Infertility/Fertility/Recurrent miscarriages

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Question
Dear Dr. Ramirez,
I would like your professional advice regarding my fertility issues. I had my right ovary and right tube removed at the age of 16 due to an ovarian cyst. I'm 35 from Florida with no children and have been ttc for a year. I went to a RE after my 1st chemical pregnancy to do complete testing. The testing for fsh, amh and others came back normal. My dr had me do 3 cycles of iui/letrozole and 1 month including injectables.  This included progesterone supps starting 2 days after ovulation and baby aspirin. Out of 3 cycles I had 1 bfp but was a chemical. This past year I had 3 miscarriages. 2 chemical at around 4-5 weeks and the last one most recently at 7 weeks. I heard a heartbeat at 6 weeks but no heartbeat at 7. It was a missed miscarriage. 2 of the pregnancies were conceived natural and 1 was through iui/letrozole. I was also tested for genetic and immunity and it came back normal. Based on my history I can conceive but have trouble keeping it. I would love the chance to be a mother and know time is not on my side. Including the fact I have 1 ovary doesn't help. Would you recommend I continue to do a few more iui/letrozole with injectable cycles? IVF concerns me and my last choice because of all the intense medications and risks of ovary hyper stimulation with 1 ovary.
Can ivf be risky in my situation?
What are my options?
What option gives me highest chance?



Bianca

Answer
Hello Blanca from the U.S. (Florida),

I presume that if you are seeing a competent RE, then he has put you through all the testing for recurrent pregnancy loss.  This includes testing for genetics in both you and your husband, immunological testing, infectious disease, hormonal testing, anatomical testing of the uterine cavity.  If these are all normal, then there is a dilemma regarding the cause of your miscarriages.  You mention that you are now 35 years old, which introduces the age issue as a possible cause (miscarriages increase with increasing age, but that does not explain the miscarriages that occurred before 35 years old.

First, let me say that in patients like you, I use low dose aspirin, medrol, low dose heparin or lovenox, estrogen and extra progesterone to cover anything that might be sub-clinical (meaning that it is below what we can detect).

In terms of IVF, that is certainly the recommended treatment for patients with RPL because it increases the number of embryos available with the hope of finding a perfect one in the batch.  Often it is also recommended to do genetic testing of these embryos prior to transferring them to eliminate the abnormal ones.  It is NOT a risky procedure.  Neither the medications nor the actual needle aspiration are very high risk.  There is some risk, as there is from anything you do to the body, but that risk is very minimal.  You are NOT at risk for hyperstimulation syndrome (OHSS) because you only have one ovary.  That one ovary would not stimulate enough to cause this complication.

I think that I would try IUI with the above supplementation, since you are able to get pregnant naturally, for no more than two cycles.  If that fails, then I would recommend proceeding to IVF.

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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