...then try, try again!
And we have been. I know that it's daft to hope that you'll get pregnant in your first month, but it's hard to be rational about this TTC stuff. After all, we women spend large swathes of our twenties and early thirties trying to suppress our fertility, and believing that one 'accident' is all it could take. Then suddenly your world goes topsy turvy and you're actively trying to get pregnant. You sit down with a calendar and try to predict your fertile days. You start thinking about icky things like the consistency of your cervical mucus. Eeeew. You agonise about how much sex to have - every other day? every day? every three days? You wonder about ovulation predictor kits, and taking your basal temperature, and then you convince yourself that you won't worry about that malarkey just yet. You read books about getting pregnant and websites about getting pregnant, and you watch all the pregnancy related TV you can find (including the wonderful One Born Every Minute on Channel 4 in the UK). You realise that you're just a little deranged!
As I've already said, I'm 36, so I'm no spring chicken! Lots of my friends, who are the same sort of age as me or just a little older, have had kids in the last 18 months. I'm happy and excited for them, and jealous as hell! I want to be in that club. Different people have had very different conception experiences. One friend spent almost two years trying to conceive, and worried that she was infertile (she now has a gorgeous 16 month old son and another on the way - the second time was much easier, and number two is due any day). Another conceived the very first month of trying, and yet another on the second month. Oh how I wish to be in that group...
The first month of trying came and went, and along came my period. Grrrr. Oh well, it's only about a 25% chance that month.
The second month also came and went, and along came my period again (just a few days ago). So, we're about to go into month three. If I'm honest, last month wouldn't have been the best month to get pregnant, since I caught a nasty bug which sent my sugars a bit haywire for about 10 days. My meter averages went up from 6.5 mmol/l for the past 7 days to more like 8.5 mmol/l. I'm now back on the downward curve, and have settled at about 7.5. Now, six months ago that would have seemed impossibly good, but things have changed, and whilst these aren't disastrous levels, they did give me pause for thought.
So... onto month three. Here we go again. Back on the stringent diet wagon (after a little lapse when my period came - which just happened to co-incide with a short holiday in Copenhagen and the availability of some very good ice cream!) Back on the counting of days and the having lots of sex (yes, there are compensations to this - S, if you're reading, I love you so much!) , and back to being just slightly bonkers about the whole getting pregnant thing (sorry lovely husband)!
Lilypie First Birthday tickers
Sunday, 27 June 2010
Fourth appointment (or the Green Light) - 13 May 2010
My fourth visit to the Pre-Pregnancy Clinic had me walking on air. My HbA1C, taken on 5 May, was 6.6%, and Dr Inspiring's response really made me smile: 'Not to be crude, but what are you waiting for?!'
Okay, if you want to split hairs, it wasn't below 6.5%, but YAY! Go me! As Dr I observed, 'you've really turned things around'. We had a long talk about why this is, and I was very open about how I've not always had the best treatment, and how I feel that the approach of this clinic is so amazing. I've had continuity since I started seeing Dr I, and I've had a huge supporter. He also feels that this approach is the way forward, and is therefore frustrated that the NHS is moving more and more to GP-centred treatment for diabetics and limiting funding for the kind of hospital based clinics where he works. It seems to me that this is madness. My GP is brilliant, and has an active interest in diabetes, but he's not an expert, and can't be on the cutting edge of every specialism. I hope that the NHS at least continues to support the kind of Pre-Pregnancy Diabetes clinic that I've been so lucky to find - anything else would just be wrong. Oh, and if it were possible to clone Dr Inspiring and have one of him in every city, that would be good too :)
I also took the opportunity to talk to Dr I at this appointment about some discoveries I'd made on the internet which I'd found incredibly helpful. He didn't know about the vibrant D-blogging and D-advocacy communities, so hopefully I've opened his eyes to something new too. I'd found quite a lot of information which suggests that a basal:bolus ration of 50:50 is a good starting point, and that a basal rate of higher than 50% can work well since it cuts down on post meal spiking. People with strong Dawn Phenomenon may find that 60% works even better.* My proportions weren't in line with this - I was taking about 40-45% of my insulin as background (or basal) dose, and I'd experimented between appointments with shifting this closer to the magic 50-60%. My control was improving, and my spikes (and hypos) were evening out. What did Dr I think of all of this? He was happy for me to tinker, and to find what works for me, and didn't play the 'God' card. Wow. A doctor who understands, really understands, that diabetes is a combination of art and science, and that diabetics can learn from one another. This man is a national treasure!
My other big question at this appointment was about maternal vitamins. I was keen to start taking a supplement, to make sure I was getting all my requirements. I already eat a good and varied diet, so this was more of a 'belt and braces' approach than a necessity, but I was keen nonetheless. However, I was already on high dose folic acid (for diabetics) and the maternal multivitamin I wanted to take also contained folate (at the non-diabetic pregnant lady dose). I'd done some Googling, and it seemed to me that what I didn't absorb would be excreted in my urine, but I wanted to double check that I couldn't overdose. Dr I confirmed this, so I was able to start the maternal vitamins on top of the high dose folic acid.
I asked what would happen next, given that I've reached my target HbA1C. Dr Inspiring explained that I'd have planned appointments every eight weeks until I get pregnant. If I have any problems in between appointments I can call him for advice. If we 'hit the jackpot' I should call him straight away, so that we can get onto the proper pregnancy treadmill of medical appointments. My next appointment will see a repeat HbA1C, to make sure that things are still on course, and a full blood panel including the thyroid tests. With that news, I got a big hug and off I went. My next appointment was set for 8 July.
Notes:
*For the interested, some links: http://www.andorrapediatrics.com/ap_folders/hand-outs/knowledge/insulin_pump_initiation.htm; http://www.diabetesnet.com/diabetes_control_tips/basal_bolus.php#axzz0s556dqml
Okay, if you want to split hairs, it wasn't below 6.5%, but YAY! Go me! As Dr I observed, 'you've really turned things around'. We had a long talk about why this is, and I was very open about how I've not always had the best treatment, and how I feel that the approach of this clinic is so amazing. I've had continuity since I started seeing Dr I, and I've had a huge supporter. He also feels that this approach is the way forward, and is therefore frustrated that the NHS is moving more and more to GP-centred treatment for diabetics and limiting funding for the kind of hospital based clinics where he works. It seems to me that this is madness. My GP is brilliant, and has an active interest in diabetes, but he's not an expert, and can't be on the cutting edge of every specialism. I hope that the NHS at least continues to support the kind of Pre-Pregnancy Diabetes clinic that I've been so lucky to find - anything else would just be wrong. Oh, and if it were possible to clone Dr Inspiring and have one of him in every city, that would be good too :)
I also took the opportunity to talk to Dr I at this appointment about some discoveries I'd made on the internet which I'd found incredibly helpful. He didn't know about the vibrant D-blogging and D-advocacy communities, so hopefully I've opened his eyes to something new too. I'd found quite a lot of information which suggests that a basal:bolus ration of 50:50 is a good starting point, and that a basal rate of higher than 50% can work well since it cuts down on post meal spiking. People with strong Dawn Phenomenon may find that 60% works even better.* My proportions weren't in line with this - I was taking about 40-45% of my insulin as background (or basal) dose, and I'd experimented between appointments with shifting this closer to the magic 50-60%. My control was improving, and my spikes (and hypos) were evening out. What did Dr I think of all of this? He was happy for me to tinker, and to find what works for me, and didn't play the 'God' card. Wow. A doctor who understands, really understands, that diabetes is a combination of art and science, and that diabetics can learn from one another. This man is a national treasure!
My other big question at this appointment was about maternal vitamins. I was keen to start taking a supplement, to make sure I was getting all my requirements. I already eat a good and varied diet, so this was more of a 'belt and braces' approach than a necessity, but I was keen nonetheless. However, I was already on high dose folic acid (for diabetics) and the maternal multivitamin I wanted to take also contained folate (at the non-diabetic pregnant lady dose). I'd done some Googling, and it seemed to me that what I didn't absorb would be excreted in my urine, but I wanted to double check that I couldn't overdose. Dr I confirmed this, so I was able to start the maternal vitamins on top of the high dose folic acid.
I asked what would happen next, given that I've reached my target HbA1C. Dr Inspiring explained that I'd have planned appointments every eight weeks until I get pregnant. If I have any problems in between appointments I can call him for advice. If we 'hit the jackpot' I should call him straight away, so that we can get onto the proper pregnancy treadmill of medical appointments. My next appointment will see a repeat HbA1C, to make sure that things are still on course, and a full blood panel including the thyroid tests. With that news, I got a big hug and off I went. My next appointment was set for 8 July.
Notes:
*For the interested, some links: http://www.andorrapediatrics.com/ap_folders/hand-outs/knowledge/insulin_pump_initiation.htm; http://www.diabetesnet.com/diabetes_control_tips/basal_bolus.php#axzz0s556dqml
Third appointment (or Spectacular Progress!) - 15 April 2010
I had called L, the dietician, in advance of this appointment to get the results of my HbA1C, and had to endure a frustrating wait of a few days whilst she was on holiday. I'd been really hopefully that it would be under 7.0%, and was gutted to find that it was still 7.3.
When I arrived at my appointment Dr Inspiring came bounding in and told me how well I looked, and then gave me the HbA1C result. 'What do you think?' he asked. 'Well...', I said, 'I'm pretty disappointed that it doesn't start with a 6.' Dr I then proceeded to tell me that I was beating myself up for making spectacular progress. He told me that he could see that I'd worked extremely hard, and took a quick look at my log book before proclaiming that my HbA1C should be less than 7.0% within four weeks. As it turns out his enthusiasm is pretty infectious, and his comment totally made my day!
He wondered aloud if I'd thought about switching from Lantus to Levemir, and when I explained that L and I had discussed it last appointment, and that I was keen to try it, he wrote me a prescription for a snazzy new Novopen and one box of 5 cartridges. We agreed that I'd try it and would see how I went. He advised starting the new insulin at a weekend, so that I could have a couple of days to settle in before going back to work. He wasn't sure if 1:1 would be the right conversion ration between insulins, as apparently it varies between people, so he told me to test frequently to start off with. Apparently it can take time for the Lantus to leave your system, so I might need to adjust things after the first few days.
We talked about my very frequent hypos, and he agreed that my strategy of holding back some food from each meal was a good one. Many of his patients eat small packets of carb throughout the day, rather than having three 'big' meals. 'Treat it like a military campaign...' he said, 'maintain the same level of food, but have more meals - small meal, snack, small meal, snack...' He gave me a leaflet about how to treat hypos, and I promised I'd try to stick to its advice, rather than doing my usual 'hoover up all the carbs within reach' approach and then rebounding. Glucose tabs are truly disgusting though, so I've not been as good as I might have. Still, I'm trying.
I asked again about my thyroid results, having had some time to digest them and read up on the internet. Dr I said that it was nothing to worry about at present, but that he'd keep a close eye on my levels.
As for TTC, Dr I suggested that we could start trying in May. I left with an appointment for 13 May, and was given a blood test request form so that I could have an HbA1C the week before my appointment. I also left with a book recommendation, having admitted reading the NICE Guidelines from cover to cover. I've promised myself that once we get pregnant I'll treat myself to the following medical tome: Managing Pre-Existing Diabetes Mellitus in Pregnancy by J.L. Kitzmiller et al (American Diabetes Association). Stupid, I know, but I don't want to order it until I see a positive test, just in case I jinx myself. I am a rational person, honest, but this TTC stuff can fry your brain just a little!
When I arrived at my appointment Dr Inspiring came bounding in and told me how well I looked, and then gave me the HbA1C result. 'What do you think?' he asked. 'Well...', I said, 'I'm pretty disappointed that it doesn't start with a 6.' Dr I then proceeded to tell me that I was beating myself up for making spectacular progress. He told me that he could see that I'd worked extremely hard, and took a quick look at my log book before proclaiming that my HbA1C should be less than 7.0% within four weeks. As it turns out his enthusiasm is pretty infectious, and his comment totally made my day!
He wondered aloud if I'd thought about switching from Lantus to Levemir, and when I explained that L and I had discussed it last appointment, and that I was keen to try it, he wrote me a prescription for a snazzy new Novopen and one box of 5 cartridges. We agreed that I'd try it and would see how I went. He advised starting the new insulin at a weekend, so that I could have a couple of days to settle in before going back to work. He wasn't sure if 1:1 would be the right conversion ration between insulins, as apparently it varies between people, so he told me to test frequently to start off with. Apparently it can take time for the Lantus to leave your system, so I might need to adjust things after the first few days.
We talked about my very frequent hypos, and he agreed that my strategy of holding back some food from each meal was a good one. Many of his patients eat small packets of carb throughout the day, rather than having three 'big' meals. 'Treat it like a military campaign...' he said, 'maintain the same level of food, but have more meals - small meal, snack, small meal, snack...' He gave me a leaflet about how to treat hypos, and I promised I'd try to stick to its advice, rather than doing my usual 'hoover up all the carbs within reach' approach and then rebounding. Glucose tabs are truly disgusting though, so I've not been as good as I might have. Still, I'm trying.
I asked again about my thyroid results, having had some time to digest them and read up on the internet. Dr I said that it was nothing to worry about at present, but that he'd keep a close eye on my levels.
As for TTC, Dr I suggested that we could start trying in May. I left with an appointment for 13 May, and was given a blood test request form so that I could have an HbA1C the week before my appointment. I also left with a book recommendation, having admitted reading the NICE Guidelines from cover to cover. I've promised myself that once we get pregnant I'll treat myself to the following medical tome: Managing Pre-Existing Diabetes Mellitus in Pregnancy by J.L. Kitzmiller et al (American Diabetes Association). Stupid, I know, but I don't want to order it until I see a positive test, just in case I jinx myself. I am a rational person, honest, but this TTC stuff can fry your brain just a little!
A short aside about periods!
I stopped taking my Cerazette on 6 February and waited patiently for my period. Actually, that's not true. I stopped taking my Cerazette and waited impatiently! I had assumed that once I wasn't taking the pill my periods would re-establish pretty quickly, but instead I had to endure a month of breast tenderness and abdominal pain, culminating in serious pain in the middle of the night on 28 February - it felt like it might have been an ovary, but what would I know?!
My first period finally (mercifully) arrived on 5 March, and I've never been so glad of it! Since then I've actually been pretty regular, which is unusual for me, as when I was younger my cycle ranged from 18 days to about 53 days.
First period: 5 March
29 day cycle
Second period: 3 April
28 day cycle
Third period: 1 May
28 day cycle
Fourth period: 29 May
26 day cycle
Fifth period: 24 June
My first period finally (mercifully) arrived on 5 March, and I've never been so glad of it! Since then I've actually been pretty regular, which is unusual for me, as when I was younger my cycle ranged from 18 days to about 53 days.
First period: 5 March
29 day cycle
Second period: 3 April
28 day cycle
Third period: 1 May
28 day cycle
Fourth period: 29 May
26 day cycle
Fifth period: 24 June
Second Appointment (or meeting the dietician) - 11 March 2010
My second appointment at the Pre-Pregnancy clinic was with L, the dietician who works with Dr Inspiring. In all honesty, I was initially a bit disappointed that I wasn't going to see Dr I again this time, but L was brilliant - and talked about much more than I'd usually expect from a dietician.
We started with a look at my injection sites and my wonky tummy. As I undid my jeans (which were held together with a safety pin) L laughed and suggested it might be time to buy some new ones, given my recent weight loss. I didn't like to say that these were the new jeans I'd bought, and that they were already too big too! I've always tried to be diligent about switching my injection sites, moving from side to side, but have been a habitual tummy injector (my legs bruise up, and I don't find the absorption as good). L took one look and told me what I already knew - 'you have hyperlipotrophy'. She gave me some great advice about using my sides and hips whilst waiting for the lumps to dissipate (which they will, if I leave those sites fallow for long enough). She also suggested using my buttocks for my Lantus dose, as this will give me slower and more even absorption.*
We talked a bit about the different insulins available, and L suggested taking my Novorapid between 10 and 20 minutes before a meal. Although I was told that it could be taken with, or even after food, L told me that most people still find that there's something of a delay before their insulin starts acting, and therefore taking your insulin around a quarter of an hour before a meal can make a difference and even out the post meal spikes a little. For me it's like going back to the old days of Actrapid - I don't always manage to get my timings right, but with a little planning it's fine. L also suggested thinking about changing my Lantus to Levemir, which is made by Novo Nordisk, the same manufacturer as Novorapid. Apparently Lantus has been associated in some studies with a slight increased risk of breast cancer, and some women who have a family history of breast cancer have been switched over to Levemir. Levemir is also considered, by some doctors at least, to be more flexible and work better for some people. It has to be taken in two doses, 12 hours apart, but since my Lantus is already on a split dose that would be no hardship! We also talked just a little about the benefits of going on a pump, although L said that the clinic had yet to switch someone over who was pregnant. It's an interesting thought, and I've wondered in the past about the possibility of an insulin pump (and especially about the wonders of the CGM - continuous glucose monitor - which is very attractive to me indeed), but I'm not won over. I can't help worrying about what would happen if the pump malfunctioned - at least when you're doing your own injections you dial up your own dose and feel the pen click as the dose goes in. Maybe I'm just too much of a control freak. Also, I have a horrible allergy to the glue in sticking plasters, and infusion sites and CGM sensors probably involve too much glue for my poor sensitive skin! :(
We also talked a little about my continuing attempts to lose weight. With my new tighter control I was having a lot of hyps - two or three every day, in fact. I could manage to keep my post-meal spikes down to 8-9 mmol/l, but this would mean going low a couple of hours later. I'd worked out a good plan to solve this, which was to hold back a small portion of each meal to eat three hours later, when the inevitable hypo struck, but I was also having fast acting carbs (often a couple of sweets) to fix the hypos I didn't catch early enough, and the extra calories from this meant that my weight loss had stalled (even though I was still only on about 1,500 calories a day). L suggested that maybe my metabolism had got used to the 1,200-1,500 calories from my diet and needed to be shocked. Exercise would increase my muscle mass, and hopefully shock my metabolism back into a place where I'd lose weight.**
Finally, I got the results of my blood tests taken at the previous appointment. My HbA1C was 8.1%. Far from the target level of 6.5%, but going in the right direction (it was 8.8% last time I had it done, in November 2009). I knew more or less what the result was going to be, as I'd had an HbA1C done at my GP surgery on 5 February, and it had been 7.9%. I was also given my thyroid function results, which were a little borderline. Apparently I have antibodies which indicate a risk for an underactive thyroid (which is another auto-immune condition often found in conjunction with type 1 diabetes). L wanted to check what Dr Inspiring thought about this result, and a couple of minutes later he popped his head around the door. He said that it was possible that a pregnancy would tip me into hypothyroidism, but that for the moment I'm okay. They'll monitor me closely, so I shouldn't worry too much - it's not unusual for T1 women. Although I'm not keen to have yet another thrilling medical condition to juggle I'm pretty sanguine - I'd much rather know, and I'm being taken good care of, so it could be a whole lot worse. And anyway, it hasn't happened yet, and might never happen, so I'll just 'keep on keeping on!'
I left my appointment with instructions to have another HbA1C in two weeks. The blood could be taken at my GPs, meaning that I didn't have to go back to the hospital to have the test, and I could call L 48 hours later for the results. My next appointment with Dr I would be on 15 April, giving me another four weeks to hammer that HbA1C.
****
I've talked about my struggles with my diabetes in a previous post, but this appointment was when lots fell into place for me. As I wrote in my earlier post, I'd been experiencing high sugars in the morning for about ten years, all told, and every doctor who I saw had a different explanation. L was the first diabetes professional, in all that time, to suggest that I might be experiencing the 'Dawn Phenomenon', where hormones are released whilst you sleep (somewhere around 4am) which cause your body to release stores of glucose from the pancreas. Knowing that I wasn't alone, and that what I have has a name, made a huge difference. I was able to read blog posts and diabetes advocacy sites which had suggestions for how to defeat the dawn phenomenon, and my new understanding has improved things for me. I'm not saying that the problem's gone away, but I've found ways of tackling it. If I wake in the night I'll check my sugars and give myself a small correction dose if I'm running high. I always test and then take my background insulin first thing when I wake up, even if I'm not planning to eat. At the weekend this means that my sugars are likely to stay more stable, before eating a late breakfast. During the week I also take my novorapid as soon as I wake. This means that it has a chance to kick in and start working whilst I'm poddling around the house getting ready to go to work. By the time I have breakfast a hour later my insulin is at peak action, and I'm less likely to spike after my breakfast. I now know, thanks to other d-bloggers, that the Dawn Phenomenon tends to make diabetics less insulin sensitive in the morning, so I'm more apt to take a bigger bolus for my small breakfast than I would otherwise be.
As I've discovered, the Dawn Phenomenon is a known feature of T1. So I feel short-changed that it's taken so long for someone to name it for me, and hence help me to tame it. I only wish that I'd found this clinic, and the D.O.C. a few years earlier, so I wouldn't have felt that I was to blame for my morning highs, and I wouldn't have felt so alone.
****
Notes:
* I've taken her advice and this works brilliantly (although I do have to contort myself somewhat to reach my bum, and my lovely hubby S has been known to have a good laugh watching this!)
** I left the hospital intending to try this, but to be honest, with all the hypos, every time I sat on my exercise bike I could only do 10 minutes before conking out and having to eat something, which seemed somewhat counter-productive. Grrrr. So, exercise would be good and is still on my to-do list, but I've so far failed in my endeavours.
We started with a look at my injection sites and my wonky tummy. As I undid my jeans (which were held together with a safety pin) L laughed and suggested it might be time to buy some new ones, given my recent weight loss. I didn't like to say that these were the new jeans I'd bought, and that they were already too big too! I've always tried to be diligent about switching my injection sites, moving from side to side, but have been a habitual tummy injector (my legs bruise up, and I don't find the absorption as good). L took one look and told me what I already knew - 'you have hyperlipotrophy'. She gave me some great advice about using my sides and hips whilst waiting for the lumps to dissipate (which they will, if I leave those sites fallow for long enough). She also suggested using my buttocks for my Lantus dose, as this will give me slower and more even absorption.*
We talked a bit about the different insulins available, and L suggested taking my Novorapid between 10 and 20 minutes before a meal. Although I was told that it could be taken with, or even after food, L told me that most people still find that there's something of a delay before their insulin starts acting, and therefore taking your insulin around a quarter of an hour before a meal can make a difference and even out the post meal spikes a little. For me it's like going back to the old days of Actrapid - I don't always manage to get my timings right, but with a little planning it's fine. L also suggested thinking about changing my Lantus to Levemir, which is made by Novo Nordisk, the same manufacturer as Novorapid. Apparently Lantus has been associated in some studies with a slight increased risk of breast cancer, and some women who have a family history of breast cancer have been switched over to Levemir. Levemir is also considered, by some doctors at least, to be more flexible and work better for some people. It has to be taken in two doses, 12 hours apart, but since my Lantus is already on a split dose that would be no hardship! We also talked just a little about the benefits of going on a pump, although L said that the clinic had yet to switch someone over who was pregnant. It's an interesting thought, and I've wondered in the past about the possibility of an insulin pump (and especially about the wonders of the CGM - continuous glucose monitor - which is very attractive to me indeed), but I'm not won over. I can't help worrying about what would happen if the pump malfunctioned - at least when you're doing your own injections you dial up your own dose and feel the pen click as the dose goes in. Maybe I'm just too much of a control freak. Also, I have a horrible allergy to the glue in sticking plasters, and infusion sites and CGM sensors probably involve too much glue for my poor sensitive skin! :(
We also talked a little about my continuing attempts to lose weight. With my new tighter control I was having a lot of hyps - two or three every day, in fact. I could manage to keep my post-meal spikes down to 8-9 mmol/l, but this would mean going low a couple of hours later. I'd worked out a good plan to solve this, which was to hold back a small portion of each meal to eat three hours later, when the inevitable hypo struck, but I was also having fast acting carbs (often a couple of sweets) to fix the hypos I didn't catch early enough, and the extra calories from this meant that my weight loss had stalled (even though I was still only on about 1,500 calories a day). L suggested that maybe my metabolism had got used to the 1,200-1,500 calories from my diet and needed to be shocked. Exercise would increase my muscle mass, and hopefully shock my metabolism back into a place where I'd lose weight.**
Finally, I got the results of my blood tests taken at the previous appointment. My HbA1C was 8.1%. Far from the target level of 6.5%, but going in the right direction (it was 8.8% last time I had it done, in November 2009). I knew more or less what the result was going to be, as I'd had an HbA1C done at my GP surgery on 5 February, and it had been 7.9%. I was also given my thyroid function results, which were a little borderline. Apparently I have antibodies which indicate a risk for an underactive thyroid (which is another auto-immune condition often found in conjunction with type 1 diabetes). L wanted to check what Dr Inspiring thought about this result, and a couple of minutes later he popped his head around the door. He said that it was possible that a pregnancy would tip me into hypothyroidism, but that for the moment I'm okay. They'll monitor me closely, so I shouldn't worry too much - it's not unusual for T1 women. Although I'm not keen to have yet another thrilling medical condition to juggle I'm pretty sanguine - I'd much rather know, and I'm being taken good care of, so it could be a whole lot worse. And anyway, it hasn't happened yet, and might never happen, so I'll just 'keep on keeping on!'
I left my appointment with instructions to have another HbA1C in two weeks. The blood could be taken at my GPs, meaning that I didn't have to go back to the hospital to have the test, and I could call L 48 hours later for the results. My next appointment with Dr I would be on 15 April, giving me another four weeks to hammer that HbA1C.
****
I've talked about my struggles with my diabetes in a previous post, but this appointment was when lots fell into place for me. As I wrote in my earlier post, I'd been experiencing high sugars in the morning for about ten years, all told, and every doctor who I saw had a different explanation. L was the first diabetes professional, in all that time, to suggest that I might be experiencing the 'Dawn Phenomenon', where hormones are released whilst you sleep (somewhere around 4am) which cause your body to release stores of glucose from the pancreas. Knowing that I wasn't alone, and that what I have has a name, made a huge difference. I was able to read blog posts and diabetes advocacy sites which had suggestions for how to defeat the dawn phenomenon, and my new understanding has improved things for me. I'm not saying that the problem's gone away, but I've found ways of tackling it. If I wake in the night I'll check my sugars and give myself a small correction dose if I'm running high. I always test and then take my background insulin first thing when I wake up, even if I'm not planning to eat. At the weekend this means that my sugars are likely to stay more stable, before eating a late breakfast. During the week I also take my novorapid as soon as I wake. This means that it has a chance to kick in and start working whilst I'm poddling around the house getting ready to go to work. By the time I have breakfast a hour later my insulin is at peak action, and I'm less likely to spike after my breakfast. I now know, thanks to other d-bloggers, that the Dawn Phenomenon tends to make diabetics less insulin sensitive in the morning, so I'm more apt to take a bigger bolus for my small breakfast than I would otherwise be.
As I've discovered, the Dawn Phenomenon is a known feature of T1. So I feel short-changed that it's taken so long for someone to name it for me, and hence help me to tame it. I only wish that I'd found this clinic, and the D.O.C. a few years earlier, so I wouldn't have felt that I was to blame for my morning highs, and I wouldn't have felt so alone.
****
Notes:
* I've taken her advice and this works brilliantly (although I do have to contort myself somewhat to reach my bum, and my lovely hubby S has been known to have a good laugh watching this!)
** I left the hospital intending to try this, but to be honest, with all the hypos, every time I sat on my exercise bike I could only do 10 minutes before conking out and having to eat something, which seemed somewhat counter-productive. Grrrr. So, exercise would be good and is still on my to-do list, but I've so far failed in my endeavours.
First Appointment (or CONTROL, CONTROL, CONTROL!) - 28 January 2010
My first appointment at the Pre-Pregnancy Clinic for Diabetics was on 28 January 2010. Almost five months ago. So, this post is reconstructed from notes I made to myself at that first appointment, when I met Dr Inspiring for the first time. All together I was at the clinic for about an hour and a half - not your usual 'quick in and out'. The clinic is at my local hospital, and runs parallel with the standard ante-natal clinics, so you see lots of pregnant ladies (of all shapes, sizes and ages) clutching their yellow folders full of their records. I just want so badly to be one of them.
Anyway, back to my appointment. After talking about my diabetes history for a few minutes, and hearing about the 35 lbs I've lost since last October, Dr Inspiring laid it on the line. He wants to see very tight control in his ladies, and I'm to aim for an HbA1C of 6.5. I don't think I've seen numbers like that in a decade. To achieve this incredible feat he gave me some targets for pre-meal sugars (3.5-5.5 mmol/l) and post-meal sugars (3.5-8.0). I didn't even think an 8.0 post meal was possible! To do this I may well need to increase and/or tweak my insulin doses.
Dr Inspiring gave me a new monitoring log book, and told me to keep detailed records of my sugars. His view is that it's not enough to keep your records on your glucose meter - writing them down allows you to see patterns much more clearly, and makes you take greater notice of what is going on. He then scribbled his mobile number in the front of the log book, and the number of his nutritionist colleague, and told me to phone at any time for advice. This is way beyond the 'normal service' in my experience (and was borne out a couple of weeks later when I went to my GP's practice to have blood taken and was told by a new trainee GP in the practice that Dr Inspiring is a bit of a legend!)
We talked a little bit about my weight loss, and whether I needed to lose more before beginning to try. At the time my weight was 14st7lb. Dr Inspiring told me that whilst any more weight loss would be great, and would certainly help in fertility terms, he didn't see a strong need for more weight loss. 'I'm not so worried about your weight - let's focus on your control'. We agreed that I'd carry on with my diet, and aim to lose more weight, but not at the expense of my overall control. Dr I was pleased to hear about the eating habits that my lovely hubby and I try to maintain, and encouraged me to keep focusing on good eating choices - minimising processed food. Following my confession that Diet Coke is one of my biggest vices he also suggested that I try (and this one's going to be really hard) to cut down, since it's an appetite stimulant (and made of icky chemicals!) We agreed that I would continue to try to lose weight slowly whilst trying to conceive, and even once I'm pregnant we should aim to minimise my weight gain.
We talked a little bit about trade-offs between weight loss and the decline in fertility that comes with age, and Dr I was very pragmatic. We agreed that the aim should be for S and I to have two kids before I'm 40, and since that's 'do-able but tight' we shouldn't wait and wait to get to the perfect BMI before starting to try, and in the meantime lose some of my fertile years. Good sense indeed. It seems to me that it's all about the risks, and minimising them, whilst recognising that it's impossible to eliminate any risk completely.
We also talked about the next steps fertility-wise, and Dr I suggested that I stop taking the contraceptive pill (Cerazette) and use barrier methods until S and I are ready to start trying. This would allow my system to settle down and my periods to restart (after many years of pill use - first Marvelon, with the associated withdrawal bleeds, and then Cerazette, with practically no bleeding at all - just a slight smear once every three months or so). Stopping the pill could also have a beneficial effect on my weight.
Dr I was pleased that I was already taking folic acid, but upped my dose from the standard non-diabetic 400mcg to the 5mg dose recommended for diabetic women, and told me to get my GP to put this on my repeat prescription. I was warned that it can take time to conceive, and it could be 9 months, or even a year of trying before we get lucky, but the clinic will be there with me all the way, offering support in keeping my diabetes well controlled. I observed that 'of course, I could be infertile' (a fear that I think we all have, even in the absence of any evidence) and Dr I smiled 'well, we even do fertility assistance if that does happen, and of course you're already in the system!' This clinic is amazing!!
At the end of my appointment Dr I introduced me to one of the Obstetricians on the team, who was lovely (and does lots of work on reproductive health in developing countries - something we bonded over). She also talked me through her expectations regarding HbA1C, saying that Dr I is extra keen on very tight control, and that the obstetricians he works with have slightly less stringent expectations, as follows:
She also told me a little more about the risks of complications associated with a high HbA1C. Heart complications manifest themselves in about 1-2% of babies born to non-diabetic mothers, which is the same as diabetic mothers with an HbA1C of 7% or less. If the HbA1C is over 8%, this rises to 3-4%, and with an HbA1C of over 10% one in five babies will have heart complications. Scary stuff.
Other complications include big babies - especially if blood glucose is high during pregnancy (and this one is a bit terrifying since my lovely husband was a 10lb baby, and my paternal grandfather was something over 14lbs, with a withered arm to show for it). Eeek. Small babies can also result from diabetes, although this is far less common. She finished up with some better news though - reminding me that this diabetes/obstetrics collaboration sees a lot of diabetic ladies, both T1 and T2, and they usually have really good results.
The last stop was for blood tests (for my HbA1C and thyroid function) and a urine sample. The nurse who took my blood was also a fan of Dr Inspiring, confiding that she is also a diabetic and that Dr Inspiring is her consultant and he saw her through a successful pregnancy! By this stage I was on a total high - never have I felt so supported by a diabetes clinic, and it's a HUUUUUGE motivation to achieve. I left the clinic with a plan, a spring in my step, a head full of determination, and an appointment to come back in five weeks' time.
Anyway, back to my appointment. After talking about my diabetes history for a few minutes, and hearing about the 35 lbs I've lost since last October, Dr Inspiring laid it on the line. He wants to see very tight control in his ladies, and I'm to aim for an HbA1C of 6.5. I don't think I've seen numbers like that in a decade. To achieve this incredible feat he gave me some targets for pre-meal sugars (3.5-5.5 mmol/l) and post-meal sugars (3.5-8.0). I didn't even think an 8.0 post meal was possible! To do this I may well need to increase and/or tweak my insulin doses.
Dr Inspiring gave me a new monitoring log book, and told me to keep detailed records of my sugars. His view is that it's not enough to keep your records on your glucose meter - writing them down allows you to see patterns much more clearly, and makes you take greater notice of what is going on. He then scribbled his mobile number in the front of the log book, and the number of his nutritionist colleague, and told me to phone at any time for advice. This is way beyond the 'normal service' in my experience (and was borne out a couple of weeks later when I went to my GP's practice to have blood taken and was told by a new trainee GP in the practice that Dr Inspiring is a bit of a legend!)
We talked a little bit about my weight loss, and whether I needed to lose more before beginning to try. At the time my weight was 14st7lb. Dr Inspiring told me that whilst any more weight loss would be great, and would certainly help in fertility terms, he didn't see a strong need for more weight loss. 'I'm not so worried about your weight - let's focus on your control'. We agreed that I'd carry on with my diet, and aim to lose more weight, but not at the expense of my overall control. Dr I was pleased to hear about the eating habits that my lovely hubby and I try to maintain, and encouraged me to keep focusing on good eating choices - minimising processed food. Following my confession that Diet Coke is one of my biggest vices he also suggested that I try (and this one's going to be really hard) to cut down, since it's an appetite stimulant (and made of icky chemicals!) We agreed that I would continue to try to lose weight slowly whilst trying to conceive, and even once I'm pregnant we should aim to minimise my weight gain.
We talked a little bit about trade-offs between weight loss and the decline in fertility that comes with age, and Dr I was very pragmatic. We agreed that the aim should be for S and I to have two kids before I'm 40, and since that's 'do-able but tight' we shouldn't wait and wait to get to the perfect BMI before starting to try, and in the meantime lose some of my fertile years. Good sense indeed. It seems to me that it's all about the risks, and minimising them, whilst recognising that it's impossible to eliminate any risk completely.
We also talked about the next steps fertility-wise, and Dr I suggested that I stop taking the contraceptive pill (Cerazette) and use barrier methods until S and I are ready to start trying. This would allow my system to settle down and my periods to restart (after many years of pill use - first Marvelon, with the associated withdrawal bleeds, and then Cerazette, with practically no bleeding at all - just a slight smear once every three months or so). Stopping the pill could also have a beneficial effect on my weight.
Dr I was pleased that I was already taking folic acid, but upped my dose from the standard non-diabetic 400mcg to the 5mg dose recommended for diabetic women, and told me to get my GP to put this on my repeat prescription. I was warned that it can take time to conceive, and it could be 9 months, or even a year of trying before we get lucky, but the clinic will be there with me all the way, offering support in keeping my diabetes well controlled. I observed that 'of course, I could be infertile' (a fear that I think we all have, even in the absence of any evidence) and Dr I smiled 'well, we even do fertility assistance if that does happen, and of course you're already in the system!' This clinic is amazing!!
At the end of my appointment Dr I introduced me to one of the Obstetricians on the team, who was lovely (and does lots of work on reproductive health in developing countries - something we bonded over). She also talked me through her expectations regarding HbA1C, saying that Dr I is extra keen on very tight control, and that the obstetricians he works with have slightly less stringent expectations, as follows:
- HbA1C over 10% - don't get pregnant
- HbA1C less than 8% - okay
- Aim for HbA1C of 7%
She also told me a little more about the risks of complications associated with a high HbA1C. Heart complications manifest themselves in about 1-2% of babies born to non-diabetic mothers, which is the same as diabetic mothers with an HbA1C of 7% or less. If the HbA1C is over 8%, this rises to 3-4%, and with an HbA1C of over 10% one in five babies will have heart complications. Scary stuff.
Other complications include big babies - especially if blood glucose is high during pregnancy (and this one is a bit terrifying since my lovely husband was a 10lb baby, and my paternal grandfather was something over 14lbs, with a withered arm to show for it). Eeek. Small babies can also result from diabetes, although this is far less common. She finished up with some better news though - reminding me that this diabetes/obstetrics collaboration sees a lot of diabetic ladies, both T1 and T2, and they usually have really good results.
The last stop was for blood tests (for my HbA1C and thyroid function) and a urine sample. The nurse who took my blood was also a fan of Dr Inspiring, confiding that she is also a diabetic and that Dr Inspiring is her consultant and he saw her through a successful pregnancy! By this stage I was on a total high - never have I felt so supported by a diabetes clinic, and it's a HUUUUUGE motivation to achieve. I left the clinic with a plan, a spring in my step, a head full of determination, and an appointment to come back in five weeks' time.
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