Learning from my patients

I am always amazed by how smart my patients are ! It's fun learning from them and they keep me on my toes. Here's a first person guest post from one of my patients ( who is a PhD and knows more about fertility than most gynecologists do !).

She has done all her learning "on the job" - and this is an excellent example of what a highly motivated intelligent patient can do to help herself, when she sets her mind to it.

She has carried out a clinic trial on herself and done an extremely good job of it as well. In fact, based on her experience, I am now going to start studying the effect of Vit D3 supplementation on women with low AMH levels. If Vit D helps to improve their low AMH levels ( and thus their ovarian reserve ) this will be a big step forward in the treatment of these women !) It's true that one swallow does not make a summer but it's careful observation and experimentation which allows medical science to advance. The big difference here is that the experimentation was done by the patient herself - something which was par for the course about 3 centuries ago, when all scientists ( they used to be called natural philosophers in those days) experimented on themselves.

Testing summary

2 weeks post D&C bloodwork (fasting)

Test	Result	Reference range	Comments
AMH	1.1 ng/ml	1.23-7.91 ng/ml	Low- very weird especially since FSH has been consistent normal (around 6.5, with E2 22-33) and my antral follicle count was 34 in an ultrasound done 4 months ago.
Vitamin D3 (ordered on a hunch)	16 ng/ml	11-40 ng/ml	Disregarding the lab’s ranges, anything below 10 is considered severely deficient while anything below 20 is considered deficient. Optimal values are above 40 ng/ml Lots of references linking this one to fertility issues…I’ve been putting the literature together, could send it to you if you are interested.
Fasting Insulin	4.9 ng/ml	6-27	Fasting blood sugar was normal
Total Testosterone	84.8	9-109	Despite lab’s reference range, this value is in PCOS range for androgens. ( I think over 60 is considered in PCOS range) I’ve had considerable variation with testosterone tests. …I’ve had 2 other tests done in the evening and there my values were low. Interestingly, found out that testosterone levels have significant diurnal variation and are highest in the morning….repeating the test in the States, this time, fasting.
DHEAS	231	35-430	Over 200 is in PCOS range

I was the most concerned about low AMH levels. It seemed completely illogical given all my markers for ovarian reserve. On a hunch, I looked in the literature to see if there was any link between Vitamin D3 and AMH.

I found one study conducted by a group at Stanford University

http://www.ncbi.nlm.nih.gov/pubmed/19056816

This group has found that in certain organs of the body, vitamin D3 binds the AMH gene and turns on its expression. I asked the group if they had done any studies looking at AMH levels in vitamin D3 deficient woman and they said that though they were interested, it had never been explored.

Either way, I wanted to recheck my AMH after trying to increase my vitamin D3 levels. I took 60000 IU weekly for 2 weeks.

I rechecked antral follicle Count, AMH, vitamin D3, FSH and LH on the same day.

Other tests

Vitamin D3	70 ng/ml	7.6-75
AMH	5.18 ng/ml	Optimal fertility according to the lab, or PCOS range according to this website	A 4 fold increase in 2 weeks, which I found just remarkable!
FSH	5.12 ng/ml		These tests were not done on a true ‘day 3’ it was just early in my cycle though.
LH	2.93 ng/ml		Does not look like a PCOS ratio……?!?!?!

Her level of sophistication is commendable , and I just wish all doctors would engage their patients as clinical research assistants - all of us would benefit from this approach !