QuestionQUESTION: Dr. Ramirez,
I'm 37 years old blessed with four young children (3 of them conceived via IUI and IVF). We were trying to conceive a final addition(s) to our family via an IVF this past July. I did end up conceiving twins, but miscarried both. This was my first miscarriage and I was devastated. At 7.5 weeks, both babies hearts stopped beating. At the time, a third gestational sac appeared as well, but I was told that it would never develop because it appeared so late. Because my uterus had been inviting to my embryos with my past IVF and because I've always conceived fairly easily with fertiliy help, I was trying to avoid a D&C because I heard there's a slight risk of scarring or uterine trauma. I opted for the misoprostol and took my first dose over Labor Day weekend 9/5/09), at which time my HCG was 35,000+. I took a second dose a week later. My HCGs have steadily been dropping. My current HCG from today is 88.5. However, last week when I went in for an ultrasound, I had a 21mm follicle on my right ovary, and my lining was 18mm thick. My progesterone was 5.5 and my estrogen was 140. They thought I had just ovulated. Two weeks prior, I didn't have any follicles and my lining was 12mm. I'm torn about whether or not to do a D&C. Currently, I'm just spotting here and there with mild intermittent cramps. It's been over 7 weeks since I took the misoprostol. I thought I'd be close to cycling again by now, but I'm not. This has been dragging on. Because I've come this far, should I just go ahead and wait until my HCGs are zero? Or, should I just do the D&C to make sure everything is "evucuated"? I've heard at least two examples where gals had D&Cs after a miscarriage and then developed lining problems (when they never had them prior). Is there a danger of old products of conception, blood, clots, etc. sitting idle in my uterus after all this time? Finally, is it possible for my HCG to drop to zero and still have old clots, blood, and products of conception in my uterus? I want to do what's best for my body to successfully conceive (a viable pregnancy) again in the near future, and I don't know what to do. I'll be at least 6 months older by the time I get to cycle again, which means my eggs will be 6 month older too. Since this was my first miscarriage and because I miscarried both twins, does this mean that my BAD EGGS are starting to surface now? I've been extremely fortunate with my past IVF conceving healthy twins, and a healthy baby boy via an IUI (on just one try). My 5-year old daughter was conceived naturally after over a year of trying. Never had a miscarriage before. My husband had to have varicocele surgery prior to us conceiving our daughter 6 years ago, and he still has variable low motility. At any rate, I'd appreciate any advice that you could give.
Thank you so much, Dr. Ramirez.
Sincerely,
Monica from Chicago
ANSWER: Hello Monica from the U.S.,
It is most likely that the miscarriage was due to abnormal embryos, which is very age dependent. That is the problem with "old" eggs.
Since you opted for the "medication" route to evacuate the uterus, it should have induced a miscarriage and you should have had a "period" or heavier bleed. You didn't mention if that was the case. At this point, the decreasing HCG's is a sign that the pregnancy is resolving and you would need to follow it down until it is zero. Of course, you could choose a D%26C at this point as well. Most physicians are very competent at doing this procedure gently so that scarring does not occur, but you have to be sure to emphasize that point if you elect to have the D%26C. The D%26C is the only way to get the pregnancy ended sooner or to make sure that all the tissue is evacuated. You can have retained tissue even if the HCG goes to normal. It just means that the tissue is no longer producing HCG. This could interfere with implantation.
At this point, I would approach your case in the following manner: I would continue to monitor the bHCG's until they are down to zero. I would do a repeat hysteroscopy prior to initiating another IVF cycle, to insure that the cavity is clear, then I would proceed with another IVF cycle as soon thereafter as possible. Keep in mind that because of your age, there is an increased risk of miscarriage. That is just a risk you have to be willing to take if you want to have another baby. In the end, once you are successful, all these events will be well worth it. Remember the old saying that was not specifically for infertility but still applies, "no pain, no gain." or the other "nothing comes for free."
I hope that helps,
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 facebook and twitter with me at @montereybayivf
---------- FOLLOW-UP ----------
QUESTION: Thank you so much, Dr. Ramirez, for your response. Yes, I did bleed and have clots and even an entire gestational sac expelled with both doses of the misoprostol, but still it seemed like there should have been more. I was told (not by my RE) that since I've been instrumented so many times with IUIs, IVFs, saline ultrasounds, etc. that the reason for my miscarriage could have been due to endometritis and that I should have that checked. I just thought it was strange that three embryos implanted, two had heart beats and I miscarried both. Out of the eight embryos from that IVF cycle, three were transferred, three did not make it to blastocysts for freezing, and two day-6 blasts were frozen. I'm very reluctant to use those eggs for a cycle because it seems like a "bad batch". Is that possible? Is a hysteroscopy superior to a saline ultrasound? To my knowledge, my clinic only does saline ultrasounds to give one "the clear" before cycling. Since I have old clots, blood, and posssibly retained tissue, it sounds like a hysteroscopy may be better than just a saline ultrasound......is that correct? Three more questions: I'm planning on doing microarray or CGH with my next cycle. Do you have any opinions on that? My husband's company placed a new lifetime $$$ max on fertility benefits and it looks like we only have 1-1/2 or 2 more fresh cycles to use. So, I want to do everything to maximize our chances of a viable pregnancy with the next IVF cycle. Next, after a D&C or hysteroscopy and all is clear, do you recommend waiting for another period to come and go before cycling or do you recommend us cycling as soon as possible due to our age (I'll be 38 in April). Finally, because I've now had a miscarriage, does that mean that I'm more suspectible to having them (kind of like ectopics)? Even if we have CGH normal embryos that are transferred, do I have an increased risk of miscarriage because I've already had one?
Dr. Ramirez, thank you so much for your help!
AnswerHello Again,
1. Hysteroscopy is superior because you are actually looking inside the cavity rather than looking at outlines of the cavity.
2. CGH is totally experimental at this stage and has not been shown to increase pregnancy rates. In fact, it may detract from pregnancy rates because of the "invasion" of the embryo. That is yet to be seen with further study. Genetic testing via preimplantation genetic testing is not recommended by ASRM/SART except in cases of known genetic disorders. I counsel my patients regarding the availability but do not encourage it.
3. I would recommend you proceed as soon as you can after the hysteroscopy to do the IVF. If you have a D%26C, however, because it causes a resultant inflammation, you will need to wait a minimum of 6 weeks.
4. Most miscarriages are due to spontaneous chromosomal anomalies in the embryos. Your age puts you at increased risk for this. This is part of the "age factor" that decreases fertility. You are at increased risk of recurrent miscarriage only because you are 37-38 years old.
5. If CGH is done and normal embryos are transferred, you are still at risk for miscarriage because the embryos still have to develop and divide beyond that point, with a resultant risk of a spontaneous defect. In addition, the embryo biopsy may hurt the embryo as well. There have been recent studies showing decreased pregnancy rates after embryo biopsy.
These are all issue that you should thoroughly discuss with your doctor as well.
I hope this helps,
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 facebook and twitter with me at @montereybayivf
