More Musings on Diabetes and IVF… and Carbs

I’ve already mentioned that one of the main things I’m doing differently in the IVF cycle is really focusing on my diet. It’s always made sense to me that what I put in to my body has the potential to affect the quality of the eggs that I’m growing. To that end it seemed logical to choose fresh and natural foods in preference to processed ones, and to choose the best quality ingredients available to me. But this cycle, I wanted to think beyond that.

Thanks to type one diabetes, I try to stick to a lower carb diet, since carbs are the macronutrient which has the greatest and most immediate effect on blood sugar levels. Now isn’t the time or place for a dissertation on carbohydrates or my feelings surrounding the recent sensationalism of the so-called “paleo” way of eating, but suffice it to say I’m not interested in labelling the way that I eat, or being particularly evangelical about it. Diabetic since the age of three, I grew up thinking about carbs, and counting them in every meal. I’ve been eating the way that I eat now for more than ten years and I just do what works for me and my health. On a day-to-day basis that means being careful about carbs, but I still indulge in bread, pasta and plenty of cake as and when the time is right. Eating lower carb, however, almost inevitably leads to an increase in the proportion of the diet that is composed of protein and fat. So when I learned before our first IVF cycle that a high protein diet is recommended during the stemming phase, I felt pretty set. I didn’t think specifically about the carbs and I didn’t delve in to it further.

This time I thought I’d check out the evidence for the high protein suggestion that seems to be so widely accepted. A quick Google instantly threw up plenty of results, most of which ultimately led back to a small study, the results of which were presented at the American Congress of Obstetricians and Gynecologists meeting almost exactly a year ago. There are plenty of problems with taking this as gospel. The fact that it is such a small study, with seemingly limited control of confounding factors, and the fact that it has not yet been published in a peer reviewed journal chief amongst them. But the findings are intriguing enough. Especially the specific relationship between low carb diets – less than 40% of calories from carbs – and IVF success rates – jumping up to 80% in this group.

Given that this may well be our last attempt at IVF, I need to feel that I’ve done it right. And suddenly my usual casual attitude to my diet doesn’t seem enough. I feel I need to make minimising carbs an absolute priority because limiting carbs is much less likely to cause a problem than eating them excessively.

I should have left it there. I should have kept my focus that simple and not over-thought it. But me being me, I couldn’t leave it alone. And given that carbs are the subject of discussion, it didn’t take very long until I began stumbling across references to insulin levels and blood sugar levels. And then the fact I’d been trying to avoid hit me in the head.

The conclusion in the popular media is the same one that crops up over and over again when anything to do with carbohydrates is discussed. They apparently cause “soaring blood glucose levels” and it is the blood glucose levels rather than the carbs themselves that are likely to do the damage.

An easy way to annoy a type one diabetic is to talk about food causing “soaring” or “skyrocketing” blood glucose levels in non-diabetics. If you haven’t experienced a blood sugar level of 20mmol/l, you have no idea what “skyrocketing” means. And here’s a hint: if you don’t have diabetes, you haven’t. Blood glucose levels can and do vary in non-diabetics, but by definition, if they get ups above around 6.5-7mmol/l, you’re probably in the club that no one wants to join.

This doesn’t, of course, mean that the assumption that raised blood glucose levels can harm eggs is a bad one. Any female diabetic will know only too well the list of potential complications for an embryo if blood glucose levels are not controlled during early pregnancy. The body doesn’t thrive with too much sugar running around in your blood stream, and it’s clearly not the best environment for creating genetically flawless material. I already know that.

But if the assumption is correct, that higher carb diets are detrimental because of the variations in blood sugar levels in non-diabetics, then what hope do I have? Suddenly this is all about so much more than my diet. Of course I work really bloody hard to keep things as stable as I can. I eat lower carb for precisely this reason – to minimise the swings. But inevitably my blood sugars stray up to the 7 or 8 region more often than in a non-diabetic, and also stray higher than that. And then I have a day like today:

Vibe graph

The red lines are all numbers above 7.8mmol/l. The gap in the graph spans about three and half hours where the sensor was changed over. I wasn’t high that whole time – in fact, I had a fairly epic low. But when I look at the rest of the afternoon, I can’t help but feel that I’ve messed up our chances of this working before we’ve even got to the exciting part.

Rationally I know that people with diabetes get pregnant all the time. They even get pregnant as a result of assisted conception all the time. and they also conceive with less than ideal control and experience no complications. My control was good when we conceived Thomas, but I’m sure I had similar strays in my blood sugars that month. It’s just that it seems like we have so much against us in this. We know that the embryo implanted last time, that I don’t have implantation issues, nor any of the other major leading causes of recurrent miscarriage. So the most likely reason for failure is a genetic one within the embryo.

I just feel as though I can’t possibly do enough. Despite the fact that my conclusions are based purely on assumptions and that the effects of diet are unproven never mind the causation of the effect, I still feel hopeless. Diabetes is a beast that just can’t be tamed all of the time. And I feel as though it has the potential to steal our last chance, no matter what I do.

No Right Time To Have A Baby?

I found myself having a conversation recently with a friend; A mother who I very much admire. The details of her life are not mine to share, even anonymously, but suffice it to say, her first pregnancy came as something of a shock. She’s gone on to have two more children and is one of the most contented parents I know, so I was somewhat surprised to hear her lamenting how life might have turned out had she not fallen pregnant when she did. She couldn’t regret it, of course, she explained, but she did feel that perhaps she and her husband had missed out on the life they had expected to lead and experiences they might otherwise have had. She laughed after a moment and added “Not really something you’ve got to worry about. You had the marriage, the career, the house first!”

On the face of it, I would be inclined to agree.

Thomas was, after all, very much a planned baby. Planned with almost military precision, in fact. Months of careful work on tightening up my blood sugars, ensuring I was taking high dose folic acid and vitamin D. I ditched the hormonal contraception many cycles before we were ready to actually try to make a baby, to make sure they were fully out of my system and unable to affect my blood sugars or my ability to ovulate. By the time we were ready to get down to the sex bit, I was desperate to have a baby in my arms to show for all my hard work!

I didn’t feel like I really had much choice in the way I went about preparing to conceive. It’s well documented that good blood sugar control both prior to and at (and obviously after) conception minimises the risks of a diabetic pregnancy. Risks such as miscarriage, birth defects, macrosomia and stillbirth.

But I didn’t feel like I had much choice in the timing either. It’s true that when Ian and I met, I had a sudden awakening of my maternal desires. But I don’t believe that alone would have driven me to trying to conceive the instant the ink was dry on our marriage certificate. I wouldn’t have felt so rushed if I’d been younger, and more specifically if I hadn’t thought it might prove to be a difficult thing to accomplish.  I honestly thought that I wouldn’t conceive without help. I’d been told as much in that many words. The fact that I did still makes my heart skip a beat and my stomach well up in to my chest. I knew that the sooner we started, the sooner we’d be eligible for fertility help, so getting started was my priority.

And, like my friend, I wouldn’t change the outcome for the world. The thought of Thomas not being part of our lives hurts me to the core. And I love my life, with a toddler, right now. (for the majority of the time, at least!)

But I do still wonder about what Ian and I missed out on, despite the fact that we entered parenthood on our own terms. On a Sunday afternoon when Thomas is napping, I sometimes wonder what we would be doing if a small person wasn’t upstairs asleep. I wonder where we might have travelled to last year and what experiences we might have had. I think of dates we’ve missed out on. Films we might have seen, shows enjoyed and gigs attended. It’s not as though I haven’t done plenty of all of these things in the years I spent as a student and afterwards. But so many of those years were without Ian. In so many of those experiences he was the missing ingredient that I’ve only just realised was absent all along. Just occasionally I mourn for the time we haven’t spent as a couple, just the two of us.

I don’t wish that we hadn’t had Thomas – obviously I don’t. I don’t even wish that we hadn’t had him at the time that we did. I wouldn’t actually trade where we are now for anything. Nothing at all. What I do wish, however, is that I’d met my husband several years sooner in my life. I wish we’d had more time to live out the glory days of our twenties with a double income but few responsibilities. I wish I’d shared more of my past with him. I’m guessing it’s probably a natural feeling, when you finally meet the person you want to grow old, wrinkly and possibly incontinent, with to wish that you’d known them all your life. I feel it very acutely some days.

This is much more about my relationship than it is about pregnancy, parenthood or my child. But at the end of the day aren’t my friend and I both in the same position? Don’t we both wish we’d had “more time” before having our children. And doesn’t it all go to prove that there is never a truly “right time” to have children?

How many more times might we have slept in an igloo?

Am I Right to Accept Induction?

I can still say no to this. Right up to the moment that they actually start the medical process, I can decline to be induced. With forty-eight hours to go, it’s something that my mind still keeps returning to.

I know that I’ve had the best blood glucose control of my diabetic life in the last nine months. I know that my blood sugars have averaged similar to a non-diabetic, with very few major spikes. I’ve essentially had an uncomplicated pregnancy. I feel like I’ve mitigated the risks from being diabetic far better than I could ever have imagined, and the numbers suggest that my chances of problems at this late stage cannot far exceed those of a “healthy” woman. If I’m honest, I feel I deserve a straightforward birth experience as much as any one else.

I know that many women don’t get anything like their ideal, or straightforward birth. But I can’t help feeling that by accepting induction, I’m not giving myself the best chance.

I don’t want to be induced because I know that it carries risks. Chief amongst them, the increased risk of needing a caesarean section. And we know that I don’t want that . In fact several studies have suggested that increased induction rates are the single biggest reason for the rising caesarean birth rate. Even if caesarean is avoided, there is a greatly increased chance of other interventions including episiotomy, ventouse or forceps delivery. Induced labours generally require continuous fetal monitoring, which restricts the options for active birth, further increasing the risks of needing assistance.

These are all things which don’t sit well with my ideals for birth. And then add to that the fact that induction can also lead to breastfeeding difficulties and you can probably understand my personal apprehension. Furthermore, yet more evidence is also beginning to come to light that babies born between 37 and 39 weeks gestation are at risk of more health, developmental and behavioural problems than those born after 39 weeks. Unsurprisingly, the internet is littered with articles urging women not to be impatient and to let labour start of its own accord.

But…. I’m not doing this for convenience reasons, or solely because I’m impatient to meet our baby. I’m doing it because its what my medical team have advised me is the safest thing.

And the medical reasons to induce are, at least at first glance, extremely compelling. And particularly now I’ve managed to carry this little life safely inside me for almost nine months. I’d obviously never forgive myself if something went wrong right at the end that could be avoided. The bottom line is that if I decline induction, anything that goes wrong after that point will lead to me wondering if an induced labour would have avoided that problem. Ergo I feel somewhat obliged to go with what is, after all, the medical standard.

It’s the medical standard for a reason. Contrary to popular belief, big babies  are not the primary reason for early induction, although it does follow that delivering a big baby early avoids the opportunity for it to increase yet more in size and so decreases the chance of delivery complications including shoulder dystocia.(In reality, this is still questionable.) The most important reason, however, is the increased risk of stillbirth.

Yeah, that’s something that doesn’t bear thinking about.

Pre-existing diabetes in particular, and especially that which has been long standing, is associated with vascular changes that can lead to more rapid deterioration of the function of the placenta. If the placenta fails and the baby is not born within minutes…. Well, you get the picture.

And of course if you start asking questions about whether the risk is correlated with glycaemic control during pregnancy, or what the actual percentage risks are of stillbirth if waiting until 41 weeks, no one can tell you. Because early delivery is the standard of care. Because the potential risk exists, no one is going to give ethical approval to a study to quantify it which would mean putting women and babies at that risk. In fact, a recent systematic review of the evidence to support reasons for induction conspicuously excludes type 1 diabetes, mentioning only gestational diabetes, which it puts in the category of having no solid evidence to support routine induction. In fact, it concludes that there is little evidence for the majority of reasons given for induction.

But even if a study were carried out which proved that the risk of stillbirth in women  with type 1 diabetes waiting until beyond 40 weeks was, say 10%, that’s meaningless if you’re the one in ten and your world comes crashing down. To be honest, once you’re aware of the risk, it’s hard to do anything but contemplate getting the baby born safely as soon as possible.

To look at it another way, though, as an individual you’re still extremely unlikely to suffer adverse complications. As one article puts it:

“Fortunately, it is uncommon in this day and age for a baby born at full-term to die around the time of birth or experience serious illness or injury. However, these outcomes still occur despite advances in obstetric and neonatal care. Doctors or midwives may recommend inducing labor as a way of lowering the chance of these problems happening. However, it is impossible to know which women should be induced because injury and death are often unpredictable. As a result, thousands of women may have labor induced to prevent just one injury or death, and all of those women and babies will be exposed to the risks of labor induction, which may include cesarean surgery, instrumental delivery (assisted by forceps or vacuum extraction), and newborn breathing problems.”

I wish there were more definitive tests to establish individual risks. I wish that this process of giving life weren’t so fragile and precarious. I wish I could just let it go and accept that what will be will be, rather than continuing to agonise over choices that don’t really exist. It was different before I was pregnant and I could indulge in being idealistic, with my image of a “normal” pregnancy and natural, spontaneous labour. I naively thought that so long as my control was good, I could be managed like a healthy person, rather than an ill person.

That was before I had a second heart beating inside me. Before I knew the kind of love and powerful, instinctive protection you can feel for someone you’ve not yet met.

My reasons to decline induction are largely selfish, and now that I’m about to be a mum, I can’t be selfish anymore. I don’t want forceps or a caesarean, but the risks of these procedures to my child seem less than the potential risks of not getting labour going sooner rather than later. I don’t want anything bad to happen to my baby either way.

Am I right? I’m right, right?

Full Term

37 weeks.

I’m officially “Full term”. Meaning that if the baby makes an appearance now, it’s considered perfectly “normal”. They wont be considered early and there will be no automatic need for special care or monitoring beyond standard blood glucose checks in the first 12 hours.

I’m not sure if it’s perfectly normal to feel such a sense of achievement at reaching this arbitrary mark. I suspect it probably is, but diabetes always makes achieving all these “normal” benchmarks that little bit sweeter.

Of course, now I’m just uber-impatient to meet this little dude or dudette. I feel enormous. I practically need a crane to shift me off the sofa and rolling over in bed is like moving an articulated lorry. I can’t sleep for more than an hour or so between the horrific heartburn and the almost constant need to pee. Which wouldn’t be so frustrating if every time I drag myself to the bathroom more than a dribble would appear!! I’m also permanently hot, with my in-built central heating, and all the effort of moving around just makes that worse. My rings don’t remotely fit and my ankles have been replaced by genuine bona-fide cankles. I’m so hormonal that the Dulux advert reduces me to tears – ridiculous!

Still, I don’t mean to moan. I feel incredibly blessed to have fallen pregnant, let alone reached this stage with fairly minimal problems. Pregnancy may be uncomfortable and damned hard work, but it is still a magical process that I feel lucky to have experienced.

I do really want to meet the child that we’ve created now though. I want to see who they are and welcome them to the outside world where I can snuggle them close. And I’m all the more impatient for knowing that all the statistics show that now is a perfectly safe time for them to make that entrance. It’s hard to remain patient, but at least I know it won’t be any more than another 3 weeks. That’s one positive of diabetes – it spares me the potential two week post-dates wait.

Prosciutto Crudo

Right now I gagging for some Prosciutto Crudo. It’s something that I used to eat by the bucket load before becoming pregnant, but now it’s off limits unless it’s cooked, due to the risk of Listeria. A few cooked slices on a pizza is nothing like the same.

It’s pretty much the only thing on the list of “forbidden foods” that I really care about. Well besides the glass of wine I’d love to have with my Prosciutto Crudo! I don’t eat raw cheese (I know I’m weird, but it has to be cooked) especially not soft or blue ones, and I despise pâté of all forms. I’ve made a decision about runny and raw eggs that I’ll eat them as long as they’re lion marked. I can skip gelato and other soft ice cream as I’d only really miss that if I was in Italy. I can make do with hard frozen shop bought ice cream for one summer. Coffee I’ve gone right off, but I know I could do decaff if I wanted to.

But Prosciutto and a glass of wine? First thing I’m eating (and drinking – between feeds of course) after Flangelina is born.

Epidural, Or Not?

I’ve touched on my fears surrounding having a epidural before. To cut it down though, I’m afraid to have an epidural for two reasons. The first is simply fear that it won’t work because they won’t be able to site it in the right place. The second is that, working or not, I’ll have a repeat of the nerve damage that I suffered before – or worse – and have to start motherhood with that hanging over me.

I’ve known all along, however, that it’s something I have to face up to and plan around. The ideal is still for me to have a natural vaginal delivery without an epidural. But I have to accept the possibility that I may end up having a caesarean section, and the even bigger possibility that I will be induced with syntocinon, which everyone says is ridiculously hard going without an epidural.

I think I’ve sort of got my head around the c-section problem. Now that we know Flangelina is not breech there is no reason why I would need a planned caesarean delivery. That means if it comes down to a c-section, it will be in an emergency situation in which there will be a significant risk to either the baby, or me, or both of us. At that point I’m willing to bet everything that I won’t care how the baby arrives as long as they do so safely and if that means a general anaesthetic and surgical arrival, then I’ll just be grateful that it’s possible.

The induction, or even simply prolonged spontaneous labour, is a bigger dilemma. I honestly think that my fear of an epidural is great enough that I’d rather go through childbirth without it almost no matter what. And my attitude to labour is perhaps slightly unusual – in that I’m excited and really want to do it. I’m fortunate to have a naturally positive attitude, believing that I can do it, and having met plenty of women who actually have . But of course, I haven’t been in labour yet.

So I need to get some proper perspective on this issue. I need to know whether it’s sensible for me to plan that I will definitely have a GA if I need a c-section. I need to know what the options are if I can’t cope with other forms of pain relief. Is an epidural likely to be possible? What are the actual chances of repeated nerve damage or other complications? The best person to answer these questions, and hopefully reassure me, is a consultant anaesthetist. After all, these are the people who are actually responsible for getting epidurals and spinal blocks on board.

I was referred to an obstetric anaesthetist fairly early on in my pregnancy, but was beginning to despair of actually getting to see them before I went in to labour. However today, I finally attended that appointment, with Ian in tow for support. And now…. Well, I’m still not totally sure.

I certainly don’t have all the answers, and much of what I think and feel is still the same. The anaesthetist reassured me that the risks of nerve damage remain low despite my previous experience but was sensitive to my anxieties and agreed that she couldn’t guarantee it would be OK, and the risk was definitely higher than average given my past history. She did say that although my spine did not feel to be the easiest shape, it certainly didn’t feel impossible either, but again could not guarantee that placing an epidural or spinal would necessarily be successful. She reassured me that a spinal block carries less risk than and epidural and seemed to feel that it may be worth an attempt at a spinal block if it should come down to a caesarean and time allowed.

Ultimately though, I still have to make the decision of what I will consent to. I still have the dilemma that I don’t want to miss our baby’s moment of arrival in to the world by being under a general anaesthetic. But I don’t want to lose out in the first weeks and months because I’m trying to recover from functional neurological loss. Considering having an epidural still puts me in to a panic and I suppose only time will tell how I’ll feel when actually faced with the decision for real, in labour. It may well be that I simply cannot make a final choice until that point.

The anaesthetist said that she would summarise our discussions to enter in to my record on delivery suite, and would also stipulate that I should be seen by a consultant anaesthetist on arrival, for cannulation (I have truly awful veins – something else with which she agreed) and should any form of spinal or epidural be attempted. I think I get the feeling that she was steering me towards considering at least an attempt at a spinal. I think she was possibly humouring me a bit in that I don’t know what labour is like – I got the impressions that she may have thought I was being a bit naive and will change my mind. She could be right. Having spent most of the rest of the day thinking it through though, I’m pretty set that my decision for now is not to consent to any form of spinal anaesthesia. I just don’t feel that I can take the risk.

I sort of feel better for having made that decision though. It means I can work on psychological pain management techniques, but also try to get truly mentally prepared for the possibility of delivery under GA. I’m not at all “happy” with the idea of possibly ending up with a GA, but I’m not happy about having an epidural or spinal either. If I block in to my mind now that it won’t be happening, I can at least stop panicking about it.

I’m just really, really hoping for a straightforward vaginal delivery. But the only thing that I know for sure about labour is that it very rarely goes to plan.

A Crisis About Clothes

I’ve been having a bit of a crisis about baby clothes. Or more specifically, about baby clothes not fitting our baby.

Since we’ve elected not to find out the gender of our child, we actually haven’t bought that many clothes. This is partly because we might want to buy some more gender specific clothes once they’re born, but also because it’s actually remarkably difficult to find that many unisex clothes, even in newborn size, unless you want to dress them purely in white or cream. Most of the ones that we have found seem to have a bit of a boyish bent too, but I may just feel that way because I’m convinced we’re having a boy. So we’ve bought a small selection in a mixture of Newborn size and 0-3 months size.

The problem is that I’ve completely convinced myself that we’ll be having a big, fat baby. And lately, I’ve convinced myself that big and fat means way more than 10lbs, which means that “Newborn” size (generally “Up to 10lb”) won’t fit even when they are actually a newborn. For some reason it’s become the focus of all my fears about the baby’s size. Ridiculously, I feel sad, to the point of tears, that some of the cute sleepsuits we’ve got might not actually fit our baby. I’m also worried that because we’ve divided our buying between the two sizes, we might find that we have way too little stuff to actually dress them in, if half of it doesn’t fit at all. In really irrational moments I can actually imagine the midwives tittering about the silly girl who didn’t bring any clothes to fit her baby, as they try to rustle something up to dress it in whilst Ian makes a mad dash to the shops in the first hours of our baby’s life.

It may seem like a silly thing to worry about, but it’s actually keeping me up at night. Along with the question of how much to unpack and wash. I can’t decide whether to keep some of the newborn size clothes and vests in their packages and unwashed, until we see if we will need them. That way, we could swap some for the next size up. Or do we just swap them all anyway, on the basis that 0-3 is likely to fit pretty much from birth in any event, and that way I guarantee not wasting any clothes. And not feeling bad that I don’t get to see our little bundle in some of the stuff we’ve picked out. These thoughts go round in my head at night, chased by all the numbers I’ve seen on my meter that day as I try to calculate the probability of not having a big, fat baby

Written down like this, they do seem such silly, trivial worries. But they represent something much deeper for me. It’s this nagging fear about having a big baby, which leads back to the worry that I’m not doing a good enough job of looking after myself to keep him or her safe. I’m even beating myself up with sleepsuits now. Teeny, tiny cute sleepsuits, but they pack a right punch.