QuestionQUESTION: Hello,
I have had 4 chemical pregnancies in the past 15 months. None were confirmed by bloodwork except for the last one in June, which had an HCG of 5, but spotting had already started at the point that I went for bloodwork. I was referred to an RE/Infertility specialist after the 3rd chemical. The specialist did not consider any of them chemicals because they were not confirmed with bloodwork. At the initial evaluation, I was concerned due to my experiences and my charts that my progesterone levels might be low. I had charted LP's of 11-13 days, my cycles had shortened to 24-26 days from 27-29 days, and periods had become very heavy and I was very tired and having headaches. My thyroid, as well as routine pregnancy screenings were done. I had an HSG done, my husband had his semen checked, u/s were done, and everything came back normal. After the 4th "chemical", the specialist put me on Femara, although I didn't really understand why. I took it and immediately got pregnant. Shortly after I got pregnant, I was exposed to a respiratory CMV infection. I had bloodwork done and it came back normal. About 2 weeks after the exposure, I became very sick with a respiratory infection, which lasted 6 weeks. At my 7 week u/s, the heart rate was only 91 and growth was a week behind. I went back a week later and the heart rate was barely detectable and growth had not changed. I ended up having a d&c August 30th at 9 weeks. Ironically, growth stopped on the exact day that I got sick. I was retested for CMV exposure and everything was still negative. Today I went back for my post op visit. The genetic testing showed that I was pregnant with a girl with NO chromosomal abnormalities. During the pregnancy, I did have progesterone levels drawn (5.5 wks I believe). It was 15. I was reassured that this was high enough and that 9 would be worrisome. He refuses to do any further testing, swears my progesterone is not an issue (and if it is, he will not treat it), and will not test for autoimmune/clotting disorders. I have since returned to my regular OB for a consultation, and he immediately felt my progesterone levels were too low and ordered a battery of tests to check for autoimmune/clotting disorders. To this date, half have come back and they are all negative.
I guess my question to you is what would cause a "normal chromosomal" pregnancy to suddenly end? The RE's answer was "25% of all pregnancies end in miscarriage". How can I be sure this won't happen again? If there is a simple cause, I want to fix it before moving forward. The specialist wants me to return after my period starts and begin Femara again, but I don't really feel it is the answer. I feel like perhaps it altered my hormones enough to stay pregnant, but then as my levels returned to baseline, I lost the pregnancy. Would you be concerned with a progesterone level of 15 and would you treat that? Do you feel that anything has been missed or do you see an obvious reason for this loss. Perhaps if I hadn't seen 5 positive tests in the past year I wouldn't be so concerned, but I don't want to have this keep happening because of something that has been overlooked.
I had a miscarriage at 5 1/2 weeks with my first pregnancy (spotting from the start) and then had 2 healthy pregnancies in the 3 years following that loss.
I am just not sure where to go from here. I am pretty sure the right choice is to return to my OB and skip the Femara. At least he is open minded and willing to look for a cause (and treat related to my personal situation). I just hate to make a wrong decision and at this point, I am just lost. Thank you for your opinions and for taking the time to read this.
Karri-NY
ANSWER: Hello Karri from the U.S. (NY),
I apologize for the delay in getting back to you. Yours was a long letter so took time to find time to get through it.
In general, studies have shown an up to 40% chance of miscarriage per pregnancy. Much of this rate is age related as miscarriage increase dramatically after the age of 35. Most of these miscarriages will be due to spontaneous chromosomal abnormalities that occur when the egg is dividing. Also, 85% of patient that have miscarriages will eventually have a successful normal pregnancy.
In your case, knowing that the genetics was normal, there must have been some other problem. Certainly progesterone could have been an issue, but this is more of an issue in very early (prior to 6 week) pregnancy losses because the placenta has not yet fully developed. After 6 weeks, the placenta takes over hormone production. Because your previous early "chemical" pregnancies were not confirmed by blood tests, in general we can't count those. In this recent miscarriage, you got all the way to 9 weeks gestational age so it was probably not a progesterone issue. However, the infection that you got could have been. One of the causes of miscarriages is viral illness. An infection at this early stage could have heightened the immune response leading to rejection of the embryo or could have affected the embryo directly leading to its death. It was unfortunate that you got this infection/illness at the time that you did. In general, when a patient becomes sick in an early pregnancy, we say that it will have an "all or none" effect. That is it will either lead to the fetal demise and miscarriage or it will not affect the pregnancy at all. I would conclude that it did affect your pregnancy. The good news in that is that you have been able to get pregnant and sustain it until 9 weeks, which means that the next pregnancy will probably go longer and hopefully, to term, and that as long as you don't get a repeat illness at the same time, you should not face the same problem.
I am in agreement with your general Ob/Gyn doctor that progesterone supplementation should be used, as this is a very benign medication and can be of significant help. Your progesterone level was definitely too low. We like it to be over 40. It should be given as a vaginal formulation and the best type is a medication called Endometrin. I would have you use it 3 times per day beginning after ovulation. Femara and Clomid are certainly appropriate as well because they do help with fixing the hormonal imbalance, such as luteal phase defect, and increase your chances of pregnancy by getting you to ovulate more than one egg per month. But it is not a necessity in your case.
In terms of which doctor to see, I would prefer that you see a fertility specialist rather than a general doc, but even more importantly, you need to see a doctor that is interested in working with you and not against you.
Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.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
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QUESTION: Thank you for your excellent, detailed answer. Since asking this question, I have two more pieces of information to share with you and I am just curious if your answer changes at all as to why I miscarried. My general OB did testing and my results came back after posting the original question. The report reads "Positive for one copy of the C677T mutation and one copy of the A1298C mutation". This individual is compound heterozygous for the mutations, C677T and A1298C in the MTHFR gene. I know people with MTHFR often are put on heparin/lovenox, but I am curious if these specific mutations require treatment or if it isn't really significant. After receiving this information, my OB ordered a homocysteine level, which came back normal. I had been taking 5 mg folic acid for about 2 weeks when the homocysteine levels were drawn if that has any impact. If I am guessing correctly, a normal level would mean that MTHFR really isn't affecting me, but I am not positive. My Dr did place me on 5 mg folic acid and 81 mg ASA and a prenatal with DHA with instructions to start after the initial blood tests were done. (All of which I had put myself on about 2 months prior to getting pregnant, but much lower folic acid). I was also taking B6 and noticed from Internet research that B6 and B12 are recommended with MTHFR. I guess with this new information I am wondering if it could be the cause or if I need to take precautions in a future pregnancy. I know anticoagulants are often prescribed, but I am guessing that with the negative homocysteine level that I may not need them. Would the B6 and B12 still be helpful?
I guess maybe it was just dumb luck that I got sick at the time I did, or perhaps my progesterone levels are to blame, but hopefully with all of this knowledge it will work next time. I am going to skip the Femara this month in the hopes that my body works the way it is supposed to on it's own. I wish you were closer. I would definitely come see you. At this point, the specialist I see is of no use to me. He is unwilling to work with me and to treat me as an individual patient, so I will not be returning to him. I do feel very confident in my general practitioner, but if this new information does not help, I will seek out a new specialist who will work with me. Thank you again for letting me pick your brain and for volunteering on this site. It is so helpful and very appreciated! Sorry I am so long winded! The nurse in me just never stops thinking...
AnswerHello Again,
The new information does not change my previous answer, but the appropriate treatment for MTHFR disorders is the addition of Folic acid, which you are taking. I don't think that heparin or Lovenox are required at this time.
It is good that your GP is working with you, but my bias is for you to see a specialist, who has a much better knowledge base than a generalist. That is up to you.
Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.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
