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About Edward Joseph Ramirez, MD, FACOG
Expertise
I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.

Experience
I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 15 years.

Organizations
American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, Society of Assisted Reproductive Technology, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists,Resolve-National Chapter, Open Path - Northern California, Board of Directors Monterey Medical Society

Publications
American Journal of Obstetrics and Gynecology

Education/Credentials
Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

You are here: Experts > Health/Fitness > Women's Health > Infertility/Fertility > recurrent miscarriage/ttc

Infertility/Fertility - recurrent miscarriage/ttc

Expert: Edward Joseph Ramirez, MD, FACOG - 11/5/2009

Question
QUESTION: I'am 36 and dh is 28.I have 3 children age 19,15 &12 from a previous marriage.He does not have any children.I had a m/c May 08 at 8w6d but baby stopped growing at 6weeks is what I was told.It had to of been right after my u/s 6w3d and we got a heartbeat of 109.Then I had another m/c July 09.It happened right at 6 weeks.I was on my 3rd cycle clomid 50mg when I got pg.I'am on my 6th cycle of clomid,3rd cycle of 100 mg.It looks like this cycle may be a bust also.After my last m/c I had a reccurrent m/c panel.Everything was normal.Years ago I had a borderline ana test and rh factor.I'am on a baby aspirin a day and 0.4mg of folic acid and prenantal vitamin.I had a leep done a few years back after an abnormal pap but it ended up being normal.I'am wandering what could be causing me to m/c each pg at 6 weeks.Why is it taking so long for me to get pg again?Could this all be age related?Any suggestions on what I should do?I really want another child.

ANSWER: Hello Tammy from the U.S.,

The most common reason for miscarriage is based on spontaneous genetic abnormalities due to decreasing egg quality. This decreasing egg quality is an age related factor. So, yes, the most likely reason for your miscarriages thus far, are due to your age. It seems to increase from the age of 35 on.

The only way to overcome this "age factor" is to keep trying, and be prepared for additional miscarriages, and the majority will be successful eventually, or proceed to IVF whereby more eggs can be retrieved, increasing the chances for a health egg to implant.

I also use heparin 2000U injections twice per day and progesterone on my patients that have had recurrent miscarriages. This is to decrease the immunologic response.

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on facebook and twitter with me at @montereybayivf

---------- FOLLOW-UP ----------

QUESTION: Thank you so much for your response to my earlier question.Will the clomid give me better quality eggs?I take 100 mg cd3-cd7.Which cd do you suggest clomid?Anything that would give me a better quality egg?
Dr. told me as soon as I get a postive hpt to call and she will put me on progesterone 2X daily.
Just want to make sure I got the understanding of the answer to my earlier question.Short version...I just have to keep on trying to conceive,possibly expect more miscarriages until I get a good egg that will stick?Or go straight to IVF.Correct?Again,thank you so much.I really appreciate response.

Answer
Hello Again,

Clomid will not influence the "quality" of the eggs. That is already inherent within the egg itself. It will only increase the number of eggs that are ovulated. It can be taken on either cycle day #3-7 or 5-9.

The proper method for Clomid ovulation inductions is to start having ultrasounds from CD#10 to determine whether you are responding to that dose, how many follicles are being recruited and to time when ovulation will occur. OPK do not give you all that information. That is the reason why the highest incidence of super multiples (more than two) occur in Clomid cycles than any other fertility treatments. Regular docs just don't take the time to look. You do not want to continue the cycle if you have more than three follicles of ovulatory size. Also, if you only make 1 follicle on 100 mg of clomid, that is not an adequate dose. Get the picture? That is why I recommend ultrasound surveillance for Clomid cycles.

That being said, the progesterone is started approximately two days after ovulation occurs. The dosage depends on the type of progesterone being used. If Prochieve or Crinone is used, you only use it once per day, in the morning. If Prometrium/Endometrin is used, it is twice per day.

In terms of your recurrent miscarriages, you are understanding me correctly. You can keep trying until you are successful, with the risk of additional miscarriages, or go to IVF to try to maximize the chances of success in the shortest time period.

Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on facebook and twitter with me at @montereybayivf

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