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Infertility/Fertility/Chances of Healthy Baby after 3 Consecutive Miscarriages

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QUESTION: I am 32 years old and from Kansas. I have been experiencing recurrent miscarriages. I had a chemical pregnancy at age 28, followed by a normal pregnancy resulting in a healthy child now 3 years old. Since then, I have had three consecutive first-trimester miscarriages. The last two miscarriages were caused by trisomy 21 and trisomy 22, respectively. I have had the recurrent miscarriage blood panel, and my husband and I have both been karyotyped. All results were normal, with the exception of me having a homozygous a1298c MTHFR mutation. Starting about six months prior to my last miscarriage, I have been taking a high dosage of folic acid (folbee plus) along with my regular prenatal. My OB/GYN thinks that the miscarriages are a result of age-related egg-quality issues, and has suggested that we pursue superovulation using clomid in order to increase our odds of getting a chromosomally-normal egg. IVF/PGD is not an option we wish to pursue. We want so badly to have another child, and I am prepared to continue trying, but I am scared that I may not find a "good" egg again. I am worried that poor choices (drinking alcohol, smoking) in my twenties have ruined all of my eggs. Is this possible? Also, I have always had irregular cycles, usually ranging from 37-42 days, with ovulation often occurring around day 20 or even later. I do become pregnant very easily, always during the first month of trying. I am wondering if you think ALL of my eggs could be "bad," and also if you think the clomid/superovulation route is a good idea. Thank you so much for your time. I greatly appreciate your willingness to help me and so many other women. Sincerely, Sherri

ANSWER: Hello Sherri from the U.S. (Nebraska),

You certainly have the potential to have another successful pregnancy.  There are lots (hundreds of thousands) of eggs left.  The trick will be to find the perfect egg that will lead to a successful pregnancy.  You are ONLY 32 years old and most of your eggs should still be good eggs.

I think that you may also have hormonal disorder, however, which could be the reason for your miscarriages.  If you have a hormonal imbalance and the early pregnancy is not getting adequate hormonal support, then it may not be able to continue.  It would be an appropriate treatment to use a fertility medication, such as Clomid, Femara or injectables, to correct the ovulatory problem and hormone imbalance.  In addition, I would supplement with progesterone starting after ovulation.  Finally, I would recommend low dose aspirin 81 mg per day starting at the beginning of your cycle and continuing until 10 weeks gestational age.  This is to increase blood flow to the implantation site by reducing microclot formation and lower the immune response.  These are all easy things that you can do.

Good Luck,

Dr. 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 twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate


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

QUESTION: Thank you for your response, Doctor. Since my first question, I had Day 3 blood work performed, and the results were FSH 3.7, LH 6.8 and Estradiol 29. I also took 50 mg Clomid on Days 3-7. On Day 14, I had an ultrasound which revealed an 11 mm follicle on one ovary and a 14 mm follicle on the other. Uterine lining was at a 9. We had planned to do a trigger shot had the follicles been larger. However, with these results, my doctor advised us to not become pregnant this cycle, and to try again next cycle with a higher dose of Clomid. At this point, I am pretty confused about what the actual problem is and what my chances of a successful pregnancy are in the future. I had originally thought we were pursuing a Clomid cycle so that more than one egg would ovulate, and hopefully at least one would be chromosomally normal. On Day 14, however, it appeared that both developing follicles were less than adequate, but that one or both might still ovulate (and I can only assume might result in a pregnancy if we tried, based on my history of becoming pregnant every cycle we try). My questions at this point are 1) does a small follicle size on Day 14 indicate poor egg quality and higher chance of miscarriage? 2) can my miscarriages be attributed to something that is inherently wrong with those particular eggs or is it something that occurs during the follicular phase (hormone related)? 3) can getting the right dose of Clomid that will grow the follicles to the right size by Day 14 result in a better quality egg? Or would we be better off to just keep trying naturally and hope to catch a good one again? Again, thanks so much for your time and your willingness to share your expertise.

Sincerely,
Sherri

Answer
Hello Again,

1.  Follicle size does not indicate any type of egg quality.  That technology does not exist.
The follicle size only means that it hasn't reached ovulatory size yet.  It still might and you just need to wait a little longer.  YOUR DOCTOR IS WRONG!

2.  Miscarriages can occur for many different reasons including: genetic, hormonal, immunologic, anatomical, infectious disease and hematologic reasons.  A recurrent pregnancy loss evaluation would need to be done to distinguish the cause. Egg quality leads to genetic abnormalities that then lead to miscarriage.  This tends to be more of the case in older women (over 36).  Most miscarriages, the majority, are from spontaneous chromosomal breakage at the time of cell division and not something that is being carried or passed along.

3.  Again, egg size does not indicate egg quality or risk of miscarriage, but using a higher dose of Clomid is indicated because you did not get the requisite number.  Certainly using a higher dose might cause the follicles to be ready sooner.  But, getting a better doctor might be just as effective; one who really knows what they are doing.  Treated appropriately, I think you could eventually be successful so don't give up.

Good Luck,

Dr. 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 twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate

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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 19 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, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

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

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