Recurrent Early Pregnancy Loss: To Treat or Not to Treat...

41 Comments:

• At Wed Dec 12, 06:26:00 PM 2007,  carole said…

  dr t, i posted on your mthfr thread from february but perhaps my questions are more relevant here. i have had 3 first trimester m/cs, one pprom at 17 weeks, one live birth at 39 weeks, and recently another pprom at 20 weeks with delivery at 22. we're still exploring underlying causes for pprom, and perhaps mthfr is one.
  
  at any rate, we're getting ready to try to conceive again, and i'm interested in your empiric therapy. it matches what i'm on except for the folate.
  
  is there any reason that 4 mg of folate might be considered toxic? or is it a generally safe level for any woman trying to conceive?
  thank you,
  carole

   

• At Fri Dec 14, 04:11:00 PM 2007,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Carole: I have no reason to suspect that the folic acid is toxic at that dose. With your midtrimester losses, I am very concerned that you could have an incompetent cervix. Ask your doctors about that. I know you have carried a baby to term, but it is not common to lose babies at 17 and 22 weeks with PPROM unless something else is going on. You may be a good candidate for either a prophylactic cerclage at 12-14 weeks and progesterone therapy starting in midtrimester or serila cervical screening by ultrasound. The disadvantage of the latter is that a cerclage becomes much riskier once the cervix has begun to open up. I would also suggest repeated screening for subclinical urinary tract infections and avoiding intercourse between 16 and 24 weeks. Good luck and thanks for being such a loyal reader! Dr T

   

• At Fri Dec 14, 06:51:00 PM 2007,  Anonymous said…

  I am 38 y/o, carried my first pregnancy to almost term (34 wk PPROM), and now have had 5 miscarriages. With the first two losses, I had normal ultrasounds (+FHT, etc) at about 7 wks, then no heartbeat at 10-12 wks and ultrasound showing what looked still to be about a 7 wk EGA. At that point I went ahead and had some testing - for thrombophlias, luteal phase progesterone, HSG, etc - found I had ATIII deficiency so I have Lovenox to take 40 mg/day as soon as pregnant, otherwise the tests were normal. My doc also thought it might not hurt to try progesterone supplement starting a couple of days after ovulation, even though the luteal phase progesterone had been fine - I did that with the next two pregnancies - both were very early losses (like 5 wks). Our REI person thought I shouldn't use the progesterone, so with this most recent pregnancy I just started the lovenox as soon as I had a positive test (2 wks after ovulation) - miscarried at about 6 wks. I'm wondering about the benefit of adding: aspirin, progesterone....anything else?? Recently read about IVIg - no one has even mentioned this. Also, I've read some studies where the medications were started pre-conception - don't know if that might help. I'd appreciate your advice.

   

• At Fri Dec 14, 07:03:00 PM 2007,  carole said…

  dr t, thanks for the assurance about folate levels.
  
  my cervix has appeared tight and closed in both pprom cases. in neither case did i have infections, although i contracted one the second time and went into resulting labor. everybody who treated me in both cases was baffled and chalked things up to bad luck.
  
  for my next pregnancy, my current ob has recommended weekly progesterone shots and has discussed cerclage with me but also expressed some concern about its add'l risks. i saw a perinatologist last week who suggested i be examined for marfan and ehlers-danlos syndromes, although based on what i've read i don't appear to be suffering from either.
  
  is there anything else we might be missing that you would recommend looking for? and...do you have any experience with or opinions on collagen supplemenation in case like mine?
  
  thank you -- carole

   

• At Mon Dec 17, 12:09:00 PM 2007,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Carole Dec 14: Hi again! If your cervix was long, closed, and firm on both of the occasions you had PPROM, cervical incompetence is much less likely. Most patients with disorders such as Ehlers-Danlos have a cervix that feels like mush - wet tissue paper. So, that is also very unlikely. I know nothing about collagen supplementaion, so I cannot help you with that one. I have had patients like you that I placed a cerclage in, despite their cervical findings in previous PPROMs, and simply kept them on antibiotic therapy from 14 weeks until third trimester with a drug we use to treat anaerobic infections - metronidazole (Flagyl) - 500 mg twice per day. If your doctors are uncomfortable with the cerclage, they can treat you with the metronidazole and simply follow your cervix with serial ultrasounds. Thanks for getting back to me and I hope things turn out well the next time around! Dr T

   

• At Mon Dec 17, 12:17:00 PM 2007,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Anonymous Dec 14: ATIII deficiencies can be BAD actors. I would suggest starting both aspirin (81 mg) and supplemental folic acid prior to conception. I still don't think the progesterone would hurt. It might not help, but I don't think it would hurt. Your doctors might want to uses a higher dose of lovenox (40mg twice per day) and start that during the luteal phase after yo have attempted conception even before confirming a pregnancy. By the way, have either you or your husband or any of the babies you lost had chromosomal studies done? And, do you have any other medical problems for which you are undergoing treatment? Consider asking your doctor to perform a sonohysterogram and hysteroscopy to see if there is a fibroid or polyp in the uterine cavity that could be acting like an IUD as well. Good luck and let us know how things turn out! Dr T

   

• At Wed Dec 19, 06:22:00 PM 2007,  Phuong said…

  Hi Doctor. This is Phuong who is your "Anonymous" post • At Thu Nov 29, 06:12:00 AM 2007 from the beginning of your discussion to "treat or not to treat". I posted the following before but I think you were having some technical difficulties so I'm hoping you are seeing it now.
  
  12/5/07
  
  Hi Doctor. Thank you so much for writing back. 12/5 when to see doctor. empty sac, dr. confirmed blighted ovum. we are going to wait 1 month for miscarriage to occur naturally instead of having D&C. The following are tests that have been performed by my doctor thus far. And no, I have not seen any specialist...My husband and I had the chromosome karotype testing and they were both negative.
  
  Not sure if I'm listing this properly from the test results, but here goes:
  
  2 - Thyroid Cascade Profile
  TSH, Glucose Serum, Prolactin, FSH, Estradiol, Lupus Anticoagulant Reflex, LH, FSH, Thrombotic Risk Profile, Comp
  
  3 - Single mutation C677T
  
  4 - HSV, IgM, Toxoplasma gondii
  
  5 - CMV Ab, IgG 10.5H (high??)
  CMV Ab, IgM <0.9
  
  Rubella Antibodies, IgG 152
  Toxoplasma gondii Ab, IgG,Qn <6.5
  
  HSV I/II IgG 41.2H (not good?)
  
  HSV I IgG, type spec 4.2H (not good?)
  
  HSV II, IgG, Type spec <0.9
  
  sorry..not sure if I'm correctly providing you info.
  
  Medical History:
  
  1 - Saw specialist regarding double vision --never got any confirmed causes...had an MRI of brain, to check for pituitary gland issues...doctor thought there was white spots may indicate MS...but had spinal tap and found nothing
  
  2 - Always had a lot of vaginal discharge...doctors used to give me a lot of antibiotics because they would see a lot of white blood cells indicating infection..but nothing concrete...this doctor thinks is gardinerella vaginosis?? saw a specialist a few years ago and he said is it was desquamative inflammatory vaginitis..prescribed cleocin? never cleared...have used clindesse during 2nd miscarriate ended pregnancy...current doctor do not think vaginal infection like gardinerella? affect miscarriage...
  
  3 - past doctors have said my prolactin levels were high (24-25)..but other doctors said that's not really high...
  
  I have seen so many doctors in the past with my double vision issue, vaginal discharges, and currently repeated miscarriages...and nothing conclusive....so frustrating and scared...
  
  I just sometimes wonder if all of this is interrelated....also..never had regular periods...45 days sometimes...but since I became pregnant 1/07 of this year, I have been regular every 28 days...
  
  I really appreciate your thoughts. I sometimes wonder whether I should just for additional specialist and doctors and just let nature do its thing...but I hate to think that there is something specifically wrong and I'm not doing anything to help me keep my baby!
  
  Regarding my current miscarriage, I've been bleeding on/off for the past week...12/19...10/12 was LMP...hoping not to have a D&C for the 3rd...should I expect a BIG gush of bleeding? or will it just be like getting your period?
  
  Anyway, I really appreciate your taking the time to respond to these posts. I can't imagine you having the time to do this. Thank you so much. Phuong
  BTW I'm is 33. Will be 34 in July 2008. I was hoping to try for a 4th pregnancy before I turn to a specialist...do you think considering my age, I should seek a reproductive endocrinologist NOW instead of waiting for my next pregnancy, or a possible 4th loss before I see a specialist?

   

• At Thu Dec 20, 04:13:00 PM 2007,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Phuong: Hi again. I am going to keep this brief! There is nothing in the laboratory work-up that jumps out as abnormal. BUT, the fact remains, you have a long history of irregular menstrual cycles. That suggests some type of 'hormonal imbalance.' Considering your age, the person who will be in the best position to continue your evaluation and to establish a diagnosis and treatment plan is a good specialist in Reproductive Endocrinology and Infertility. I would NOT wait for another loss to find one! Good luck and let us know what you find out. Dr T

   

• At Sat Jan 05, 01:56:00 PM 2008,  ONE OUT OF SIX said…

  Your blog is great! After 3 losses (2 of which occurred prior to uterine septum removal - the third occurred after) - my RE ordered an RPL panel. I was very surprised at the results: heterozygous Factor V Leiden and homozygous MTHFR C677T.
  
  It's hard to say whether my pregnancy losses (10 wks, 5 wks and 4 wks - in that order) were related to the septum (the 2 earlier losses), chromosomal, or the clotting disorders.
  
  We are taking an aggressive approach. I am on pre-conception baby aspirin, foltex & a prenatal vitamin - and will start Lovenox - 40mg/once a day right 2 days after IUI (I have had some fertility/conception issues in addition to pregnancy loss. This is my second IUI - my first resulted in the 4 week loss/chemical pregnancy.)
  
  I've already had one MFM/peri tell me she thought the addition of the Lovenox - especially prior to positive pregnancy test - was way too aggressive. But my RE and hematologist are in agreement that it's a safe way to go - and could prevent another pregnancy loss and/or implantation failure. Post-IUI - I will also be on 50mg progesterone suppositories once a day.
  
  I am interested in your thoughts on my treatment! Does it sound reasonable to you? Again, there is no way to know if my clotting disorders caused my losses. But there is no way to know if they did not either. (For what it's worth - the septum I had removed was small.)
  
  I guess we'll see! Thanks so much.

   

• At Sun Jan 06, 08:53:00 PM 2008,  peter said…

  Out of many complexities RPL is one, It is not common to loose the baby in first trimester, you need to treat these abnormalities, Lot of care has to be taken during first and third trimester, since some common problems like Stretch marks and sleep problems can arise in this period.

   

• At Thu Jan 17, 09:13:00 AM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To one out of six Jan 5: Sorry for the delay in responding. I got hit by about 60 comments at one time and it has taken forever to 'catch up'! Given your cicumstances, that is a reasonable and fairly 'safe' approach since you will be on only 'prophylactic' doses of the Lovenox. If this doesn't work, I would suggest adding metformin to the mix or considering an alternative form of ovulation induction such as letrazole and hCG on the outside chance that subclinical endometriosis is the actual source of your implantation problems. Thanks for reading and good luck! Dr T

   

• At Fri Jan 18, 07:14:00 PM 2008,  ONE OUT OF SIX said…

  Hi - just wanted to follow-up based on your answer to my January 5 posted comment. I did have a lap in March 2007 - whereupon stage one endometriosis was found and removed. When you say subclinical endometriosis - are you referring to something like this? For what it's worth - a recent S-HSG (November) showed my uterus to be normal - no leftover septum or visible scar tissue.
  
  I am also curious as to how metformin might help? I am only familar with this drug as something used by PCOS patients - one ailment I know I *don't* have.
  
  My RE has put me on follistim for all of my ovulation induction cycles so far (3 total - timed intercourse - negative, first IUI - positive - chemical pregnancy - and second IUI - negative.) There were breaks of 1 - 2 months in between all of those cycle (my choice.)
  
  We're taking a break from meds again this month (well, injectable meds. I am still on pnv, baby asa, foltex.) We will try another OI/IUI cycle next month if needed...
  
  Thank you again for a great blog - and taking the time to answer questions from so many readers.

   

• At Wed Jan 23, 05:11:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To One out of Six: If there is no evidence of insulin resistance, then the metformin would purely be empiric therapy. I still like the idea of the letrazole though. It is an aromatase inhibitor that increases certain cell surface factors in the endometrium that are sometimes down-regulated in endometriosis patients (which it sound like you have) and improves the chance of successful implantation. Just a thought! Good luck. Dr T

   

• At Fri Apr 11, 05:40:00 PM 2008,  Anonymous said…

  Hello doctor, what a great blog! I just found you and would love your thoughts. I am 39 years old, and have conceived naturally twice and m/c'd twice: last month at a little over 5 weeks, and this month at a little under 5 weeks. Both times have been a spontaneous and complete m/c. My HCG levels at time of onset were 14, and down to 4 two days later.
  
  I am anticipating ovulating as usual this month and trying to conceive (I didn't have a period between the 2 m/c's; simply ovulated), and am wondering what you think of my getting progesterone therapy soon after ovulation.
  
  I'm guessing my doctor would want me to wait till my progesterone levels are tested, but by then I fear it would be too late to save the pregnancy.
  
  I'd really appreciate your advice.
  Many thanks.

   

• At Tue Apr 15, 07:36:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous Apr 11: I always have more questions for folks in your situation than answers! But, to keep things simple, unless you have some medical condition that has not been diagnosed or needs attention, there is very little risk (none major that I can think of) in empirically trying aspirin, folic acid, and progesterone! I would stick with a 'natural progesterone' in first trimester (my personal preference). Good luck and thanks for reading! Dr T

   

• At Fri Apr 18, 02:16:00 AM 2008,  connie said…

  Dear Doctor, thank you very much for your response (I am the poster from 4/11). I've been taking 1 mg + 400 mcg of folic acid and 200 mg of B6 daily since October on my acupuncturist's advice, and will now talk to my doctor about baby aspirin and natural progesterone as well.
  
  Emotional reasons aside, do you feel there are any physical reasons for me to wait to conceive (I had 2 m/c 2 months in a row at around 5 weeks each)? I have heard conflicting advice re the uterine lining needing or not needing to properly repair. (While painful, each m/c was spontaneous and complete after 5 days or so; physical exam showed cervix closed and no abnormalities.)
  
  Thank you, Connie

   

• At Sun Apr 20, 06:40:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Connie: In all honesty, if you did not have a D&C, it probably does not make that much difference when you try to get pregnant again. Good luck and thanks for the feedback. Dr T

   

• At Sat May 24, 06:00:00 AM 2008,  Anonymous said…

  I have 2 children, no problem w/pregnancies. My husband had a vasectomy then a reversal 3 years later. We got pregnant and I miscarried at 6weeks4days and got pregnant again and I miscarried at 4 weeks 3 days. I got blood work done and the only thing it showed was heterozygous for the PAI-1 4G/5G allele. What type of doctor is the best to see about this? Do you think this is the reason for my m/c? What type of treatment if any would help me if this is my problem?

   

• At Tue May 27, 06:37:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous May 24: I am presuming if you had the PAI 4G/5G polymorphism detected that the rest of your thrombophilia work-up, including antiphospholipid antibodies and lupus anticoagulant, was negative. Have you been screened for thyroid disease and do you have any other medical problems or weight change since the births of your other children? Have you had a sonohysterogram done to evaluate the uterine cavity? Since your husband had the reversal, has he had a good semenanalysis done to assess whether the count, morphology, and motility of his sperm are normal? If they are not, that can increase the risk for early miscarriage as well. All that said and done, I doubt the PAI status alone is the major cause of your losses. However, a baby aspirin 81 mg each day might help restore any contibution of that. Let us know what you find out and best wishes! Dr T

   

• At Mon Jun 16, 02:20:00 PM 2008,  Anonymous said…

  Hello Dr. Trofatter. I've stumbled upon this blog which has great information. I'm 30 y.o. and have had 2 m/c (blighted ovum at 6wks did not find out until 10wk appt & m/c at 11wks after seeing a seemingly normal developing embryo in u/s at 7wks). The OB ran some tests and found that I have the MTHFR compound Hetero mutation. However my homocystine levels were normal (had levels check after 2wks of not being on any prenatals).
  I'm currently pregant again and the OB has me on prometrium 200mg, 4mg of Folic Acid and prenatal. She wants me to start the baby aspirin at 12 wks because she says that there is a small chance that baby aspirin in the first trimester may cause intestinal problems in the baby. What do you think of this? Should I ask to take baby aspirin sooner (have an 8wk appt on 6/23)? I hope I've given you enough info or that my question makes sense. I appreciate your time. Thank you.

   

• At Mon Jun 16, 05:18:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous June 16: I have used low-dose aspirin for almost 30 years and in patients who I really think might benefit from it, I have yet to see any reproducible fetal complications related to its use (and I ususally start it PRIOR to conception). In your case, I don't know if it is going to be necessary anyway because the folic acid should greatly reduce your risks for complications from the MTHFR polymorphisms. A recent review has been written about this and I would suggest you take a peek at it if you are interested: James AH, Brancazio LR, Price T.
  "Aspirin and reproductive outcomes." Obstet Gynecol Surv. 2008 Jan;63(1):49-57. Best of luck and let us know how things turn out! Dr T

   

• At Wed Jun 18, 03:39:00 PM 2008,  Anonymous said…

  Thank you from anonymous June 16!! The quick response was greatly appreciated. It sounds like I'm on the right track (fingers crossed). I found/read the review you recommended, very helpful. Thank you and hopefully I'll be able to post again with continued good news!!

   

• At Sat Jun 21, 06:52:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous: You are welcome and GOOD LUCK! Dr T

   

• At Tue Jun 24, 12:49:00 PM 2008,  Anonymous said…

  From original post on June 16...my name is Hope. Well went to the md and we are 8wk5d along!!! The heart beat was strong and things look like they are going well. The md went ahead and gave the okay to take the 81mg of baby aspirin so I'm gonna be starting that today. I understand it may be overkill but if it won't hurt and it may help we're willing to try. Again thanks for the information.

   

• At Thu Jun 26, 06:34:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Hope: Congatulations! Best wishes for the rest of the pregnancy. Let us know how all of you do! Dr T

   

• At Sat Jul 05, 10:19:00 AM 2008,  Anonymous said…

  i have had 3 miscarriages. all pregnancy's did not go past 7 weeks. i now have a gn/ob specialist for the first time. He ordered a number of blood test and we are awaiting results. He gave me a prescription which am not sure of . He asked me to buy Folic Acid 5g . I have been taken folic acid for months and what i know is you cant take more than 1mg a day.
  when he wrote 5g, i thought it was the same as the one i've been taken. it was only when i got home that i realized the grams were different. am writing from Canada. thanks

   

• At Sat Jul 12, 07:40:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous July 5: Let's see what the test results show. I bet he meant to write for folic acid 5 milligrams (not grams) because of your previous miscarriages. Dr T

   

• At Fri Aug 01, 02:19:00 PM 2008,  Anonymous said…

  Hello this is Hope again (original post on 6/16). Went for 13wk4d appointment and heard the heart beat!! So excited. OB said that I could get off Prometrium now but I'm worried. Should I ask to have my levels checked? I've read info that says to stop at 10wk, or 12wks, or 16wks...ahhh! I'm just scared that I'll m/c again. Any recommendations that I should bring up to my OB? Thank you in advance!

   

• At Thu Aug 07, 06:37:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  Hi Hope: Congratulations! No, the prometrium has probably done all the good it can by this point. The placenta takes over progesterone production by 10-11 weeks, so you should not need extra at this point! Let us know how things turn out. Best wishes for the rest of the pregnancy!
  Dr T

   

• At Wed Aug 20, 07:08:00 AM 2008,  Connie said…

  Dear Dr T,
  
  I have posted before (4/11 as Anonymous, 4/18), and am hoping to get your thoughts again. Here is my background:
  
  I just turned 40 in July, and my husband is 43. After my 2 early (5 weeks or so) m/c's in March and April, my progesterone was tested at normal (17), and chromosomal karyotyping for both my husband and I also came back normal. I went on to have another m/c at 4 weeks or so in June before trying your empiric therapy. (HCG level came back under 1, but my doctor thinks that we probably just missed it.)
  
  Since then I have had a sonohysterogram (normal), and a transvaginal u/s which was normal except that I have a tilted uterus, and a 2.5cm cyst (likely dermoid) that we are going to check again in a few months. I have also had extensive bloodwork done:
  
  Antithrombin activity 97 (reference range 84-124)
  
  Cardiolipin Ab (IgA) normal (<10)
  
  Cardiolipin Ab (IgG) normal (<10)
  
  Cardiolipin Ab (IgM) normal (<10)
  
  Prothrombin/Factor II Mutation: negative for G20210A mutation
  
  Lupus Evaluation
  Lupus Anticoagulant not detected
  
  PTT LA: High at 50 (normal < 40)
  
  Hexagonal phase conf negative
  
  DVVRT screen 30 (normal < 42)
  
  MTHFR, DNA: Positive for one copy of the C677T mutation. Heterozygous for the C677T mutation and does not have the A1298C mutation.
  
  Protein C Activity 100 (reference range 70-180)
  
  Protein S Activity 93 (reference range 60-140)
  
  Factor V Leiden: no mutation detected
  
  Based on the 2 things that seem off (the high PTT LA at 50, and the MTHFR mutation), my ob/gyn has prescribed a baby aspirin each day (as in your empiric therapy). My internist has suggested I have another lupus panel done as she found it odd that I had one mutation, and perhaps it was a false positive.
  
  In this most recent cycle I have followed your empiric therapy, and really thought I was pregnant (twinges in abdomen, increased oiliness of skin, bloatedness, hunger in the middle of the night, etc). The only exception was that my b.reasts did not engorge the way they did before-- just a little bigger and now not so much. And now many of my symptoms seem to have gone. :-(
  
  I normally have a 32 day cycle (ovulating on day 18 or 19), and today is day 34. I have had several negative HPTs but my period has not appeared. I am wondering if a) I could have been pregnant but just m/c early on again, b) the progesterone could have delayed my onset, and c) if I should discontinue it? I don't want to have false hope, nor do I want to delay my next cycle. Also, since my levels came back normal (17), is this one part of the therapy that I might skip?
  
  I would really love your thoughts on my situation and any advice you might have.
  Thanks so much,
  Connie

   

• At Fri Aug 22, 05:05:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Connie: If you are not pregnant this time, stopping the progesterone is probably reasonable. Have you tried ovulation induction - even thoough you are having regular periods, your delayed ovulation (from the normal day 13-14) may be throwing the endometrium a little out of sync by the time the embryo gets there. And, if that does not work, have you discussed ovulation induction and intrauterine insemination or in vitro fertilization with anyone? You could also consider three months of Lupron followed by ovulation induction - that might help suppress any subclinical endometriosis that may be interfering with your fertility. My biggest concern is your age and the fact we may be running out of time....Hang in there. Dr T

   

• At Sat Aug 23, 11:34:00 AM 2008,  connie said…

  Dear Dr T,
  
  Thank you so much for your thoughts. I did get my period the next day, so I will discontinue the progesterone portion of the empiric therapy moving forward.
  
  I have to admit to being thrown a bit by your post, as ovulation induction hadn't yet been mentioned to me-- efforts have been focused instead on bloodwork to determine the cause of the recurrent miscarriages. I thought the sonohysterogram would have alerted us to any endometrial issues? I will be looking for an RE next week though here in the SF Bay Area to discuss this and all other-- any suggestions you may have would be very welcome!
  
  For various reasons (my disposition to altitude sickness and having had mono/Epstein Barr virus in late 06, my mother's myasthenia gravis), we have been focused on thrombophilia and autoimmune issues as possible causes. Do you think there is any merit to that line of thinking?
  
  I have also had a very stressful last few years (auto accident in late 05, mono/walking pneumonia in late 06, and walking pneumonia/chronic bronchitis in late 07/early 08, dealing with my mother's MG in 07-08), so I have been more focused on reducing my stress levels than on my actual age-- I have been going to acupuncture and eating very healthily since last fall.
  
  The chemical pregnancy in June galvanized me into quitting my job in order to cut down on travel and the unrelenting stress levels. We had really been hoping this would make the difference but I am feeling quite discouraged by this latest cycle (seems a very early miscarriage to me).
  
  Thank you for reading this very long post, and for any new thoughts/suggestions you might have. I am grateful for your blog as it has been a wonderful source of information and quite comforting during this rollercoastery time.
  
  Connie

   

• At Tue Aug 26, 06:13:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Connie: Thanks for checking back with us. Tell you what, why do't you go see the REI doctor and get back to us with what you find out. That would be much more valuable than me trying to gaze into my crystal ball right now! Good luck and please let us know. Dr T

   

• At Thu Aug 28, 05:50:00 PM 2008,  Anonymous said…

  Hello. Even though I was a high risk OB RN, I feel like total IDIOT reading these posts. I guess it's different when it's actually happening to you, ya know? Here's my situation in a nutshell. I'm 35, have had problems with infertility from 30-34 then gave up (we tried clomid and then IUI twice, ovulation predictors, etc. etc.) I am very regular about 27 day cycle. Then, out of nowhere in June found out I was pregnant only to miscarry at about 5 weeks. Got pregnant the very next month (July) only to miscarry again at just under 5 weeks. To my total shock found out I was pregnant AGAIN THIS MONTH. I found out on Aug. 25th. Since I started bleeding from July's miscarriage on July 28, I'm guessing this barely puts me at around 4 weeks? Right?
  Anyway, I'm healthy and since we were always classified as "unspecified infertility", meaning apparently he was fine and I was fine, I have no clue what to think led to these past two early miscarraiges.
  1)Am I at a higher risk of miscarrying this time because of the prior two? Do you think it's likely to carry this one to term?
  2)what tests specifically should I look into if this pregnancy fails?
  3)I started 200mg bid prometrium today, at 4 weeks (I'm guessing). Can this cause any potential increased risk of miscarriage or do you think i should keep taking it...I read so many conflicting things.
  Thanks for your help

   

• At Wed Sep 03, 04:56:00 AM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous Aug 28: You are probably at higher risk because of your age and the fact it is unclear what is contributing to your infertility. If this pregnancy fails, I would suggest taking a pause, having a hystrosalpingogram and possibly a hysteroscopy done to look for intrauterine abnormalities, having a general screening panel done for heritable and acquired 'thrombophilias' and a screen for thyroid function. There may be other studies that are worth doing as well. Let us know what you find out and best wishes this go-around! Dr T

   

• At Sat Sep 13, 06:27:00 AM 2008,  Anonymous said…

  i have had 3 losses at between 13 and 16 weeks and one live birth at 37 weeks. My son has just be diagnosed with Ehler Danlos Syndrome and we are waiting to have the whole family tested. My sister has also had 2 miscarriages and this could be the reason ofr it.
  Perhaps you should take a look at the symptoms and see if anything fits.

   

• At Tue Sep 23, 05:18:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Anonymous Sept 13: Ehlers-Danlos comprises about 10 different gene mutations that affect collagen synthesis and structure. Most are inherited as autosomal dominant mutations - that means it only takes one dose of the bad gene to cause problems. The genetic defects have variable penetrance - that means some individuals in a family may be affected more than others. E-D usually does not cause fetal deaths to my knowledge, but it may increase the risk of women for cervical incompetence and early delivery or losses due to extreme prematurity. Mutations may arise spontaneously, so your son could be the only afected person in the family, but the gene defects can be identified and traced in families. Good luck and let us know what you find out! Dr T

   

• At Sat Oct 04, 12:22:00 AM 2008,  Jess_Y said…

  Hi Dr. T.,
  
  I am new to this board, and so glad that I found it! I am hoping that you can give me some insight about some things.
  
  A little history:
  
  I am homozygous for an MTHFR mutation, and I have PCOS. Of 5 pregnancies I have had 2 live births (40 weeks and 27 weeks), and 3 losses (6 weeks, 5 weeks, 4 weeks). My first 2 pregnancies (both losses) occured after I slipped up with my OCP's, and were back to back.
  
  My first successful pregnancy was acheived through the use of clomid, estradiol, and metformin. I had a subchorionic hemorrhage in my first trimester with my first daughter, which led to my OB doing the blood work-ups and diagnosing the MTHFR mutation. My homocysteine levels were not checked. I was put on B6, B12, 4 mg folate, and a baby aspirin daily, as well as oral progesterone supplements.
  
  Our third loss was a baby concieved using letrizole, ovidrel, and metformin. Our second successful pregnancy was acheived using these same medications, with the additon of progesterone vaginal suppositories because of the previous pregnancy loss, and frequent spotting in my fisrt trimester. In my second trimester, I was diagnosed with placenta previa after an episode of bleeding. I was given restrictions, and then after a second episode of bleeding I was put on complete bedrest (23 weeks), and my daughter was born at 27 weeks via emergency cesarean due to a placental abruption.
  
  My husband and I went to a perinatologist to discuss our risks for any future pregnancies, as well as to ask what treatments and precautions would be taken in any future pregnancies. My homocysteine levels were checked and were normal. The perinatologist did the complete blood work-up, and the only thing showing positive is the MTHFR mutation.
  
  He said that lovenox would not be used in any future pregnancy because my homocysteine levels are ok. I have read conflicting evidence about homocysteine levels, and whether they are a cause of pregnancy issues, or a consequence of them, and most of the people I have talked to who are on lovenox or heparin have said that their doctors didn't even check their homocysteine levels, and just put them on the lovenox right away.
  
  Just curious as to what your approach would be, and if you have any other thoughts or suggestions. Thank you so much! It is wonderful that you take the time to help so many people!

   

• At Tue Oct 07, 06:45:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To jess_y: You have been relatively successful with the infertility treatments you have received and the tretament for the MTHFR polymorhism is certainly appropriate and probably adequate by itself. Your PCOS may have put you at gretare risk for the complications you have had than the MTHFR mutations! I have a low threshold for using heparin or lovenox, but I doubt your last pregnancy would have been improved at all by these. If you did go that route, I would probably recommend using no more than a prophylactic level. Good luck. Dr T

   

• At Tue Oct 21, 01:37:00 PM 2008,  Dorly said…

  Dear Dr. T.,
  
  Thank you for your wonderful blog. I miscarried on September 13at 6 weeks (first pregnancy) and found out on Saturday (October 18) that I am again pregnant. My first miscarriage went naturally and the doctor gave a green light to start trying again, he said he didn't see any need to wait for a period. As I didn't get another period after my first m/c, I'm uncertain as to how far along I am supposed to be, but I think I'm about 2 weeks past ovulation.
  I had my hormone levels measured yesterday (Oct. 20) and my hcg is 24, prog. is 4.2. The doctor said that these numbers aren't looking good and put me on 200mg prometrium to take twice daily, vaginally. I am going in again on Thursday to get my levels measured again, to see if the hcg is at least multiplying properly.
  Is there any chance of this pregnancy being viable?? It breaks my heart to think about going through this again...it's too much for a person to take.
  Thank you very much,
  Dor

   

• At Thu Oct 30, 03:41:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Dor: Those sre very low levels, but are you sure you completely miscarried everythiong from your last pregnancy? Did your doctor happen to look by ultrasound afterwards? The reasn I ask is that those lab values could simply reflect an incomplete miscarriage from September. If this is indeed another pregnancy and you do miscarry, I would suggest waiting 3 months before trying again. Give your body and your mind a chance to heal. Best wishes. Dr T

   

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