It's That Time Again!

Wednesday, July 16, 2014


It's Wednesday, but it's technically my Thursday because I am taking off on Friday! HURRAH! I haven't had much time to blog this week because my brain is in 947 different places between trying to wrap up things at my job and oh, we're also buying a house on Friday, so that's kind of a big deal. So, since it is Wednesday, it's confession time with Kathy from Vodka and Soda!

Vodka and Soda

Last Friday, I said that I met with some new doctors and now had a lot to think about, and then I ended my post because I am cruel. Well today, I'm going to talk about that. Settle in, it's a doozy.

About a year ago, I met with Dr. S, a reproductive endocrinologist. I had just had my second laparoscopy for endometriosis, and my gynecologist who did the surgery was strongly suggesting that I take Lupron again.

Pause.

For those of you who are unaware, endometriosis is a condition where the lining of the uterus grows in places it's not supposed to grow, like everywhere in your abdomen and pelvis. It's extremely painful and can cause infertility, but they don't really know why. The treatment is often birth control pills to help control the hormones, but the only way to get rid of the growths is to have them surgically removed. Except they grow back. So that's fun. Lupron is a drug that induces menopause, which is the only "cure" for endometriosis (besides pregnancy, which is just so adorable since many people with endometriosis can't get pregnant. Thanks, nature.)

Okay, unpause.

Anyway, I had been on Lupron in 2005 after my first surgery and to put it mildly, it sucked. If your mother ever complained about menopause, let me tell you, she had every right to do so. Hot flashes and night sweats, along with weight gain and crazy mood swings are NO JOKE. After 6 months of hell, I said enough was enough and stopped taking it. Unsurprisingly, I was not totally enthused to try that drug again. My doctor was being really pushy and I didn't like it, so I sought a second opinion with Dr. S at Penn. He was quite lovely and after looking at my records and listening to my history, said that he wouldn't require a patient like me to go on Lupron, especially since I hated it so much, and that the only risk I might face was that my endometriosis might come back, but that was a risk anyway. I was thrilled. No Lupron for me!

Then Dr. S asked if Ken and I were thinking about having kids, and I told him that we weren't ready to do that yet. He (gently) impressed upon me that idea that younger is better, as far as fertility is concerned, especially when the patient (see also: me) has reproductive issues like endometriosis (and PCOS, for extra fun). He also remarked that since I had just had the endometriosis adhesions removed, now was probably the best time to try and get pregnant. I politely declined to do that and said we'd be back if we changed our minds. He ordered some genetic testing for the Jewish genetic diseases, just because I think he thought he needed to do something besides tell me I didn't have to take a drug, and I went on my way.

Pause again.

PCOS, also known as Polycystic Ovarian Syndrome, is a poorly-named metabolic disorder. It was named back in the day when the hallmark of the disease was thought to be, you guessed it, lots of cysts on the ovaries. That can still happen. However, the diagnostic criteria for PCOS now are insulin resistance, hormonal imbalance, and irregular periods. I was diagnosed about 2.5 years ago after gaining 40 pounds in 3 months, having a lot of my hair fall out, growing hair in weird places, and having wildly high cholesterol. I was put on some meds for the insulin resistance, started thyroid medication (because apparently, I also have hypothyroidism), and subsequently lost almost 50 pounds. And my hair stopped falling out. Yay. PCOS is problematic for a number of reasons, but reproductive-wise it is an issue because many women with the disease don't ovulate, and as you can imagine, no ovulation means no baby. No bueno.

Unpause.

So, on top of endometriosis possibly making it impossible for me to get pregnant due to scarring from adhesions, blockage of ye olde plumbing from endometrial growths, or damage to the organs that are important for baby-making, I might not even ovulate. We won't know until I get off the pill and start trying to do this baby thing.

Of course, this is further complicated by the fact that, oh by the way, I have some unknown autoimmune disease that is either RA or lupus, so I'm on a lot of medications that are completely contraindicated if you'd like to grow a human. Isn't this fun?

Ken and I knew that we wanted to have kids way before we got married. In fact, we talked about kids on our third date. Yes, our third date. No, he didn't run screaming. It was impressive. We also knew that we wanted to wait at least 2-3 years after we got married to bring a baby into our lives, mainly so we could enjoy being married and get the hang of that whole thing for a bit first. When we talked about how old we thought we'd be when we became parents, we said, "Oh, 28... 29... 30. Somewhere in there." Suddenly, we were married for almost 2 years and we were both approaching that magical age. And yeah, we still wanted kids. Yes, even though I'm going to be in medical school. More on that later.

Anyway, I knew from the start that this wouldn't be a case of simply throwing the birth control out the window and, for lack of a better phrase, getting down to business. I knew that I would need guidance from my (multiple) physicians with getting off of my medications and possibly to even get  pregnant. This was not going to be spontaneous and romantic, this was probably going to be more like a science project. Whatever, I was determined to be positive about this! And also terrified. But hey, you can be afraid and you can do it anyway, right? Right. So, I went back to Dr. S.

To say he was surprised when I sat down in his office and told him that Ken and I were ready to start a family would be an understatement. He was, of course, very pleased with our decision. We went over a few things, including my multiple medications, and he expressed his concerns. I was surprised when he said that he wasn't very concerned about the endometriosis/PCOS issues. In fact, he said that he has had many patients with similar histories to mine in that regard, and they were able to get pregnant very easily with very little intervention, if they needed any at all. He said that the bigger issue to him was the autoimmune disease and how I wouldn't be able to be on any of the strong, good, medications that had been controlling most of my symptoms. This roughly translates to, "You're probably going to feel like absolute garbage, and since it might take you awhile to get pregnant, that might suck. A lot." He even suggested that if we wanted to be super aggressive, we could go straight to IVF and try to get me pregnant as fast as possible. I said that at this moment, no, we did not want to be super aggressive and instead would like to try this the old-fashioned way first. Because he is a sane, nice, understanding man, he said that was fine... but that if I wasn't pregnant after 3-4 months, he was going to investigate the plumbing and see what was up. I'm okay with that.

I'm not sure what else I thought he'd do that day, but he referred me to the Maternal Fetal Medicine department at Penn because I'm automatically considered a high-risk pregnancy due to the autoimmune disease. Last Thursday, I met with Dr. E and her resident and fellow physicians, and they were all really great. I spent about an hour with the resident and fellow, during which they took an extremely detailed history, and then we went through all of the risks to me and potential baby... of which there are many, of course.

For me, there's an increased risk of pre-eclampsia (high blood pressure, protein in the urine), which is a precursor of eclampsia (seizures during pregnancy). The only cure for pre-eclampsia is to not be pregnant, so... yeah. There's also an increased risk of Preterm Premature Rupture of Membranes (PPROM), which is when the amniotic sac breaks way earlier than it should, and there's an increased risk of my autoimmune disease flaring, which would lead to anything from increased pain to organ damage and hospitalization. I also am at an increased risk of development gestational diabetes because I am already insulin resistant from the PCOS. For potential baby, there's an increased risk of being born small, preterm, or being stillborn. Aside from that, it should be totally fine...?

After that joyous conversation, I met with Dr. E and she went over my meds again and we set up a loose plan for going forward. I stopped taking my methotrexate back in June after discussing potential babies with my rheumatologist. Methotrexate is a Class X drug for pregnancy, which means under no circumstances can you take it, period, end of story. This makes sense, since methotrexate stops rapidly growing and dividing cells from doing so. Since growing a human requires that the cells grow and divide rapidly, stopping that process would be... less than ideal. Methotrexate tends to hang out in the body for awhile, so I have to be off of it for a few months before trying to get pregnant. Within three weeks of stopping the MTX, I started to feel my symptoms coming back. Morning joint pain and stiffness returned with a vengeance, and since I am 307 years old, I now have what appears to be bursitis in my hips. I have had a few low-grade fevers, and two face rashes, and I can tell my fatigue is getting worse. Last week, I stopped the Orencia, which is the injectable drug I started a few months ago. I wasn't sure it was actually improving my symptoms when I started it, and to be honest, I haven't felt any worse having not taken it last week, but again, it's only been a week.

The rest of my meds are ones that I can stay on until I am actually pregnant, although there is some debate over whether Dr. S will want to take me off of the Metformin (a diabetes drug that I am on for my insulin resistance). I would really rather stay on the Metformin if I can because it controls my PCOS symptoms really well and it is safe for use during pregnancy, but I will obviously defer to my docs. The only things I'll have to stop taking are my allergy med with the decongestant (no pseudoephedrine for developing fetuses, apparently), my NSAID (so sad about this... no Aleve, no Advil, and no Mobic!), and my cholesterol lowering med (because cholesterol is necessary for baby-growing). Oh, and the birth control pill, obviously.

I can stay on the non-decongestant allergy medication, Prilosec (for acid reflux), and Plaquenil, which is a drug for the autoimmune disease. Thankfully, I can also take Fioricet for my migraines if necessary, and I can keep getting my trigger point injections. I also was told, under no uncertain circumstances, to continue drinking 1 cup of coffee a day, even if I felt like I was going to barf, because the caffeine would help keep the migraines away, haha. Yes, ma'am!

l was surprised to find out that I can actually stay on my antidepressant, and in fact, it's recommended that women with well-controlled depression prior to conception stay on their SSRI's. Apparently, depressed women don't make healthy babies, and both mom and baby have worse outcomes following pregnancy when the SSRI's are discontinued. There is, of course, a risk to staying on them, the main ones being pulmonary hypertension of the newborn (which is apparently transient) and possible symptoms of withdrawal (also transient). Yet another thing to consider.

So, I left that office with instructions to see my rheumatologist, and it was at this point that I asked myself why my doctors' appointments always seem to breed more appointments. Then I decided not to ponder that further because it wouldn't get me anywhere, and instead called my rheumatologist. We had a semi-confusing discussion about stopping the Orencia, but in the end, he approved it and basically said that I would probably feel like crap and that we would deal with that if and when it happened. Thank God for prednisone, is all I have to say.

The other fun (?) part of all this is once I'm actually pregnant, we have no idea how my autoimmune disease will act. Since we're not sure if I have RA, lupus, or some strange mix, it's hard to predict what will happen. Women with RA often have remittance of symptoms during pregnancy, then flare immediately after, while women with lupus often get sicker during pregnancy, as well as in the post-partum period. It's yet another "wait and see" kind of thing. We all know how much I love those...

I also had to make an appointment with a new gynecologist who is a part of the Penn practice, because the rest of my doctors are over here and if and when the time comes, I will need to deliver over here anyway. Of course in typical Penn fashion, the first available appointment when I called yesterday is 9/24, so thank God it's not any kind of emergency...? Oh academic medical institutions... you slay me.

Questions? Comments? Concerns?

Let me address the elephant in the room. (Hello, elephant. Nice to see you. Okay, I'm done now.) But seriously, yes, I am considering getting pregnant, on purpose, while in medical school. No, I am not completely insane. Well, probably not, anyway. In fact, the physicians I've spoken to (both male and female) advocate for having babies during medical school over having them during residency, and I certainly won't be the first person to produce a child while attending medical school. In fact, I know a woman who had 2 of her 5 babies while in med school, and she lives to tell the tale. (Her kids are absolutely precious, too, haha.)

But yes, I am aware that this is kind of a crazy proposition. That being pregnant is hard, and that med school is hard, and doing both at the same time may make me wish that I were dead. I am aware that babies are expensive. I am aware that I will not have a lot of time to spend with said baby once it arrives. However, I also know that I don't want to wait until I'm finished medical school in 2018 to start trying to have a baby. I will be 32 when I graduate, and it is really ill-advised to have a baby during your first year of residency, so we'd be waiting until I was 33. Given the fact that it's probable that I will have problems conceiving, I don't want to be running up against the magic age of 35, at which point risks of all kinds of things shoot up. I also know that I am fortunate enough to have my mom nearby, and she has already volunteered to help as much as she can with potential baby. I also know that Ken is an amazing man who seriously wants to be a dad, and so while I don't know what parenting will be like (since I haven't done it), I know that Ken and I are on the same page with how we want to do it. At the very least, we know we want to tackle it together.  

Not for a minute do I believe that any of this will be easy, or even very fun. But I do believe that if I am meant to be a mom in this way, that it will work out. I know that I'm staring down the barrel of a lot of potential complications, but I have a great team of physicians and a supportive husband and family. I'm also ready to 86 the entire plan and move to alternate plans for becoming parents if I get too sick trying to get pregnant or if my body basically refuses to cooperate. Ken and I are both 100% okay with adopting if we can't have our own babies, and while we'd rather be able to do this "the normal way" (whatever that means), the important thing to us is being parents, not how we get there.

How do I feel about all of this? Terrified. Excited. Nervous. Anxious. Overwhelmed. Worried. Hopeful. Crazed. It's a lot of things. One thing it definitely is not is boring.

So that's my big confession this week. We're thinking of having a baby. We are moving towards starting the process of having a baby. I solemnly promise that this will not turn into a baby blog. Pinky swear.

That seems like enough news for now. In addition to linking up with Kathy, I'm linking up with Shanna for Random Wednesday. Yay random!?



Have a good day, all. I'll be over here deeply breathing and trying not to murder anyone from the mortgage company. More on that later.

- A

4 comments:

  1. If it turns out that you need another RA/Lupus medicine while you're pregnant, I take sulfasalazine along with plaquenil for my RA, and they are a great combo. It looks like sulfasalazine is class B, so unless you're allergic to sulfa that might be a good option for you. Good luck with everything!!

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    1. (from @hannahvaughn33 on twitter)

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    2. Hey Hannah! Glad you found me here! Also, I definitely will mention the sulfasalazine to my rheum in a couple of weeks. My MFM docs said that I can definitely take it, so hopefully it will help! Thank you so much for reading. :)

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  2. I have PCOS as well and I'm not even in a relationship. I definitely want children but I have to wait (like you said) for the right time but good luck with the baby making....

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