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I'm curious to hear your input about chemical pregnancies. I had my son 21 years ago. he's perfectly healthy. i had a blighted ovum and an ectopic pregnancy with in 5 years of him being born. Some pregnancies were chemical in between. i've had over 20 chemical pregnancies that are documented. i know theres many more, i am just too tired of hearing your miscarrying again. i been trying for a 2nd child since i was 19. Every test came back normal except my lining and that was only a few times i had endometrial biopsies (on sonograms it apparently looks ok). With Crinone 8% twice a day i wanted to get a biopsy to make sure it was working. i was cycle day 24, my lining was day 15.then i moved to progertone oil injections, twice a day (forgot the cc's). I didn't have a biopsy done while on it. Now I wish i had.  I've never done IVF nor have i ever gotten pregnant on any assisted cycles. Genetic testing was done and other than myself carrying the cystic fibrosis gene, i'm ok.  I know i'm 40 now but my fsh is good. I've stopped fertility treatment on and off, i mean 20 years is a lot. Can you please tell me what you think of this and chemical pregnancies in general. Not much is known obviously because they happen to early to stop them or biopsy them. I'd love to hear what you think. Thank for your time.
Caren

Answer
Hello Caren from the U.S. (New York),

"Chemical pregnancies" are a form of miscarriage; they are just very early.  The most common reason is a genetic disorder, but considering that many of these occurred when you were younger than 35 years old, there may be other factors as well.  With the number of miscarriages your have had (>3) you quality as having the diagnosis of recurrent pregnancy loss and should have undergone a complete evaluation for this disorder.  Such an evaluation is to try to determine the cause of the miscarriages.  There are basically 5 known causes of miscarriages: genetic, hormonal, anatomical, immunologic, infectious.  Each of these has specific testing that needs to be done.  I would add that there is a 6th category which is "unknown".  

Genetic:  You mention that you have had genetic testing and your only abnormality is that you are a carrier for the cystic fibrosis gene.  Did you have chromosome testing as well?  Has your husband undergone genetic and DNA testing?  Is he a cystic fibroisis gene carrier?  Even if you are negative for all, genetics can still play a factor.  The majority of embryo genetic disorders are not heritable disorders but spontaneously occurring ones.  That is, as the cells are dividing an error occurs that is then exacerbated by continued divisions.  The only viable treatment for genetic disorders is to have PGS (preimplantation genetic screening) done on embryos obtained in an IVF cycle prior to transfer of the embryos into the womb.  This helps to identify the genetically abnormal embryos.  This is something you should strongly consider especially since you are now 40 years old and your chances of spontaneous genetic mutations is higher.  Another genetic test that should be done is MTHFR.  If you are a carrier for a gene defect then it is treated with high dose folic acid (folate).
Hormonal:  Luteal phase defect (out of phased endometrial lining) is easily treated by the additional of progesterone.  I give progesterone to ALL my infertility patients to prevent this from being a factor.  Other hormonal disorders such as thyroid and pituitary can also contribute and need to be tested.
Anatomical:  This is evaluated by hysteroscopy and pelvic ultrasound.  You want to make sure that there are no abnormalities in the uterus that would make the uterus inhospitable to an embryo.  Also you want to make sure that you don't have a hydrosalpinx (blocked and dilated tube) on one side.  In the presence of a hydrosalpinx, the pregnancy rate will decrease by 50%.
Immunologic:  This where your body subclinically (without evidence of disease) will mount a reaction to the embryo.  This is tested by antiphospholipid antibodies, anticardiolipin, lupus anticoagulant, anti-thyroid antibodies, natural killer cells.  These are blood tests.  Treatment is low dose aspirin, low dose prednisolone and low dose heparin.  I often will give these medications to all patients will history of pregnancy loss as part of my treatment cocktail.
Infectious:  This is probably the least viable category, but tests for diseases such as HSV, Toxoplasmosis, Lyme disease, CMV, bacterial infections.

Sometimes I find that these tests don't reveal anything so there is no specific disorder found.  In that case I treat with extra estrogen, progesterone, heparin, aspirin and prednisolone beginning with ovulation.

Your age now is a significant factor because, despite having good ovarian function, the eggs within you are 40 years old and so the majority are not going to be good eggs.  Eggs get old and debilitated with time.  This is a barrier that you are now facing.  As a result, my recommendation would be to strongly consider doing 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
info@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.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.  

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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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