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Tuesday, May 20, 2008

Barren Advice: Five

This is the fifth installment of Barren Advice. You can ask questions that are fertility or non-fertility related.

Barren Advice is posted each Tuesday. If you have your own question for Barren Advice, click here to learn how to submit. Please weigh in with your own thoughts in the comment section and indicate which question you're addressing if there are multiple questions in the post.

Dear Mel:

I have a history of recurrent pregnancy loss and am currently 5 weeks pregnant. I'm taking 200mg prometrium suppositories three times a day. If this pregnancy fails, will the prometrium cause a missed miscarriage?

--Antigone from Antigone Lost

It's a complicated question because not only does every body respond differently to the medication, but so many other elements--both known and unknown--contribute to how our body deals with a loss. Boiling it down to the most basic level, Prometrium does not trump all other functions or hormones. It is not powerful enough to hold the body at bay: there are women who bleed regardless of Prometrium (either related or not related to a loss) and there are those who do not.

Prometrium definitely can delay a period if the cycle is going to end regardless, which is why REs run a beta at the end of the cycle to know definitively your status before stopping the medication. There are those who are given the advice to keep taking Prometrium until their period arrives, but this isn't the correct use for the drug. Prometrium may not delay a period in everyone but as a progesterone supplement, it will certainly delay a period in a large portion of women since the drop in progesterone is one of the signals to your uterus to lose that uterine lining.

With loss: if one of the reasons for early loss is low progesterone, then Prometrium can aid the body in maintaining the pregnancy. If the reason for early loss is not tied to low progesterone, taking additional supplements is not going to maintain the pregnancy. Which is when we come to the situation you asked about--can Prometrium cause a missed miscarriage; in other words, can Prometrium keep the body from letting go of an embryo that is already lost?

I consulted with a doctor to answer this question and these are her thoughts:
Generally progesterone, either natural or artificial, simulates a luteal phase. This phase promotes a secretory endometrium in the normal menstrual cycle which is best for implantation.

The practice of giving progesterone in early pregnancy in the face of low progesterone levels is supposed to decrease the likelihood of loss due to poor implantation or poor development of a nice hospitable lining. The lining matures under progesterone's influence.

So about missed miscarriage. Progesterone can indeed make it more likely that you will not bleed after a 1st trimester loss, but it is not the only factor since people not on exogenous progesterone still have missed miscarriages until the conceptus stops producing enough hormone to trigger the uterus to expel the tissue.

Thus progesterone can make it more likely but it is not the only factor.
And I'll just add that I hope this isn't a situation you have to deal with this pregnancy. Sending many good thoughts to you.

Dear Mel:

Lately, I have been really trying to read a lot more blogs, be present, be available to other women who struggled with IF or are still struggling. In doing that, I knew that I would be reading things that would be about things not quite working out for some couples. I thought I was really ok with that, when we were still struggling I know that some people wouldn’t want to read about how we our IUIs failed or the decision we came to try IVF. I know that in the world of IF--as in the greater world--there would be stories of success and stories of failure. I am, by heart, very sentimental and emotional and in knowing that about myself, I knew that reading about both the good and bad would touch my heart for lots of different reasons. I guess what I am trying to say is that I thought I was prepared for the failure stories and could read them with a heart that could take it.
I am not so sure these days (and it really bothers me).

I am feeling a whole lot of survivor guilt, enough that I am crying almost daily about other couples and their losses. I wonder if I should step back from the blogs and then I feel even more guilt, because I truly want to “be there” for other women, to show them the same kind of support they showed me. Yet, when I read about the losses, I can’t comment, there is nothing in my heart or mind that is good enough to say and I can’t just forget them.


When the war started a few years ago, I stopped reading the newspaper and listening to NPR. It was too upsetting and it was affecting my whole day. The decision was definitely the best choice for my mental health. But how could I not think of the people who were over in Iraq who didn't have the choice to flip off a radio or stop buying the newspaper? The ones who couldn't blot out reality and go about their day--those serving our country or living in Iraq or the people they left behind at home? It felt like by not reading or keeping up with the news, I was turning my back on them. And certainly, there are those who will still agree with that statement regardless of what I write after this point.

My lack of newspaper reading is different from my unwillingness to watch movies that scare me including war movies, stories about serial killers, or child endangerment. I know my limits and I know how things affect me. And while some movies are not placed out there for entertainment value but to raise questions, awareness, and conversation, I still cannot take partake in watching them. Yet I don't feel badly about this even if I'm not supporting film makers or actors by carrying through on this decision--and they're real people too. It just feels different somehow.

As much as we are a community and part of being a community is taking support and giving support, at the end of the day, we also have to be for ourselves. Which is why I always believe that a person needs to do what a person needs to do in order to keep putting one foot in front of the other. If the stories of loss or cycle failure are affecting your day and the way you are living your life and the idea has already come to you that you may be better off stepping away, I would recommend stepping away. Either temporarily or permanently--whichever one brings you greater peace of heart.

At the same time, I return to the newspaper and film boycott. There is more than one way to support a person or group of people and I think that a one-size-fits-all approach only builds guilt. Some people are wealthy and can afford to contribute financially to causes and others feel guilty when they receive the same request for funds yet can't afford to participate. At the same time, some people have an abundance of creative energy and are great about pulling together a fundraiser whereas others simply don't excel in that area. I can support our troop by reading about the war, or I can participate in numerous programs established to support the troops or their families back home.

Reading their blog is simply one way to support a person. But there are so many other things you can do that also show support or bring comfort. It is harder to come up with a unique way to support a specific person--in other words, not a random group of those experiencing loss but specific people who are currently experiencing a loss who supported you through IVF. Harder, but not impossible. And sometimes, it simply takes time for the good idea to come to you, but I trust that it will.

No really, the beauty of a blog advice column is that you get to weigh in with your two cents too. Let the questioner know if you support the advice, add to the response, or dispute it completely.

Leave a comment in the reaction box below--only keep in mind that conflicting advice is embraced and rudeness is not. Make sure you indicate which advice you're addressing by numbering your comment with a 1 or 2. Want to ask your own question? Click here to see what you need to send in order to be included in a future Tuesday's installment of Barren Advice


Jen said...

Antigone, I also hope that you don't get to find out this time. You have been very much in my thoughts.

Anonymous, my thought is that you have to protect yourself before you can support other people. Otherwise you'll burn out and be no good to anyone! :) I know, if it were me on the receiving end, I would rather you didn't try to support me if it were too much for you. For example, I had my missed due date one day and then announced my new pregnancy the next day. I got almost twice as many congratulations. I totally understood that. It is so much more difficult to know what to say to horrible things. And it is okay with me if people step away from me if my situation is too much. The great thing about this community is that there is always someone able to support, even when I cannot.

calliope said...

wow- bravo Mel!
This was a truly outstanding column.

Anonymous- The thing about the failures and the bad news is that sadly there are other people in the thick of it that will rally around the woman in need of support. In fact sometimes the last person you want a comment from in times of loss is someone who isn't in the trenches.

It makes me so sad that women that have success have this sort of residual guilt, but this is what makes our community so effing beautiful. We are all so so empathetic with each other.

Thank you for sharing your feelings here- it actually was pretty therapeutic for me to read.

K. said...

Anonymous - Emotions are a funny thing, aren't they? Even though we all know perfectly well this isn't a zero sum game, that one person's success isn't hinged on another's loss, it's still hard not to feel guilt or jealousy about those on the other side of the fence. As someone who hasn't yet had success, there are days when the stories of others' victories against infertility are inspiring and give me hope, and other days when those same stories are a painful reminder of what I don't have yet. It sounds like what you're feeling is sort of the flip side of that. We are all part of the infertility community and have shared a lot of the same pain and frustrations, but at the same time there's a reason why infertility forums will have separate sections called things like "primary infertility", "secondary infertility", and "pregnancy after IF". On those days when we're feeling the most vulnerable, sometimes we just want to be around those whose current situation most closely matches our own. As long as those days aren't most days or every day, I don't think there's anything wrong with that. If the blogs of those still struggling are too painful for you to read or comment on, then don't. No one should hold that against you.