Recurrent Early Pregnancy Loss - 1 - Implantation
Thursday, March 22, 2007
Kenneth F. Trofatter, Jr., MD, PhD
Although uncommon, about one out of every 100-200 women will have recurrent early losses without a successful pregnancy and another small percentage will have recurrent losses only after initially having successful outcomes (these women have been termed ‘secondary aborters’). A woman who has had one clinically recognized miscarriage is probably at no greater risk than any woman in the general population for having another (15-20%). However, if she has had two spontaneous losses in a row, the risk rises to about 35% for a third; and, if she has three consecutive losses, the risk is about 50%. Before looking at some factors that can contribute to early pregnancy loss, let’s review the ‘normal’ sequence of events that lead to a ‘successful’ pregnancy.
Under ideal circumstances, a woman with regular menstrual cycles (every 28 days) produces an egg (ovulates) around day 14 (counting from the first day of the last menstrual bleeding). The egg contains 23 ‘normal’ chromosomes and begins the trip down the fallopian tube where it becomes fertilized (ideally within less than 24 hours of being ‘hatched’) by a sperm, also containing 23 ‘normal’ chromosomes, producing a ‘fertilized’ egg, or zygote, with 46 chromosomes. Over the next two days, the zygote undergoes rapid cell divisions, entering the uterine cavity as a relatively homogeneous mass of about 16 cells called the morula. Once in the uterus, the cell mass begins to ‘differentiate’ (separate into cells that will eventually form the baby and those that will eventually form the placenta) into a structure called the blastocyst which must then attach to a favorable location on the inner lining of the uterus (the endometrium) within about 48 hours. Over the next week (and prior to the time of the next expected menstrual period), the blastocyst solidifies its attachments to the endometrium and, while continuing to differentiate into tissues that will eventually form the placenta or the baby, literally buries itself in the endometrial lining.
The cells (trophoblasts) that will develop into the placenta first anchor the blastocyst to the endometrium, eventually burrowing further into maternal tissues in which there are lakes of blood, an early source of nutrients for the developing pregnancy. Over the next 6 weeks (the embryonic period), not only will all major internal and external structures of the baby develop, but the trophoblasts will begin an extremely important 'second wave’ of invasion that involves a dangerous journey through the relatively ‘hostile’ environment of the maternal endometrial tissues where they are exposed to both nonspecific and specific mediators of the mother’s immune response. At the end of this long journey, under 'normal' circumstances, the trophoblasts will have successfully invaded and replaced (remodeled) the lining and muscular wall of the endometrial portion of the mother’s ‘spiral arterioles’ assuring the developing placenta of a continuous source of maternal blood in which to ‘bathe’ and, thereby, providing the placenta (and hence the baby) a source of oxygen and nutrients to continue its growth.
Factors that contribute to recurrent early pregnancy loss can result from problems occuring at ANY of the stages (and more that haven’t been mentioned) detailed above; and in our next post, we will begin the discussion of specific areas of concern to which evaluation and treatment might be directed.
73 Comments:
At Tue Jun 05, 01:44:00 PM 2007,
Anonymous said…
i am 26 yrs old and my husband is 29 yrs old both are healthy and have been examined by many doctors but we have lost to babies both not going over 6 weeks and the last one in 2003 was supposed to have stuck in my tub in which case i had to get a toxic jag to break up the cells of the baby what i am asking you doctor is could have the jag caused anything as i have not concieved natuarly since
At Wed Jun 06, 10:07:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
I believe what you are telling me is that you had a tubal ectopic pregnancy and your doctors were able to treat that with a drug (most likely methotrexate)rather than having to operate on you. Women who get tubal ectopic pregnancies are more likely to have had some damage to the tube that caused the fertilized egg to get stuck in there while it was traveling down to the uterus. Unfortunately, if that is the case, you might have some damage to your tubes that is now making it more difficult, or even impossible to conceive again. The methotrexate therapy is not causing your current problem with infertility. With your history, you should go to see an infertility specialist (Reproductive Endcocrinologist) who will be able to evaluate your tubes and tell you if there is a problem and what can be done about it and if there is some other reason you have not been able to get pregnant. Good luck and thanks for reading!
At Fri Jun 15, 11:57:00 AM 2007,
Anonymous said…
I AM 27 YRS OLD AND MY BOYFRIEND IS 29 YRS OLD. I HAVE TWO KIDS FROM PREVIOUS MARRIAGE,HE HAS NONE.I HAVE GOTTEN PREGNANT 3 TIMES AND HAD 3 MISCARRIAGES WITHIN THE PAST YEAR(6/06,1/07,4/07).I HAVE DONE EVERYTHING BUT IVF.I WILL GET PREGNANT AND LAST ABOUT 4-5 DAYS AFTER PERIOD IS DUE.THE LAST TIME I BROUGHT SOME PROGESTERONE PFF THE INTERNET AND USED AS DIRECTED DAYS 14-28 AND ON CD29 POSITIVE TEST BUT IN 3 DAYS STARTED PERIOD/MISCARRIAGE.WHAT DO I DO .MY DOCTOR STARTED ME ON PROVERA 10ML,BABY ASPARIN 81MG,PRENATAL PILL DAILY.IS THIS ALL I NEED.PLEASE HELP!
At Mon Jun 18, 10:22:00 PM 2007,
ss.abhilash said…
sir
I am 31 years old and my wife 24 years she was carrying and 15 weeks but it get aborted and the doctor says it has only 11 weeks growth.The biopsy has done and here is the result sir
Nature of Specimen: D&C
Macro: Placemental bits whole measuring 8x5x3cm Cutsection spongy.Foetus measuring 3.5cm in length recieved seperatly.
Micro: Section shows sheets of decidual tissue and multiple normal sized and enlarged chorionic villi lined syncytio and cytotrophoblasts.The enlarged villi show peripheral scalloping and central cistern formation. only minimal trophoblasts proliferation noted.
Impression: suggestive of partial mole.
At Tue Jun 19, 05:02:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous from June 15: You are young and you have a new partner. This may simply be a case of your immune not correctly recognizing your new partner's contribution to the pregnancy and rejecting it outright, but I sense there is something else going on here. It could be that your partner has a chromosomal abnormality such as a 'balanced translocation'. Under those circumstances, he would have the correct amount of chromosomal material and appear 'normal' but may have a hard time making chromosomally 'balanced' sperm. Anyway, I think tthe two of you need to find a specialist in reproductive endocrinology and infertility fpr a proper 'couples work up' rather than taking chances with "progesterone off the internet." Good luck and thanks for reading!
At Tue Jun 19, 05:17:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To sshabhilash: Your wife had a "missed abortion (miscarriage)" which means the bay died at about 11 weeks but it took awhile for the pregnancy hormones to drop low enough for her body to recognize that the baby was not alive. This is not uncommon. It is also not uncommon for the placental tissues that did develop to undergo 'hydropic degeneration' under these circumstances. This causes the villi to look like a 'partial molar pregnancy' but it probably was really not that. The baby might well have had a chromosomal abnormality. Triploidy pregnancies (wherein the baby has 3 complete sets of chromosomes rather than two), frequently have placentas that take on this appearance. Thanks for reading and for your comment. I a sorry for your loss, but bet things will work out better the next time!
At Wed Jun 20, 03:24:00 AM 2007,
Anonymous said…
I am 37 yrs old and since Sep 05, I've had 3 consec miscarriages - one at 6 weeks, one at 7 weeks and one in Jan this year at 15+2 weeks. Even up until literally the day before I miscarried for the 3rd time, the babys heartbeat was heard. I'd been feeling unwell for a few days and had some bleeding, but hospital said all was ok, nothing obvious as to why I was bleeding and told me to rest. The morning of the miscarriage, I started getting realy bad cramps - which obviously were contractions, and I was really sick and my temp went to 38.5c - anyway was rushed to hospital where I lost my baby. I was given antibiotics through a drip and had to be put on double dose iron tablets. Eventually tests were done on the placenta etc. for both me and my husband, and all came back as normal - no specific reason why I miscarried, but possibly had an infection, but they couldn't be specific as to whether it was the 'cause' or 'effect' of my miscarriage.
I'd had bouts of bleeding all through the last miscarriage bu not once did the hospital check to see if i was anaemic, or picked up some kind of infection - until perhaps it was too late. We are trying again now for another baby, but I am so worried that I may never be able to carry full term. I'd like to hear your views on this. Thank you
At Thu Jun 21, 07:01:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
When you carry to 15 weeks or more and then have the sequence of events you describe, I always worry about cervical incompetence, a septate uterus, or an intrauterine source of 'chronic inflammation' like a polyp or fibroid. Before you get pregnant again, consider having a specialist in REI perform a sonohysterogram and/or hysteroscopy to evaluate the uterine cavity thoroughly. If nothing is found, let me know and I will have some other suggestions! Good luck and thanks for reading!
At Tue Jun 26, 03:25:00 AM 2007,
Anonymous said…
hi, im 24 yrs. old, i got married a month ago and we were together already for five years, and have been sexually active. after a week of getting married i was diagnosed of having a cervicitis. i have experienced the symptoms a year or two years ago. but i didnt know that it will be a serious problem for me and i didn't mind it. is there a possibility that i will get infertile. im just curious about this coz i want to have babies. pls give advise. thanks
At Wed Jun 27, 05:51:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Infertility is rarely associated with cervicitis alone, but that depends on the cause of the "cervicitis." If it is associated with a chlamydia or gonorrhea infection, it might eventually be accompanied by infertility. If it is associated with a human papillomavirus (HPV) or herpes simplex virus (HSV) infection, these also are usually not associated with infertility. If it is simply the result of intercourse from your "honeymoon" then it is probably not an issue at all! Bacterial vaginosis and yeast infections are, themselves, also rarely a cause of infertility. If you are worried about it, ask you doctor for more details about what they think is causing your "cervicitis." Thanks for reading!
At Thu Jun 28, 12:50:00 AM 2007,
Anonymous said…
I have been through extensive genetic and fertility services and have had 2 m/c less than 8 weeks, 2 live births and now 2 m/c less than 8 weeks again. Chromo tying done and no abnormalities found, I have regular periods 27 days, mild cramps, light bleeding. The Drs cannot find a cause and I don't know where to turn for help. thanks, "mom in hawaii"
At Thu Jun 28, 06:32:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Dear Hawaii Mom: The best thing you have going for you is the fact that you have had two normal pregnancies! OB history increases the likelihood you will be successful. If these children were fathered by the same person who fathered your most recent losses the odds are in your favor. By the way, has he had chromosomal studies done or were they done on any of your miscarriages? If you want to go all out with 'empiric therapy' (that means, we don't know what we're treating, but it's safe enough to try!) to improve your chances, you can get some ideas on that from one of my last posts in this series on that subject. Good luck and thanks for reading.
At Mon Jul 09, 02:49:00 PM 2007,
Anonymous said…
I am 32 yrs old and my husband is 34 yrs old. We have a healthy baby born out of my first pregnancy in year 2002. We started trying for our second one in Year 2005.
In April 2005 I got pregnant but had a miscarriage in Mid May 2005 (7 weeks or so) and I was told by the doctor that there was no embryo just the sac. I had a heavy bleeding and eventually the sac came out on its own. After that, I got pregnany again in April 2006 and the baby was growing fine.
But during 16th week,I was told that the baby didn't have any heartbeat and most likely had become still 2-3 weeks ago. I had to go through a D&C for cleanup. Since begining of year 2007, I am trying to conceive and its not working out. I am going to the doctor in REI department of my hospital. The doctor has done many blood tests and ultrasounds during
the last 5-6 cycles and everything came out fine and they couldn't find anything abnormal. Even the sperm analysis for my husband has come out fine. For the past couple of cycles I can feel some symtoms of pregnancy like heavy breasts etc but the bleeding starts as per the normal cycle. I recently saw another specialist and she right
away suggested some drugs like Z pack, folgard etc.
Please advice on the following questions -
1. Do you think I am conceiving and having very early miscarriages?
2. What could be the reason of not able to carry the pregnancy?
3. Am I at the point where I should try these drugs?
4. What are my changes of having a successful pregnancy if I conceive naturally?
At Fri Jul 13, 06:58:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous July 9: I doubt you are actually conceiving on those cycles wherethe period starts on time. I would be curious to know what tests have actually been done by your infertility specialist. Do you have the results of those? Regardless, consider the medications recommended by the doctor. These are harmless enough and afll under my recommendations for 'empiric therapy' that you can find in one of my last posts in this series. I cannot tell you what your chances are for a successful pregnancy because we don't know why you are having trouble. Your odds of success, however, will decrease with time. Good luck and thanks for reading.
At Tue Sep 04, 03:36:00 PM 2007,
Anonymous said…
hello, I am 29, my husband 34. I am going through my 5th miscarriage now. They are all happening at exactly the same time - very early 3-4 weeks preganant. I have gone through all the testing and everything is normal (endometrial biopsy, x-ray of uterus, test for the antibodies, thyriod testing, and the other standard blood testing, chromosomal testing of me and my husband). With my 5th pregancy dr. recommended to take clomid which i did, and this time even though I was bleeding, my hcg started to go up , but not exactly doubling. At 6 weeks (going by the obgyn calendar)i had an ultrasound done and the dr said there was nothig in the uterus so she suggested I use the drug (metroxate)to end my preganancy as it is not a viable pregancy and might be ectopic, even though i did not feel any abdominal pain. I followed the instructions. When I was 5 I had the appendix removed (which raptured),so she is thinking that my recurrent pregnancy loss might be related to the fallopian tubes being damaged/having scar tissues, which may be preventing the ebryo to travel to the uterus - my questions is , is that possible? my second question is , what could be wrong with me- all the miscarriages happen exactly at the same time? I just feel that there must be somethig that causes me to miscarry this early. could you please help me
At Thu Sep 06, 12:00:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Sept 4: It is possible that you had tubal damage as a result of a ruptured appendix, but I would tend to doubt it because you seem to have no trouble actually getting pregnant, and at this point you have not had a proven ectopic (tubal) pregnancy. I think something else is going on here. Did your doctor use the clomid because you are haing irregular periods? Do you have any medical problems at all? I know you have had an "X-ray" of your uterus, but was that done by a real expert. X-ray studies are not the most sensitive way to pick up uterine abnormalities such as polyps and fibroids. I would suggest that with 5 losses, and none getting past very early first trimester, you are having an 'implantation' problem related to a chronic inflammatory condition secondary to an intrauterine abnormality or even endometriosis/adenomyosis. Why don't you see a specialist in Reproductive Endocrinology and Infertility (REI). They will review the studies you have had done, perform additional studies as necessary and recommend a comprehensive treatment plan. Let me know what they find out and suggest, okay? Thanks for reading and good luck to you! Dr T
At Thu Sep 06, 02:46:00 PM 2007,
Anonymous said…
from Anonymous Sept 4, dr, Trofatter, thank you so much for your response,you suggested I see the REI experts - I am actually seeing them for over a year now (and tried different doctors), and they cannot come up with anythig . They suggested I use clomid to help strengthen the follicle. I have regular periods. Some of my medical problems are migraines on regular basis, constipation, other than that I am a healthy person. the x-ray I mentioned before was the sonohystogram - and they said that everythig is normal with my uterus. Is there any other x-ray I should consider? You mentioned I may have chronic inflammatory condition secondary to an intrauterine abnormality or endometriosis/adenomyosis. Could you explain what they are and if there is any treatment to those conditions? Also just wanted to mention that with my last miscarriage, when the dr. did the ultrasound and she did not see anyhting in the uterus she mentioned that the lining was very thin. If it was not an ectopic pregnancy , why would my hcg go up after I bled? I am sorry for all the questions, but I am trying to find out what could be wrong with me .
At Thu Sep 13, 05:25:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Sept 6 (and 4): Thanks for filling me in on more of the details. The lining of the uterus is the endometrium. If women have endometrial-like tissue outside the uterus this is called endometriosis and if the same sort of tissue is actually in the muscle wall (myometrium) of the uterus, it is called adenomyosis. Endometriosis (and adenomyosis) are not only associated with primary infertility, but also (probably) with recurrent miscarriages because they stimulate the local infiltration of inflammatory cells from your immune system because of the 'irritation' they cause. These inflammatory cells can disrupt the early implantation of an embryo. I do not know if you have that, but it is something to think about. One of my last posts in this series is on "Empiric Therapy for Recurrent Early Pregnancy Loss." One of your options would be to pull out all stops and go that route. Another option is in vitro fertilization. Has your REI doctor discussed that with you? We have a couple of very good REIs where I work who have a strong interest in recurrent early pregancy loss. I will ask them what they might offer someone in your situation in addition to what I have already suggested. Hang in there! Dr T
At Tue Sep 18, 06:21:00 PM 2007,
Anonymous said…
I am 35 years of age and have had much difficulty carrying to term. Since 27 years of age, I've had 4 miscarriages, 1 live birth, and 1 ectopic pregnancy (tube removed). Not in that specific order. I am concerned that my age is against me at this point. Is there anything that you can suggest that I can be tested for? My miscarriages end quite early - within 5 - 7 weeks. I am currently pregnant again but extremely paranoid that I will lose this one as well. My breasts feel very tender and heavy one day and not the next. I do not feel pregnant (no vomiting). I find this to be quite confusing!!!
At Mon Sep 24, 12:56:00 PM 2007,
Sue said…
I am 29 years old and my husband is 33. I have now had two miscarriages. One ended at 5 weeks and they saw nothing and had no reason for me having it. The second miscarriage happened at 8 weeks and prior we heard a heart beat and a week later the baby had died. I ended up having a D&C a week later. The results came back as me having a partial molar pregnancy, that was in Mar 2007. I have had my bloodwork done every month after that and my numbers have been at 0. It is now Sept 2007 and I am pregnant again. My LMP was Aug 13 but I didnt stop taking the BC pill until the end of Aug and started bleeding again. My husband and I only started having sex again Sept 4. Is it possible to get pregnant that soon. What are my chances in having another partial molar or miscarriage again?? We had chromo testing done together to make sure that wasnt an issue and it came back that we didnt have any issues. I dont go to the Dr.'s until next week so I am worried. I also do not know what date to give them as far as my LMP since I started bleeding right after I stop taking the BC pill, can you give me some advice.
Thank you so much.
At Thu Sep 27, 12:46:00 AM 2007,
Anonymous said…
i am 28 yrs. old and my husband is 33 yrs. old. we had tried to get pregnant for a year but with no luck. i am really worried my chances are getting slimmer the longer we wait. i have gone to the doctors and they've told me there is no reason why i couldn't get pregnant, even though my menstrual cycles are not regular. is there any reason for my to worry or any advice on increasing my chances?
At Fri Sep 28, 10:49:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Sept 18: I always have more questions than my readers do under these circumstances! For example, do you have regular periods? Pain with your periods? Any other medical problems? Is the father of all your pregnancies (at least the recent ones and your live born) the same? Whenever someone has several miscarriages interspersed with one or more live births, the likelihood of chromosomal fetal abnormalities goes up dramatically. Thes might simply be the result of chance, but they may lso be the consquence of either you or your partner carrying a balanced chromosomal rearrangement (translocation or inversion). Under the latter circumstances, you (or your partner) are perfectly normal because you have the correct total amount of genetic material, but when you make gametes, there is a greater likelihood that the egg (or sperm) will not have the correct amount of genetic material. If you lose this pregnancy, you should talk with a genetic counselor and perhaps find a specialist in Reproductive Endocrinology and Infertility since all of your losses have been so early. Good luck to you and thanks for reading! Please let me know how things turn out. Dr T
At Fri Sep 28, 10:56:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Sue Sept 24: Yes, it is possible to get pregnant the first cycle coming off birth control pills and that also slightly increases your risk for twins. Don't worry about your LMP. Your doctors can figure out how far along you are (and if you have twin) by an early ultrasound. If you haven't started already, get some prenatal vitamins and extra folic acid. If your doctors agree, start a baby aspirin (81 mg) each day as well. If you lose this pregnancy, you should take a break and have a thorough evaluation before you try again. At this point I cannot tell you what your risks for miscarriage or anothet 'partial molar pregnancy' are. The latter was either associated with a chance chromosomal abnormality or simply appeared to be 'molar' due to the hydropic degeneration accompanying poor implantation. Best wishes to you and I really do wish you everything BUT twins! Thanks for reading and let me know how things turn out. Dr T
At Fri Sep 28, 10:59:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous sept 27: I will be perfectly frank with you. If you are not having regular menstrual cycles, you are not "normal", that may be contributing to your infertility, and you need to find a physician who will take your concerns more seriously. Your age should not be an issue right now, so don't panic. Good luck to you and your husband and thanks for reading. Dr T
At Mon Oct 01, 06:18:00 AM 2007,
Sue said…
Dr. Trofatter,
Thank you so much for the advice and information. It was very helpful. I went to the Dr.'s last Wednesday and he said it was too early to see anything. He took some blood work as well to see where my numbers were at. He did not say how far along I was just that it was too early. I have had a little bit of cramping and sharp pains. I had a little pink discharge but it was very little and stopped right away. The Dr. did do an exam on me when I was there last Wednesday and thought it may be from that. I called him today and just to be safe I am going back in to have him do another Ultrasound done. I hope this time he can at least see something. To be honest if it was twins it was just make it even better. I will take whatever healthy baby or babies God can give me. This has been an emotional roller coaster and I just want to have a healthy baby. Thanks again for your advice and I will let you know how everything went.
~Sue
At Wed Oct 03, 05:32:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Sue Oct 1: Good luck Sue. We will be pulling for you! Dr T
At Fri Oct 12, 12:47:00 PM 2007,
Anonymous said…
I am 36 years, am a research scientist, and have been trying to get pregnant for a year using FAM method of predicting ovulation. I finally got pregnant but had brown spotting for 8 consecutive days at 5 weeks fetal age. Ultrasound showed a heartbeat and viable pregnancy but also a hemorrhagic corpus luteum and uterine fibroid, both about 3 cm. I was told the spotting was likely the ruptured cyst and put on pelvic rest and told no exercise etc. Spotting continued for four more weeks and then became heavier and turned into miscarriage. This time ultrasound showed no heartbeat and the corpus luteum had shrunk and I was told this was not a good thing because it was needed to support the pregnancy but no opinion offered as to whether or not this could have played a role in the miscarriage. I was also told by an on-call doc who never saw my med recs that the spotting couldn't have been from the ruptured corpus luteum and had to be coming from my uterus, which contradicts what I was told was the likely cause of the spotting in the first place. I want to get pregnant again but am now very confused about that hemorrhagic corpus luteum and whether or not that could have been the problem or could be a problem for pregnancy in the future, and even whether or not I was getting correct info. I have no frame of reference and can find very little info in the literature about hemorrhagic corpus luteum and pregnancy outcomes. I do have a history of problematic ovarian cysts - never required surgery - and am wondering if a hemorragic corpus luteum is related to that, too. Any insights or references you can offer are appreciated. Thank you.
At Fri Oct 19, 07:05:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Oct 12: There is little if any literature that spesks to your questions related to the hemorrhagic corpus luteum. I too oubt that the cyst caused your bleeding; that was more likely due to unsuccessful implantation that finally led to your miscarriage. If this was a first pregnancy, that might have resulted from simply an inadequate or inappropriate 'immune response' to the pregnancy, but at your age, the risk of aneuploidy is also a likely cause. With only past experience, and no good data, women who have polycystic ovaries seem to be at greater risk for hemorrhagic corpus luteum cysts, but that is not a reorted finding to my knowledge. Many women who have these have no problems with pregnancy, but I have also wondered if significant hemorrhage could occasionally disrupt normal progesterone production and undermine necessary support for the early pregnancy. Could this happen again? Sure, but I wouldn't hold off trying to conceive for that concern alone. By the way, you might consider finding a good Reproductive Endocrinologist in your area (if you haven't already) who may be in a better position to answer these questions and successfully get you through the early stages of pregnancy. Best of luck to you and if I find out anything more myself, I will be sure to let you know! Dr T
At Sat Nov 10, 03:25:00 AM 2007,
Anonymous said…
I just had my transvaginal ultrasound taken today, Nov 10, 2007 and was able to have this seen by my OB-GYNE today. I was so overwhelmed that the result has normal anteverted uterus that I forgot asking her what would "corpus luteum vs endometriotic focus on right ovary " probably mean. It measures 1.5x1.4cm.
Can you further explain what is this all about, Doc? Thanks in advance.
Libra from Philippines
At Tue Nov 13, 03:37:00 PM 2007,
Anonymous said…
From Anonymous, Sept 6 (and 4).
Dr. T. I have had hsg done this past week and the picture of my tubes did not look very clear. They think that my right tube did not have any spillage and it was swallen , and for my left tube they think they saw some spillage, but were not sure. They also noticed lymphatics in my uterus - which I am not sure what that means. I had a dr. visit today the she suggested I should go for the mri of pelvis with and without the contrast to take a better look at the uterus, which I already scheduled. After that's done, she wants me to have a tubal surgery done to possibly remove the right tube and correct problem with the left one, which should increase the chance of me keeping the pregnancy. I just wanted to ask your opinion on all of this. I am a little affraid that the surgery will not necessary correct the problem of me not being able to carry the pregnancy. I have no problem getting pregnant, just keeping the pregnancy is the problem (I miscary very early - 3 weeks, before anything can be seen on an ultrasound). Dr. T, could you please let me know your opinion, I just would like to have thought of another dr. before I go through the surgery. Thank you very much in advance.
At Tue Nov 13, 05:58:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Libra Nov 10: Why did you have the transvaginal ultrasound done? Anyway, a corpus luteum is simply the site from which you ovulated that makes the progesterone that supports the second half of your menstrual cycle and a pregnancy for the first trimester. It can look a lot like a small active implant of endometriosis, so the two can be difficult to differentiate. Neither is anything to worry about at this point. Dr T
At Wed Nov 14, 06:36:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Nov 13: Well, hello again! I guess I, too, am having a hard time understanding how tubal surgery is going to help you get through first trimester! Did they explain that to you? Do they believe the fertilized egg may be getting 'hung up' in the tube on the way to the uterus, thereby, arriving too late for implantation? If that is the case, you might be better off going directly to controlled ovulation (maybe with Femara rather than clomid) or in vitro fertilzation. There are still lots of 'empiric' things (e.g., 3-4 months of metformin) that could be done in your case, so don't give up hope. Thanks for writing back again and good luck, whatever you decide to do. Dr T
At Thu Nov 15, 02:21:00 PM 2007,
Anonymous said…
from anonymous Nov 13
Dr.T, thank you for responding. Yes they think that the fertilized egg gets stuck in the tube and cannot get to the uterus, although nothing ever got proved by ultrasound as my miscarriages happen so early. they base it on the hsg I mentioned before and my last "abnormal miscarriage" where the hcg was increasing but not quite doubling. Would you mind explaining to me :
1. How Femara would help me if in fact the fertilized egg gets stuck in the tube, and if there are multiple births associated with this drug
2. What other empiric things can be done in my situation, you mentioned 3-4 months of metformin(what this is and how should it be taken?), would you mind explaining to me further.
3. They mentioned invitro to me as well.Do you think this would be really the only solution?
Thank you
At Mon Nov 19, 07:45:00 AM 2007,
Joanne said…
Hello Doctor,
I had a succussful and totally non eventful first pregnancy resulting in the birth of my son in April 2005. We had been trying for about 7 months, but no miscarriages before I fell pregnant with him.
We started trying for a second (same father!) in October 2006 and fell straight away - but had a missed mc that ended at 12 weeks, but scan showed only a 5+4 sac. I had an erpc to remove this. Since then I have had three completely identical early mc (so four recurrent in total) at exactly 5 weeks since day of last period. I basically get a faint line on a pregnancy test on day period due which gets slightly darker the next day, and then a couple of days later is gone again and I start bleeding three days or so after that. My cycles are regular - shortest being 25 days and longest 31 in the last year - usually 30. I tend to ovulate 14 days before my period starts. I don't have any pain with my periods, or with my miscarriages even.
Before my last mc I had various tests. Mine and husbands chromosomes were normal, I had a laparoscopy and hysteroscopy and some scar tissue was removed and I was diagnosed with very mild thrombophilia. I was taking 75mg baby aspirin every day (not just from pregnancy) and when I got a faint line I had daily clexane injections and progesterone tablets. All of this did not stop the exact same version of events happening again.
It seems like something is going wrong very early - but I am confused because I've had a child, and I have regular cycles. I am fit and healthy, age 29 and husband is healthy too, age 36 - we don't smoke and drink very rarely.
What could cause such early loss to be repeated like clockwork? and could have simply just devoloped in the last two years rather than be something that has always been a problem for me?
Thank you so much for your help,
Joanne
At Fri Nov 23, 06:04:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Nov 15: Hi again. Sorry I am so late getting back to you. Femara is a drug called an aromatase inhibitor. It has been used to treat breast cancer patients but has also been shown to be very effective in the treatment of unexplained infertility. It appears to reduce estrogen negative feedback on follicle stimulating hormone (FSH)secretion without depleting estrogen receptors in the endometrium. I am not sure if anyone knows all the ins and outs of its beneficial effects, but the REIs with whom I work believes it helps to upregulate certain substances on the endometrial cells called integrins that improves fertility, particularly in women with endometriosis. If you really have a tubal problem, it won't help, but from what you have told me, I am not entirely convinced that you do. It can be associated with multiple births, and ovulation induction requires the same careful monitoring that is necessary whenever that is done. It is very inexpensive compared to some other forms of therapy.
Metformin is an oral agent that is used to treat diabetes. It also appears to have a benefit in the treatemnt of some women with unexplained infertility or infertility associated with polycystic ovary syndrome. See my post on this topic earlier this week - "Plasminogen activator inhibitor-1 (PAI-1): Role in Adverse Pregnancy Outcome....). Quite honestly, if these things did not work, rather than the tubal surgery, I would suggest moving directly to in viro fertilization. Current success rates in really good places exceed 60% and some places even have a money back guarantee! Good luck and again thank you for readding
At Fri Nov 23, 06:11:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Joanne Nov 19: Sorry I am a little slow to respond. You may be ovulating each month, but your periods are still somewhat irregular. You might ask your doctor about taking clomid or femara to see if you can regulate the time of ovulation. I am also curious about your "mild thrombophilia." Can you tell me more about that and exactly what kind of testing you have had done and what were the results. Also, with the "scar tissue" that was removed at your surgery, was there any evidence of endometriosis? If you can give me a bit more information, I might be able to come up with some other reasonable suggestions. Thanks for reading. Dr T
At Fri Jan 04, 06:31:00 PM 2008,
Anonymous said…
Dr. Trofatter,
I am 38 yrs. old. Last year I experienced 3 early miscarriages all before 8 weeks. We went to a fertility specialists who did a couples work-up on us both and found nothing, no physical deformities either. We were both treated with antibiotics for possible infection causes as well as givien three rounds of clomid to induce pregnancy. All with no luck. It has now been a year and I have not gotten pregnant again. With my age I feel time is running short to keep trying on our own. We are also considering adoption, but not ready to give us just yet. My dr. is now suggesting IUI. I am concerned that this will only be a costly way of miscarrying again. Do you have any additional suggestions or ideas? Thank you.
At Thu Jan 17, 09:20:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Jan 4: I apologize for the long delay in my response, but I have been swamped by questions lately. I do not make any claims about my expertise in REI! But, our REI specialists do believe that IUI may improve your prospects for conception and it is a lot less expensive than IVF. My only other suggestion is that, despite having found nothing to date, that doesn't mean there isn't something there that might respond to aggressive 'empiric therapy - e.g., aspirin, folic acid, lovenox or heparin at prophylactic levels, and perhaps even metformin. You are right about one thing, at age 38, the 'biologic clock' is ticking more quickly, so I would not beat around the bush if you hope to conceive successfully on your own. Best of luck to you and if things turn out well, please let us know! Dr T
At Mon Jan 21, 07:20:00 PM 2008,
Anonymous said…
Dear Dr.T, I am a 36 years old and had a successful surprise pregnancy at 27. About 3 years ago, I had another surprise pregnancy that unfortunately ended at about 8 weeks (LMP) - I believe there was a heartbeat on the ultrasound. Three months ago we decided to try again and the first month we tried, my period was late and the HPT showed a faint line on the date of my missed period. The next few days I continued to get faint but stronger lines on the HPT until about a week after my missed period I started to bleed and went to the doctor's office. My urine and blood tests came out completely negative. The doctor told us to try again as she thought that it was a false positive for the HPT. The next month exactly the same situation occurred, missed period, and multiple positive HPTs including digital for the week following the missed period. Unfortunately that week I was travelling and started to bleed on the plane ride home, and by the time I got to see my doctor for tests they were all negative again. I feel that I have had 3 miscarriages, especially since I had mild but distinct symptoms of pregnancy. My doctor feels that it would be impossible for a blood test to be negative so soon after a miscarriage, and doesn't consider my situation to be recurrent miscarriage and require any investigation. I believe that I was pregnant all three times as I had quite distinct symptoms, and would like to have this looked into as my biological clock is ticking loudly. Have you encountered this situation before? Do you have any recommendations? Thank you in advance for any insight.
At Wed Jan 23, 05:17:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Jan 21: You are either having early pregnancy failure or ovulating irregularly, or both. There are many things that can be causing your problems, but my suggestion at age 36, if you really want another baby, is to find a good reproductive endocrinologist to be evaluated and treated as efficiently as possible rather than beating around the bush! Good luck.
Dr T
At Thu Feb 21, 07:46:00 PM 2008,
Anonymous said…
i am still 23 years old and have 1 kid.i got pregnat but miscarried it after 8 weeks.after two days i still got positive pregnancy test result.why is it that the result is till positive i saw the embryo comes out from my outs?
At Thu Feb 21, 07:54:00 PM 2008,
Anonymous said…
i am 23 years old and have 1 kid.i got pregnant but miscarried it after 8 weeks.after 2 days i try to test.i got amazed i still got positive result in pregnancy test.why is it positive though i really saw the 8 weeks embryo came out from my vagina...pls give me some advice.
At Thu Feb 28, 05:55:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Feb 21: It can sometimes take several weeks for all of the pregnancy hormone (hCG)that is detected by the test to be cleared by your body. Also, you may still have some placental cells (trophoblasts) in the uterus that are continuing to make that hormone even though you have aborted the baby. If the test is still positive two weeks from now, you should probably talk to your doctor. Dr T
At Sun Mar 09, 07:57:00 PM 2008,
Anonymous said…
I am 27 years old and my husband is 28, both healthy without any medical problems. I have never been pregnant before. We have been trying to conceieve for 1 month and we were successful on the first try. We had 4 positive HPT on DPO #12. 4 days later I started my period and went to the OB to find out that my UPT was now reading negative. I had a transvaginal US with showed a uterine stripe of 12mm. My periods have always been very regular with 29-32 day cycles that I have charted over the past 4 months prior to conceiving. My ovulation patterns have been on day 19-20 as estimated by ovulation predictor kits the past 2 months. Placing my luteal phase as lasting about 11-12 days for those cycles.
Other than this chemical pregnancy I suspect I may have had a similar issue several months ago. I was 7 days late with a neg HPT the day before menses started, I never tested before that. I wonder if it is possible that this too was an early pregnancy loss. I am NEVER that late. I am concerned about my luteal phase being less than 14 days. I am not underweight 5'4, 130lbs, and do not exercise heavily. We are worried this is going to happen to us again, do you have any thoughts or advice? I did have blood work drawn at the OB, including a progesterone level,but I do not have the results yet. Any insight would be appreciated.
At Tue Mar 11, 06:08:00 PM 2008,
Anonymous said…
I the 27 year old who recently wrote to you about my chemical pregnancy loss a couple of days ago. I just received the blood work from my OB that was taken a couple of hours from the onset of bleeding. My HCG was 3 and the progesterone level was 1.2. Does the low progesterone have any significance, or is it low simply because I had already miscarried and I was starting my period.
At Wed Mar 12, 06:04:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Mar 11: Most likely it was low because you were at the end of your cycle and you had miscarried. If you are worried about low progesterone as a cause of the miscarriage as the result of a possible 'luteal phase defetc', your doctor can check a progesterone level in mid-luteal phase after you ovulate. Take care! Dr T
At Fri Mar 14, 02:23:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Mar 9 (and presumably Mar 11): Dn't know why I did not get the earlier post until now! Ah, the mysteries of cyberspace and the internet. Anyway, if you are ovulating late, you have some degree of ovulatory dysfunction and usually this is the result of a 'hormonal imbalance' of some sort. My first suggestion would be to have your doctor evaluate you for evidence of thyroid disease, PCOS, and hyperprolacinemia and simply treat you with a drug such as clomid so that you ovulate closer to midcycle. Progesterone support could be added during the luteal phase after ovulation induction if a 'luteal phase deficiency' is suspected. That is certainly harmelss enough. Good luck to you and let us know how things turn out! Dr T
At Wed Mar 26, 08:46:00 PM 2008,
Anonymous said…
Dr Trofatter, I am the anonymous writter from March 9 and 11th. I wanted to give you a quick update on things and ask another question. BTW, I appreciate your insight on the first questions. I am a resident physician myself but am not going into OBGYN so I really appreciate your insight.
I had my second OB appt after my miscarriage, my HCG levels are undetectable officially (which is good news). Our doc has given us the green light to try again.
I mentioned to the Dr. also about my possible miscarriage incident in May so she suggested that we just do a basic panel to work me up as if I had experienced more than one miscarriage. She ran tests for clotting aberrations and autoimmune diseases including, anticardiolipin, ANA, protein c and s, etc. She did not do a TSH or any other PCOS workup that I know of. I had a TSH done 2 years ago at my PCP and that was wnl and am asymptomatic for thyroid disease at this time. As for PCOS, I have no family history of this, I do not display the typical clinical features of PCOS (obesity, excessive hair growth, insulin resistance, etc) and I always have regular periods. Could it still be PCOS potentially?
Here is another thing that I noticed...I have been using ovulation predictor kits(OPK's) for 3 months now. For the first two months I would test until I got a positive result, indicating my LH surge, then would stop testing. This month I started testing on cycle day 12 like usual and got clear negative results from day 12- day 17. Then on the am of day 18 I got a good, strong positive. (which has been similar to my past two cycles)
I have continued to test since that time to see how long it would take for the surge to disappear. Much to my surprise the surge has continued until today (so far) which puts me at 72 hours with positive OPK's. I have had other signs of ovulation starting around day 16, (similar to other months), including appearance of fertile Cervical mucus and lower abdominal cramping/pain.
This is my first cycle after my miscarriage, I am worried about the long surge that the OPKs seem to be detecting.
I realize continuing using the OPK's after a positive result is reached doesnt follow the directions on the box insert, but it still concerns me.
Do you think that this means I didnt ovulate this month, or worse, that you suspect PCOS or another disorder?
What are reasons that a woman could have a long LH surge? Thanks!
At Thu Mar 27, 06:28:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Mar 26: I still think you are simply ovulating later in your cycle than normal and that can lead to asynchrony in the endometrial development and a less favorable environment for implantation. My previous response holds - I would still like to see a prolactin level and TSH and perhaps a testosterone and luteal phase progesterone. PCOS doesn't just happen in overweight, hairy women, so that is still something that could be going on. Empiric treatment with clomid or referral to an REI specialist are two options to explore. Best of luck to you. Dr T
At Mon Mar 31, 02:55:00 PM 2008,
Anonymous said…
I am 27 years old, husband is 34 years old. We have one surprise pregnancy together a son who is 2 years old. I was diagnosed with mild hypothyroidism during that pregnancy and have since been on synthroid. My current TSH is 2.77. I had the Mirena IUD in place for 2 years and had it removed Oct 07. I did not have any kind of period with it in place. Since IUD removal I have been pregnant 3 times and lost all very early. First was 4w3d second was 5w2d and third was just last month at 4w. The last was the only one I had documented with blood hcg, my hcg was 9 at 12 dpo and 3 at 14 dpo. I am waiting to have an ultrasound done to check for polyps/fibroids etc but am wondering if you think this could still be a lasting effect of the mirena IUD? I have always had regular periods about 30 day cycles, but since having the IUD removed and even with my early miscarriages I have very light bleeding followed by many days of spotting and hardly any cramping or pain which I used to get before I was ever pregnant. If you do think this could be from my IUD, how long do you think it might take for my body to recover? It will be 6 months on April 2. Thank you! Amy
At Thu Apr 03, 06:22:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Amy Mar 31: I doubt this is any hormonal effect of the IUD, but it could be the result of some adhesions you might have developed wihin the uterus during the time the IUD was in place. Also, if you have had 3 pregnancies in rapid succession, you have not given yout uterus much of a chance to recover. See what the studies show and then let us know, okay? Maybe then I will have some additional suggestions. Best of luck to you and thanks for reading! Dr T
At Wed Apr 23, 11:37:00 AM 2008,
Anonymous said…
Dr T,
I have had 3 chemical pregnancies that have all ended at or before 5 weeks. Confirmed on blood tests at my OBGYN's office and HPT. I am 28 as is my husband, this will be our first baby. My cycles are on average 30 days and regular. No family history of genetic disorders.
We dont seem to have a problem getting pregnant, just staying pregnant. I am terrified I will not be able to carry a baby to term. My OB doesnt seem overly worried and wants to start me on baby aspirin, and then progesterone and lovenox once I have a positive HPT.
I have read that if you start taking progesterone after a positive pregnancy test, it will be too late already. Also the doc did the blood panel looking for clotting disorders and that came out negative. So why do the lovenox and baby aspirin, is it really going to help?
What do you think of that plan?
At Thu Apr 24, 06:36:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 23: Have you had a sonohysterogram or hysteroscopy done to rule out a uterine anomaly? I usually will start the progesterone in midluteal phase (6-7 days after you ovulate). The lovenox can probably wait until you have a confirmed positive pregnancy test, although in folks who have a diagnosis of a thrombophilia, I will start that in midluteal phase sometimes as well. Although you do nat have a thrombophilia that has been established, you could still have an undiagnosed thrombophilia. Also, many of us frequently use heparin or Lovenox as empiric therapy in women who have recurrent losses that defy ready explanation. At prophylactic doses, both of these drugs are very safe. Best of luck and let us know how things turn out. Dr T
At Thu Apr 24, 07:20:00 PM 2008,
Anonymous said…
My husband and myelf are both 28 yrs old. He is healthy and I have Multiple Sclerosis that is being treated. I recently had a miscarriage in which I had a D & C done. I did not have my first period after the D & C but I may be pregnant. I went to have my HCG levels tested and I have to go back again to do the same. If I am pregnant is there a risk of an unhealthy child due to us not waiting at least until I had a period?
At Sat Apr 26, 11:59:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 24: I think you have a better chance of having a successful pregnancy if you wait a few months after an early pregnancy loss (particularly after a D&C) for the lining of the uterus (the endometrium) to heal and regenerate and the 'inflammation' to die down. However, I also have had many women in your situation who conceived again before having another pregnancy and went on to carry successfully. Best of luck! Dr T
At Sun Apr 27, 06:53:00 PM 2008,
Anonymous said…
On an average. How long does it take for the HCG levels to get back to normal after a miscarriage? What is the normal HCG levels if you are not pregnant? Thank you for your time Dr. T.
At Wed Apr 30, 05:13:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 27: The time it takes for the hCG to return to normal depends on how high it was when you lost the baby. In most caes it is normal (< 5 mIU/mL) by one month. That should answer both of your questions! Dr T
At Fri May 02, 07:57:00 PM 2008,
CB said…
TETRAPLOIDY?? I SO hope you read my comment!!! I just got back the analysis of my 3rd early fetal loss D&C performed at 8 wks due to no hb, and it said there was a 96xxyy chromosome pattern (tetraploidy).
Here is my record:
1 live healthy birth (age 30)
1 natural m/c at 6 wks (at age 34)
1 natural m/c at 5 wks (2 months after first m/c)
1 d&C at 8 wks (3 months after last)
Same partner, 3 different RE doctors, who all don't seem to offer me anything. I've had some of the lipid antibody tests, progesterone, etc. All fine. My first progesterone of this last one came back as 12 at 10days past ovualtion (lowish).
The RE i just saw today wants to do an endometrial biopsy and saline infusion, that's all he can offer. I feel neglected.
Also as a crazy thought, there was also a normal healthy female cell found in the fetal tissue analysis, which they are attributing to my own cell. Could that actually be the baby, and the tetraploidy have been from my uterus, because I read that some organs are tetraploid, like the liver? (I can't find the chromosomal constitution of the uterus or placenta on the internet to see if it is indeed tetraploid rather than diploid.)
Any insight??
At Tue May 06, 03:57:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To CB: I think it is much more likely the baby was tetraploid and not your uterus. Are ovulating regularly and do you have normal 28ish day cyscles? Do you have any medical problems? What has been done to date to evaluate your 'secondary infertility'? The best thing you have going for you is that you have previously had a successful pregnancy, but conditions might have changed subtly since then or you might have had a string of bad luck with chromosmally abnormal embryos. Let me know the answers to my questions and then I will offer some suggestions. Dr T
At Tue May 06, 07:10:00 PM 2008,
CB said…
This is in reply to your questions to me on May 6. (Thank you!!)
My cycles are always between 27-34 days, averaging more like 30. I just got my pd at day 32 this week after my d&c last month.
I have been monitoring my LH surge and temping for two years, and always get a surge with a + ovulation test around day 16, used to be around day 14 before the miscarriages. One thing I've noticed since the first miscarriage is that I get the positive surge on the test, then my temp immediately goes up the next day, sometimes that day, which before the pregnancies it would wait two days to go up before the LH surge.
I have no medical conditions, although I was loosely diagnosed with Crohn's disease 5 years ago based on severe rectal bleeding and lesions noted in the small intestine on colonoscopy, but the biopsy came back negative for Crohns. I have had no symptoms sine then and am perfectly healthy except for always being cold with dry skin (thyroid tests come back fine, though).
I consider myself hairier than a lot of women, and wondered about polycystic ovarian syndrome, but one of my RE said I was too skinny for that (?) and wouldn't pursue it.
I do have very painful periods and pain with intercourse and pain with bowel movements during my period (suggestive of endometriosis), but the current RE is stuck on the tetraploidy and doesn't want to pursue the endometriosis with a laparascope (yet), even though we don't know what the other two early m/c were caused from.
All we've done so far (since I keep getting pregnant)is have lots of blood tests that include the clotting disorders (negative), the antiphospholipid antibody (negative), progesterone (slightly low).
I am scheduled for a saline infusion and endometrial biopsy next month (after my 2nd period from the D&C).
I am not satisfied with the Florida doctors I've been seeing (3different ones, the one I'm seeing now is considered the best in our area), but it just seems to me the previous two REs only care about the process of getting people pregnant, not keeping them that way. Since I get pregnant without their help, I feel a bit 'second rate'.
Thanks so much for your time,
CB
At Fri May 09, 07:46:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…