for more info soon.