QuestionQUESTION: Hello Dr,
I'm 29yo female, trying to conceive for 1 1/2 years.
So far I've had 2 chemical pregnancies (lost at 4w5d and 3w6d) and 2 early miscarriages where the yolk sac was seen (5w6d and 6w). All were spontaneous abortions/expulsions. I've never had a normal pregnancy.
I've been diagnosed with Grave's disease - TRAb 5.8 (elevated), ATPO 115 (elevated), TG Ab 33 (mildly elevated). I've had overt hyperthyroidism with one of the pregnancies but not with the others.
During the last 2 pregnancies I've taken 75mg aspirin and 200-400mg progesterone daily but there was no difference (in fact these pregnancies went less far than the 2 before them).
My doctor recommended APS and thrombophilia panels which I'm currently awaiting results for.
I've also discovered recently from an older MRI from 5 years ago that I have an arcuate uterus (around 8-9mm long), which I've read can cause repeated pregnancy losses.
My question is, if the thrombophilia and APS panels don't show any issues (and even if they do), would you say a metroplasty for the arcuate uterus is in order given my miscarriage history? I just get tired of losing every pregnancy like this and I think I should eliminate any issues that might be causing my losses, am I correct?
Thank you!
ANSWER: Hello Cristina from Romania,
I don't think that the arcuate uterus is the cause of your pregnancy losses because it would cause an implantation problem rather than losses at the gestational ages you were able to get to. I would not recommend a repair procedure as this can lead to further infertility problems.
The most common cause of recurrent pregnancy loss (RPL) in a young woman your age, would be immunologic followed by hormonal. As such, I do agree with the testing for anti-phospholipid antibodies and thrombophilia. In my clinic proceed with an RPL protocol using low dose aspirin, low dose medrol (methylprednisolone), low dose heparin or lovenox, estrogen supplementation and progesterone supplementation. I also test for MTHFR and if positive, then treat with additional Folic acid. That is what I would do next. What your doctor does to treat from this point will depend on his/her knowledge, experience and preferences.
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 for replying, Dr.
In the meantime my Thrombophilia panel results came back all good except for MTHFR A1298C (heterozygous). So I guess thrombophilia was not the cause for my miscarriages. I will also have the APS panel.
From my understanding of the arcuate/sepate uterus, the area of the septum or the arc can be less vascularized than the rest of the endometrium, which causes a new pregnancy to either not implant or exceed its supply too soon which leads to implantation failure as well as early pregnancy loss. Can this not be the case? I've had development issues with all my pregnancy - they all had slow rising hcg (72-96h) and the ones that were picked up by the ultrasound were behind their gestational age.
I was thinking I should continue trying for 3 more pregnancies. But if I continue to lose them despite having my thyroid under control and taking lovenox/heparin (in case I have APS) and take progesterone and aspirin (which I've taken with my last 2 pregnancies anyway) and adding prednsione for immune issues... basically if all the other causes are accounted for and I still continue losing pregnancies (which is no fun, truly) - do you think I should eventually fix the arcuate uterus as well? Just in case it maybe is an issue?
I have read very promising studies about women with arcuate uteri and RPL that have greatly benefited from this surgery such as this https://www.asrm.org/detail.aspx?id=12926
What are the risks of the hysteroscopic metroplasty if performed by an experienced surgeon? Can it leave me completely infertile and what are the odds of that? After 6-7 losses, would it not be reasonable to also fix this malformation - Mullerian defects are known to cause RPLs.
Also, what Prednsione dose do you usually suggest to the patients and when should it be started - before or after the positive test?
Thank you very much
AnswerHello Again,
Arcuate uterus is only a slight ridge in the uterus and not shown to be a problem with implantation. The more serious uterine abnormality is a uterine septum, bicornuate uterus or uterine didelphys where, as you described, the septum is not fully formed or vascularized and therefore not a good place for implantation and pregnancy support. Arcute uterus does NOT have this problem. The difference could be described as this: a bicornuate, septate or didelphys uterus looks like a heart with two chamnbers, whereas, an arcuate uterus has a slight curve at the top, like a triangle with the upper side as curved and not straight. Because it is a nearly normal formed endometrial cavity, there are not issues. That is why I stated that the anatomical defect is NOT the cause of your miscarriages. The biggest risk of endometrial surgeries is the formation of adhesions or scar tissue, known as Asherman's syndrome. If that happens, you them may have to use a surrogate to get pregnant. It is a difficult problem to solve.
On the other hand, MTHFR has been clearly shown to be a cause of recurrent pregnancy loss. The treatment for that would be to add 4 mg of Folic acid per day,and is what I would recommend.
I start the methylprednisolone at the beginning of the cycle, at 16 mg per day, then decrease it to 8 mg per day at the time of the retrieval or ovulation and continue this until 10 weeks gestational age.
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.
