QuestionHi Dr. Ramirez,
HISTORY:
My husband and I have been trying to get (and STAY) pregnant with no luck for 5 years. We have been given the diagnosis of "unexplained infertility." My first pregnancy was in Dec 2004, as a result of starting Metformin. It was a Chemical pregnancy and I miscarried in Week 5. No D & C was done. From 2004 until now, we have done the following: 7 IUI's (using one or more of these drugs: clomid, letrozole, injectable gonadotropins and/or metformin). Non IUI ever lead to a pregnancy. I have also had a laparoscopy, where they found mild endometriosis. I have had dye injected into my fallopian tubes - result was completely normal. I have also had 2 hysteroscopies, both normal. I have had all the standard blood tests, plus some non-standard ones. Some of them were: LH, thyroid, lupus anticoagulants, post-coital, hcg, FSH...
Last year (January 2008), we did a cycle of IVF (Lupron protocol). They retrieved 13 eggs and 8 fertilized. By Day #3, only 2 survived and we tranferred both of them. I had a positive pregnancy test, with a Beta of only 11. Every 48 hours it did triple/double until Week 5 when it started going back down. I miscarried in February. No D & C was done.
We tried another IVF cycle at the end of last year (Nov 2008) with a different protocol - ganarelix. This time, we retrieved 16 eggs (several from immature follicles), with only 6 that fertilized. We biopsied all 6 for PGD, with 2 embryos coming back as "chromosomally normal." We transferred both of the normal embryos. First beta was 36, and doubled consistently. Two weeks later we saw a normal heartbeat at 132 BPM. One week later, the vaginal ultrasound showed the heartbeat had slowed to 60 BPM. One week later (at 8 weeks 3 days), the heartbeat stopped. D & C was performed, with the results being a "chromosomally normal male." Anticoagulant blood tests were performed during AND after pregnancy to rule any blood clotting disorders out.
I saw an auto-immune doc and had tests run. Everything came back normal.
We have a 3rd cycle of IVF scheduled for the end of September.
MY QUESTION:
The doctors have mentioned the possibility of trying IVIg and/or Heparin with this next IVF cycle, although, I have never been diagnosed with ANY auto-immune or blood-clotting disorder.
Do you have any opinions on IVIg or Heparin for multiple miscarriers like me? I don't like the idea of other people's 'blood products' in me, with IVIg. And I am very nervous about the use of Heparin for someone like me with NO blood-clotting disorder.
After giving your opinions on IVIg and Heparin, please tell me your thoughts on doing IVF (with PGD) a 3rd time, using no different protocols than the last time. Are we potentially wasting our money? Do my miscarriages sound like a problem with my BODY or my EMBRYOS? I mean, if PGD before implantation AND a tissue biopsy during the D & C ruled out chromosomal abnormalities, wouldn't the liklihood of our issues be my body rejecting the fetus? Is it a good sign that my 3 pregnancies have progressed a little bit farther along each time? Or is that just coincidence? Lastly, is it possible that I have Natural Killer Cells, since we had a strong heartbeat with a chromosomally normal fetus and then it slowly faded until it stopped?
Any insight you have on our situation would be helpful. I don't know if we should go through the emotional, physical and financial pain of IVF a third time, if chances are we will get pregnant and lose another baby.
Thanks so much for any advice you have!
Heidi
AnswerHello,
You are in contention for having one of the longest letters.
The fact that the pregnancy got as far as it did the last time is a very good sign. It is likely that you will eventually be successful if you don't give up. Based on your history, you certainly are a perplexing case. I believe in some of the thoughts on the immune system causing miscarriage, but not all, and as such, I don't use IVIG. I used to in the past, because I trained under a prominent IVF pioneer who was strongly in favor of using IVIG, but since, multiple studies have not confirmed any benefit. In addition, it is very very expensive with the risks of a blood product for a theoretical gain. There is a newer drug that some patients have told me about, but I don't remember the name.
I DO use heparin and aspiring with my patients who fail IVF or have a history of multiple miscarriages. It works great and is low cost. You can substitute Lovenox for the heparin although it is more expensive. I have my patients take Aspirin 81 mg per day beginning at the start of the cycle. I have them take Heparin 2000 units twice per day starting at the beginning of the cycle. Both medication are stopped on the day of HCG trigger. I also use Medrol 16 mg per day beginning at the start of the cycle and decrease to 8 mg per day with the embryo transfer. It is then stopped at the time of the pregnancy test. I also double up on my progesterone with 50 mg injectable progesterone and Endometrin 100 mg twice per day, both starting at the time of retrieval. This protocol has certainly helped many patients, including patients that I have done IUI"s on with a history of recurrent miscarriage.
Once thing I always tell my patients. If you don't try, you certainly have a less chance of becoming pregnant. So, I would recommend that you continue to try. You got pretty close the last time. One of these times, it is going to work!
Sincerely,
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.
check out my blog at http://womenshealthandfertility.blogspot.com
