Macrophage colony stimulating factor- yes/ no?

http://en.m.wikipedia.org/wiki/Macrophage_colony-stimulating_factor
" Additionally, high levels of CSF-1 expression are observed in the endometrial epithelium of the pregnant uterus as well as high levels of its receptor CSF1R in the placental trophoblast. Studies have shown that activation of trophoblasitc CSF1R by local high levels of CSF-1 is essential for normal embryonic implantation and placental development. More recently, it was discovered that CSF-1 and its receptor CSF1R are implicated in the mammary gland during normal development and neoplastic growth.<sup>[5]"

http://www.hindawi.com/journals/mi/2012/967629/
"</sup>While much research has been dedicated toward circulating cytokines in pregnancy, local cytokine production at the maternal interface may be of greater significance than measurements obtained in the peripheral blood [23]. IL-4, IL-10, and macrophage colony-stimulating factor (m-CSF) production by T cells at the maternal fetal interface is associated with successful pregnancy [23]."

^{http://www.drugs.com/sfx/neupogen-side-effects.html
"}Oncologic effects may occur due to filgrastim (the active ingredient contained in Neupogen) effect as a growth factor with any myeloid tumor.^[Ref]" 

http://www.neutropenia.ca/about/patient-evaluation-and-treatment/treatment-for-severe-chronic-neutropenia
" The SCNIR collects information on SCN patients and pregnancy; however, the number of pregnancies reported to date is relatively small and thus little information is known about the potential effects of G-CSF during pregnancy. Therefore, the use of G-CSF during pregnancy should be evaluated individually with your primary physician, who can weigh the currently known risks and benefits of treatment in the context of your individual situation. Because the safety of G-CSF administration during pregnancy is not yet established, the current recommendation given by the experts of the SCNIR is that if possible, G-CSF should be avoided or minimized during the first trimester. You should discuss this issue with your physician well in advance of any decisions regarding pregnancy. It will then be possible for your physician to review the current pregnancy data with you and develop a plan for G-CSF dosing."

http://www.ptglab.com/Products/G-CSF-R-Antibody-18310-1-AP.htm
" GCSF receptors can be found on neutrophils, myeloid leukemia cells that respond to GCSF, bone marrow cells of neutrophilic granulocyte lineage, and on placental trophoblasts. "

^{http://chemocare.com/chemotherapy/drug-info/granulocyte-colony-stimulating-factor.aspx#.VKS6S38ayK1}



- csf and tropoblast growth factor
- Is there a growth factor for cancer cell? Does csf promote its growth?
- ehem ehem, why am I so particular with cancer. Hey, there is a risk for spleen rupture as well.
- anyway, if csf does not promote growth factor for cancer or tumor, i may give it a try
- wait... Csf promote white blood cell production or neutrophil only? I am thinking it will magnify my nk cell count. 



Ei.... My dear immunologist, I walk to have a long chat with you. Grrr.... I hate "neoplasm". Excuse me. I admit I am an ignoramus. To me, neoplasm is synonymous to tumor or cancer. Grrr... yes or no? Oh no... There gm-csf, gcsf, m-csf sounds like different things?  Google google...

Gonal-f, menopur, cetrotide drug interaction?

I feel dry eyes. A little blur vision. Oh my god...
http://www.ehealthme.com/Menopur-Gonal-f-Cetrotide-3735486

My new year's resolution- avoid stress

What is my new year's resolution? How to avoid stress? I cannot think of solution other than resigning from work. Family business is where my life and work integrates. I cannot stay away from mental stress. I am a short tempered person.

1. Office work at home.
2. Eat less red meat.
3. Eat more fruits and vegetables.
4. Learn to cook.
5. Eliminate processed food in my diet.
6. I wish to have three- week intensive yoga before embryo transfer. (Not everyday... Let us see.). Try to exercise more?
7. 7 pm dinner, sleep at 10pm. Ai... Bad influence husband always sleeps very very late.
8. Less coffee
9. Less sweets

---- "Steptoe and Brydon speculate on the reasons why acute stress responses may raise fasting serum lipids. One possibility may be that stress encourages the body to produce more energy in the form of metabolic fuels - fatty acids and glucose. These substances require the liver to produce and secrete more LDL, which is the principal carrier of cholesterol in the blood. Another reason may be that stress interferes with lipid clearance and a third possibility could be that stress increases production of a number of inflammatory processes like, interleukin 6, tumor necrosis factor and C-Reactive protein that also increase lipid production. "
http://www.medicalnewstoday.com/releases/34047.php

" What are the harmful health effects associated with stress-induced obesity?
Chronic stress can contribute to several harmful physiological events. When body tissues are exposed to high levels of cortisol for extended periods of time, some cellular and tissue alterations may occur. High levels of cortisol cause fat stores and excess circulating fat to be relocated and deposited deep in the abdomen, which left unchecked can develop into or enhance obesity. In addition, hypertension (high blood pressure), hyperlipidemia (elevated lipids), and hyperglycemia (elevated glucose) have been linked to elevated cortisol levels (10,14). Individuals with a high waist-to-hip ratio (which identifies visceral obesity) are at a greater risk for developing cardiovascular disease, type II diabetes mellitus, and cerebrovascular disease (8)."
http://www.livestrong.com/article/272648-liver-function-and-cholesterol-levels/

"Metabolic and Long-Term Health Effects of Elevated Cortisol Levels

• Metabolic effect (cortisol-induced) Chronic health condition
• Increased appetite, accelerated muscle catabolism (breakdown), suppressed fat oxidation, enhanced fat storage Obesity
• Elevated cholesterol and triglyceride levels Heart disease
• Elevated blood pressure Heart disease
• Alterations in brain neurochemistry (involving dopamine and serotonin) Depression/anxiety
• Physical atrophy (shrinkage) of brain cells Alzheimer's disease
• Insulin resistance and elevated blood-sugar levels Diabetes
• Accelerated bone resorption (breakdown) Osteoporosis
• Reduced levels of testosterone and estrogen Suppressed libido (reduced sex drive)
• Suppression of immune-cell number and activity Frequent colds/flu/infection
• Reduced synthesis of brain neurotransmitters Memory/concentration problems http://cortisolconnection.com/ch6_1.php

What to do next if I have implantation failure?

I pray I am not buying false hope on my immunologic treatments. Shhh... I dont believe much in HLA tissue crossmatch. But, I follow religiously my immunologist instructions because I have autoimmune disorder. What to do next if those don't implant?

- neupogen?
- pgs? To detect unbalanced chromosome translocation only. Unbalanced chromosome translocation- no implantation. Down syndrome does not cause implantation failure. I don't believe much in pgs. Mosaic down syndrome maybe undetected by pgs, because we are playing lucky pick on cell sampling.
- fibroid removal? < 2 cm.  I remember morcellator was recalled. Fibroid removal may cause cancer.
- polyp? < 0.3 cm
- blocked left fallopian tube? Not sure...i guess this may cause ectopic pregnancy. Implantation per se, there will be implantation (on the fallopian)

Whatelse, pls share some inputs. On spiritual aspect, I had my pilgrim already.


http://humrep.oxfordjournals.org/content/21/12/3036.full

My christmas giift and neopogen guinea pig

Today is Christmas day. I am stucked in my mom's house for five days. Nothing to do here- just blogging and doing some reflections. Btw, What is my gift from God? I hope the seven embryos are indeed a gift of God. I hope this entails implantation.

According to the nurse, my 5 embryo are of outstanding quality. I don't want another false hope here. Good embryo quality does not guarantee an implantation.  This reminds me of Neupogen. Yay! I am a bit skeptical on its safety.

What is Neupogen?

I am poor in decision making. To use or not to use Neupogen? If I don't use Neupogen and implantation failure happens, I will blame myself for being stubborn.  Neupogen does not guarantee implantation either.

What is wrong if Neupogen is a new drug? New drug= new hope (+ new risk?). If I wait for this drug to mature in the market, I guess I am already in menopausal state! The ultimate question here is whether I want to volunteer to be a Neupogen guinea pig?

My greed

My day5 embryo update: 5 excellent, 2 normal = 7 embryos. They called me to ask how would I want them to be freeze. Five individual test tubes for the five excellent embryos and one test tube for the two embryos? They explained the number of test tubes corresponds to the freezing cost. I said OK!

My greed pushed me to recount my 20 eggs ... 12 fertilized... 9 excellent cleavage... 7 embryos... (5 excellent, 2 normal)... Oh no! I paused for a while. What will happen to the seven after thawing? I was speechless.She then said that my embryo so far is the best embryo they have ever cultured this year. I laughed out loud. She insisted she was not kidding!

5 excellent embryo from 20 eggs. 25% ya. If I did not have hyperstimulation, let us say 12 eggs were retrieved, 25% of 12 eggs is 3 embryo? Then, how many embryo will survive after freezing? Scary... Maybe I am just looking for a safety net.

Btw, how many babies do I want? I prayed for one pregnancy and successful a birth only. After all, I am battling with the pregnancy safety issue. TNF-alpha may flare up. Immune suppressants may cause cancer. 

Day 16

I have been experiencing small amount of orange discharge since day 14. I am helplessly stuck in Guangzhou? I remembered the doctor said my menstruation will come few days after the decapeptyl shot. Observe! Observe! My menstrual period came on Day 16.

What happened to my embryo? From 20 eggs,  12 were fertilized. 9 was of outstanding quality. They said they will grow them into full blast.  Because my embryo quality was outstanding. They said they do day3 freezing with so-so growth embryo only.

Day 13

My pelvic girth is 92 cm. Perhaps, they did a typo error yesterday. It was 82 cm yesterday. I did not notice any bulging around my waist. No tightening of my pants. Re：weight gain, maybe I ate too much in Hong Kong. My weight was 130 pounds on day 4. Now, it is 137 lbs already. No big deal! I can still walk to their clinic. My ovary isn't bursting yet. Then, I was warned of OHSS by the nurse again. OHSS usually occurs after egg collection... Blablabla ... I need to report my weight tomorrow morning. They will call me to update me on my embryo development.
Well it is too late for the warning. I booked my return flight via Guangzhou- Manila.  I am staying in Guangzhou for two days. Because, the plane ticket rebooking fee HK-Manila will costs 862 USD. The budget airline fare to Manila via Guangzhou cost 333 USD. Stingy me!

Day 12

Egg collection today. We got 20 eggs. I just remembered lying on the operating table for less than a minute. No idea on how long did I sleep. I just feel somebody woke me up to make sure that I am still alive. I woke up helplessly dizzy and I have cramps in the pelvic area. I feel nausated. The doctor dropped by to confirm the ICSI procedure. He reminded me that ICSI adds 1 to 2% risk of congenital abnormality.

They checked my urine to make sure that there is no internal hemorrhage. They measured the girth of my pelvic area as a baseline for edema. I admired their professionalism but something very important was skipped! They forgot to weigh me! They just said I need to weigh tomorrow to make sure that there is no weight gain because of water retention. I need to drop by their clinic to let them measure the girth of my pelvic area.

Freezing and embryo transfer

According to the doctor, not all embryo will survive the freezing. Here is our plan: freeze all embryo at the cleavage stage Day3 then cultivate the warmed embryo for another 48 hours to let it reach the blastocyst Day5 stage. Those with arrested growth after thawing means they did not survive the freezing.

https://my.clevelandclinic.org/ccf/media/files/OB_GYN/CP-LB-from-vit-D3-embryos.pdf
http://www.victoriafertility.com/our-services/embryo-freezing-and-transfer/

Day 10

I had my blood extraction at 9 am in the morning. My schedule with the doctor was 10:15 am. It was moved to an earlier slot. My eggs are big. Egg collection on Friday. Wow! I was optimistic that we will have an embryo transfer this cycle. I crossed HK border just to extend my validity of stay in Hong Kong.

I went to Shenzhen during lunch time while I was awaiting for my blood result. When I returned to the clinic, they shared me my bad news. No embryo transfer. My progesterone went up to 1.7 while my estradiol went up to 7900. I have high risk of OHSS. Two days ago, my estradiol was just 1890.

Things are not always smooth sailing. What matters most right now is my safety during/ after the egg retrieval. We discussed what will happen after the egg collection and frozen embryo transfer.

Decapeptyl trigger shot later. My largest follicle size is now 20 mm.

I am indecisve

I am not good at decision making. When will I have IvIg? The hematologist told me before, I should do it again two days prior to embryo transfer. So, when is the embryo transfer? Three or five days after egg collection. Is it 3 or 5? Will it coincide with holiday? My hematologist is having vacation very soon. He said I can have ivig today. But, I declined. I said, Ivig is very costly. It is useless if we will not have an embryo transfer. He said study shows that IvIg can help improve the egg quality. I just have Ivig on Day 1. Hmm... Expensive. I told him that I will drop by his clinic in the late afternoon on Day 10.

Why am I not firm to tell the ivf doctor that I wish to have embryo transfer on the fifth day of egg transfer? And have my Ivig on the third day after the egg collection?

This morning, I was faced with another decision making task. Should I cross Hong Kong border or not? I am permitted to stay until Dec 26 only. My return ticket to Manila is on Dec 31. I will be overstaying in Hong Kong. If I postpone going to Shenzhen til tomorrow, I dont know what will be my condition. Hcg trigger shot may cause cramps, making me unable to go to Shenzhen. If I developed OHSS after egg collection, I may need to be hospitalized. If this happens, I cannot go to Shenzhen. If I go to Shenzhen and my blood result is bad, then my Shenzhen trip is a waste. Should I or should I not go to Shenzhen today? It is 11 am already, my blood test will be out by 2:30 pm. If I dont start my journey to Shenzhen, I will be wasting my 3.5 hours. If I started my journey to Shenzhen at 3 pm, what time will I be back to Hong Kong? What time should I inject my new medicines?

Whatever it takes I still need to wait for 3.5 hours. I started my journey to Shenzhen at 11 am. I got a sad news in the late afternoon.

Day 9

I still feel nausated. I was feeling groggy this morning. I had my breakfast at 10am, lunch at 2:30 and dinner at 7:30pm. At least no more headache for the rest of the day.
Check up tomorrow morning. Wish me luck!

Day 8

I have 24 follicles already. 8 are big follicles. The biggest size is 16mm. Small follicles are useless.

Erase my worries, it is too early to have OHSS. Usually, OHSS is after egg retrieval. If my estradiol level hits 3000 and progesterone hits 1.5, that is the time I need to worry about OHSS. I need  to go back the medications where we have started, GonalF 300 IU + Menopur 150 IU, plus Cetrotide 0.25mg.

Poor shel, pls bear the indigestion and headache for a while.

Day 7

Today is Sunday. I woke up at 7:30 am. I tried to sleep longer but I could not fall asleep. I had my breakfast at 8 am. I was feeling full til 2 pm. Soda water help a little. I had my lunch at 2 pm. I was thinking to have my Gonalf shot or not. Should I call my doctor? Should I just skip the GonalF shot?

I was thinking OHSS can't be too early. I just proceeded with the GonalF. Help me, God! After eating dinner at 7 pm, I felt little cramps. I still have the mucus discharge. My pelvic area is heavy. Call it a day!

Cant sleep... Random thoughts

I cant sleep. I feel uncomfortably bloated. I WANT to fart! Uhmmm... Nothing coming out!

I feel Hong Kong's medical cost is very steep. Don't know... Perhaps, I am comparing it with the Philippine cost. Bingo! I found one cost comparison chart.

http://www.geobaby.com/pregnancy/practical-advice/item/prenatal-charges-and-ob-gyn-fees

Where is my doctor on the list? There you go... Consult:  HKD 2000 ; ultrasound: HKD 1500. How much is the minimum wage in Hong Kong? HKD 40/ hr?  How many hours should a fast food employee work in order to pay for infertility consultation? 75 hours. How many hours of work to fund ivf? 2750 hours. Wa! Unless there is a subsidy or the doctors cost chart is applicable for expat and foreigners only.

In the Philippines, a minimum wage employee needs to work for about 5600 hours to fund her ivf.  So, where is cheaper? ^.^ Whatever... I need to work thousand hours of hard labor in order to build a dream family! I had encountered several obstacles along my journey. Now, the impending OHSS. This is indeed a bumpy journey towards my fertility! I pray that I am on the right path, with the right doctor and the right timing as well.

Ivf in philippines or abroad

In the event of OHSS, I feel I am safer in the Philippines. It is my home!

How about in Hong Kong? Ai ya... Scary... I maybe saved as well but I may burn my pocket. I want to do Ivf in Hong Kong because I learned this doctor has a good success rate. I don't trust much in Filipino embryologist.

I feel nausated. Today is just Day 6. My OHSS worries is not far from becoming a reality.  After taking gonadotropin releasing hormone for 5 days. Here I am, injecting gonadotropin releasing hormome antagonist. The doctor said it is to prevent premature ovulation.Btw, is there a difference seeing a reliever from seeing my doctor? It is just a psychology thing! I believe he will do the same. But, I am just worried OHSS may happen. I have 17 follicles already. Oh my god!

How many obgyne have i seen?

Philippines- 4
Hk-2 (one is the main doctor, the other one is a reliever)

So far, only one in the Philippines had complained that I have polyp. I need to do laparoscopy and polypectomy. I just realized that some doctors are abusive. They would advocate unnecessary treatments. I dont experience menstrual pain, why do I need laparoscopy? I dont experience spotting between periods, why do I need polypectomy? I believe the only way to see small polyp is through saline infusion sonography. Less the 0.3 cm is not clearly seen via regular ultrasound. The doctor who prescribed me to do the polypectomy never did a saline infusion sonography on me. She just told me that my polyp is 1 cm. How do I trust her? Am I a money vending machine? Shhh.... No comment. Only time will tell.

If I am lucky to get pregnant, who will be my new obgyne? I need an obgyne that is expert in immunology. I don't feel like going back to my first obgyne. I feel I am more of a commodity than a patient. I really can't imagine why she insulted me. Autoimmunity is karmic in nature. My clan is bad!

The third obgyne, does not like me. She asked me to go back to her mentor. The fourth obgyne? Aya! I let my reproductive immunologist decide who will be his partner.

Day 6

Day1-day5
Menopur 150 IU, GonalF 300 IU. Headache on day2,3,4. I vomitted on day3.
I have cervical mucus discharge as every as day5. What is happening to me? Am I ovulating very soon?

I went to The Women's Clinic today. I have about 17 follicle. This explains my discomfort. My estrogen is high, this explains the cervical mucus discharge. LH meanwhile rose to 10 already. We stopped the Menopur.

Day6 and Day 7 Gonalf 300 IU, cetrotide 0.25 mg.

Day 1- i saw the measurement of the biggest follicle 0.5 cm
Day 6- the biggest follicle is 1.3 cm

Ivig infusion rate

I heard Ivig before. I heard the former obgyne secretary compute for the grammage based on the patients weight.
I just don't know how much was my dosage.
Headache headache, vomit... Oops maybe that is caused by follicle stimulation drugs.


http://www.calgarylabservices.com/files/CLSForms/TSO1312.pdf
http://www.ecomm.baxter.com/ecatalog/loadResource.do?bid=60331

IVIG and Neupogen

I had my first shot of IVIF on Dec 8. My head is heavy til today. I will have my second shot of IVIG two days before embryo transfer. I am quite scared. After the Lymphocyte immunization therapy and IVIGs, I feel I will cry more if it fails.

The hemotologist said he will use 4 shots Neupogen on me. He explained it promotes the development of the placenta. Growth factor for tropoblast.

Google, google... Whew! I thought neupogen is a TNF-a inhibitor! He said he doesn't want to use tnf-a on me because it sometimes rebounds. Neupogen promotes white blood cell production etc... etc... Ehem! Good Luck Shel! Never mind... I trust!

http://www.preventmiscarriage.com/Reproductive-Immunology/Treatments/Neupogen-Filgrastim-.aspx

Risk of IVF and my obstacles- dumb you do, dumb you dont

What are the risk of IVF?
- during the stimulation, the ovary may twist off, cutting its blood supply. In this case, emergency operation is necessary.
- during the stimulation, the ovary may burst.  In this case, emergency operation is necessary.
- Hemorrhage and infection may happen during/after the egg retrieval. Hemorrhage may result into blood clot. Blood clot may result into stroke.
- ivf may also result in ectopic pregnancy. If this happens, the fallopian tube needs to be surgically removed.
- ovarian hyperstimulation syndrome may cause fluid retention in the internal organs like lungs and etc... If the lungs squeezes the heart, this may cause cardiac arrest that may result to death.
- multiple pregnancy

Did I still miss out something? Surgery, surgery and death... At least, patients are well informed. Ivf is dumb you do, dumb you dont.

With the standard IVF, the sperm and eggs are put into a dish.  Natural selection takes place- survival of the fittest theory holds. It is believed that only the healthy sperms can fertilize those eggs.
My husband has 1% normal sperm morphology. If none of my husband sperms has fertilized any of my eggs, oh my god! So, we will be using ICSI- intra cytoplasmic sperm injection to increase our chance. Since, we have eliminated natural selection process... the success of the fertilization lies in the hands of the embryologist. ICSI increases the risk of birth defect by 2 to 3%.

I have been hearing all the negative side of IVF that afternoon. Now, Am I ready for IVF? I gave him a firm YES!

Thank god, the weather was cooperative. We thought our consultation might be cancelled because of the typhoon in Manila. Luckily, we were able to fly to Hong Kong. We thought we might get stranded in Hong Kong, again our return flight was unaffected by the typhoon.

I am clumsy. I forgot to bring our original marriage contract to Hong Kong. Doctor said soft copy or photocopy is not admissible. If the nurse approve us to sign the contract, we can start the stimulation that day. If she doesn't... Sorry! I have a soft copy in my phone. Wa! I haggled to bring the original marriage contract to Hong Kong when I fly back. No marriage contract, no egg retrieval.

We then signed off the ivf consent form. What shall we do with the excess egg? What should we do with the excess embryo? In the event of any change of marital status (divorce or death), neither of us can benefit from the embryo. The validity of the contract is six months. I was thinking of possible loop holes. Haha, cannot fool them.

I had my IVIG in the late afternoon. I also have started my follicle stimulation.

Day1 to Day5 (Dec8to Dec12) - Menopur 150 iu + GonalF 300 iu
Dec13- blood extraction and check up.

The joys of overcoming infertility

What is the definition of a family? I remember this was taugh to me in grade school: a family consists of father, mother , brother, sister and baby. Can husband and me fit into the definition of a family?

It is my challenge on how to build our own family. I love short cuts, but I reject the idea of adoption. Under the Hong Kong law, ivf doctors must remind patients that adoption is a better alternative to  ivf. My eyes were wide open. 

I wish I could reply: "Can't you understand why I am here in your clinic? Doctor, I want to show the world that I am not infertile. With the advanced technology nowadays, I believe you can help me. Can't you? Now, will you still want me to consider adopting?"

How to calm the untamed dragon inside me? Why do i need to prove to the world that I am infertile? Since, I really need is to fill the emptiness of OUR family, why not consider adoption? Adoption maybe cheaper than IVF + immunologic treatment combined. Adoption is a better alternative than to have pregnancy related complications. Honestly, I don't feel satisfaction when I adopt a baby.  Something is not complete. Ai... Arrogant me or flamboyant me? I need to see psychiarist . Or perhaps it is just a JCDS. Jayden' Coke Deprivation Syndrome... Will discuss this cute syndrome next time. Hehe ^.^

Lazy me says surrogacy is acceptable. Are sperm donation and egg donation acceptable to my standards?

I quietly listened as the doctor explained all the risk of ivf and its procedures. Am I ready?

probability: pgs

If my 8-cell embryo has 6 normal and 2 abnormal cell. If the embryologist is to pick 2 cells at random, what is the probability that both cells are normal?

 answer: = combin(6,2)/combin(8,2)            (microsoft excel)

              = 15/28

              = 53%

My silly instinct says mosaicism at 8-cell embryo level is not reliable. I will not do PGS. I feel if the embryo passed the PGS screening for genetic defect meaning no trisomy, no down syndrome. Mutation can still happen beyond the 8-cell stage. Somatic mosaicism Down syndrome may also happen.

Knock on woods... If I dont get pregnant, maybe I will try to do the PGS on the frozen embryos.

https://www.khanacademy.org/math/precalculus/prob_comb/prob_combinatorics_precalc/e/probability_with_perm_comb
http://paper.wenweipo.com/2004/05/05/MR0405050001.htm

A second look at genetics

I am just an ignoramus. My imaginations has gone wild because of my desperation to have a genetic counselling. I heard one of a friend's friend twins has Down syndrome. Oh my god, pre implantation genetic screening could have helped prevent its occurrence.

http://downsyndrome.about.com/od/whatcausesdownsyndrome/a/mosaic_ro.htm
*   Understanding the cell division process.
" The zygote starts as one cell, duplicates itself and then divides into two cells. Those two cells each duplicate themselves, divide and create four cells. Those four cells duplicate and divide to create eight cells, and so on. This process of cell duplication and division occurs throughout the life of an individual."

* What is Down Syndrome?
"With full trisomy 21, the presence of an extra number 21 chromosome, the error or misdivision of chromosomes occurs in the egg or sperm cell that becomes the zygote. Because this error was at the very beginning of development, every cell that comes from this zygote will have an extra number 21 chromosome.

With mosaic trisomy 21, the error or misdivision occurs after fertilization at some point during early cell division. Because of this, people with mosaic Down syndrome have two cell lines -- one with the normal number of chromosomes, and one with an extra number 21."

* How Mosiac Down syndrome is detected?
It is detected by blood test on the baby or amniocentesis or cvs during pregnancy.

To summarize, I feel pre-implantation genetic screening is not a reliable screening for mosaic Down syndrome. Pre-implantation genetic screening is usually done at eight-cell stage. It is an invasive test wherein two cells are removed from the embryo. And then screened for chromosomal abnormality.
What if mosaicism exist but the cell picked was good?

inspiring story

What is the success rate of my ivf doctor? I did not have the courage to ask yet. So far, I was referred to this doctor by 3 people. And the fourth one was my aunt. Fairy God Father? I learned my lesson, I am not into fantasy this time around.

I checked the web for forums on IVF Hong Kong but there was a handful few only. I saw a China mainlander forum. Wow! Despite of her ivf failures, her determination led her to success. Oopps... Humira! Ehem... Ehem... I am afraid of Humira. Humira is a tumor necrosis factor-alpha inhibitor. Inhibiting the TNF-a can induce cancer.

Let us see what the hematologist will say on Monday.



http://www.ivfbbs.com/read.php?tid=32244&page=1

Of chromosomes... Iui and ivf

I am funny. I was so stressed about my husbands karyotype. The Hong Kong clinic that I am going to does not do PGD, I almost booked another hospital in Taiwan. Wahaha...

Wake up! Why did I do IUI, if I fear that my husband's translocation can cause genetic abnormality to my baby? Is it really the survival of the fittest sperm theory? I believe those with double head, small head, bent tail are sluggish. Those healthy sperm can fertilize my egg first. Btw, is my theory supported by evidence?

IVF with ICSI... I don't want it to be done in Philippines. I complain the experience level of our embryologist here.

Normal morphologic sperm may have abnormal chromosome content. I may still have unbalanced translocated baby with congenital defect. It seems like I never entrust the sperm selection to the embryologist. Oh my god! I just worry too much. Come what may!

Karyotype nightmare

My cousins's classmate has successfully gave birth to a twins few months ago. Wow! It seems Taichung has a reputable success rate ya. But the sad story is one of the twins has Down syndrome. Oh my god, PGS!

My husband's karyotype nightmare is bugging me again. I wish to retest his chromosomes. But my plane ticket is non-rebookable. I hope we can have karyotype done in Hong Kong next week. Help please!

All set for the ivf consultation

We have completed all the bookings for my ivf consultation. I am excited. I was busy this afternoon compiling all my records.

I will fly out this Sunday. I will be back again on Tuesday. Hong kong is just two hour flight away. It is very near! Perhaps, it is faster to reach Hong Kong than from our store going to our warehouse! Traffic.

I am no longer nervous of meeting the hematologist. Relax!

Ivf cost- ouch ouch

I was indecisive few days ago. One of my consideration was the cost. Of course, I like the cheaper, the better- Taiwan or Philippines. Back in my mind, I wish to have ivf done in HK. I just don't know how my husband will react. Because few months ago, he said he prefers Philippines. Hk including the accomodation maybe about three or four times the ivf cost in Manila.

Finally, my husband agreed to support my choice. I hope this is a wise spent money. If unsuccessful, I will cry. I will feel guilty of overspending.

I just remembered  my friend-Susan. She feels sorry whenever she sees kids begging in the streets.  Dear god, why are there so many street children? Why not grant us one child? These street children are deprived of basic education. It seems that their parents are very irresponsible. She will be a very responsible parent.

Why god is so unfair? I laughed out and replied: God is fair! God knows those irresponsible parents have no means to undego a fertility treatment. How much is the iui or ivf? Wahaha... My boomerang hit me! Ouch!

Don't be in despair. It is just about money. We can earn back the money someday. I don't want to regret not having ivf done in this reputable HK clinic in the future. Hmmm... Has anyone regret of staying in five star hotel? Perhaps, it is the other way around.

Who is Dr. Chan?

Google google... who is Dr. Chan? Sounds scary... He is a hematologist / hematological oncologist. I suddenly got phobia in blood and the big C!

I feel nervous.

when to go to have my initial ivf consultation?

My estimated menstrual period is December 10. This means I should have already decided what to do before Dec 15. I should be taking ivf preparation medicine by then. The following cycle - January will be the egg retrieval and embryo transfer cycle. Why I keep on delaying? Maybe a part of me is leaning on the hope that I will get pregnant with this IUI.

If I start my ivf preparation medicine in January, my first menstrual period will be Chinese New Year. Then my next period will be on Feb 26. My last lymphocyte immunization was in October. It will be about five months gap. I don't know my LAT level by then. I complain March egg retrieval and transfer is too far.

I procrastinate because I try to minimize my travel. From third week of October to December 1st week. I flew three times already. Indonesia, China and China. Maybe because of my belief that flying will cause me to become infertile. I am afraid that my IUI will not implant. The reality is I am not optimistic that this IUI will be successful.

Anyway, I  to have my little vacation in Hong Kong. Vacation on tight budget! IVF cost in Hong Kong is very expensive to our standards. This brings me to question again: why Hong Kong? Ooops... Wrong question... The correct question is: why I am poor? Grrrr... I will strive to work harder after I have babies.

Why Hong Kong?  That clinic has 26 years track record. They believe in immunology as a factor for infertiltity.  For now, I don't want to put a period in the end of my sentence. I am afraid of monstrous doctors. I look forward to meeting well mannered doctor. I hope we can cooperate well.

Single or double embryo transfer

How many embryo shall I allow to be transferred to me? The Taipei doctor puts one embryo only. It is believed to be safer. Twin pregnancy poses the risk of preeclampsia, gestational diabetes and pre term labor.

What if  we tranfered one embryo and there was no implantation? What are my overhead cost? Air fare, hotel, and ivig. Whatelse?

What is my view about pregnancy? Pregnancy is dumb I do, dumb I don't. I am willing to take the risk once. If I have a baby already, I can't imagine myself of having my second ivf.

I think, I will allow to put two embryo. Come what may. I surrender to god.

Where to do IVF?

These are my considerations in choosing IVF center:
What is order of my priority?
- success rate (conservative or aggresive?)
- years of service
- location (Ideally, the best place is Philippines)
- cost

I personally believe the success of IVF greatly depends on the embryologist. I have bad experience in one of the IVF center in the Philippines. Their andrologist did a shameful semen analysis. The total sperm count of motile and immotile had exceeded 100%. My husband's morphology was always 1% in Kruger standard. But is lab, he got 7%. Location plays an important factor for our IVF center selection. So, I decided to have IVF in the Philippines. Due to holidays we can have our IVF January. Since, I have been taking viagra and heparin for the uterine biophysical ultrasound. Perhaps, it is wise to try an IUI. So, we tried IUI in a prominent hospital.

My husband semen analysis last week was so great. Is it a miracle or what? Am I just so pessimistic? In the span of 7 days, the semen quality was greatly improved. Is this a case of double standards? The Quezon City people observe Kruger standards. The semen analysis report were done by andrologist. Who does the semen analysis in Global City? Medical technologist but I feel they are interns. I heard them exchanging jokes and I also overheard somebody asking how to make the report. Does he need to just sum up the sperm blablabla? I don't feel like going to this hospital for IVF anymore.

I am thinking to do whether to have IVF with one of the oldest IVF center in the Philippines or just go abroad for treatment?

I guess years of service isn't an important factor, since my choices are all above 10 years already.
Again, what is order of my priority?
- success rate (conservative or aggresive?)
- cost
Taipei, Taichung or Hong Kong?

Taipei
- single embryo transfer; This means lower success rate.
- affordable

Taichung
- one to three embryo transfer
- according to friends: it looks like a production line. Many patients
- don't believe immunology as a factor for infertility. They will believe in immunology only when I have three unsuccessful IVF with grade A embryo. I am not in the position to argue with them.
- affordable

Hong Kong
- one to three embryo transfer
- they do consider immunology
- expensive

This brings down my choices to two: Taipei or Hong Kong.
Taipei- although cheap it has lower success rate. I saw in many blogs implantation failure. Ai... One embryo or two embyo transfer is best for me?

For the meantime, I prefer Hong Kong. My friend called me today, re: new ivf center which uses japanese technology. Ai... I am just riding a merry-go-around. Embryologist experience matters a lot. I want to have ivf in HK.

A coincidence

Today is a perfect Sunday morning. I went to Ongpin Street to buy something. I met my monstrous obgyne secretary along the way. It was just a coincidence. Why? Should there be a reason for everybody's existence?

In fairness, I don't have grutch against her. I just hate her boss. We had a little chit chat. Why I left with teary eyes again? So what, if autoimmune disorder is karma? So what, if I have bad karma?

Being infertile doesn't make me a second class citizen. I surrender to my fate. I don't want to regret in the future why I did not struggle to overcome infertility.

Palpitating

Lately, I have palpitation and anxiety. Could this be the aide effects of Viagra? What caused my blood flow impedance?

where to do ivf

I shun away from Hong Kong because it is expensive. I don't like Taichung because of the PGD issue. Some says Taichung's clinic works like a production line. I doubt the success rate in Philippines. Should I discuss with Taichung over the PGD issue again? Or should I just look for another ivf center. Here I am again fickle minded on where to do my ivf.

Many doctors don't believe immunology as a main factor for infertility. Should I still check Taipei? My god sister suggested a Hong Kong clinic. She said that clinic believes in immunology. Though more expensive, I wish to give it a try.

http://comtecmed.com/MSRM/2014/Uploads/Editor/PPT/Leong.pdf

Think, think and think. It also sounds scary. They use tnf-a inhibitor.

Seventh iui

I am sick and tired of iui. But, there is a good reason to do so. This will let me validate the tissue crossmatch theory of my immunologist. I planned to do the ivf as soon as possible but the egg retrieval and embryo implantation will fall on very unholy schedule. Everyone will be in vacation mode. Perhaps, the lab is also closed.

Rather than trying to conceive naturally, we will try iui for the last time. My new obgyne uttered a joke: She said I am a veteran iui patient and I feel very at home and comfortable with IUI. I told her that I am sick and tired of IUI. She asked me to bear the pain as she insert the speculum. Upon her withdrawal, she asked how does it feel? I said I enjoyed! Everyone else laughed.

I hope seven will be my new lucky number. When did I started to believe in lucky number and lucky color thing? Oops, what is my lucky color? Seven means infinite. Would this mean infinite iui? I believe luck is on my side. Because I have just whispered to god while our plane cruised at high altitude last week. I just don't know whether god has heard my prayers because the propeller is noisier than my whisper. I hope my seventh iui will be my answered prayer. I promised god to go to putuoshan for pilgrimage again next year.

Seriously, what are my chances? My husband has 1% normal morphology and my uterine artery doppler says i have large blood flow impedance. pulsatility index was over 3.0.

https://www.auanet.org/university/abstract_detail.cfm?id=MP68-11&meetingID=14ORL

http://www.fertstert.org/article/S0015-0282%2897%2900333-6/abstract

http://www.willowtreeclinic.com/category/womens-health/

Second uterine biophysical ultrasound

I told the sonologist that my first biophysical uterine ultrasound was 16. I am on viagra + heparin. We are eyeing for a 19. He did my first uterine biophysical ultrasound in a government hospital. Haha, we are running after his schedule.

I laughed as I heard the doppler. It sounds like I am farting. After finishing the entire ultrasound, the sonologist told me that he feels my score will not reach 16. It was a torn hope. What shall I do? Should I schedule an immunologist appointment? Should I just ask my new obgyne? I patiently waited for 2 hours for the report. Wow! It was a 17. My myometrium blood flow was perfect! Thanks to Viagra! Wait... Why did not score a 19? Why my uterine artery pulsative index doppler failed?  I asked the sonologist if his report was accurate. Because last time, my score for the uterine artery pulsative index doppler was perfect. He said he did the doppler twice already. Yep, i remember. Then, he assured me that 17-19 is in the same range. That means 77% chance of implantation. I was not happy with the 17. Perhaps, because my friend who failed the first doppler was able to achieve a 19 score on the second doppler. Perhaps, I was conditioned by the immunologist to aim for a 19.

What is uterine artery pulsative index?  I did my seventh iui today. But, the new obgyne did not explain to me. She just left my room. Then, a fellow came to explain that I have good pulsative index, see it is greater than 3.0. I told her, it was contrary to the sonologist explanation in the morning. He said the pulsative index should be less than 3.0. She then explained that I have a good blood flow and the pulsative index is just a measure of resistance. Hmmm.... Google google.

Of Pilgrimage, AS, pregnancy and cancer

I went to Putuoshan to pray. There are four 送子观音 songzi guanyin in the island.

In the first statue,  I asked god for a baby. Then I suddenly remembered my friend, who had fetal rejection. I remembered her pelvic chain story. She had delivered premature babies. One died after two months of incubation. Oh my god, I prayed for "a" baby. I should say babies. Oops, one more thing the baby boy who died had ROP retinopathy of prematurity.

I prayed in the second statue that I want healthy babies - change "Y" to "I"+ "ES". Ooops, what if the baby is healthy but mentally retarded?

I prayed in the third statue that I want to have intelligent and healthy babies. What if, what if and what if my life will be in danger?

Finally, I prayed: Guanyin Pusha, I came here to ask/pray for babies, I surrender to your will. I just pray for smooth and uncomplicated pregnancy.

But I found on the web that AS is not scary after all. In contrast to my doctors advise. Of course, my doctors are speaking based on their experience. Maybe those remarks were exaggerated.

http://www.spondylitis.org/patient_resources/women.aspx
http://www.medicinenet.com/script/main/art.asp?articlekey=16694&page=2
http://www.arthritistoday.org/about-arthritis/arthritis-and-your-health/pregnancy/pregnancy-and-ankylosing-spondylitis.php

of fate and destiny

What is the difference between fate and destiny? To me, destiny is a product of my conscious choice or decision. Fate is quite tricky. It has unexplained or uncontrollable attribute.

To me, fate is like tripping over a small stone. It is something like carelessness, accident or god's will that prevents me from achieving my goal. Is clumsiness a fate or destiny? Is having no offspring a fate or destiny? Should I be dictated by the prophecy? Is being childless my choice?

My mom told me to go to the temple and to exchange flower. I don't know exactly what tradition is it- buddhism or chinese? The scary part of it is I need god's permission. I need to toss a pair wooden half moon. A "yes" means- I should get either piece facing up side and down. A "no" means- two both wooden half moon facing down. A "no" means- I cannot take home the flower. Flower symbolizes kids. Granted if I have successful implantation on IVF, I may have spontaneous abortion along the way. Because, I did not have God's permission. Scary!

Question: should I be dictated by the wooden half moon tossing? I partly believe but I am quite hesitant to surrender to prophecy? Prophecy is not my cup of tea. My fate is a product of my conscious choice.

I am in the crossroad. YES- continue pregnancy treatment ,  NO- halt the pregnancy dream. I follow my heart first. I don't want to forgo my opportunity. I don't want to blame my wooden half moon tossing in the future. I will have IVF. I fully understand the risk. Now, I am ready to accept the challenge. I pray for no complication, no life threatening fetal resistance. I surrender to god.

Btw, why am I so negative? I am lucky that nowadays medicine and technology are so advanced. I am lucky because as of now we are still able to fund our fertility work up. Amen! I will try to get pregnant.

of immune suppressants and cancer

I have taken Methotrexate 12 years ago. I was lucky that my sacroiliitis activity had went into remission. It has been reported that Methotrexate causes cancer in small population. Scary as it sounds, Methotrexate is actually an anti-cancer drug for treatment of breast, skin and other types of cancers. Methotrexate is an immune suppressant. It induces adenosine which can inhibit tnf-a, interleukin gamma, etc... In the course of treatment, I had suffered drug induced hepatitis. What are the other side effects? Desperation drove me to try Methotrexate. I don't want to think too much. I prayed that Methotrexate would work for me. Thank god, it did.

Ten years ago Tnf-a inhibitors were in experimental phase. I believe it is now available in the market. TNF-a inhibitor is used for treatment of rheumatoid arthritis, ankylosing spondylitis and etc... This drug can cause cancer also. Oh my god, why is it in the market anyway? Same reason as the above. Same approach as the above. If ever needed, I just need to pray that this drug will work on me. How about Imuran- immune suppressant primarily used by kidney transplant patients? Same same!

I am not a cat with nine lives. Question: is it safe for me to get pregnant? My tnf-a:il-10 ratio is a bit above the border. And, delayed cytotoxic hypersensitivity reaction is quite real. I just afraid that my th1 will get out of control when exposed to foreign particles like toxoids and fetus.

Question: forgo the pregnancy dream or try to get pregnant? I have went this far. I guess I should give it a try. If I forgo the pregnancy dream, I may regret this in the future. If I try to get pregnant, I may also regret this in the future. Dumb I do, Dumb I don't.

http://www.webmd.com/rheumatoid-arthritis/news/20041116/rheumatoid-arthritis-drug-linked-to-cancer?page=2

http://www.drugs.com/methotrexate.html

autoimmune disease and cancer

I just realized today, I don't have butt pain anymore. Less than a week? I forgot the exact date. ^.^

I was warned when I get pregnant my immune system may flare. It may cause ankylosing spondylitis activity again. Immune suppressants may cause cancer. Another doctor told me,before, that I am at higher risk of developing cancer compared to the general population. There is a strong link between autoimmunity and cancer. Dumb I do, dumb I don't. I have family history of cancer. It seems to me that cancer is inevitable.

http://www.ingentaconnect.com/content/sp/or/1998/00000005/00000003/art00039

New obgyne = new hope ?

I went to consult an ivf doctor today. She said I should have ivf as soon as possible.  I am not getting any younger. Most people around forty years old have babies with genetic defects. But for now, I am in the middle of my menstrual cycle. December cycle is not feasible. Everyone is in vacation mode. Our target is January.

Taiwan or Philippines? Ai... I let go Taiwan for now. PGD pre implantation genetic diagnosis on HLA-b27 gene sounds illogical for me at this moment. I can't schedule a geneticist appointment up to now. Embryos with HLA-B27 gene will be discarded. What if I have a homozygous HLA-B27? I guess all my embryo will be discarded. Another point to consider is HLA-B27 allele or subtype. What is my subtype? Actually, I am just guessing my subtype maybe HLA-B*2704 or HLA-B*2705. Any other possibilities? Oh my god, should we play a guessing game here? I agree with my immunologist, no to PGD for now. HLA-b27 is just a marker, we need to know the sequence fragment.

I have letrozole this cycle, because I will test the uterine biophysical ultrasound. Plus, I will be taking Viagra and heparin. Would this be too wasteful for a natural cycle?  My new obgyne said we will try iui next week.

What is CARMI? If it is used as adjective... carmic? This reminds me of karma, karmic. My karma is good or bad? New obgyne is a start of my new hope?

Target score= 19

My first uterine biophysical ultrasound score is 16. This translates to 60% chance of conception. I was happy and contented with the 60%. My immunologist said it could have been better. He targets a score of 19%, that translates to 77% chance of conception.

I will be on heparin and viagra starting from day 6. We hope that my next uterine biophysical score hits 19. Whew! I salute him for being a perfectionist. After all, he promised 85% success rate for IVF. I almost forgot his promise. He was too serious about it. I almost forget to IvIg before egg collection, before embryo transfer and after positive pregnancy. Wow! Geee high maintenance cost.

Btw, why some friends (fellow patients) were not instructed to take viagra? To start with, my first uterine biophysical was higher compared to theirs. Oops, it seems like I need another debate with immunologist about the viagra issue. What is the side effect of viagra? Anyway, if it is headache, blirred vision only... I may as well try Viagra. My cousin, a cardiologist, never heard that Viagra is used for women.

Viagra for me, clomid for husband. It makes a perfect sense to me!

Butt pain

Oh no! It strike back. I have been experiencing mild butt pain for about a week already. No medication for now. I hope it will subside on its own. Sacroiliitis? I hate eveything with suffix 'itis'.

I got mycoplasma infection

I recently got mycoplasma pneumoniae infection. What was my symptoms? Hmmm... I got less than a week cough and colds. I thought that was because of late night sleep. Three or five days ago I have small mouth lesion. Immuno assay says IgM is positive, IgG is negative.

What are the symptoms of mycoplasma infection? Well, it attacks the mucous membrane. Lungs lining, mouth sore, sore throat and etc...? I am so amazed with immunology. Thanks to my overly suspicious immunologist, he did a great job! Yes, from now on let us use cannon ball to kill a mosquito!

I think this explains why I got pustules I had from the fifth LIT. Clarithomycin to the rescue. I love immunology.

If karma theory were true...

I tried to re-assess the situation if I am over-reactive or she went too much. Granted it is true that she can read karma and do voodoo stuffs... I went to her clinic for medical advice and that karma/ aura or voodoo thing is unsolicited.

I just feel uttering those harsh words against a patient is not yet scientifically proven to cure any disease. If it is not scientifically proven then dont use it!  Instead of consoling people with incurable disease, her harsh sacastic words can drag down autoimmune patient's self esteem. I just feel she is abusing her good karma.

I can't take such discrimination. Why is she so harsh on autoimmune patients? Why did she think the karm as the root cause for autoimmune disease? I am just curious whether infertility has any association or correlation with karma? If it has, infertile couples should be condemned and burned to ashes as well!

Next time, I wish to send her a plaque:

Dr. xxx xxx

Obstetrician and Gynecology / Voodoo and Karmic reading

My monstrous obgyne

I cried I lot when My monstrous obgyne said: autoimmune diseases are karmic in nature! I should sue her for slander. Anyway, I dont want to waste my emotions and time for her unprofessional remarks.

My tears had cleared my vision. I will not let negative comments to affect my self-worth. Gee, why did I cry so much? I cried for two days already. Now, I am already dehydrated no more tears. Haha, I have recovered.

I just feel it was unjust. I have bad karma and she tried to drag me to the lowest tier of this society. Why is her perception of autoimmune patients so degrading? Ei, I look like a normal person. I dont have psoriasis. My eyes look normal. I have straight body (for now. ) What is wrong if my father is a killer? I went to her clinic for professional advice not to receive her defamation. What did I do wrong? I never asked for discount from her professional fee. I demand the reciprocity of respect that I have given to her. Now, I accept nothing is fair in this world. She is meant to me superior than me. Because she had good karma.

I don't know why I have cried so much. Shhhh... I haven't told anyone that I have donated to a lupus foundation. I feel somewhat like autoimmune society is where I belong. Maybe that made me to hate her remarks even more.

I am not ashamed of being label as autoimmune disease bad karmic person! I hate her to demeaning autoimmune patients. I feel I am a helpless victim of genetic defect. Whatever... Ok... I accept I am a victim of bad karma! I should suffer uveitis and ankylosing spondylitis for my entire life. I just hope she does not abuse her good karma!

I want to stay happy and optimistic. And I want to enjoy my every moments.  My life is a time bomb after all. Ah... I should start working on my grandest dream. Shhh... I also never told anyone my grandest dream!

Overcoming my autoimmune disease

Ankylosing spondylitis is an inflammatory disease that can cause vertebrae to fuse together. Once fused, it becomes permanently joined together. It is an autoimmune disorder wherein the immune system mistakenly attacks the patient own body parts like: joints, vetebrae, eyes (uveitis) and etc.

I had my first episode of uveitis (inflammation) of the eye when I was 24 years old. I was so curious what triggered the inflammation activity. Was it infection or allergy? I was not referred to a uveitis specialist at that time. That more than a month inflammation caused some of my eye muscles to fuse together.

How does uveitis feel? I feel cloudy vision. I was photophobic. Our eye muscle normal instinct is to make the aperture of the iris smaller when there is bright light. When it is dark our iris dilates. Whenever my iris moves (whether dilate or contract), it is terribly painful. Even if I cover my left eye, my left eye will move synchronous with the right iris. It is painful!

I forgot when was the first time I had lower back pain. I thought it was because of my improper posture. Sometime the pain was dull. Sometimes it was so intense. I thought I have torn my muscle.

One time I had a very lengthy conversation with a neurologist. He tried to associate uveitis to lower back pain. He recommended HLA-B27 screening and series of xrays. Oh no, I have HLA-B27, spondylosis, osteoarthritis ... Then he refered me to a rheumatologist.

I cried when I saw my HLA-B27 screening result. I cried that I will suffer, tendonitis, sacroiliitis, uveitis and other inflammation for the rest of my life. I felt I am an unless citizen. I belong to the handicapped society! Eventually, I learned to accept my fate and I tried my best to stay positive!

Ticking Time Bomb

My life is like a ticking time bomb. I keep myself busy. Otherwise, I will hear that annoying ticking sound. I don't know when my immune system is going to flare up again. I just stay happy and optimistic. I wish to enjoy every single moment of my life.

I was informed by the immunologist that pregnancy can trigger my ankylosing spondylitis activity again. Should I or should I not take the pregnancy risk? Immune suppressant may cause cancer. What if I have a double jeopardy- miscarriage + ankylosing spondylitis + cancer? What if my fear will not happen?

Should I just use optimism and gut feel on this matter? What if I regret of not trying IVF in the future?

  

Living with autoimmune disease

I never thought myself as a second class citizen. I live my life to the fullest. I am an optimistic and happy person. I have ankylosing spondylitis, luckily, it was in remission for 12 years. I remembered my rheumatologist explained to me before ankylosing spondylitis does not affect fertility. Not unless, my sacroiliitis prevents me to have sex.

Unfortunately, I received a blantant insult from my OBGYNE1 last week. She said she believe autoimmune disease is karmic in nature. She sarcasticly asked whether my clan are good guys? I laughed it off last week. I thought she was making a sarcastic joke. Today, she made the same remarks. To my disgust, I said why she feels it is karma? She replied she knows how to read karma. I cried for the whole day! I told my obgyne1 secretary that our clan work as humble trader earning a decent living in Divisoria. We are not killers, carnappers, swindlers and kidnappers. I exercised my maximum tolerance for my obgyne ya! I told the secretary that the doctor is really tactless. She should keep her karma theory to herself. Then, I cried again. I feel unjust. Even if I am a criminal , a prisoner- I have the right to medical attention. I deserve the reciprocity of respect that I have given to her. I never ask for discount in my bills.

My mom said enough crying. I have been crying all day long. My nose is red and has sores already. I said I can't help because of my genetic defect. She should help me pinpoint what is the cry-baby genes. ^.^

I begin to think of famous people with autoimmune disorder. Hmmm... So far I tried to name two only: former President Marcos and Luisa Conjuanco.  Oops.... Will my obgyne make the same remarks as what she did to me? Perhaps not! I feel my doctor has no heart! If she dares to belittle me, she will not care for me. Good bye Obgyne! Grrr... I never thought that a physician utter such comment.

Trying to analyze HLA-B27 and PGD

What is HLA-B27? Oooh there are many subtypes of HLA-b alleles.
HLA-B*2704 , B*2705, B*2709 etc... Scandinavian countries has high incidence of uveitis. Equatorial counties has fever incidence. Wait, does this have something to do with the sun? Vit D deficiency?

Nicholas J. Sheehan,  Rheumatology 2010;49:621–631. Http://rheumatology.oxfordjournals.org

In Taiwan Chinese, susceptibility to AS is determined by homozygosity for HLA-B*2704, whereas B*2705 may confer protection [23]. 

It has been suggested that B*2709 arose in the Mediterranean region by a single mutation from B*2705 on a haplotype associated with low susceptibility for AS and that it is the haplotype that is more important for disease predisposition than the immunobiological differences between B*2705 and B*2709 [19].

In contrast with an early report [40], a recent Finnish study showed that HLA-B27 homozygosity is associated with a moderately increased risk of AS compared with B27 heterozygosity [41]. 

AS develops at an earlier age in patients who are HLA-B27+ than in those who are HLA-B27(negative)[42, 43]. In a Chinese population, the earliest age of onset of AS is associated with the HLA-B*2715 subtype [43].


Wait ya... The alleles are getting more diverse. Not all ankylosing spondylitis patients are HLA-B27 positive. I saw another article citing ankylosing sponylitis HLA-B27 negative father and son. HLA-B27 being the most popular, other genes may also be the culprit. My genetic study might be a waste of resources. 

Genetics, to me, is getting complicated. Homozygous- means two genes are affected. While, heterozygous mean only one gene is affected. This reminds me of the Mendelian matrix again. Father x mother. During the fertilization, what is the chance that the embryo will get two HLA-B27 alleles from me? Am I homozygous or heterozygous HLA-B27 positive? What is the PGD standard operationg procedure? Discard all embryo with HLA-B27, even if that is heterozygous? Do I still need a geneticist consultation? This reminds me of my immunologist remarks: I am playing god. I said I am just embracing what technology has to offer. Ooops, few month ago, I wish to have PGD because my husband has genetic translocation. After the retest was done, it says normal chromosome. ai... PGD or not? Pray and trust God! 

Actually, I dont want to make my decision. I dont want to be guilty in the future. I have to opportunity to have PGD done and but I turned it down. What if, It so happen that my child does not have ankylosing spondylitis but he has Down syndrome? Advanced age moms are at high risk of bearing aneuploidy offspring.

My apical lung lesion ordeal

Who should I blame for the apical lesion scare? The radiologist or my immunologist who had amplified the findings?

A decade old letter from the rheumatologist says: she asked for xray baseline of my lungs because TNF-alpha and glucocorticoid may cause fibrosis. I went to visit my rheumatologist. Time travels so fast, unknowingly, 12 years has lapse since my last visit. This also means, that I am in remission. I asked her for her input on my xray films. She said x-ray film is clear. I said my immunologist said I have smoker's lungs and that lesion maybe a koch's lesion. I maybe put in immune suppresant. I need a pulmonary clearance from her. Was the scar caused by tnf-alpha or tuberculosis?

She said since I am in remission, it is not caused by TNF-alpha. It maybe caused by tuberculosis. Ok noted! I asked: Where is the lesion? Xray report says in the apical right lung. She replied, the radiologist is too good to see that small lesion. She feels it is clear. Ok noted again! Do I need to see a pulmonologist? She said the proper doctor to consult is an infectious disease doctor. So, he can rule out whether I had tuberculosis infection or not.

I then went to an infectious doctor. I told her I have an apical lung lesion, I suspect it is tuberculosis. What shall we do- what is tuberculin skin test? How do I know if the scar is new or old? Worst case scenario, if that were a Koch's lesion, what shall we do? I noticed she did not read my xray film. She just read the xray report. She suggested a tuberculin skin test. But, I will be going abroad I cannot come back after 48hours. I rescheduled the tubercullin skin test. I also told her I fear for a false positive. I told her I may have delayed cytotoxic hypersentivity reaction. She said it was meant to be that way.

Ring ring... Wow, I got a slot for consultation from by beloved immunologist. I tried my best to move him. I told him that I was bothered by his comment that I have smoker's lungs. And I am dying and yet he had not referred me to a pulmonologist. He laughed at my tuberculin skin test. What is the worst case scenario? He said he can put me on minimal immunosuppression + IvIg.

The pulmonologist said my xray is clear. I said the chest PA is clear but he needs to read the apico lordotic view. He laughed out loud and said it was clear. I showed him the xray report. He said my lungs are clear. No smoker's lungs also.

Bad immunologist! Same old comment: he is trying to kill a mosquito with a cannon ball. ^.^

I see this scenario as somebody sharing rumor about my trusted cashier in our store. When I secretly get feedback from her colleagues, I found out majority of the people can attest that the cashier is honest. But a selected few loyal staff will say otherwise. I am not zeroing out the possibility. I still trust to some extent. Deep in my heart, I believe the possibility that my immunologist theory is true. I close this issue for now.

No more Preimplantation genetic diagnosis

We have different belief with my obgyne and immunologist. What shall we do with the abnormal embryo? My answer is quite simple: discard the abnormal embryo!

My immunologist said I will not exist in this world if my parents did a preimplantation genetic diagnosis on me. I said I am not playing Hitler or God. I just want to embrace science.  He held my hands then I cried. I said I don't want a child with juenivile arthritis. His words reverberated til this morning.

Btw, what is the mechanism of the inflammation- how does HLA-B27 promote inflamation? If I look the other side of the coin, seronagativity to HLA-B27 does not mean you will not have ankylosing spondylitis. Seropositivity to HLA-B27 does not necessarily mean a person will have spondyloarthropathy. I need to consider recessive and dominant trait also. Grrr... What is HLA-B27, a dominant or recessive allele? This reminds me of the Mendelian Matrix from high school biology. I somewhat understand his point. I am trying to digest its meaning.

I just detected an inflammatory marker-- HLA-B27 , the allele. I never did the genome sequence in the past. I need to know the gene sequence to probe in my embryos. I guess this is a polymerase chain reaction.

He said I begin to think with the same wavelength. As of this moment, I feel I don't want to do PGD yet. I maybe throwing away life. Ai... Need to reconsider this.

If the belief of doctors here in Philippines that life starts at embryo stage, I guess I will not be able to schedule a geneticist appointment. I told her secretary I want to do PGD in Taiwan. By the way, PGD is banned in the Philippines.

Visited obgyne again

I feel unease. I feel there is a need to get a pulmonary clearance. I feel she thinks my apical lung lesion is a Koch's lesion. Btw, why did she not give me an action plan. I asked her today whether I need to go to pulmonologist , rheumatologist or immunologist first.

Pre implantation genetic diagnosis

About half year ago, my husband's first chromosome karyotype says he had a reciprocal translocation. But, it failed to establish that he has more than one cell line. And what does this mean? Huhuhu, I cried. I checked the net with 46,xx balanced translocation the chance of conception is less than 20 percent.  I don't want abnormal kids.

I went to consult a geneticist. She then suggested that my husband and me to have karyotyping in the state hospital. This is to rule out mosaicism for both of us. She then asked why did I not have my karyotype tested together with my husband? My naive answer was: whether my chromosome is good or bad, it will not prevent me from trying to conceive. Whew! Luckily our karyotype results were normal.

I though our genetic issue is over. I don't have to be put into maximum dose ovarian stimulation. Thank god, I thought I dont need a very aggressive therapy.

I confess that I did not share my entire autoimmunity story to my doctors. On my last consultation, my immunologist said he needs to see a psychiatrist. He complained that I am driving him crazy. Why I am feeding him one small piece of info at a time? On my last consultation with my obgyne she also commented that I should have given to her my 'decade old letter' on day1. Bad me! I just do not want to be misdiagnosed because of my biased info.

Anyway, I tried to be very open in my new IVF inquiry yesterday. I partly regret me and my big mouth. I was required to go to Taichung, just to have some basic immunologic tests. I cannot send out my blood via courier. I need to personally go to Taichung. Grrrr... Then I tried my best to explain what is ankylosing spondylitis. It is a spondyloarthropaty caused by HLA-B27 gene. My main problem is TNF-alpha.

Oopss... What HLA-B27 gene? Do they heard it right? GENE? I need PGD pre implantation genetic diagnosis. Whatever... Now, PGD sounds like a brilliant idea to me. I should thank my big mouth!

Apical lungs lesion

What is lungs granuloma? What causes Apical lesion? Is my immune system attaching my lungs? It thought my lungs are foreign? Oh my god!

I am disturbed with my immunologist comments. My xray looks like a smoker's lungs. Anyhow, he gave me a go signal to under IVF already. He will not mind my skin reaction result of my LIT since my laboratory report shows I have 100% PRA already. TNF-alpha maybe responsible for the pustules.

Post 5th LIT consultation

I had developed pustules in the 3rd and 4th LIT. Is LIT really the ultimate treatment for my underlying immune problem? 5th LIT is a make or break. I should not exposed to any sick person- virus or bacteria. Should I be wearing a bunny suit to work? I told myself: after my 6th LIT, with or without my doctor's consent, I will push through with my IVF plan.

Sad enough, I had developed pustules again in my 5th LIT. My immunologist new task is to find out what is causing the infection. Chest X-ray, hepatitis test and pap smear were requested.

Chest X-ray: previous x-rays were PA view and lateral view. Recent test includes the apico oblique view. The impression was: I have small lesion in the apex of the lungs. This is usually not visible in the PA and lateral view. How can the radiologist conclude that it was an old lesion? It may be an active tuberculosis. Uhu Uhu Uhu... Uhu.

Hepatitis: negative

Pap smear: no result yet. The obgyne's remark was no sign of infection.

Uhu Uhu Uhu... I have tuberculosis. How can this be? I never did the apico oblique xray view of chest before. What if I had that lesion 2 years ago? But two years ago I had taken prednisone for my two bouts of uveitis. In theory, when my immune system was suppressed, it may have given the opportunity for tuberculosis to grow. I had prednisone again last year. Oh no, my tuberculosis is quite new. Uhu Uhu. Sorry, if I spread my tuberculosis germs while you were reading my blog. Uhu.

Out of no where, I found a decade old letter. My rheumatologist wrote a letter to the referring doctor. The letter mentioned I had taken several months of nsaids... and I had took methotraxate... I also mention tnf-alpha and infliximab. I says have ankylosing spondylitis. It says my rheumatologist requested and xray to serve as baseline since apical lungs lesion maybe a part of ankylosing spondylitis ... Suddenly, my immunologist changed his perception. He then commented I was driving him crazy. Why am I feeding him small fragment of info at a time?

Anyway, I thank that letter. My obgyne has also commented I should have submitted to her that letter on day1. I smiled and replied: I am stubborn. I may not believe in her until I tried.

Grr... granuloma sounds scarry.

Post 4th LIT consultation

Yes, I remember it clear. HLA class 1 is HLA-A, HLA-B, HLA-C ... While HLA class 2 is HLA-DR, HLA-DQ.... Lost in translation. Where did I arrive at this explanation: HLA column1 is from husband and another column is from donor?  Grrrr.... Those secretaries and fellow patients were feeding me with the wrong info. I asked doctor again today: what is the LAT-M columns about. Wahaha... He said I better enroll in his immunology class. Who am I talking to? I said never mind... He asked again: who? wahahaha his secretary :(

I need to have another LIT next month. That will be my 5th LIT. Did I had another bout of infection? My immune system was very active or by coincidence? Majority of the patients just had 4 LIT prior to conception. Comparing the four session, my induration was getting bigger each LIT session. And I had developed pustules again. After the fifth LIT, I will be sending my blood abroad from testing again.

My uterine biophysical ultrasound result says my uterus echogenecity was course. Uterine NK cells were responsible for destroying the smoothness of my uterus muscles. Calcium deposits... The coarse texture affects the implantation success.

Endometrium layer blood flow... What was it again? I forgot... I was tired and sleepless. I went to the clinic at 4am... I remember the explanation was NK cell are causing the scar again. Restricting the blood flow and thinning the uterus.

How bad is the picture of my uterus? Why not just try to have a pregnancy work up? He showed me his worksheet of my induration sizes after each LIT. My immune system will prevent the implantation. Poor shel!

My impression is my Nk cell is causing scars and permanent damage to the uterus and endometrium.

Question: how bad is my uterine NK cell? How does my peripheral blood Nk cell correlate with my uterine NK cell? My peripheral blood NK cell is just boundary level with no killing power. Is there a way to test the toxicity of my uterine NK cell? Answer: it is impossible to test the uterine NK cells. Not unless I am an animal, he can cut and slice...

4th LIT

Tomorrow is my fourth LIT. Why I am resisting it in the past? Misdiagnosis, and blood products risks... I somewhat feel like a guinea pig.

Now, I feel my reaction code is 8-8 already, because my husband need not to donate blood tomorrow. I am quite doubtful. Last test it was just 6-4.

My uterine biophysical ultrasound

I got a profile score of 16 in the uterine biophysical ultrasound. It says the conception rate is 60%. I don't know whether I should be happy or not. After getting the report, I smiled at the sonologist and thanked him. He then asked whether I have tried ivf. Why did he asked that question? I can't help but to think that 60% is not a good score. Whatever.... I guess my score will improve by blood thinners.

I also had my LAT-M done today. Let's see.

Two schools of thoughts: Lymphocyte immunization therapy

What if I had LIT solely on husband's lymphocyte? What if, we share many HLA antigen in common? I will not produce antibody against the common HLA. If I and my husband share many HLA antigen, chances are after 10 x of LIT with husband's lymphocyte the reaction code remains unchanged. Am I correct? What is more important- the reaction code between or the panel reactive antibody score? I guess I don't need to have a positive reaction in each of the serum from the panel reactive antibody. I need positive reaction to my husband's lymphocyte only. Immunologist wants 100% score because they feel high PRA is safe?


Oh, two school of thoughts. First, husband as the sole donor. Second, unrelated donors + husband.

I trust my watch 100%. I wear one watch only, or never at all.  Wearing two watches is quite confusing, if both are not synchronized, I don't know which is telling the correct time. It defeats the purpose of wearing a watch. Wearing three watch will be acceptable but quite odd. The logic here is majority wins. Wearing 4 watches is funny. 

And... what about my immunologist protocol on the number of donors? Why husband + 3 unrelated donor? My immunologist also wears three watches? He is not happy to wear one watch? Why not 7 donors at a time? I have 3 unrelated donors on first LIT, and another set of 3 unrelated donor on second LIT + husband= 7 donors total? Why not do it together?

"Dear Obgyne,
... She is responding slowly to the LIT. Most likely they share more than one HLA antigens in common...
Regards,
Immunologist"

It is betting time! what will be my reaction code 8-4 , 8-6 , 8-8 or 0-0 on my next LAT-M IgG test? Winners will receive surprise gift.

Back to my very old sentiment... my husband has erectile dysfunction. Limited exposure to sperm creates limited antibody. Therefore I failed in the LAT-M IgG test. I contested I don't have immunologic problem. I don't believe in the PRA thing.

My third LIT consultation

Doctor said my I have developed pustules against all donors, lymphocyte. This maybe viral infection. Yes, I have colds. Virus and bacteria makes our immune system to be active.

My base line for the reaction codes: 2-2. It has jumped to 6-4. The bad news is I slowly respond to LIT.  Ideally, the reaction code should be at the same. My induration from husband lymphocytes are smaller. He concluded that we share at least one common HLA.

Btw, what is LAT-M IgG? It measures the anti-HLA antibody. How can I be sure the my body will produce anti-iditotypic antibody after I have produced the anti-HLA antibody. Doctor said it definitely will. Anti-idiotypic antibody stops the production of rejecting antibody (anti-HLA antibody). Its function is to bind to anti-HLA antibody. Otherwise, my anti-HLA antibody will reproduce without limit.

What is PRA? What does it have to do with pregnancy? I don't believe much in PRA. There are cases wherein the father had raped his daughter. And they were able to bear a child. I feel blocking antibody is not a necessity to get pregnant. My fetus will be safer if I don't produce blocking antibody against my husband. Doctor said re: father raped daughter case. After the daughter has given birth, definitely she will have high level of blocking antibody against her father. Our body is programmed to distinguish our own cells from cancer cells, bacteria, etc... It is the function of ourmy immune system to restrict the unnecessary growth. Oh my god! My PRA theory is defeated.

I had a very long story of latent tuberculosis, what if my donor has latent tuberculosis? No medical and scientific studies show that latent tuberculosis can be spread through blood donation.

He requested for a uterine biophysical profile to see whether I have enough blood flow to the uterus at the time of ovulation. This affects the implantation success of ivf.

P.S. Doctor said don't get pregnant.

My blood safety questions

These questions popped up the yesterday while I was doing my lymphocyte immunization therapy:
1. People with latent tuberculosis may get positive in the skin tuberculin test. What is responsible for the skin sensitivity test? We are expecting for a delayed type hypersentivity reaction, correct? So, are we checking for its T-cell? Hmmm... T-cell is a white blood cell.

2. What if the donor has latent tuberculosis, can pulmonary tuberculosis spread through blood transfusion?  I believe Philippines belongs to the top 10 countries with the most incidence of tuberculosis cases. But my doctor assured me tuberculosis bacteria cannot be spread thru blood transfusion.

3. What if my donor had undetected autoimmune disorder? I have read some articles say having HLA-B27 gene does not necessarily mean that you will get spondyloarthropy. Why is it so? I guess because there is no HLA-B27 antibody to react with the surface antigen of the host cell. Therefore no inflammation. What if the donor has undetected rheumatoid arthritis? This entails I will produce HLA-DR4 antibody. Do I know my genome sequence? If I dont have HLA-DR4 gene, it will not affect me. What if i have that gene, then it will trigger my autoimmunoty. Correct?

4. Prions are not also included in the blood screen.

5. Are there other infections that can be spread thru blood transfusion? I am referring to mycoplasma and other curable bacteria infection that is not included in the standard blood screening test.

My third LIT- giant pustules

I feel febrile and little throbbing pain on the injection sites. I thought I have developed immune tolerance. After 8 hours, I saw 14 out of 16 injection sites developed pustules. They were bigger than the first LIT. I thought I will be graduating from lymphocyte immunization therapy in no time. Now, I feel not febrile anymore.

I said in my previous post, Anti-idiotypic antibody may compete with my donor's HLA in the binding site for anti-HLA-antibodies. Anti-idiotypic antibody halts antibody production. Ei, Did it just enhanced my immune activity? Anti-idiotypic antibody triggers the production of anti-HLA antibody. Hehe looping! Donor HLA triggers the production of anti-HLA antibody. Ergo, it has additive effect. Wahaha, my stilly theory.

Questions on idiotypic and anti-idiotypic antibody

I am stucked with my own reasoning glitch. I said in the past:  If I don't develop anti-blocking antibody against my husband , it does not necessarily mean  that I may not produce anti- blocking antibody against my husband in the future. Applying my logic, if I don't develop  anti-blocking antibody against my fetus in the first trimester, it is not guaranteed that i will not develop anti-blocking antibody against my fetus in my second trimester of pregnancy.

What is the anti-idiotypic antibody for? I guess this is a principle of double negation: -1x-1=+1. Double negation cancels the effect of negation. I guess anti-idiotypic antibody (anti-anti-HLA antibody) mimics those of my husband's HLA? Does anti-idiotypic antibody trigger the production of idiotypic antibody? Who knows, it is a cyclic and reversible process. How does anti-idiotypic antibody suppress immune response? I guess anti-idiotypic antibody mimics that of my husband's HLA. And I guess it will compete with my fetus HLA antigen in binding with anti-HLA antibody.

Can we do some immunologic engineering here? What if we intentionally select those with autoimmune disorder as donors? Then inject their lymphocyte NOT on me (on other patients please....). Their immune system will create anti HLA-B27 antibody and then it will trigger the production of secondary antibody which is the anti anti-HLA-B27 antibody. Then collect the anti anti-HLA-B27 antibody and sell it as vaccine.  Perhaps not for fertility treatment but this will be a breakthrough cure for spondyloarthropathy and uveitis. Anti Anti-HLA-DR4-antibody,  anti anti-cancer protein-antibody. Isn't it great? I will be the future Nobel Prize awardee in immunology. Ehem...

I am not against my immunologist. ^.^ I am just inquisitive. I don't believe much on the PRA thing. But I believe in him. Cyclic reasoning ya! Whatever.

I have 100% PRA

After two LITs, my PRA had shot up to 100%. My reaction code is now 6-4. My next LIT will be on Wednesday.  Then what? Should I start celebrating my 100% mark?

I told my obgyne's secretary that I feel like ovulating today.  I wish to have IUI tomorrow. I share to her my good news- my PRA is already 100%. Where is my immunologic clearance? She asked me where are the other parameters- KCT and etc...? She said it is a waste to do IUI.

Little sour-graping here, who wants to have IUI in ghost month? Better luck next cycle, after the ghost month is over.