Wednesday, July 19, 2006

Thyroid Autoimmunity and Miscarriage

Mark F Prummel and Wilmar M Wiersinga, "Thyroid Autoimmunity and Miscarriage," European Journal of Endocrinology (2004) 150: 751-755


To ascertain the strength of the association between thyroid autoimmunity and miscarriage…A CLEAR ASSOCIATION BETWEEN THE PRESENCE OF THYROID ANTIBODIES AND MISCARRIAGE WAS FOUND…This associaion may be explained by a heightened autoimmune state affecting the fetal allograft, of which thyroid antibodies are just a marker. Alternatively, the association can be partly explained by the slightly higher age of women with antibodies compared with those without…A THIRD POSSIBILITY IS MILD THYROID FAILURE, as thyroid-stimulating hormone (TSH) levels in antibody-positive but euthyroid women are higher than antibody negative women…"

Treatment Recommendations:

"It is possible that the association between thyroid antibodies and miscarriage has to be explained by a general increase in autoimmunity against the fetal allograft. If this were to be the case, there are almost no theraputic interventions to offer these women. The two other explanations, i.e. MILD THYROID FAILURE or the TPO antibodies themselves DO HOLD PROMISE FOR SUCCESSFUL INTERVENTION. The higher TSH values in antibody positive women warrent a randomized clinical trial to evaluate the effect of T4 substitution therapy AIMING AT TSH VALUES BETWEEN 0.4 AND 2.0 mU/L." *

* Emphasis in ALL CAPS is mine, not the authors'.

Folks, I am one person, not a randomized clinical trial. But I would just like you all to know that I tested positive for thyroid antibodies before my first pregnancy and was diagnosed as "euthyroid," that is as having subclinical thyroid disease. Yet my TSH levels were never monitored carefully until my 4th pregnancy. With each of my 3 losses, by the time my TSH was tested it had already climbed to anywhere between 6 and 10 mU/L.

Not that I'm the slightest bit bitter or angry at all the doctors who claimed my thyroid disease was way too mild to be the explanation for my 3 losses. But I beg you, if you're having recurrent miscarriages:

1-GET TESTED for THYROID ANTIBODIES. Do NOT just let them test your TSH. Lots of docs are too conservative and think anything under 5 is fine. Some even say anything under 10. SO FIND OUT IF YOU HAVE THYROID ANTIBODIES.

2-If you test positive for antibodies & are diagnosed with mild hypothyroidism, please, please, please know how important it is to keep that TSH UNDER 2 from the very beginning of the pregnancy.

3- "T4 substitution therapy," the cure for this disease, involves nothing more than taking 1 tiny pill a day to "substitute" synthetic thyroid hormone for the body's deficit. Give your body the hormone it needs and TSH (the hormone that stimulates the body to make thyroid hormone) falls to safe levels. Keep a close eye on those levels because your body's needs can fluctuate very rapidly. Repeat: keep TSH under 2. Voila. Wait 9 months and enjoy your baby.

I love my Turtle soo much, but I will never stop wishing those first three could have stayed with me. This is such a ridiculously easy thing to fix, it's amost incomprehensible that I went through such suffering before it was addressed at my stubborn insistence.

Monday, June 26, 2006

The Voice of the Turtle

My due date was today. But because the apparent cosmic purpose of my years of infertility was to make me forget about clocks, calendars, and stopwatches, let go of the last illusion of control created by the industrial revolution, and bow instead before nature's timescale, I am neither in the hospital, nor in labor, nor anywhere near giving birth.

On the contrary, I am the exhausted, ecstatic mother of a one-month old. Yes, my little trick-or-treater decided to arrive a month early. And, continuing my temporal rehabilitation, the baby has decided to sleep all day and eat all night, so that, although the computer claims it’s 5 PM, I am sitting here with a nice glass of orange juice and a bowl of granola, rubbing the dust from my eyes, while my sleeping baby coos occasionally beside me.

I thought I owed it to you all to let you know how the story starts. I still cannot say what I will make of this blog. I have really really been helped by the process of reading and writing blogs. At the same time, it has taken time from my life and my work that I certainly can’t afford in an industrial sense, and maybe shouldn’t give at all…

But at the very least, I wanted to offer a vision of myself and the baby as we ride off into the sunrise together. We live in an age too cynical for happy endings. But I have to say that this has been an extraordinarily happy beginning.

I was prepared for sleep deprivation, colic, baby blues, post-partum depression. I had primed myself with the understanding that motherhood is not all it's cracked up to be, that the joys of maternity have been gravely exaggerated by right-wing fanatics who want women out of the boardroom and trapped in boredom.

I was utterly unprepared for the sheer primal joy of holding the warm weight of a living child against the gaping, aching hole infertility had carved in my chest. I did not count on the sense of awed wonder of holding close a little body that I created and carried in my own, of leaning down to breath in the golden, baked-hay scent of baby skin, of brushing my cheek against silken baby hair, of gazing into my own baby’s face and loving every pimply, rashy inch of pink skin, of laughing with delight at every fart and burp. A baby is a feast for the senses, a salve for the wounded soul. I did not know that love could feel like this. I’ve been blindsided by joy. And I wish, really, that time could just stop right here.

"For, lo, the winter is past,
the rain is over and gone;
The flowers appear on the earth;
the time of the singing of birds is come,
and the voice of the turtle is heard in our land."

P.S. A bit about my treatment: I never received any medical explanation for my unexplained recurrent miscarriages. This successful pregnancy occurred without treatment of any kind.* Except. When I first began trying to conceive more than three years ago, I was diagnosed with Hashimoto's Thyroiditis, an autoimmune thyroid disease. I personally believe (and there are European studies to back up this possibility) that under treatment of my thyroid disease with inadequate levels of thyroid hormone replacement could be the explanation for my earlier losses. With this pregnancy I insisted on WEEKLY testing of my thyroid levels through the end of the first trimester (unheard of frequency in endocrinology circles, but Dr. Cookie-Pie, my RE, was at a loss for anything else to do and agreed to humor me) and found I needed to increase my thyroid hormone dose regularly, until I reached a dosage about 1/3 greater than before the pregnancy. (Once my TSH levels seemed to stabilize, I tested once/month for the rest of the pregnancy.) My doctors *do not* believe that this explains the success of this pregnancy. They say vague things like, "your body finally figured it out." But I think that *I* finally figured it out and I want to offer up this shred of a possible explanation to any other recurrent miscarriers who might be able to use it...

*You may recall the use of a little supplementary progesterone, true. But this was the first pregnancy in which there was any indication I might need it. My hormone levels have always been fine; we did it as a precaution this time due to the spotting, which I now think was caused by 1- the rough internal exam I was given on 10/31, before we knew there was a heartbeat and 2- the baby aspirin that I was briefly on initially (on my RE's advice on the off chance that it would help, despite the fact that a hematology consult turned up no evidence of a clotting disorder). In other words the unnecessary aspirin cancels out the unnecessary progesterone, meaning that this pregnancy needed nothing but synthroid.

Monday, May 15, 2006

If a Tree Grows in the Forest…

After 5 months without posting, I do not know if there is still anyone out there who would hear it if a tree fell in my forest. But I can’t resist making a joyful noise today to say that—on the contrary—the tree is growing very well indeed.

I am now exactly 34 weeks pregnant. At my OB appointment this morning, my doctor told me that if I were to go into labor now, they would do nothing to stop it. While the baby is not yet technically “term,” he is developed enough that he would not just survive but thrive if born now. Wow.

Afterwards, on the street, I ran into my RE, Dr. Cookie-Pie, the first time I’ve seen her since early December. She was thrilled at the sight of me, but actually kept repeating, “I can’t believe it.” She said, “as soon as we get this baby delivered we’re going to have to send you on the speakers’ circuit to give inspirational lectures to all the women who are on the brink of giving up hope.” It was a little disconcerting to have my main medical support person regarding this pregnancy as something close to miraculous, but at the same time it validated my own ongoing sense of pleasurable disbelief.

Once the nausea wore off completely (at about week 16) I began what, at least from the outside, seems to be an entirely normal and complication-free pregnancy. And though I have mostly spent it holding my breath, nothing of note has occurred. Even my moods, always so mercurial, have been remarkably stable.

It is just now hitting me that the long longing may at last be nearing an end. While I will always think of myself as infertile, I may soon be stripped of the title “Her Barreness” on account of having a babe in arms.

I feel filled now with hopes and fears: hopes for a new life of love and a new sense of grounding, fears about labor and delivery, about the possibility of post-partum depression, or even just garden-variety psychic disorientation. I’m afraid of the fact that life will never be the same, and afraid even of the fact that I may not wish it could be. I can’t wait to meet the little person I carry in my body, but I am anxious about getting to know the person I myself am about to become.

So, in this time of transition, I find myself filled with the urge to reach out to all those who helped me to get to this point. So many wonderful flesh and blood friends have stepped up to share this time of joyful anticipation. But it’s the virtual folk out there in the ether who were there with me through so many truly dark days. I want you to know how grateful I will always be for that fellowship and how often I think of you all, vivid characters in a story we wrote together.

If you’re still struggling, please know that while nature may be maddeningly inefficient, (and when it comes to human emotion horribly indifferent) you can also always count on what Kahlil Gibran called “life’s longing for itself.” You may remember a piece I wrote last spring about the doomed maple saplings springing up all over the lawn. What I didn’t mention then is that a few also took root in an abandoned flowerpot. They sprouted there for a month or more until finally the summer heat withered them away. I never watered them, much less transplanted them. I was angry at empty symbols and unwilling to lavish care on mere plants when my own womb remained a dry and desolate place. So imagine my bemused surprise this past weekend, when I uncovered those same pots under a pile of dead leaves and found growing there some very sturdy-stemmed maple saplings. Somehow, it seems, the roots had survived when the first year’s leaves died.

I don’t know what exactly my plans are, if any, for the continuation of this blog. But I wanted to leave a note for any old friends who might happen by, just to say thanks, I’m still here, and I’m almost in the clear.