Infertility/Fertility/recurrent pregnancy loss
Dear Dr. Ramirez,
I wrote to you at the beginning of the year and am looking for your input again. I am a 34 year old healthy female with a 31 year old healthy husband. I have had 3 consecutive miscarriages. My first pregnancy (after 2 months of trying)ended in a miscarriage at 7 weeks with no D&C. I had no period afterwards and got pregnant right away (perhaps considered a chemical pregnancy) which ended in miscarriage quickly (dating was difficult as I had no normal period after the 1st). I had normal CD #3 testing with FSH, estradiol, normal hysterosalpingogram, normal thyroid/thyroid abs, glucose, autoimmune/hypercoagulable w/u. I waited 2 cycles and got pregnant after the first try. I started progesterone suppositories 100 mg BID after ovulation. I had a normal pelvic USN at 5 weeks with "a good decidual reaction" and gestational sac seen. I had a normal pelvic USN at 6 weeks with a fetal pole and yolk sac and HR at 162. At 9 weeks, I had a routine pelvic USN again (due to my history)which showed I had miscarried "likely around 6 weeks". I had NO sxs of miscarriage. I required a D&C and the chromosomal testing on the placental tissue showed XX Trisomy 10. After D&C, I had continued bleeding and cramping and was diagnosed with a hematometrea and was given Methergine 0.2 mg TID for 2 days, the blood collection persisted and I was given Cytotec 2 tabs after I had in office cervical aspiration. 10 days after D&C, pelvic USN finally showed 6 mm uterine lining with no further blood collection. ASA 81 mg started in July. My husband's and my karyotyping were normal and his sperm analysis was normal including morphology. We have started trying to conceive again per our RE.
1. Should we just continue to try naturally or consider IVF with PGD now?
2. Any role in enhancing egg development with ovulation induction meds; is it an egg quality issue?
3. Should I have MTHFR genetic mutation checked?
4. Thoughts on immunologic implantation dysfunction?
5. Any other advice?
I understand RPL w/u often yields no cause and this is so frustrating. Your input is really helpful.
Hello Margaret from the U.S.(Massachusetts),
Thanks for making your questions succinct.
1. I think that if your recurrent pregnancy loss testing was complete and was negative, then I would probably still allow you to try naturally but would use the following cocktail: low dose aspirin, estrogen supplementation, progesterone supplementation, prednisolone (Medrol) and low dose heparin. The reason for this is that the fact that the last embryo was abnormal does not necessarily mean you have a predisposition to chromosomal defect. It could easily be, and was most likely, a spontaneous abnormality, which means it occur while the cells were dividing. Not all your miscarriages may have been due to this. However, you need to make sure you have been testing for antiphospholipid antibodies and MTHFR. If the MTHFR is positive for a defect, then high dose Folate is also required. However, if you are tired of trying naturally and having miscarriages, and we know that you can achieve implantation, then going straight to IVF with PGS would streamline the process and get you pregnant the fastest. That is your personal decision.
2. Ovulation induction does not enhance egg development but egg recruitment. The advantage is it increases the chances of pregnancy by making more than just one egg available. It also helps with recurrent miscarriage by increasing the chances of finding a good egg in any particular cycle. That is why IVF works better for RPL and age factors.
3. I answered that before looking at the question. The answer is YES.
4. I am a believer that there is a subclinical immunologic defect going on in many of the cases of RPL. For that reason, I treat it with aspirin, Medrol and heparin. Some doctors and clinics are even more extreme than I and will also treat with IVIG or Intralipids. I'm not convinced that these help so don't use them. There is a preponderance of medical studies refuting the validity of these medications.
5. RPL can be a truly frustrating problem, but the good news is that studies have shown that patients with RPL eventually have a successful pregnancy so don't give up!
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
for additional information check out my blog at http://womenshealthandfertility.blogspot.com
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