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Saturday, August 30, 2014

My follicles were growing but my eyes were wet!

On the day of my first ultrasound, I entered the clinic. I am no more a stranger there (but it is not so amusing to visit an infertility clinic often); people were greeting me with a smile. I sat there waiting for my turn to be scanned. I could hear Dr’s voice in his consulting room. I was looking at the baby pictures on the walls as usual. I started to think of my children. I dreamed of bringing them both to the clinic, to meet everyone who took part in creating them. I always imagined how happy those moments would be, but, now, I am sitting in that same place with empty arms and an aching soul! Suddenly all my happiness vanished, I felt gloomy; an unknown fear gripped me strongly. I felt miserable. I wondered what I am doing there! Like in snake and ladder game, I was back to square one when I was thinking that my destination is at arm’s reach. I realized the cruel joke life played on me much more intensely at that moment! I had tried 6 long years to achieve my dream and suddenly it was taken away from me in the most unfair manner. What is the guarantee that such a thing will not happen again? How long will I be able to play this IVF roulette? Why I am not provided with the ease and security of normal conception? What is the guarantee that I will produce enough eggs and embryos, what is the guarantee that I will become pregnant again?  Even if pregnancy happens, will I have a healthy child in hand? What gave me the courage to try this stupid stuff all over again? My eyes started to tear. I tried hard to concentrate on my smart phone. Dr came out of his room, and I tried even hard not to look at him. I was sure that, if I do so, I will cry. I expected that he will greet me, say hi and ask how I am. But he just carried on with his work. That was even more hurting. He didn’t even say hi! It brought more tears.

Dr. Anjali came. She was as cheerful as always. She gave me a warm smile as she entered her room. Sister Mary called me in. The moment I entered in, I broke down. I started to cry. I felt embarrassed but I had no control over my crying spell. Dr. Anjali did the scan; she said that everything looks fine and showed me the growing follicles. There were many. There was one follicle which was well ahead of the others. I was a bit worried whether this lead follicle will suppress the other small ones. But, there is nothing more I can do than to just wait and watch. Dr. Anjali called Rajender inside and explained him the scan picture. I was asked to continue the same dose of menogon (300 IU) Dr. Anjali said, ‘we are sorry, it was really an unlucky happening. We were shocked when we heard about your loss’. She asked me, ‘is it still painful?’ I replied, ‘this place is painful for me, I have gotten over it (really!) and sometimes the pain is unavoidable’. She said, ‘try to forget it and move on’. I smiled and came out of the room. We went to the reception to buy some medicines. 

Rajender was looking at me. He understood that I cried. He asked me what happened. That was enough to trigger my crying episode again. He was so used to this. I just went on shedding tears. He said, ‘Manju, there are people around you, stop crying’. I told, 'Dr didn’t even talk to me’. He said , ‘didn’t you see, he is busy’. I replied, ‘but how much of his time will be wasted if he asks me how I am!’ Rajender said, 'when you went out of the room, Dr came outside, he did greet me'. My sobbing got even more uncontrollable, ‘see, he did talk to you but he didn’t talk to me’. He looked at me as if I was mad and he realized too it was a waste of time talking to me, consoling me. Sister Lizzy gave me that day’s injection. I haven’t stopped crying yet. She was curious to know what is going on. She asked me, ‘aren’t you responding well to medicines, aren’t your follicles growing?’ She said, ‘don’t worry; you have taken medicines just for four days’. I told her that my follicles were growing nicely. She looked at Rajender. He was forced to respond and he said, 'she is crying because Dr didn’t talk to her'. For the first time I came to my senses, felt ashamed. I stopped him in between and said, 'nothing sister, I am a bit depressed'. She told that it is very normal to feel so because of all the medicines I was taking, might be she was right! She consoled me by saying, do not worry, all will be well. I said to myself, 'yes, all will be well!'

We came out of the clinic. I wanted to go to marine drive, so we went and sat there. I was getting back to normal. My fears eased a lot. The vast, roaring sea always brings calmness within me. I was watching the huge crowd in that area. There were so many different people and everyone must be having their own world filled with struggles and happiness. I was thinking, what for should I worry. I am following my dream and that makes my life interesting. Life is more beautiful when there is a challenge to face. I must be proud of myself; I am strong even after going through so much. Living in the present moment is the best thing I can do. I don’t know what tomorrow holds for me. I do have problems in life like everyone else and I have learned a great deal out of it. Those lessons have helped me to enjoy life even better. Hard times in life have taught me many things than any of my good times. Struggles are what that gives definition to my life.

During the days which followed, I had two more scans. My follicles grew luxuriously and there were many too. My only concern was that of the fast growing follicle. Dr. Anjali said that, it might be just a cyst and we might not get an egg out of it. I was thankful that it didn’t hinder the growth of other follicles. The second time when I went for scan, Dr was not there in the clinic. So there were less patients around. I and Rajender had time to have a hearty chat with Dr. Anjali. I told Dr. Anjali how difficult it was for me when Rajender tries to control what I eat too during IVF times. He doesn’t even want me to eat papaya when stimming, and I love that fruit. Even worse, for breakfast, in the hotel we stayed, they always have that colorful fruit. Whenever I pick a bowl of it, Rajender gets restless. He believes that it enhances body heat and it might interfere with the cycle. I have tried to make him see the truth, I told him how nutritious it was, I even fought with him but I could never get back the joy of eating my bowl of papaya. Dr. Anjali was kind enough to explain him why he must allow me to do what I like. She said, ‘the more stress you put on her, it is not good for her during this time. I believe that stress do play an important role in hindering IVF success, but, Dr. Malpani might not agree with this’. This is enough to put my dear hubby at ease. The next day I took an extra large bowl of papaya and sat in front of him. I ate to my heart’s content and he was not bothered too, atleast he tried hard to act as if he was not bothered :) Not only that, he allowed me to eat whatever I wanted thereafter. He was also extra nice to me the entire cycle and I must thank Dr. Anjali for that :)

The day of egg retrieval approached very fast. I took menogon only for nine days. For the last two days I took 450 IU of menogon. This cycle was somehow much easier. I never obsessed about the number and size of follicles. I never asked Dr.Anjali how many eggs I might get. I just took each day as it was; neither did I expect anything miraculous, nor was I fearful. I had copious amount of EWCM and my estrogen rose very nicely. This put my mind at ease.If I remember correctly my estrogen was 2000 plus (pg/ml) before I took the trigger shot (hCG). On the day of egg retrieval I was eagerly waiting to go under anesthesia and I just love it!

Friday, August 29, 2014

I started injections for ovarian hyperstimulatimon

I started to take birth control pill 12 days before my expected menstrual period. I do it to make sure that I get my periods on time. There were times when I wait and wait for my periods to start and it never happened. The reason was, either I failed to ovulate that cycle or I ended up with a cyst which prevented my periods. So, to be on the safer side, I took birth control pills. After 7 days on birth control pills, I started taking lupron too (overlapping BCP and lupron). I stopped BCP after 10 days and continued only lupron. When my period arrived, I started FSH injections on day 3 of my menstrual cycle (lupron continued until egg retrieval). Don’t ask me the name of this protocol. This is what has helped me previous time to get more eggs and so we followed the same. 

I ordered medicines in Madurai. In the beginning, I was scared. Medicines necessary for IVF will not be available in nearby medical shop (definitely not in our village). In a small city like Madurai, I was wondering, where will I go in search for it? But to my surprise, I found that, I could order all the medicines from home. I just have to call the pharmacy and order the medicines and they delivered the medicines to my home safely in a cool pack. I never expected this in Madurai and I was relieved. If any of you staying in Madurai was wondering how to order the necessary medicines, please contact Vasan medicals. They are very sincere, and prompt. They do their best to get the medicines you ask for in time.

I called Vasan medicals and the first question I asked them was which FSH preparation is the cheapest in the market. FSH is available in 3 different forms – Gonal F, Menopur and Menogon. Gonal F is the purest form of FSH. It is a recombinant preparation (genetically engineered) and hence very costly too. Menopur and menogon are prepared from the urine of post-menopausal nuns and hence called as hMG (human menopausal gonodotrophins). They are of course purified (not as pure as Gonal F) and contain equal amounts of LH and FSH. Menopur is a much purer version than Menogon. Menogon is the cheapest. I ordered Menogon. I used Gonal F for my first five IVFs in Germany. My ovarian response to Gonal F is very, very poor. But when I came to Dr. Malpani for my 6th IVF, I was given menogon and I responded so well to stimulation and produced many, many eggs. Might be I needed LH too for getting my follicles to grow. So, when you are given an option to select between gonal F and menogon, chose the cheaper one. Scientific studies have failed to show that one form of FSH preparation is superior to the other.

When I got all the medicines and when my mom saw it, her eyes became so wide for a moment and then watery too. She asked with fear, do you have to inject them. I said, amma I am so used to it. I don’t even feel any pain. If at all I feel something, it is just like an ant bite. From that day onwards I made sure my mom doesn’t see me injecting the medicines. Many women who are about to start IVF ask me with fear, "I am so sacred of injections, will they hurt?” Believe me, they don’t. I think, when compared to all the emotional turmoil we undergo during IVF, pain caused by these injections are nothing, absolutely nothing. If you are afraid of these injections, how will you face the pain of child birth? They say childbirth is the worst pain you could ever feel. I actually like those injections (FSH) for another reason. They are like costly anti-aging drugs (who wouldn’t love to look younger!). This is what my RE in Germany says. I truly, truly believe so. When you take those injections and when your estrogen level starts rising, it is a wonderful feeling, at least for me (I know women who suffer from nausea and other side-effects because of it). I feel like a teen ager. My thoughts change. I become so optimistic, I sleep too well and my skin becomes beautiful. Do you remember the first time you fell in love as a teenager (your first crush), it feels exactly like that! As a scientist, I am amazed to see and feel by myself how hormones could control our brain, our thoughts, perhaps our actions too. Is there anyone out there who could relate to what I say (very curious to know)? So, please do not panic about your injections. They are not as evil as you might think. One another fear most women have about IVF drugs is, “will I put on much weight when I take them?" I have heard women complain – “only after I started using them I became fat”. Please be assured that it is not true! What makes you gain weight is the depression that you go through during your infertility treatment. Because of the stress and depression, you unknowingly increase your food intake. Eating food, especially which are rich in carbohydrates, creates a feel good sensation due to the release of a hormone called serotonin. In order to beat depression, many women get addicted to the effect of serotonin and overeat unknowingly. The best way to prevent weight gain during fertility treatment is to develop creative strategies for beating depression. In my case, infertility actually helped me to maintain a healthy BMI. I understand the impact of body weight on fertility and I don’t want to put myself through another problem, I think I already have enough problems to tackle!

Rajender came to Madurai. I was eagerly waiting for him. How happy I was to see him! The first question I asked him was, “did you miss me?” He replied with a naughty smile, “no, never!” But his happy face said otherwise. I took my medicines for the first four days in Madurai, and on the fifth day we were in Mumbai for my first ultrasound. I asked Dr whether I could come to Mumbai much later, after 8 days of taking stimulation drugs (I thought I will reduce the hotel expenditure there, Mumbai is of course costly!). He was not happy. He said, “If you want to do so, I need a very good digital picture of your ovaries after 4 days of starting stimulation”. I was so sure I wouldn’t be able to get a digital picture (I remembered the not so cooperative doctor in that scan center).  He said, “Manju, don’t be penny wise and pound foolish. It is better we monitor you closely so that we can adjust your stimulation drugs as and when needed, this will provide you with a high chance for having an optimal outcome”. So, we were in Mumbai a lot earlier this time and I love Mumbai.

Mumbai is very beautiful and lively. People are friendly. Shopping areas are amazing. But the most important attraction for me in Mumbai is the Marine Drive area. I just love to sit and watch the sea. I feel so happy and relaxed when I do so. One thing that makes me sad about Mumabi is the wide-gap I see between the rich and poor people. There are overwhelmingly rich people who drive BMW and dine in Taj, and on the other hand I could see poor people, especially poor children who are just left on streets. I really, really feel guilty at such times for pursuing a costly way to have a baby, after all a baby, which are present in abundance in India, even on roadsides (babies, babies everywhere but not even one for me !) Once I was walking near the Taj hotel. The beauty and richness of it always amazes me! There were so many Benz, BMW and Jaguars parked there. Rajender was telling how much those cars would cost. I was hearing it open-mouthed. I thought what a life it is! I wanted to be that rich too. I want to drive a costly car, enjoy my evenings in a five star hotel like Taj and want to live like a queen (who wouldn’t want to!) Caught up so much in those thoughts I forgot to see the foot path. I was about to stamp on something and Rajender pulled me aside and looked at me angrily (It happens many a time when we go out, most of the time I will be too attracted by what I see or will go into dream mode). I looked down and realized that I was about to place my leg on the hands of a 12 year old girl. All my excitement drained in a second. There lay a poor girl, near that richest hotel, clothed in rags and with a small torn bag under her head (I hope it is her only possession). She was fast asleep in that busy roadside (serenity amidst chaos!). I was ashamed of my inability to do anything for such unfortunate children, yet, desiring after things which could make my life even more comfortable. I felt guilty. I was angry and bitter, I cried. People like me, easily blame Karma for such inequality and unfairness, and move on with their life. I realized that there are so many things in my life I must be grateful for. I had a safe childhood, I couldn’t imagine the life that little girl was leading. How unsafe it is for a girl to live on streets! I have a shelter above my head, I have good clothes to wear, I have food not only to satisfy my hunger but I could have food for my enjoyment too. If I start writing the things I must be grateful for I need several, several pages. If that is so, do I have any right to complain about infertility, not being able to have a child?

I went to the clinic for my first scan after four days of taking 300 IU Menogon. I was very happy when I went in. I was eager to meet everyone, especially my Dr. I was very eager to know how I am responding to stimulation. But when I came out of the clinic I was too tired, tired of crying my eyes out!

Monday, August 18, 2014

Difference between hope and false hope: what every woman undergoing IVF must understand!

Every woman steps into the world of IVF with the hope that IVF will give her a deeply desired baby.  Unfortunately not everyone who undergoes IVF ends up with a baby to take home .  Every IVF cycle provides you with a 40-50 % chance of getting pregnant (this success rate is for young women with good ovarian reserve provided they are with a good IVF clinic, their uterus does not have any obvious defect and their partner is fertile) and the chance of take home baby (live birth rate) is lesser !  Women who are of advanced maternal age (greater than 35 year old) and women who produce only a few eggs due to poor ovarian reserve have a lower chance of success. This is the bitter truth.

We all need hope to stay motivated. The motivation to fight the unknown and the inspiration and energy to deal with uncertainty definitely comes from hope. No one will step into IVF treatment without hope and motivation.  But when hope turns into false hope and delusion, patients are headed towards heartbreak and pain.  I even find searches like this leading to my blog – ‘my IVF cycle failed, I want to suicide’.  If a failed IVF cycle triggers the desire to end one’s life then readers must understand how huge the emotional turmoil the patient might be undergoing! Another search word I frequently see is – how to cope with a failed IVF cycle.  What makes coping with a failed IVF cycle so difficult? What is the difference between hope and false hope in the context of IVF? Does the same hope which provides the motivation to fight steal the courage to face the failure?

The field of IVF is highly commercialized. Many IVF specialists sell false hopes in order to lure patients to their clinic. Also, because of their extreme desire for a baby , many IVF patients  become delusional and live with false hope. They look at IVF with rosy lenses because it’s their last chance and desperation makes it difficult to think clearly. They over-estimate their chance of success - and back up such false hopes with unrealistic facts and expectations. 

There are many ploys they use to justify this false hope.

-          That celebrity had her first baby at 45 with IVF , which means I can have one too

-          I read in an online infertility community about a woman who got pregnant after acupuncture at the age of 43, which means there’s hope for me too, no matter what everyone else says

-           Statistics are fine, but they don’t apply to individuals, and because I am healthy and fit and god-fearing, God will definitely give me a baby.

-          The author of Inconceivable conceived a healthy baby with such a high FSH after making life style changes, so if she could conceive, I can too.

Are these women just fooling themselves ?

When undergoing IVF, hope must be based on reality and facts. You must cultivate hope based on sound scientific evidence. False hope can be cruel , because your heart breaks when you are forced to encounter harsh reality. 

She produced only 1 or 2 eggs in her IVF attempts and her embryos arrested after day 2.  She has a very high FSH and low AMH. It clearly shows that her ovarian reserve is nearly depleted and the genetic competence of her embryos is poor. But she insists that she doesn’t want to use donor eggs and will try acupuncture to improve her egg quality so that she can get pregnant.  Now until she produces eggs which could be fertilized and give rise to a healthy embryo, there is no chance for a pregnancy. Now the question is - how high are her chances? If we look at the figures from IVF clinics all over the world, her chance of success using her own eggs will be less than 3 %.  That is, if 100 women of her age and diagnosis undergo IVF, three might get pregnant and the chance of a healthy offspring is much lesser, because the miscarriage rate is very high in these women ! IVF is costly; and the emotional and physical strain it can put on someone is high as well . In such a situation how many times she will be able to play the IVF roulette without becoming an emotional wreck, especially, when there is only a miniscule possibility for a favorable outcome?  

Her false hope stems from two aspects: her desperation to have her own baby and her willful ignorance. While denial can be a useful protective mechanism, it can cause a lot of harm. She fails to understand the reality of  scientific data, and is living in a fantasy land (because of her dreams of having her own genetic baby , and also by reading many anecdotal success stories) . She is hopeful that if she tries acupuncture ( or any other therapy ), a miracle will happen. This is also the case with many young women who have very poor ovarian reserve. One must understand that miracles do happen but very, very rarely – and this is why they are called miracles ! Exceptional stories like that of the author of Inconceivable do happen , but it cannot become the norm! Not every woman who has a high FSH level conceives after making ‘adequate’ life style changes.  Sadly, we never get to read their “ IVF failure stories “ !

Relying on such anecdotal stories and ignoring sound scientific data is like buying a lottery ticket and waiting to become a millionaire , just because someone else you know has won a huge jackpot. Any rational human will agree that it is utter foolishness to do so. In short, because of your desperation, you are allowing someone else to laugh all the way to the bank - and even worse , you are doing so by emptying all your hard earned money! This kind of over-optimism will not only harm your bank balance , but also your emotional well-being.

A good IVF doctor will clearly explain to you your low chance of success and will advise you to consider alternative, such as using donor eggs. He will not lure you into trying unproven expensive therapies , such as immunotherapy . In fact , some genetic tests like Preimplantation Genetic Screening (PGS) have been shown to decrease the chance of success in older women undergoing IVF, even though the IVF clinics which offer them promise the moon! In short, a good physician will not sell you false hopes by overstating your chance of success. Please be happy when you meet a doctor who is honest with you because he is the one who genuinely cares for you. Do not get taken in by sugar-coated words by doctors who are trying to sell you their expensive services.

Remember, a cruel truth is always better than false hope.  You must let go of false hope and fill yourself with acceptance of your real situation. This will be the best step forward to bring peace and happiness , and it will also help you decide wisely about your next steps.

There are also young women with good ovarian reserve who have highly unrealistic expectations about IVF. They believe they will definitely succeed in their first IVF cycle. They think only of a successful outcome and shun all thoughts about a negative outcome. Many believe that even thinking about a negative outcome will jinx their chance of success. Some put all their faith in God and obsessively pray 24/7 for their IVF cycle to succeed. When such women face failure , they find it very hard to cope.  Facing success doesn’t need any prior preparation but for facing failure you have to prepare your heart and mind beforehand. You have to develop effective coping strategies to face IVF failure, just in case your cycle does fail. Seeking strategies to cope after a failure will not work effectively. 

 Even if you are young and have good ovarian reserve, your chance of success with a good IVF clinic is just 40-50%. This means your chances of failure are as good as your chances of success. Statistics show that 60-70% of women succeed within 3 IVF attempts , while others will not conceive at all!  You will understand the need to have a plan B if plan A doesn’t work. Blind hope will only lead to depression and enormous emotional pain. If you don’t learn to deal with the possibility of failure by designing proper coping strategies, the fear of failure itself can stop you from pursuing your dream.

It appears as if false hope is what gives you the strength to fight, but what it actually ends up doing is leaving you emotionally drained after the IVF roller coaster ride. A balanced sense of hope is extremely important , so you don’t drive yourself insane. Realistic expectations come only when you educate yourself thoroughly.  A realistic hope is flexible as a negative result does not break you , but helps you to cope better , so you can make optimal use of all the options that are available to you in the field of IVF. A realistic hope admits uncertainty.  When false hopes come crashing down, you are likely to be resentful and angry – and you will often need to vent this on the IVF doctor who helped to create some of the high expectations.

A realistic expectation of IVF is not always a baby , but receiving good medical treatment , and making use of all the scientifically sound options that are available to help you to reach your dream.  

IVF doctors have an important role to play. They must realize that it is extremely cruel to sell false hope to their patients who are fighting to have a baby.  IVF is usually a happy specialty because we help to create life. However, we do sometimes have to give bad news to patients, and this can be hard to do. For example, what do you tell a 45 year old woman who has failed 3 IV cycles and has a high FSH level and wants to do one more IVF cycle with her own eggs.  By telling her chances are slim, are you being unfair and unkind by depriving her of hope ?  By saying No, you are passing a death sentence in one sense – the death of her dream of having a baby with her own eggs.

Is it better to be frank and forthright ? It’s no fun having to counsel patients who are not willing to listen to the truth . It’s much easier for IVF doctors ( and more profitable too !) to go along with their patient’s wishes, even when the chances of success are zero. A lot depends upon the maturity of the doctor – and the patient as well ! Is the patient willing to absorb the truth ? Does she understand that only an upright medical professional will tell her what’s in her best interests, rather than try to sugarcoat the truth ? Does she trust her doctor ? Has she done her homework ?

Remember that a failed IVF cycle does not mean you are a failure. When one door closes, another window opens up. IVF can teach you a lot of life lessons, and while these are not easy to imbibe, rather than become bitter, angry and unhappy, you can end up becoming more mature and empathetic , if you can weather this storm in your life.

This article is the brain child of  Dr. Malpani and me. Thank you so much Dr !

Friday, August 15, 2014

AMH, Vitamin D and my ovaries!

An AMH value of 0.6 ng /ml is bad, really bad. In the report I got in hand, it was written that, an AMH value of less than 1.6 ng/ml might indicate a poor response to ovarian stimulation. I was heartbroken and angry; my reproductive life is nearing its end! I expected it, but I didn’t expect such a drastic fall in my AMH. After I returned home with the results, I called Rajender. He was cool as a cucumber. He said, I read about women who produce eggs even with much lesser values. I was irritated by his positivity; I thought, why won’t he leave me in peace, take an alternate solution (donor eggs) and move on. I had no energy to argue with him or break his enthusiasm. Dr. Malpani gave me one more suggestion. He asked me, from which lab did you measure AMH. I told him that I got it measured from Thyrocare. He replied, Thyrocare is not so reliable, please measure your AMH again from SRL (Ranbaxy)! I was not hopeful, but I was badly in need of a miracle. I gave blood to SRL for AMH and Vitamin D measurement and waited for a couple more days.

From now on, this post will turn a bit more scientific.  Many of you might wonder why I measured Vitamin D along with AMH. Is it necessary? What is the rationale behind that? There is a connection between Vitamin D and AMH. AMH gene (the sequence of our DNA which codes for AMH protein) has a Vitamin D-response element (a region which is responsive to the presence of Vitamin D in a positive manner). To put it in a more simple way, Vitamin D can bind to the AMH gene and increase its expression.  If this is so, can low Vitamin D level lead to low AMH levels in blood? When they initially found the presence of Vitamin D-response element in the AMH gene of prostate cancer cell line, frenzied researchers, as usual, hyped out of proportion the importance of Vitamin D in reproductive biology.  Their understanding was and still is, if high AMH levels in blood indicate good ovarian reserve, increasing AMH levels by increasing Vitamin D intake, especially when one is deficient,  (since Vitamin D could increase AMH level) will lead to good ovarian reserve too. What a simple way to solve the problem of poor ovarian reserve! Just pop in Vitamin D, and the problem will be solved! But, this kind of (il)logical reasoning without understanding the basics of the science of AMH is half-witted! To read more about the science of AMH please refer to:

It is true that Vitamin D could increase AMH levels. But increasing the expression of AMH from the already existing follicles (antral follicles) cannot increase ovarian reserve. More antral follicles lead to more AMH production, but increasing your AMH levels artificially (either by taking substances which increase AMH production, like Vitamin D, or by injecting AMH into your body) cannot increase your ovarian reserve. Actually, increasing your AMH level artificially, could lead to opposite effect - high AMH can decrease the amount of antral follicles available for FSH stimulation. So, if you are having poor ovarian reserve, taking Vitamin D is unlikely to help and in worst cases it can bring down your antral follicle count (AFC) too.  In case, if your Vitamin D levels are low, or if you are Vitamin D deficient, your AMH levels might be artificially lowered even though your ovarian reserve is good (there is no solid proof for this statement!). And, this is the reason I measured my Vitamin D levels too when measuring AMH. 

After two days, I got my blood test reports from SRL. My AMH level was 1.6 ng/ml and my Vitamin D levels was 17ng/ml, while the minimum recommended Vitamin D level in blood is 20ng/ml. Need not to say that I was happy and hopeful again.  A value of 1.6 appeared very great when compared to 0.6.  My thoughts used to wander, and I would wonder, which lab result is correct! But, as per natural human tendency, my mind decided to stick with the more promising value.  I had only 12 more days for starting the stimulation. I was waiting for my periods so that I can measure my antral follicle count (AFC). I knew well that, AMH value could only be interpreted sensibly with antral follicle count (AFC). I was afraid, yet eager to know my AFC! I was wondering, what if there were only few antral follicles left!

You might ask whether I took Vitamin D to correct my deficiency. Again, I have a very different view of the whole Vitamin D story. I was in India, I was getting ample sunshine. I had no signs of Vitamin D deficiency. I read somewhere that 99% of Indian population is Vitamin D deficient. This kept me wondering! If 99% of Indians contain a particular range of Vitamin D in blood, then, which is the normal range for that population ( whether the value which occurs in 99% or the one in the remaining 1%) ?  There are not enough studies to show the normal range of Vitamin D for a healthy, Indian population. No one still knows how Vitamin D is processed by our body. People who live in places where sun light is meager, must have or must need mechanisms to store Vitamin D in body, so that they can utilize it during days where sunlight is not available. But, do people who live in tropical regions like India have such mechanism? If not, then what should be their normal blood levels? Nobody has the answer for these questions. After, all the initial hype about Vitamin D, and connecting its deficiency to almost all the diseases in the world, researchers have recently started to understand that, measuring Vitamin D or supplementing Vitamin D to a healthy person is not advisable. As more randomized clinical trials are performed, the results of such studies shows that there is no benefit of Vitamin D supplementation whatsoever, and some studies even showed a negative effect (17% increase in kidney stones!).  For further reading: To [Vitamin] D or Not to D? That Is the Question. After considering everything, I decided to not take Vitamin D. Since I had only 12 more days to start the stimulation, I was too chicken to change anything in my body drastically! Vitamin D has the ability to change the expression of 3000 different genes (not only AMH!) in our body and I didn’t want to take any invincible risks.

My periods arrived after making me to panic a little! Have you ever noticed this - when you don’t need it, it comes on time and when you are waiting for it there will be no sign of it? I went to a nearby scan center to have my antral follicles counted on day 3 of my menstrual cycle.  I was too nervous. I entered the scanning room and there stood a lady doctor and her assistant. I told them that they must measure my antral follicle count, ovarian volume and make sure my uterine lining is thin and the cavity is free from any abnormality. She asked me where the doctor’s prescription was. I said, I don’t have one, I do my IVF in Mumbai and my Dr emailed me that I should measure all this. She looked at me uninterestingly and said, we do only follicle tracking studies. I had no energy to argue with her or teach her about IVF and the importance of measuring AFC! She was not ready to hear any of my lectures too; there were so many people waiting outside. She was still looking at me as an unwanted intrusion. The assistant was smirking. I felt so helpless and then I literally pleaded them, please do what I say. Since I have to do IVF, I need all these details. I must say that the scanning machine they had was excellent. The lady doctor counted my antral follicles. Unable to control my curiosity, I asked her, do I have antral follicles. She said 8 on one side and 10 on the other. I was so happy; I forgot how they behaved with me. With a broad smile I thanked them and came out, ignoring their strange looks. I waited for some time to get the results in hand. From the beautiful picture of my ovary they gave me, I counted my AFC once again. The result read: one of the ovaries is bulky – possible PCOD! I was too happy to have PCOD or anything that could give me more follicles and more eggs. I thanked my ovaries. Immediately after reaching home, I conveyed the results to my hubby and Dr. Malpani. I started to eagerly look forward to go to Mumbai- our happy vacation after staying away from each other for so long !
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