Noted

We had our consult with Dr. Smiley today, and we emerged feeling pretty good, considering that all is not sunshine and rainbows. I had a list of questions that we took with us -- and one of the reasons I left feeling good is that he complimented me on the thoroughness of the list! -- and rather than try to develop a tight narrative that stuns you with its precision and beauty, I'm going to copy over my questions and scrawled notes.

Thanks to Shelli and Liza who reviewed the list before the appointment, making suggestions for improvement, and Shannon* who tipped me off to AMH testing, which earned me BIG smartypants points with Dr. S!

Is the elevated FSH a real problem or possibly a fluke?
Perhaps both. Anything over 10.2 worrisome, but FSH "pulsile hormone": can't ever know whether you caught it at peak, low, or somewhere in between. Stressed that researchers hypothesize high FSH may indicate fewer eggs, but no way to determine egg quality. FSH levels not adversely affected by stress, diet, other lifestyle factors.

Could prolactin be interfering with the FSH level?
Prolactin only lowers FSH levels. Not a factor after 6+ months of breastfeeding. He is totally unconcerned by nursing. (Note to self: did not ask about nursing while on injectables or other IVF meds!)

Is there any point in checking other things – inhibin B? AMH/MIF? Antrals? Thyroid? Clomid challenge? [Ed. note: no fucking way am I going near clomid after so many stories of psychosis!!!!]
All crude measures which (except Clomid challenge) could corroborate diagnosis of diminished ovarian reserve (DOR). No point in Clomid challenge if FSH is already ^. Injectables can serve both as a response to DOR and a way to determine how bad it is. If respond with 3-4+ follicles, reserve is OK. If respond poorly (0-2), screwed.

Generally speaking, what do you do to address elevated FSH?
Not Clomid (see above) [Ed: Yay!] W/ ^FSH, tends not to help ovulation but does usu. mess up lining.
Injectables, but beware risk of multiples.
Best plan: IVF because reduces risk of +++s

Mother’s fertility as predictor? Impact of previous pregnancy on odds of success?
Mother's fert can only be used as negative predictor
Previous pregnancy indicates presence of some good quality eggs [Ed: Except that whole molar mess.]
In my case, Mom's fert. at 40+ and my own fert history is encouraging but not necessarily predictive.

Let’s develop a plan to maximize odds for the 87 remaining vials:If needed, repeat FSH testing on CD3 next cycle. No need for AMH or inhibin B testing yet. Check antrals.
If either reveals further problems, ramp up plan to next step. Perhaps test anti-thyroid antibodies.
If FSH no worse and decent antrals, keep on keepin on 2-3 mo.
Then, inj. and/or IVF.


*Get a blog, woman! You are too damn funny not to be blogging!