Help me understand my appt - long

[tarasattva]

I know that the real answer is 'see an RE', but since my insurance doesn't cover fertility (even diagnostics) I am trying to get as much information as possible from the OB while it can be considered 'treating menstrual symptoms'.

Here's my story - I've been seeing my CNM (who I love) and she has been consulting with the visiting RE. Based on several days of pre-AF spotting we suspected LPD. Did a CD21/7dpo progesterone test and got a result of 8. From the CNM's conversation w/ the RE I understood this to be high enough to assume ovulation but not as high as they'd like to see it.

I get 3 days of positive OPKs (digital) each month, and my CMN believed this might indicate a low quality egg (having trouble getting it out the door b/c it's not quite up to size).

To add to the fun I have a small cervical polyp.

I was sent to the OB to have the polyp removed and talk fertility (my CMN thought clomid would be the next step - presumably based on her convo w/ the RE).

So fast forward to yesterday's appt -

The OB says there is nothing wrong my progesterone numbers (she said 3-20 was normal and I was right in the middle), that clomid is only used to increase the number of eggs (not the quality of the eggs) and has substantial side-effects.

She blamed all spotting on the polyp (before she looked at it, afterward she thought it was so small as to not interfere w/ conception - but still I guess believed it was responsible for the spotting. I thought it strange that the spotting from a polyp would only occur in the 3-5 days preceeding AF but she said this could be hormones).

Her prescription was to have more sex and call her in 3-6 months. (We've only been trying for 4 months, but since I'm 35 and we had what I understood to be LPD symptoms I thought 'let's get it taken care of sooner rather than later').

So - here's what she recommended:

Next cycle do day 3 bloodwork (FSH,LH) and sometime just after period do ultrasound with water injected into my uterus to check for other uterine polyps (she said they'd take a look at other reproductive structures to make sure everything was in order).

Questions for you guys:

-- She seemed to indicate day 3 b/w was 3 days after spotting started. I told her I understood that CD3 was 3 days after real flow started and she said that was fine too. Huh???

-- Any time early in my cycle that's better than others for the U/S (I was going to try to avoid days before O so as not to mess with our chances that month, but anything more specific than that - when they'd be able to see egg size etc?)

-- Anything else I should be gathering up for test results before I finally give up and pay out-of-pocket to see an RE?

-- What do you think of the progesterone numbers?

FYI - I do have one child already (DD 12/07) so the structures all exist, and were in working order at one time. The pre-AF spotting is a postpartum thing.

Thank you all for reading, I've already learned so much lurking in the forum, and appreciate beyond words the shared wisdom of this group - you guys are so wonderful!

--Tarasattva

[kristenok18]

question 1- I always go by the first day of bright red as CD1

question 2- I have U/S done around CD12-13 to check for follicles (size&number), since I have PCOS. To make sure they don't interfere with the CF, they don't use any lube. Then, if I have a follicle that looks large enough to be considered "good", I have b/w done to see where my estrogen levels are at. Too often they've been in the crapper, which means the egg isn't really a good egg and we cancel our IUI.

question 4- if you are spotting several days before your period starts, and your temps are dropping significantly earlier than CD1, definitely have your progesterone levels checked to see if supplementing after O is an option.


I've been out of the game for a while (we took a 1yr+ break for my sanity), so I probably can't offer the best advice. Hopefully you'll find more answers than questions.

[FtMPapa]

You might want to think about a new OBGYN.

Does your insurance cover referral from your family doc to an endocrinologist? Not a fertility clinic RE, but a normal endocrinologist and there may even be one in your area who is an endocrinologist who specializes in reproductive endocrinology but who is in private practice. I saw one a million years ago, he was awesome.

You might have to have a reason for the referral, maybe your doc can put it under menstrual irregularities and low progesterone? Progesterone is a hormone, hormones are an endocrinologist's specialty.

Now, your questions:


-- She seemed to indicate day 3 b/w was 3 days after spotting started. I told her I understood that CD3 was 3 days after real flow started and she said that was fine too. Huh???

Nope. CD 3 is the third day of bleeding - CD 1, bleeding, CD 2, then CD 3. Not saying you don't know this, but maybe your doctor doesn't! Spotting is brown, pink, or very light...once you have bright red flow, that's bleeding. Your day 2 may be much heavier than day 1, for example, mine is, but it doesn't mean day 1 isn't day 1.

-- Any time early in my cycle that's better than others for the U/S (I was going to try to avoid days before O so as not to mess with our chances that month, but anything more specific than that - when they'd be able to see egg size etc?)

The U/S she's talking about is specifically a sonohystogram, or SHG. Often mistakenly called an HSG, which is a similar test with dye and an xray instead of water and an ultrasound, the SHG is best done before O. When I had mine, the protocol was to do it on CD 5-12. They're pickier about scheduling the HSG day 5-12, but I had both done at the same time and it just makes sense to do it in that window. You don't have to sit that cycle out, you can go ahead as normal. It's completely fine to conceive in the same cycle. You may not want to take the just-in-case antibiotics though, if you're hoping to conceive that cycle. They may not offer them to you, but other doctors will tell you they're essential. Make your own informed decision. I didn't take them, I wasn't even offered them.

Incidentally, get this. Totally get this not only to visualize the uterine cavity, but there is some evidence that the SHG/HSG may help "powerwash" the fallopian tubes - there's an increase in fertility in the three months following the procedure.

-- Anything else I should be gathering up for test results before I finally give up and pay out-of-pocket to see an RE?

Yeah - get her to give you this bloodwork:
CD 3 - LH, FSH, estrodiol (estrogen or E2), prolactin
CD 10 - LH, FSH, E2, prolactin
CD 14 (or whenever you typically ovulate, like the day before) - same thing
CD 21/7 DPO - P4 (estrogen level)

Try to get her to send you for an ultrasound to get a follicle count a couple of days before you ovulate or so...when you get the SHG, it won't show the follicles unless they're looking for them. And you don't want to do the SHG that close to ovulation. You want the follicle count ultrasound test to correspond with the "CD 14" bloodwork to get your E2 levels.

While you're at it, get her to run a thyroid panel, it's just another tube or two of blood. And get the specific numbers and troll the web for info. If your TSH (Thyroid Stimulating Hormone) is still within normal parameters, but toward the high end, it can be considered "sub clinical low thyroid" - i.e. not low enough to be officially low, but low enough to interfere with conception.

-- What do you think of the progesterone numbers?

Too low.

You want 10 or higher on your own, some docs say 15, some say 20 or higher if you took fertility meds.

You could try over the counter progesterone supplementation. I used an herbal cream this cycle for the first time, and my lp was a very long for me 15 days, plus my bleeding was much heavier than my usual heavy bleed, indicating either that the acupuncture I just started is working, or that the progesterone helped the lining develop.

Check out this link for an idea of what the ranges of hormones are and what tests to get: http://www.fertilityplus.org/faq/hormonelevels.html

I noticed one typo - with prolactin, lower is better, the chart shows the wrong symbol for greater/less than. Prolactin promotes lactation, so higher levels suppress ovulation.

Hope that all helps! clearly I've been at this a little too long.

[FtMPapa]

Originally Posted by tarasattva

I was sent to the OB to have the polyp removed and talk fertility (my CMN thought clomid would be the next step - presumably based on her convo w/ the RE).

So fast forward to yesterday's appt -

The OB says there is nothing wrong my progesterone numbers (she said 3-20 was normal and I was right in the middle), that clomid is only used to increase the number of eggs (not the quality of the eggs) and has substantial side-effects.

Oh, you didn't ask about this...but Clomid is used to increase the number of eggs when taken CD 3-7 and there's something about improving the quality of eggs when taken CD 5-9...I don't know much about that, Clomid and I don't get along.

I've also heard of people getting poor eggs to be better eggs with DHEA.

I really think - time to get a new OB! This one clearly isn't up on her stuff.

She told you three wrong things (at least) in one appointment. That would be a major red flag for me.

[livinzoo]

Oh, not to High jack the thread but if my Estradiol was 58 on CD 14 (I either ovulated that day or the next) does that mean that was a low quality egg? My day 3 and day 21 labs look fine but it has been 8 months and no BFP. Hubby is going for a SA soon.

Thanks

[tarasattva]

Wanted to add a happy update to this story -

At 10 dpo (yesterday) I got a BFP!!!! http://www.mothering.com/discussions...milies/joy.gif

I know that one of the effects of a LPD is that you are at higher risk of an early miscarriage, so I'm trying not to count my chickens before they hatch (or my bean before it sticks), but I'm cautiously optimistic.

I haven't canceled the sonohysterogram or day 3 bloodwork yet, but I'm hoping I won't need to do either!

And am trying to get into either the midwifes office or the OB to have them check my progesterone levels.

FX that this is it and I'm on my way to a H&H 9mo.

--Tarasattva