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QUESTION: Hello Doctor,

I am a 30yo woman from Romania, trying to conceive for 2 years now. I've had 2 chemical pregnancies, one miscarriage at 6 weeks and an abortion at 19 weeks due to ruptured membranes after 2 months of continuous bleeding and SCHs (unknown cause, no infection, no thrombophilia, no APS, no ANA, no visible fibroids). The only issue I have is an arcuate uterus, incidentally seen on a pelvic contrast MRI, which I've been told could increase miscarriage rates especially in the 2nd trimester but is usually not a problem.

Currently I'm on a 3 month break after the last loss and will be trying again starting in March.

My question however is related to MMR immunization. Both me and my partners have never been vaccinated. I had rubella as a child and I am immune to it (IgG testing), however neither me and my partner has had the mumps and I've read online that it can cause infertility when caught in adulthood. Is that true and should we both have the vaccine in this case? Also, can the vaccine by any chance cause any fertility issues in males or females when given in adulthood?

Is it perhaps a better idea if only my partner gets vaccinated, since the disease is more damaging to male fertility?

Also I was wondering if my multiple issues with my pregnancies might be related to the arcuate uterus, especially since I have no other issues? Perhaps I should look into fixing it if I continue to have more losses? Having to give up a pregnancy at 19 weeks is a horrible experience and I would hate to repeat it - unfortunately I seem to have a lot of trouble with all my pregnancies.

Thank you!

ANSWER: Hello Cristina from Romania,

Mumps can cause infertility in males, but has less effect in females.  However, since you have never been vaccinated, I would strongly recommend it.  In the U.S., it is recommended policy for all women planning on pregnancy to be fully vaccinated with all available vaccines.

An arcuate uterus, although classified as a uterine anatomic abnormalilty, is not a signficant finding since the uterus is nearly normal.  There is NO increased risk of miscarriage with this.  The biggest abnormality associated with increased risk is a septate uterus or a full bicornuate uterus, which is much different.

The first pregnancy, a chemical pregnancy, was probably due to a genetic abnormality in the fetus and so development stopped.  The second pregnancy was due to Obstetrical factors, although nothing tangible was found.  We call that preterm premature rupture of membranes (P-PROM).  The most common cause is some type of bacterial invasion, not necessarily an infection, that usually is not detectable.  Beta strep is the most common bacteria but it can be multiple bacteria as well.  In addition, it is thought that a cervical incompetence may also lead to this.  An incompetent cervix is when the cervix prematurely dilates, which may have been the case considering that you had bleeding preceding the PROM.  Did you have cramping as well?  Cramping with bleeding could be a sign of preterm labor, also thought to be due to bacteria.  Cervical dilation without cramping would be an incompetent cervix, which is due to weakness in the cervical muscle.  This can be treated with a surgical procedure called a "cerclage" and is done around 16 weeks gestational age.

These are all things that your Ob doctor should be considering and evaluating for early in the next pregnancy.

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.


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

QUESTION: Thank you very much for your help, Doctor. I have only a few follow-up questions.

1. Is there any chance the MMR vaccine could cause fertility issues in me or my partner, if taken now during adulthood? Or is it safe to take in what regards conception?

2. Do I need to wait 1 or 3 months before trying to conceive after the vaccine?

3. During my last pregnancy (with pPROM) I had continuous bleeding and cramping from 9 weeks to 16 weeks (when I pPROM'ed). Then the bleeding and cramping were significantly reduced, I don't know why - but as soon as I ruptured the cramping subsided. Any possible reason for this? The cervix however was always tightly closed and long (4cm) so they had to induce me with misoprostol for 3 days to get the pregnancy out. I assume this suggests the cervix was not incompetent?
The fetus was alive and growing normally throughout, however the doctors were adamant in that I should end the pregnancy, that the baby had no chance of survival.

4. If a bacterial invasion/infection was the cause of the pPROM but no bacteria was found in the cervical swab culture, what can I do with the next pregnancy to prevent this? Should I take a course of antibiotics that work on strep B regardless of the negative culture?

Thank you again!

Answer
Hello Again,

1.  No.  The MMR is safe.
2.  No, unless you want to be extremely cautious.
3.  Yes, if the cervix was closed then, by definition, there is no cervical incompetence.
4.  Can't answer this question for you since there is no clear protocol or answer for these situations.  It will be up to your doctor.  You might want to get the opinion of your local Perinatologist regarding these recommendations.  They are an Obstetric subspecialist that specializes in Obstetrical complications or complicated pregnancy.

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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