Tuesday, November 25, 2008

When to see an RE...

Well, with the 2nd cycle of clomid being anovulatory, we are getting closer and closer to when we need to decide how much further to go with our OBGYN, verses seeking out the opinion of a more experienced reproductive endcronologist. If it wasn't for our insurance not covering any diagnostic tests or treatments, we would have gone a long time ago. However, we're trying to start with a few basic things and get those done with the OB. The only problem is I'm worried we're wasting time and energy and are putting my body through things that might end up doing it more harm than it's worth.

Today is cycle day 37 with no sign of ovulation or my period. We're pretty much assuming nothing is going to happen now, although it could still I suppose, and have an appointment set up for two Tuesdays from now to go see the new OB (since my old OB up and moved on us!). Before then, we need to do some serious talking and figure out what our ideal next step is based on our research and then come up with a list of questions to get answered that day.

In the meantime, I found another online radio show program (yes, I LOVE that site!) where an infertility specialist talked specifically about when and how to go about choosing an RE. My notes are below!

A little of the subject, but here is a handy guide of one Infertility Center's quick "diagnosis to treatment" comparison. http://www.makingbabies.org.uk/index.aspx?pageId=11

Success Rates of Infertility Centers
Missouri: http://apps.nccd.cdc.gov/ART2005/clinlist05.asp?State=MO
Find your state: http://apps.nccd.cdc.gov/ART2005/clinics05.asp

Local Infertility Centers of Interest (use the above site as a good resource for other centers)
1) Washington University (St. Louis) Infertility and Reproductive Medicine Center at Barnes-Jewish Hospital - http://www.infertility.wustl.edu/fpp/infertility.nsf
2) Sher Institutes for Reproductive Medicine in St. Louis -http://www.haveababy.com/index_stl.cfm?&city=stl&site=stl

When to Seek Help from a Reproductive Endocrinologist

Please note: This is my personal synopsis of the free online radio program hosted by Kim Haun, founder of Conceive Magazine, with guest Dr. Peter Ahlering, an ob/gyn and medical director of the Sher Institutes for Reproductive Medicine in St. Louis. To listen for yourself, go to this site and find the show in the archive on the left, dated 8/2/07, titled "Know When to Seek Help").

If you can't retrieve a decent number of good eggs, then chances are slim of success. (10-15 eggs are best). These non-ideal patients can be identified. The things that doctors look for are: high FSH (over 9), late 30s or older women, low ovarian reserve (via ultrasound during early part of cycle - antrafollicle count, which is similar for the next several months; this count is indicitive of how many max eggs you can get, typical 70-80% of the count).

Patient Example
1st Transfer - no baby; 2nd Tranfer - good quality by appearance, but no baby - look for embroy problem (after 1st failure)

Remember: IVF removes factors of a natural pregnancy - tube picking up egg, egg fertilizing in tube, egg coming down tube to fertilize in uterus.

IVF success depends on (should figure this out before hand)
1) eggs - how many and quality (FSH, antrafollicule count, age of patient)
2) sperm - how good
3) uterus - physical characteristics, and implantation factors: thickness, blood flow, emunological factors on uterine level

Stories of women having many many IVF cycles with no success... you should be finding out where there are issues. After 2 cycles of an otherwise good IVF, you make sure to not have any techincal factors.

When to see a RE, when to select one, how to be prepared for 1st visit
(Dr. Alering used to be an OBGYN) Old standard of HSG, etc. is not necessarily a good thing. Most people start with OB's because of insurance issues. Ends up being a big delay and they get lost and delay can be critical in becoming pregnant. One office visit for male and female can cover initial diagnosis. Or, you can take a letter to your OB and have them do it. Testing normally includes:

The Blank Slate (has had no tests before)

1) ultrasound: check tubes (for tubal patency) ovaries for ovarian funcation (for antral follicle count), uterine anatomy (like you would with HSG - fluid ultrasound); takes about 10 minutes. Ultrasounograpy you can tell if you have blocked tubes, instead of an HSG
2) blood test: CD 3, 4, or 5 of cycle - tells all you need to know about fertility situation, except endo and pelvic disease

Pelvic disease - to proceed with laproscopy at a different time, but not necessary in most patients. Depends on what you've done already. Lap is mainly done for diagnosis of endo; has limited value. If you're going to do IVF, you don't need this. Lap might help you determine if you want to do IUI or IVF.


Semen sample: semen analyis (count, motility, morphology + dna testing, which takes a week to get back)

Natural vs. IVF Now Days...
Block tubes, natural conception is out. Unblock? Not very often this way - tubal surgery usually isn't the way. 10 years ago, IVF wasn't as good so it made sense, but now it doesn't make much sense. 3 months of shots and IUI might work, but when you come back in 305 months IVF will have a smaller chance b/c you did the shots.

OB vs RE
The difference as to the education. Yes, they do go to school more, but a lot are self taught - doing ultrasounds, fluid ultrasounds. Depends on a person's interest. If interested, their office will be set up as such, up to a point and they might be able to give a fairly thorough exam.

How to find the RE that's right for you
Matter of shopping around to find a center with experience, technology and lab on site and offer a wide of services to be able to do all of the things you might need. It also suggests a level of sophistication. Experience in doing procedures is important. You need to like the office, the system and the doctor and provide information. Patients need access to physicians and personnel and you can get that impression from the moment you contact them.

What is an acceptable level of access to their RE? At SHER...
1) They have a website to communicate with doctors anytime they want. 2) Every client has the doctor's e-mail, and all of the staff. These would be for non urgent, and within a few hours they typically answer. Is someone answering an e-mail, or the doctor? No, the doctor answers their own e-mail, forwards it on if that is necessary. 3) Providing effective evaluation and diagnosis in a quick format.

What is Lupron and how is it used?

After reading about women using Lupron to suppress cysts, and then after hearing a doctor mention it in passing on a recent online radio show I tuned into (see two posts ago about PCOS and Infertility), it make me wonder what the heck Lupron even is and how it's used in infertility.

From what I've gathered thus far, it seems like Lupron is used in a few different ways: to treat of endometriosis, used prior to IVF and combined with other infertility meds. My only concern with it is that, as drugs.com reads, the "FDA pregnancy category X. This medication can cause birth defects. Do not use Lupron if you are pregnant."

In any case, here are some more links I found regarding Lupron and it's use in infertility.

Here is a general overview of what Lupron is, how it's often used and common side-effects:

Here is one doctor's take on Lupron:

Some posts:

Personal Infertility Story:
I met one woman through soulcysters.net (a PCOS forum) who shared her experience with me..."I had been seen by another RE for years (TTC for years total). I did 6 cycles of Clomid up to 250mg and 3 cycles of Bravelle (no Lupron). None of which ever even got having mature follies without overstimming. I never even got to trigger with any other cycle before. I just started seeing this new RE in July. DH and I reloacted to another state due to him being military. First cycle with this new RE on this protocol resulted in my BFP. So I am a firm beleiver in this Lupron protocol."

Here is the Lupron protocol she is referring to:
9/2008-Hysteroscopy~Removed large fibroid & polyps & D&C
10/4-Started Lupron 10u
10/13-Follistim 150u started, Lupron decreased 5u
10/21-Follistim increased to 200u
10/28-Follie U/S~6 follies 13-16mm
10/31-Follie U/S 20 & 18mm follie~TRIGGERED!!! BD TIME!!
11/17-Beta 128!
11/19-Beta 298
Baby Dust and Lots of Prayers!!

Friday, November 21, 2008

What Infertility Tests are REALLY Necessary?

Ok, I can't get enough! That radio show was so informative that I had to listen to another one this afternoon. This one is also VERY relavent because we are trying to decide next steps. My first thought was that we try and figure out what test are critical and get them done with our OB now, before moving on to an RE. After listening to the show and what the doctor had to say, I definitely am thinking of things a little differently. Please note that the notes below that I've taken are my (hopefully close) interprutation of the thoughts expressed by Dr. Dlugi and should not be taken verbadem. Please refer to the show to draw your own conclusions on what he has to say. The show can be found here.

Avoiding Unnecessary Testing and Treatments, Hosted by Kim Hahn talks to Alexander Dlugi, M.D., SIRM New Jersey. Dated 3/27/08. (located in the scrollable column on the left-hand side).

Which diagnostic tests are necessary before beginning advanced infertility treatments?

Male Tests
Semen analysis (key because 40% of infertility are male related, 10% combined factor). DNA testing of semen doesn't matter all that much, but costs a lot. FWIW, we don't know a lot about sperm because most types of testing kills the sperm. Infertility centers are probably doing it the same way (rather than a one-off lab), and is of good quality and understands results well. One-off labs are more unreliable. Can a semen analysis change with time? Depends on the situation. Results will fluxuate for sure, but if you find signifigant abnormalities, it will probably still be present. Retesting is sometimes encouraged.

Female Tests - "Old-Fashioned" (thru 80s to early 90s) Standard Testing...

1) HSG (hystosalopingogram - used to look at uterus and tubes).
2) post coidal test (cervical mucus, are sperm getting there)
3) endo bioposy (uterine lining changes) not done much anymore
4) laporsocopy (look inside pelvis and perform surgery if needed). Everyone got testing and then tailored treatment according to results.
5) Basal Body Temps (BBT) - To track ovulation.

Of these, it depends on couples history and what they are willing to consider (IVF, etc). If they're not willing or want to do IVF, then yes, it makes sense to do some of the below.

Thoughts about Diagnostic Testing and What is Actually Helpful

1) HSG: Hystosalopingogram - Used to look at uterus and tubes. Make sense to do.

However, if there is a problem found with an HSG, here are the senerios:
a) Uterus (polip, fibroid, etc) - fix is surgical
b) Tubes - surgery to fix tubes or IVF

10 years ago, recommendation would have been to operate, but because IVF rates are so high these days, that is the way to go. With the surgery, there is recovery time and it takes 1-2 years after surgery to be able to get pregnant, typically, and these problems also will come back. Therefore, surgery doesn't make much sense unless there is a mass or there is pain. Then it's totally different. If for fertility, there isn't much point.

2) Post Coidal Test: Checking cervical mucus to see if are sperm getting to uterus. Not done much anymore.

Problem with this one - you don't really know what the definition of "normal" is. Is a role where a couple uses clomid because it could dimish CM and make it hard to get pregnant. It's good to get one of these done at least to see what findings are. If test is abnormal, you do IVF with clomid, or something else. You will see treatment options come down to trying IUI with fertility meds or move to IVF. So, if you are going to do this anyway, why bother doing the tests if you're going to do the same treatments anyway. If there is a tubal issue, go directly to IVF.

3) Endometrial Bioposy (uterine lining changes) Not done much anymore.

4) Laprosocopy (look inside pelvis and perform surgery if needed). Case by case, but usually not useful.

To check for endo and tubal disease. A lot of people do this before going into something else, but why put people through surgery unless they're having pain. Again, it can take around 2 years before you know if it worked or not. If you're going to turn to IVF anyway, then why mess with it. Probably more successful for people who didn't have much going on, but for people with a lot going on, it's probably not extremely effective.

5) Basal Body Temperature chart and OPK kits - Recommendation to not bother doing those because they are useful for 1-2 cycles, but if you are having regular cycles and you check a chart a couple cycles and if LH surge is fairly consistant, you don't really need to do it. If you do this, you can fall into a trap every month and be more stressed. I'm not sure what his comment would be if you are NOT regular. My feeling is that it can't hurt really to go ahead and do it!

Blood Tests - Used when clinically relevant.

If finding dictates a change in course. A lot of places run the tests purely to get money. Clinically they don't make sense. Where are most blood test applicable? Knowing FSH, Thyroid, Prolactin are important.

Immunological issues should be screened if you have multiple miscarriages
or if you've done 2-3 IVF cycles with no success then you should ask is there something else going on when embryo arrives in the uterus and it is being rejected, this is where immunological test are key. This is very
controversial. This doctor wasn't in agreement when he first started working with the SHER Institute. If you are going with IVF, you might want to rule this out and have this test. But, is it cost effective - how many people do you need to screen to rule things out. $1,000 for
screening usually.

New Procedures - Genetic Testing

Genetic testing of egg and embryos. If there are no sperm issues, the egg is doing most of the work. Now you can biopsy the polar body which is a mirror image of the egg, in terms of the genetic. You can see if the egg has all of its chromosomes. Good for fertility preservation and egg donors - you can go to egg repository and pick out the good ones.

The success rates of IVF depend on
if the 1) embryo is normal 2) is uterus receptive and able to accept an embryo and propagate a pregnancy. So it's basically, do we have a normal embroy. One of the reason why miscarriage happens is that the embryo isn't good.

More on Advantages of Skipping Some Tests
Will now get results quicker because these test might not be necessary. When they do test, they might have a mild male factor. Maybe try a few IUI's and then go to IVF. If you don't ovulate regular, yes then try infertility drugs. But, if you haven't found anything, most people would say to look towards clomid and injectables because it's easy to do and doesn't hurt and some get pregnant. The problem is that we dont' know what that really accomplishes. If you ovulate and have normal sperm, then drugs and IUI don't do much that you aren't already doing. The pregnancy rates for unexplained infertility with clomid IUI is only about 7% or up to 10% with injectables. People do it because they have been told to do so, or are afraid of IVF. A lot of patients ask for it, so it is often done. If IUI and drug induced cycles are done for 3-4 cycles and it hasn't worked, it's probably not going to work so you should move on. For most who choose this route, by the 3rd cycle people are fed up and end up moving to IVF.

For people who don't have mandated coverage for IVF, what do you do then? He would say that then it makes even more sense to go to IVF because if you add up all the potential costs throughout each of the procedures, it easily amounts to $1,500 to 2,000 per cycle if you divide by 7% success rate you get a high number - and then 6-7 K later and still not pregnant, you've already paid a lot and haven't tried IVF yet which yields a MUCH higher success rate of 70% or more.

Increase in pregnancy rates from clomid to clomid with injectables is small. Skip injectables move to IVF is becoming more of the rule.

In Summary
Endless months and money spent doing tons of treatments which might not work and will probably end with IVF anyway is a route that some are beginning to take. In my opinion, this doctor is leaning towards doing less tests and moving to IVF sooner.

Free Infertility Radio Show - PCOS and Infertility Treatments

Frustrated with my current cycle (I think it's a total bust, but I'll post more about that later), I have been surfing the net to try and find some answers. Answers for what to do next, what various tests and procedures cost, etc. I came across Haveababy.com's live one-hour online radio show, which I hadn't heard about before. It seems like they do a lot of interviews with reproductive endocrinologists, so it seems like a good opportunity to get some reputable info.

HaveABaby.com Live

Their shows broadcast every Thursday at 10:00am PT/1:00pm ET. They also keep a database of past shows, so you can listen to the topics that are of real interest to you. I came across the following topic, which really hit home for me, and took a few notes while I was listening... sorry for the incomplete sentences and/or misspellings. :)

Goodbye PCOS, Hello Fertility Treatment, hosted Kim Hahn and Dr. Drew Tortoriello, Medical Director of SIRM-NY. Dated 10/30/08 (archived in the scrollable column on the left).

In PCOS patients, excess androgen test worthwile. Remember, just because you have a period, doesn't mean you ovulated. Even if women do ovulate, they might be at an increase for abnormal oocytes. Excess androgen causes problems with eggs. So, even with women who get pregnant with IVF, their risk for miscarriage is 2x more, due to the androgen excess their eggs are under.

Are OPK tests or OV Watch good for PCOS patients? Yes still good to use. LH elevation in pcos patients cause false positive in opks though, so it just depends on that particular person.

Mid-cycle Follicule Check via Ultrasound while on Clomid
Recommend starting with monitoring with ultrasound to find out when a follicule is developing to give better guidance. Rather than only do ultrasounds, start on clomid. Are people monitored a lot on clomid? Always recommend both scanning and clomid because you don't want to waste time if you don't have response to the clomid and you won't know unless you get your period or if it doesn't come, you then have to figure out what to do next. If clomid is working within 10 days of last pill you should see evidence of this by an enlarged follicule through an ultrasound. If it's not enlarged, then start new dose (higher) the next cycle.

If your partner has normal sperm, it's ok to not to IUI as the first option because the problem is due to anovulation in the woman. But, IUI's are good if you have unexplained infertility because clomid by itself and insemination by itself really didn't do much, but the two together have shown better results. IUI's are fairly inexpensive, easy to do, and invasive, so these combined treatments can be very benefitial.

Things that Mimic PCOS
1st thing - rule out other things that might mimic PCOS, like congenitial adrenial hypoplasia (when adrenial gland pump out excess androgens), cushings syndrome (too much cortosol), insulin resistance b/c 40-50% can be insulin resistance (not necessairly diabetic, but their body pumps out too much insulin to fight off the diabetis; an insulin problem might cause an ovulation problem.

PCOS and Metformin
With PCOS, should metformin be used together? Open for debate. Connection between the two was discovered by a guy named Nesslin. High androgen levels can be due to not ovulating. Metformin can bring androgen levels down. However, it shouldn't be exepected to work alone (without an ovulation inducing drug).

Clomid vs. Injectables
Why is clomid the best? Why aren't injectables even better than clomid? Related to heirarchy of treatments. Injectables are an option, but most people would start with clomid first because it's easier, shorter duration, cheaper and it works for about 70% of women. Clomid is also pretty gentle - as in you don't have to cancel a cycle most of the time because they don't produce too many follicules. 25-30% of each follicule turning into a baby.

Injectables cost more, and could cause a much more troublesome response, even with low dose because the produce too many follicules. It's an option for sure if clomid has failed. Also, sometimes if you do injectables you should strongly consider IVF because you control how many embroys go into the uterus. If you can just get a PCOS patient to ovulate you don't have too many other issues getting pregnant.

Increase in Miscarriage due to Excess Androgens Present
However, there may be an increased risk in miscarriage regardless of IVF, clomid, IUI.. because oocyctes have grown up with excess androgen, which does bad things to egg quality. If you're going to to injectables you should consider doing birth control or lupron injectables to bring down androgen levels for a month or so, so that you can have eggs that grow up in an environment without all the excess androgen. Lupron PCOS users have shown a reduced rate in miscarriage (though, I've read there can be bad side effects with Lupron).

Next Steps after Ovulating on Clomid, but no BFP
If you do about 4 cycles with clomid and are ovulating but don't get pregnant, then you should consider injectables with IUI, or move straight to injectables and IVF. Most people feel comfortable with that because there's not much difference between clomid and injectables (just ovulate in a different way).

Hyperstimulation Risks
Are these people at risk of hyperstimulating? It's rare with clomid only patients, but people using injectables DO have a higher risk. In IVF you usually are at a bit higher risk because you are trying to encourage as many eggs as possible because you can control how many go back in.

Excess Testosterone?
Having more testosterone - Does your body just create this or do you get it more for hormones or steroids (possibly in food). Likely no, it's just your body. Some studies do show DHEA supplements (a weak androgen which has quality of life benefits) encourage androgens, so you should avoid this if you have PCOS. Mostly genetic that we don't completely understand. Not many meds to bring those levels down except for things like Lupron and Birth Control, which only brings it down for a short time (while on the meds and shortly after).

Tuesday, November 18, 2008

Looks like I might ovulate after all :)

So, the newest series of events in the clomid round two saga is that the temperature rise (which made it look like it dipped) must have been a fluke due to my cold and I actually haven't ovulated, yet anyway. I had been going back and forth in my mind, really wishing and hoping it wasn't true and that I had ovulated, and figured it would be a good idea to just run my chart past my new doctor and see if she wanted to do a progesterone test. I did end up having it done and my results were that of an anovulatory cycle - 1.2.

But... Today is CD30 and I think I will ovulate any day now. I had my first positive OPK on Saturday and have had a positive every day since (3 days, not counting today, which I won't know until this afternoon). They say you could ovulate anywhere within 12-36 hours from either the beginning or end of your LH surge. So, again - we wait.

In the past week or so, I have continued to have side effects from the clomid. I had hot flashes about 4 or 5 days in a row, mostly in the evening. And then, the previous two days, I had been nauseous in the AM and in the PM. Yesterday I came home with a headache and sat down to eat supper, thinking that would get rid of it. As I was finishing my last bite, I was thinking "I feel like I'm going to barf if I eat this". I did some googling and it seems that some women experience nausea around ovulation time. Weird. Maybe it's not due to the clomid after all.

As with every cycle, you can't help but wonder what the next step will be if the current cycle doesn't bring a BFP. With this cycle, even though I haven't even met my new doctor, if we don't get pregnant, I believe she will want me to do at least a month of birth control to try and suppress the cysts that are present. I believe the idea is that we might be more successful if we can just get them to go away and try the clomid without all of that present. Someone did bring up the question - is there another TTC friendly way of doing that same thing, instead of doing BCP, where you have no chances of getting pregnant that cycle. Good point. It had crossed my mind once, but I forgot to look into it.... my initial thought was is there some regimen of hormones (customized based on your personal, current levels) that would get rid of them. I still need to google and ask my doctor about this, if we end up needing to go that route. If I do have to go with BCP, I wonder which particular one will be right for me in my circumstances (for example, one that is better about clearing your system so that we can TTC the next cycle).

I decided while I am writing this that I would look into the suppression alternatives now - why wait :) I came across a site that tates "The oral contraceptives suppress gonadotropins which support "functional cysts". So, if the idea is to suppress gonadotrophins, and that is the only way to get rid of cysts, then I don't think that it's possible to get pregnant. I think you need gonadotrophins to be released for the rest of the key hormones that encourage ovualtion to work. So, I'm betting that a BCP alternative is out of the question, but I will definately still ask. The worst that could happen is that I get a weird look from the doctor, and I'm used to that by now!

I also came across this, though, and now I'm wondering if BCP would even work. When asked if BCP or injectable progestins (DepoProvera) prevent the formation of ovarian cysts, Dr. Frederick R. Jelovsek replied "Oral contraceptives are known to block ovulation in women with polycystic ovarian syndrome as well as lower the circulating androgens which can cause excessive hair growth. They are also used as pretreatment to decrease cyst formation when giving LHRF for in vitro fertilization. Thus they can be used to lessen the risk of new ovarian cyst formation even though they will not suppress any currently existing cysts. Neither oral contraceptives nor injectable progestins totally suppress all follicle development but they do suppress large follicles in the range of 3.0cm." I'm so confused. I know you can't believe everything you read, on the internet especially, but I am very curious now.

Anyway, I need to stop and focus on the here and now. Please be praying that I ovulate soon!! :)

Wednesday, November 12, 2008

My temp is back up. I'm cautiously optimestic...

Because of that, I just HAD to search the Fertility Friend chart gallery to see if anyone else has had a two day dip like that and then been pregnant.

Here are my findings... it doesn't appear it happens a lot, but it is definitely possible. Here's to hoping!

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Tuesday, November 11, 2008

Trying not too loose faith...

Round two of clomid (this time at 100mg) looks like it might be a bust. That, or I will ovulate late again, which isn't what my doctor was hoping for. I was thrilled when I thought I had ovulated on CD16 (no positive OPK, but my temps really did seem to shift appropriately) and I thought I was in the two week wait.

It now appears that maybe the head cold I came down with messed with my temps. One of the guides on Fertility Friend said that the spike in temps could have been from my body fighting off an infection and then the dip in temp (which I at first thought could have been a early implantation dip) could have been a product of me breathing through my mouth too much. She recommended I wait another day or two and see what my temps do. If it stays down below my coverline tomorrow, it will remove the crosshairs. Otherwise, we should BD to make sure our bases are covered.

I'm going to be honest. I am pretty bummed. I have tried to get better about not getting my hopes up, but I really was fooled this cycle. I pray that I at least ovulate late. It's better than not at all. I need to figure out whether or not I am calling my doctor about all of this. I called and spoke with a nurse on Friday (before all of this went down) to see if the new doctor (er, remember my ob moved recently) wanted to do a 21 day progesterone test. Instead of her asking the doc and calling me back, she said to not worry about it this cycle. That the new doc prefers to do a mid-cycle follicule scan instead. Now with my temps all crazy, I'm wondering if they should do a draw to tell us what the heck is going on (if I ovulated or not). The OPK I did today was still negative, but was mid-range dark, so maybe a positive will happen in the next day or two. I think I'll wait another day at least to see what happens before calling her.

Moving on to other things.... this past weekend was "girl's weekend" for Mom and I. It had been awhile since we took time out to do that and it was nice. We were both sick with colds, but still had fun. The big thing is that the cat is now out of the bag. I had been wishing and hoping we would get pregnant in time for Christmas, or anytime in the near future, so that we could really surprise her, and everyone for that matter. But, she asked me directly and I didn't want to lie. Honestly, it was good to be able to share everything with her. Sometimes this stuff feels like a bit too much to bear and it's always nice to have your Mom to share stuff like that with. She was extremely supportive and I am very thankful for that.

Now, if I can just clear my mind and focus on preparing for the holidays - both mentally and physically. I can hardly believe that it's nearly mid-November already and that I haven't purchased a single Christmas gift. That is horrible. I wanted to be done by Thanksgiving. With my Dad returning from Iraq around the 12th of December and us hosting the Payne Family Christmas Bash, there will be so much to think about and do during December that I don't want to still be shopping for presents. Honestly, if it comes down to getting gift certificates for people, then I'm fine with that. I mean, I always find those useful and sometimes I appreciate them more than when I receive something I really don't need or like.

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