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Question
Hello,
My daughter in Britain (20 years old) who has been married 2 years has in this time suffered 6 miscarriages with in a few weeks of becoming pregnancy. She has been tested in the hospital and they have found nothing. When ever she is pregnant she has low levels of hCG. They have given her progesterone pessaries in the past.

The hospital now says they do not know what the reason is, it is probably just bad luck and to just wait and see. All they are now doing is giving her 8 times the normal level of folic acid. They say once the pregnancy is seen on a scan they will give her progesterone again. She has never yet reached the 7 or 8 weeks at which they will do this scan.

Each pregnancy is getting further and further apart. Every time she becomes pregnant her breasts grow substantially meaning that her breast size is now impressive and yet an other cause of embarrassment and pain. She also has low iron despite taking supplements.

My daughter has done everything possible with in the National Health Service. She is afraid of not getting pregnant and of getting pregnant and losing the pregnancy again. We no longer know what to do. We would be grateful for any advice.

yours

Naomi

Answer
Hello Naomi from the Netherlands,

It is difficult to comment specifically without doing a formal review of her medical records and see what testing has been done or left off.  I could certainly do that via Skype, Telephone or Email in a formal consult if your daughter desires.  She can contact me directly via email (website address given below) to set that up.

In general, the most common reason for miscarriages that occur in the 1st trimester (before 12 weeks gestational age) is genetic.  That is a spontaneous genetic abnormality caused at the time of egg division and formation into an embryo then fetus.  A few of the genetic disorders are caused by a silent genetic abnormality carried by the mother or father so genetic/chromosome testing should be done on each.  In the case of spontaneous abnormalities, there is no formal treatment, but the good part is that most of these patients will eventually be successfully pregnant.  Other causes of early miscarriage include hematological problems (such as clotting disorders), immune system problems, anatomical problems, infections and hormonal problems.  In most cases of recurrent pregnancy loss, we don't find a specific issue or problem and so the treatment becomes a hit or miss, blanket treatment (cover everything that can be covered).  For genetic issues, the only treatment option is to do IVF (In Vitro Fertilization) with preimplantation genetic screening (PGS).  This is where the embryo is made outside of the body (in a lab) and then a biopsy is done to evaluate the embryos genetic makeup so that only a normal embryo is transferred.

In my patients, I have a protocol for treating patients with RPL of unknown cause by using the following course of medications: Folic acid 2 mg per day, Aspirin 81 mg per day, Heparin 2000 units twice per day (or Lovenox 35 mg per day), Estrogen patches (Climara or Vivelle) and Progesterone injection or suppositories.   All the medications except the Progesterone are started with the beginning of the cycle (when the period starts).  The progesterone is started after ovulation (it should not be started sooner).  These medications have all been used successfully with recurrent pregnancy loss and proven by many studies.  They serve to increase blood flow to the implantation site, decrease the immune response, decrease inflammation and cover any hormonal deficits.  If your daughter were my patient, and her evaluation was completely normal, this is the regimen that I would use.

I hope this helps and gives some clarification.  I have not heard the best things about subspecialty care through the NHS in England (by English patients writing me), so she may have to see a private Infertility specialist to get the correct care.

Good Luck,

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