A Second Chance
Sunday, July 05, 2009
Kenneth F. Trofatter, Jr., MD, PhD
About a month ago, I started writing again and had at least tried to begin responding to the many queries that have kept coming in the door – some left on posts that are a year or two old. (And for all of you out there who have asked, those old posts are still ‘open’ so that you can leave a question or comment and they will be forwarded to me). Due to the volume of the queries, I had to limit my responses to some of the most recent ones and to those that are not adequately addressed in the original posts or in the ‘strings’ of comments that follow.
Anyway, despite my best intentions, I am afraid I was side-tracked early in my return engagement by another round of medical problems. I had actually been under the weather for awhile, but had thought it was secondary to all the administrative responsibilities I had had as interim chair as well as my clinical load. To make a long story short, I had a series of tests that culminated in a cardiac catheterization 3 days ago and placement of stents in one of my coronary arteries that was 99% blocked. It just goes to show, “It’s always something.”
Mind you I am not overweight and have always exercised religiously, even at the expense of time spent with my family, and that is probably what had saved me to this point (I do come from a family with BAD GENES - a very poor track record of early onset and severe arteriosclerotic cardiovascular disease). Indeed, I actually passed the exercise portion of the stress test with flying colors to the amazement of my doctors because when they looked at my perfusion studies, the whole anterior wall of my left ventricle was hardly getting any blood. In all honesty, I feel I was only days to weeks away from a heart attack or lethal arrhythmia that may well have put me in the grave.
So today I decided to test out my new stents! I went out and walked 4.5 miles and for the first time in ages, I had no tightening in my chest or shortness of breath. Indeed, there were several times during the walk that I wanted to burst into a run, but sensibly controlled my exuberance for the sake of my right groin (the entry site for the heart catheter). When I got back to the house, my pulse was only 80. But, the most amazing thing I noticed was the ‘fog’ that had clouded my concentration for the preceding months, and truly had made writing a burden, had also been lifted. I was thinking clearly again!
In the big scheme of things, I feel as though I have been spared a relatively early grave and, as so often happens under these circumstances, that has given me a sense that my work on this earth is not yet done. It’s not too often we get second chances like this and I wanted to tell you all that at least part of that work is attention to this blog. Please bear with me again as I get back into the routine and thank you for hanging on as loyal readers through all of my down time over the past six months.
Sincerely yours,
Dr T
49 Comments:
At Mon Jul 06, 06:19:00 AM 2009,
Ashley Breslin said…
Dr. T - I am so sorry to read about what you have been through recently, but am happy to see that you are feeling better and able to increase your activity level. I am an exercise fanatic/long-distance runner as well, so I know the hardship of not being able to exercise. Hope you continue to feel better!
I just came across your blog last night, as I am frantically searching for answers. It looks like I am having my 3rd threatened m/c, all associated with subchorionic hematomas.
I have had 1 healthy pregnancy, followed by 2 years of infertility that resulted in a first round success with ivf, but a slight IUGR baby, born at 37.5 weeks. In Aug 08, I miscarried at 6 weeks, an FET embryo, after hemmoraging and seeing a heartbeat and SCH. Went on to have a failed fresh ivf cycle (with AB quality embryos) in Jan 09. April 09, another FET, which I lost at 8 weeks (baby only measured 6) after hemmoraging with a large SCH, and seeing a normal heartbeat twice after hemmoraging.
We had a d&c on May 27th and miraculously conceived on our own within 2 weeks of surgery. Yesterday at a little over 5 weeks, I started hemmoraging. Gestational sac, yolk sac, all present and normal,beta continuing to appropriately rise, but yet another SCH is found IDENTICAL, same size (3x3x1.5 cm), same shape, and same location to the one last pregnancy.
I have been tested, non-pregnant, and shown to be normal for the following:
Lupus Anticoagulant
Antiphosphatidylserine
Anticardiolip
Beta-2 Glychoprotein
Factor II, DNA Analysis
Factor V Leiden
Protein S
Protein C
Homocystine
Antithrombin Activity
I am wondering if you have ANY thoughts as what can be causing these recurrant somewhat large SCH's with heavy bleeding, as well as should I also request to be tested for the above items while I am still pregnant with a potential bad pregnancy?
All pregnancies are same father, and my husband's Karyotype has come back normal, I am waiting the results of mine, but presume normal, since RE office never called with results. My RE, Perinatologist, and OB are all at a loss with me. We are desperate for help! Any information you have would be extrememly helpful.
At Mon Jul 06, 03:08:00 PM 2009,
IAN said…
Hello DR T i only joined this site today in search of a medical queiry for my wife,and i found your posts You are truely a fantastic DR .
And i too also beleive your work on this earth is not yet done.
congrats on getting through your own health issues and as everyone who reads this will agree i wish you a long life infront of you.
Yours MR Williams
At Mon Jul 06, 10:41:00 PM 2009,
Anonymous said…
Dear Dr. T,
Thank you for letting your readers know how you are doing! I am so thankful that you discovered early enough your heart problem and are recovering so well!! Besides being a blessing to your family and patients, this blog world needs you! We thankfully and patiently wait for your kind and helpful replies. Yea! for second chances!!
LB in WA state
At Tue Jul 07, 08:05:00 AM 2009,
Anonymous said…
Dr. T:
I am so glad you are on the road to recovery. You're health is very important.
I am 30 years old (almost 31.) I will try to make a long story short. In 2006 I suffered from two miscarriages. The first was a chemical pregnancy and the second one my levels just kept raising and falling. So for that one I had a d & c. My levels never went above 75.
After a complete workup, it was discovered that I have a thrombophilia. In 2007 when I discovered I was pregnant again, I immediately started heparin and progesterone, even though I didn't really need the progesterone. I delivered a healthy baby girl in Sept. of 2007.
In May of this year I discovered I was pregnant again. I started the same regimen as my previous pregnancy. At 7.5 weeks we had a healthy baby with a healthy heartbeat. This past weekend I started having heavy brown spotting and went to the ER. They did an u/s and discovered that my baby no longer had a heartbeat. They called it a missed miscarriage. I was devastated. I am scheduled for a D&C tomorrow.
My question to you is, what are the chances of me being ever to have another healthy baby? I read that after 3 miscarriages that my chances are only 55%. I want to know if my chances are better because I did carry one baby to term. Also, does heparin sometimes not work when you have a blood clot disorder?
Thank you for taking the time to read this?
At Tue Jul 07, 12:19:00 PM 2009,
Anonymous said…
Dr. T,
I just wanted to say how much I enjoy your blog and how much we all appreciate you. I am so thankful that you are doing so well after surgery...and will continue to keep you in my thoughts and prayers.
Ashley Adams (L&D)
At Tue Jul 07, 01:01:00 PM 2009,
Cathy said…
Best wishes for a speedy recovery Dr. T!!! Thank you again for the valuable information you provide- it is appreciated by so many women.
Cathy
At Tue Jul 07, 03:00:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
Ashley: I have more questions for you than answers right now. The one thing you probably don't need to do is repeat the laboratory studies you have already had done during early pregnancy. I will sometimes check complement levels early on but that is a topic for another discussion. Your problems do seem to be related to an 'implantation' problems and that might well have been reflected even in the pregnancy you did carry. Here are a few of my questions: 1) What do your doctors believe were the causes of your infertility (e.g., elevated prolactin levels; reduced ovulation; endometriosis, etc.) and do they think any were 'exercise-related'? 2) Have they had you reduce you exercise program early in the pregnancies or modify to one (such as swimming) that might not cause so much jostling of the uterus? 3) Despite your negative "thrombophilia' workup, have they tried empirically treating you with prophylactic doses of low-molecular weight heparin or heparin during the early time of implantation? (I know this may not seem to make sense because of your history of subchorionic hemorrhage, but there are reasons to consider that). It can always be stopped once you have gotten through first trimester.
Regardless, presuming your own chromosomal studies are normal, I think you have a good shot at another successful pregnancy alone the way, and don't write this one off quite yet because of the SCH.
Best wishes and thank you for writing!
Dr T
At Tue Jul 07, 03:01:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
Ian: Thank you.
Dr T
At Tue Jul 07, 03:02:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To LB: Thank you too. The support of our readers all over the world has kept me going even when 'the going got tough.'
Dr T
At Tue Jul 07, 03:09:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 7: Before I offer any suggestions, get back to me with a few answers: What is the "thrombophilia" disorder with which you have been diagnosed? Did your workup include chromosome studies on you and your spouse? Did any of the early losses have chromosomal studies done? Do you have any medical problems? Do you have regular menstrual cycles? Are you overweight? Do you smoke? Let me know and I will give you my thoughts. The best thing you have going for you is that you HAVE successfully carried a pregnancy to term! Thanks for writing!
Dr T
At Tue Jul 07, 08:46:00 PM 2009,
christine said…
Dr. T, I'm glad you're feeling much better and I'm sure you will continue to get even better.
I have been burdened with a miscarriage problem and I don't know what to do, I hope you can give me an answer to help ease my mind.
I am 22 years old and found out I was pregnant a month ago. I just came in for my first ultrasound (abdominal and vaginal) a week ago (tuesday, 6/30/09) and it showed no fetal heartbeat. I came back three days later for a 2nd ultrasound and it was the same; no fetal heartbeat or movement BUT they told me the embryo grew and was 2.5cm long which is where it should be. They told me everything else looks good--gestational sac, uterus, etc.. Is there a chance that the baby is still alive and that they just missed the heartbeat?
At Tue Jul 07, 08:51:00 PM 2009,
Christine said…
Btw, I haven't been spotting or cramping (and they told me I should be within a week). I am still having pregnancy symptoms; nausea (even more so now), sore breasts, etc..
At Tue Jul 07, 09:24:00 PM 2009,
Stephanie said…
Before I offer any suggestions, get back to me with a few answers: What is the "thrombophilia" disorder with which you have been diagnosed? Did your workup include chromosome studies on you and your spouse? Did any of the early losses have chromosomal studies done? Do you have any medical problems? Do you have regular menstrual cycles? Are you overweight? Do you smoke? Let me know and I will give you my thoughts. The best thing you have going for you is that you HAVE successfully carried a pregnancy to term! Thanks for writing!
Dr T
Dr. T:
To make it easier for you, my first name is Stephanie. I am 30 years old (almost 31). I am 124 lbs, 5'4". Unfortunately, I am unsure of the thrombophilia disorder that I have. I am not sure if I was ever told. I'll be sure to ask tomorrow at my appt.
My other d&c I did have the chromosome testing and found nothing wrong. It was thought that I miscarried because of the clot disorder. My husband has not had chromosome testing done. I am not sure if my work up included included chromosome testing. I was just told about the thrombophilia that was present. I do not drink nor do I smoke. I have always had very regular menstrual periods. They average about 32-34 days in length and I usually ovulate around day 20-22. I do not have any medical problems that I am aware of. Hope this helps some.
At Wed Jul 08, 01:17:00 AM 2009,
Ashley Breslin said…
Dr T - Thank you so much for your reply! We are very confused here!
A quick update on yesterday's OB followup and sono from ER visit. The u/s showed shrinkage to the SCH which has never occured in the previous pregnancies, very good news. It is still there, but only 1cm, vs a 3x3. However, we still saw only gestational and yolk sacs. My OB does have an old sonogram machine so the variance between his and ER higher quality machine could be the issue with not seeing a fetal pole yet. Also we aren't exactly sure how far along I am because of not having a lmp to go off of, just d&c date. Did another beta as well. It went from 4800 in Er Sunday afternoon to 10,543 in less than 48 hours. So the hcg is rising appropriately. Can hcg rise like this concurrently with the baby not developing? I thought hcg would not more than double if something was wrong at the exact same time?
I have another sonogram on Friday. Still lots of cramping, but cervix is high and closed, and we are praying for this situation to be different.
The OB did re-run my thrombophilia tests now that I am pregnant, as the others were done pre-FET in March. Just a shot at seeing if anything is different.
To answer your questions.
1. There is no known reason for my infertility and needing ivf, other than 2 years of failed cycles, including 6 months of Clomid/IUI's and 1 round of Gonal F/IUI. I have had 3 laporoscopies for endo, but only the 1st one showed much endo in 2002, after that had another in 2003 (got pregnant with Daughter immediately following that surgery) and that lap as well as another I had in 2006 showed minimal to no endo. So RE has ruled endo out as being a big cause to my infertility. Fsh, prolactin, etc, are all normal. I am also 31 years old, so age isn't a factor quite yet. Considering we were having problems in our 20's too.
2. I am a tiny person in weight 115-120 lbs and 5'9" with relatively low body fat. I have always been this way. In regards to exercise, yes, I had drastically reduced exercise to walking and lifting very light weights with the last pregnancy that ended with d&c before I even began FET all the way through to the d&c. As I had just started back into my routine when I found out I was pregnant miraculously on my own, I have done zero exercise since June 23rd and still managed to hemmorhage, but will continue to do nothing until we know more of what is happening.
3. No, they have not prescribed a low-dose Heprin, baby asprirn, etc. I have asked repeatedly about this and both OB and RE have said no because I am already bleeding with these pregnancies and that could make the bleeding worse? (I am not just spotting, but very heavy bleeding when these hemmoraghing episodes occur). I am wondering if it could prevent the bleeding/clotting from happening in the first place? My OB, however, did say it would be something to consider with a future pregnancy (I guess if I could ever get pregnant on my own again). I don't know if RE would support it with another FET. I do have one embryo remaining, and if we lose this pregnancy, I am strongly considering surrogacy to try to bring that embryo to life.
My karyotype did in deed come back normal. Also found out yesterday that the d&c from last m/c showed chromosomal abnormalities of a very rare condition where 15/20 cells examined showed 4 X chromosomes. Could have been the cause of the m/c, and just a fluke that it happened with the sch, but OB believes I may also have something vasucular going on in the uterus causing these SCH's in the exact same place with every pregnancy since my son.
We are still hanging on like crazy to this pregnancy, yet another very hard emotional and physical roller coaster. Thank you SO much for your replies and I look forward to hearing back from you.
Ashley
At Wed Jul 08, 02:50:00 AM 2009,
Anonymous said…
As you lend your helping hand to extend the life of unborn babies, its just a way of saying thanks by all these kids to you. Will keep praying for your good health. Your blog is highly appreciated. Continue doing your good work.
At Wed Jul 08, 07:32:00 AM 2009,
DPF said…
Dr. T -
I came across your blog today while looking up information on ectopic pregnancy.
First, let me say I am happy that you are doing well after such a personal medical scare. I hope you continue to feel better and better.
Second, I want to say that I do not know how you keep up with this wonderful blog with all of your professional responsibilities, but THANK YOU for doing it.
Last, I wanted to share my expereience with an ectopic pregnancy and ask for your thoughts.
I am a married, 39 year-old physician with a healthy 2 year-old son who was diagnosed with an ectopic on 6/16. I have no risk factors other than age. We have been trying to have a second child. My initial HCG was 11,000, tubal diameter 2.7 cm, no pelvic fluid, but a heart rate was present. I chose MTX instead of surgery and had A LOT of pain, weakness, bleeding, etc. with the treatment. My HCG only decreased to 8000, so I had a second dose of MTX on 6/24. Four days later it was 5000. I felt horrible with the treatment but was doing much better until about 2 days ago. Now I have abdominal/pelvic/back pain again (although not as bad as before), pain with bowel movements and after meals, and spotting that is not fresh blood. Also, severe acne has popped up on my face again and this is what happened at the beginning. I am not scheduled to go back in for bloodwork until next week but think maybe I should go sooner.
Do you think the pain and symptoms are because of intraabdominal bleeding and scarring? What do you think the likelihood of needing surgery is at this point? I am not a wimp (have actually been in contact sports internationally) but just can't do MTX again. Also, I have a lot of responsibilities at work and am at the point where I really need to get better.
Thanks for your thoughts.
At Wed Jul 08, 10:25:00 AM 2009,
Anonymous said…
Dr. Troffater,
Just read your "Second Chance" posting and everyone here at Fairview University MFM Center want to send you our greetings and best wishes. Remember your 50th Birthday Party? --- We want you to have many, many more. If you forgot, we still have photos. Glad to hear that you are feeling better. Sounds like you are doing excellent work and you are continuing to make a difference.
All your friends at the University of Minnesota.
At Thu Jul 09, 05:04:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Ashley and Cathy July 7: Thank you for the kind comments - they keep me going and are a great help in lifting my spirits right now. Confronting your own mortality can be a trying experience and focus your attention on the things that are most important!
Regards,
Dr T
At Thu Jul 09, 05:09:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Christine July 7: I am honestly not sure what's going on. If the baby was not alive, then how could it have grown normally over that period of time? Perhaps they did not get an accurate measurement with the earlier ultrasound. Unfortunately, at 25mm, a fetal heart should be readily visible by ultrasound. Consider getting a 'second opinion' by a specialist in Maternal-Fetal Medicine or Radiology. I wish you the best. Thanks for writing.
Dr T
At Thu Jul 09, 05:16:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
Stephanie: I would still like to know what your 'clotting disorder' is, but all that aside, I would have one suggestion. Although you appear to ovulate regularly, you are doing so somewhat late. This can results in a little asynchrony between the endometrial development and its preparation to receive a fertilized ovum. In addition to your other therapy, your doctors might still consider ovulation induction so that you ovulate closer to days 13-14. I have found this to be very helpful in many women in your circumstances and will frequently supplement with progesterone support during the luteal phase as well. Best wishes!
Dr T
At Thu Jul 09, 05:23:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Ashley July 8: At this point the hCG is still rising normally, so don't give up hope. In women that have 'implantation problems' heparin may still help because it might improve the implantation, normal migration of the rophoblasts and promote normal 'vascularization' of the placenta (and perhaps actually decrease the risk of bleeding)! I would not use the aspirin under these circumstances. It appeasr you lost that other pregnancy because of a chromosomally abnormal baby. Most are lost early and you have no control over that. This could be a recurring 'random' event for you, but that increases the likelihood you will do better if the baby is chromosomally normal. Remember, far and away, chromosomal abnormalities are THE most common cause of pregnancy loss. you should discuss the findings with a genetic counselor if you have any questions. Best of luck to you.
Dr T
At Thu Jul 09, 05:38:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To All my Friends at the University of Minnesota: Time goes by too quickly! Thank you for the kind words. Miss and love you all...
Dr T
At Thu Jul 09, 06:06:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To DPF July 8: You should most certainly go see your docs. When the initial hCG is that high and there is a live baby in the tube, there is an increased risk of rupture even with the MTX treatment. As you know the hemorrhage can be rapid and severe when that occurs. I wish you the best. Thanks for writing and let us know how things turn out.
Dr T
At Thu Jul 09, 07:54:00 PM 2009,
Stephanie said…
Dr. T:
Thank you for your suggestion. I know my clotting disorder is nothing very serious (according to my doctor). In fact, he said it's so minor that I probably don't need the heparin, but it's better to be safe than sorry. I know it's not Factor V (I think that is the name) or MTHFR. I will find out for sure in a couple of weeks at my post op. My d & c went well yesterday.
I will mention to my dr. about the late ovulation. I am also thinking about trying Vitex to help promote earlier ovulation.
Stephanie
At Fri Jul 10, 07:13:00 PM 2009,
Ashley Breslin said…
Thank you Dr To for responding again. We had a u/s today and looked like the sch has grown back to 3 cm amd has some tissue inside of it, or I have another gestational sac with a fetal pole where the sch was. Highly doubtful of that being the case, but we will know more on Tuesdays u/s. But the original gestational sac shows a baby with a strong heartbeat and measuring exactly 6 weeks, which is where I thought I should be.
My question is in regards to the low dose heprin, do you think I should have that with this pregnancy now, would it make a difference at this point? Or just with future pregnancies? I have now for sure hemmoraged with my last 3 of 5 pregnancies, 2 of those I lost, we are still holding on to this one!
Thank you again for caring so much about this topic and all of us out here desperate for more knowledge from dedicated doctors like yourself.
Ashley
At Fri Jul 10, 07:21:00 PM 2009,
Ashley Breslin said…
Dr T-
Thank you so much for writing me back! I appreciate your comments and dedication to the many women who are struggling through fertility/pregnancy issues!
My question to you regarding the low-dose heprin is, would you recommned it now with this pregnancy (6 weeks) or with a future pregnancy if we lose this one? I had another sonogram today and the baby has grown and has a strong heartbeat and measured exactly 6 weeks where it should be. However, the sch has grown again to 3 cm and appears to look just like another gestational sac with something similar to a fetal pole in it? We won't know for sure that it isn't that until next u/s on Tuesday, but doubtful that it is a twin with the hemmoraging and seeing the sch last weekend in the ER in the same location. With that to say, I was discouraged to see the sch growth, and hope it is "lycing" to be reabsorbed into the body? Haven't given up hope just yet though.
Ashley
At Fri Jul 10, 09:47:00 PM 2009,
Anonymous said…
I just stumbled upon this blog tonight and I wanted to say that out of all the "medical" blogs I have seen so far tonight, yours is the most informative and caring. You are a great doctor and I wish you all the best in your health. You definitely deserve it. Your just fantastic and have a great gift.
At Sun Jul 12, 05:13:00 PM 2009,
stylechild said…
Hello Dr. T,
I have read up on your blog and read about your medical issues. I am glad to hear you are doing well. I know darn bad genes can't get away from them. I for one know to well about bad genes being passed along with ICP. I contacted before to thank you for your blogs on ICP. There are many ICP sufferers who you have responded to and helped. I am the editor of the www.itchymoms.com site. If you do another write up on ICP, please kindly let me know.
I appreciate all you do!
Thank you
Donna Diaz
donna@itchymoms.com
At Tue Jul 14, 06:19:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Stephanie July: Good luck to you and let us know how things turn out.
Dr T
At Tue Jul 14, 06:22:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Ashley July 10: If the SCH is really growing or if you do start bleeding, you might consider stopping the aspirin. As I said before, heparin or a low molecular weight heparin might be safer and more effective than the ASA this early in pregnancy.
Dr T
At Tue Jul 14, 06:25:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Ashley again: Ooops, I thought you were asking about aspirin. Personally, I would go with the heparin, but would prefer to start that earlier in a subsequent pregnancy. Pardon my brain lapse! Dr T
At Tue Jul 14, 06:26:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 10 Thank you so much for your kind words, You cannot believe how much they are appreciated.
Dr T
At Tue Jul 14, 06:29:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Donna: thank you too and I certainly will. I appreciate your feedback very much!
Dr T
At Wed Jul 15, 01:58:00 AM 2009,
Sarah said…
Dear Dr T
A quick post to say that whenever I visit your blog, I find such important and useful information. I appreciate your manner - the way you share plenty of technical information and in an entirely friendly and unpatronising way. Thank you for sharing your knowledge so generously.
I am very sorry to read of your recent health troubles and wish you a speedy and complete recovery.
At Thu Jul 23, 10:22:00 AM 2009,
ONE OUT OF SIX said…
Be well Dr. T!!! I'm so sorry to hear you've been ill. You were a great help to me when I pregnant with my now 8 month old son (4th pregnancy - first successful live healthy birth.)
Wishing you all the best!
At Thu Jul 30, 03:20:00 PM 2009,
klct said…
Dear Dr. T,
Thank you so much for taking the time to answer all of our questions, especially after all you've been through!
I have a question about IVF. I had a naturally conceived, healthy pregnancy in 2005, right before my husband was diagnosed with mesotheliomia. He is doing relatively well now but is currently sterile from the chemotherapy. We have been trying to have a second child through ICSI, and so far I have had an ectopic pregnancy and two unsuccessful IVFs (2 embryos transferred each time, including one transfer with frozen embryos). My doctor is now recommending that I do a hysteroscopy with curettage. He says the hysteroscopy could uncover any abnormalites (athough he doesn't suspect anything) and that the curettage could increase the chances of implantation. I live in France, so am wondering if this is a common route to go in the U.S.? And could you explain how a curettage could help implantation? I am 36 years old.
Thank you!
-klct
At Thu Aug 06, 09:57:00 PM 2009,
Anonymous said…
Hope all is well with you Dr. T!
I am a regular reader of yours and have noticed that you have been MIA again. I am hoping that you are just on a much needed restful vacation with your family!!! Look forward to reading more on your blog when you return. In the meantime, just so you know...I am praying for you!
At Thu Aug 13, 06:59:00 PM 2009,
April said…
Dear Dr. T.,
You might be the answer to my prayers! I wanted to ask you for advice. I am not sure if this is the right way to do it, but Ashley's situation reminded me a little bit of my own, and I can't figure out how to reach you otherwise.
Thank you so much for answering questions online. Here is my situation.
My husband and I have had unprotected sex since the fall of 2001. Since then, I have had four miscarriages.
1. November 11, 2002: The m/c was a result of implantation issues (as suggested by gynecologist) at around 6 weeks. I miscarried naturally.
2. June 8, 2006: The m/c was the result of a blood clot in the uterus past 10 weeks. We saw the heart beat at 8 weeks, where the nurse discovered an unspecified mass on the ultrasound. By the time I had the u/s at the hospital with more advanced equipment two weeks later, there was no longer a heartbeat. I had a D& C.
3. October 13, 2006: The m/c was the result of a blighted ovum. I miscarried naturally at around 10 weeks the night before my scheduled D & C.
I saw a RE in November 2006. He administered the following tests: nml SHG, TFTs, LAC, ACL, ANA, ovulatory P4 (10.4), Prot C, Prot S, AT-III, Factor V Leiden, Prothrombin, my karyotype, and a hysterosonogram. All results were normal, except for mutations on both copies of the MTHFR gene and elevated PAI-1 levels. He told me to come back when I was pregnant to put me on Heparin. He also told me to take a prenatal vitamin and 4,000 mcg of folic acid daily and a baby aspirin daily after ovulation.
In November 2008, I was referred to a fertility specialist as recommended by my regular gynecologist. He administered the following tests: my husband’s karyotype, progesterone, semen culture and mobility, FSH, Estradiol, post-coital test, and a hysterosalpingogram (all normal results). As a result, the fertility specialist diagnosed unexplained infertility for my husband and I. He also stated both baby aspirin and Heparin treatments were not necessary.
4. June 2, 2009: The m/c was the result of a subchronionic (sp?) hemorrhage. We saw and heard the heart beat many times next to the hemorrhage, which started showing up on the u/s around 6 weeks and grew in size over the time of the pregnancy. The last visible heartbeat was at 10 weeks in the ER after heavy bleeding the night before. Two days later at the follow-up appointment, the heartbeat was gone. I had a D&C the following day. We did chromosome testing on this one, and all the chromosomes were there.
As you can imagine, I am devastated. My gynecologist has no answers, but tells me not to give up. On the other hand, I really want to fix this blood clot/hemorrhage issue in order to have a healthy pregnancy next time around.
Your time and answer are very much appreciated.
April
At Tue Aug 18, 07:32:00 AM 2009,
Anonymous said…
Hello Dr. T. Thank you for a informative web site and for taking the time out to offer some hope and answers to those us riding the rollercoaster of emotional highs and lows. Glad to hear that you are doing well after your own health scare.
I'm from Canada, so I don't know if our test results vary greatly from yours. It's unfortunate that "gold standards" are not across the board for most things, but I'm hoping you can shed a little light for me.
I'm 39 years old. This is my fourth pregnancy. I have a condition called PCOS (Polycystic Ovaries) and suffered three misscarriages in my late teens - late twenties.
I had tried to get pregnant, but did not do the Clomid or other things that were recommended to me. My attitude was if it was to happen it would and it didn't while I was married. Recently I divorced after a long marriage and I met a younger man (he's thirty). I was on low dose birth control and by no means did it even occur to me I could get pregnant after my past history.
I'm officially 12 weeks 2 days. I went in yesterday for another ultrasound because about a week ago I had some cramping, without bleeding. I have not spotted once in this pregnancy nor I have had any of the off putting symptoms that I did in the other pregnancies when I did misscarry. I have simply felt like a growing, tired pregnant women and everything has been "normal" by my standards.
So yesterday after they realized that I was about 10 days further along then originally thought, they rushed to get me in First Trimester Screen.
Here are the results...
Findings: Live intrauterine gestation
Fetal Heart Beat: Present (150)
CRL: 49.3mm
NT: 1.9 mm
BPD: 16.9mm
Nasal Bone: Present
Stomach: Visable
Bladder/Kidneys: Bladder visualised
Hands: Both arms seen
Feet: Both Legs Seen
Placenta: Predominantly anterior
Amniotic Fluid: Normal
Biochemistry:
Free B-hCG 2.226 MoM
PAPP-A 0.478 MoM
I was told after both ultrasounds that my baby looks great and healthy. "Lovely" was the word the Dr. used and that it was my bloodwork that was cause for concern and putting me at a higher risk for Triosmy 21.
My results were such.
Background risk: Trisomy 21 1:86
Adjusted risk: 1:9
Background risk: Trisomy 18 1:195
Adjusted risk: 1:3903
Background risk: Triosmy 13 1:616
Adjusted risk: 1:1385
So although no abnormalaties were seen on ultrasound they have found that my risk for carrying a child with Down Syndrome is Greater than the screening cut off, however my risk for Trisomy 13 or 18 is less than the screening cut off.
I have been referred to a genetic counselor as well as told that I will need amniocentesis for certain.
This baby has already been considered a miracle by everyones standards as the odds of naturally getting pregnant at my age on the pill with a prexisting condition that causes infertility seems remarkable. Both my boyfriend and I want this child very much, but we are very uncertain as to what we are suppossed to feel at any given time.
My question is...because my risk for others conditions lowered and I have no markers visualized, how worried should I be? How accurate is the blood work? Could I be in one of those situations that there is nothing to really be concerned about and chances are everything is fine? From reading your site and listening to others, "false positives" seem to be pretty generic and cause a lot of undue stress and worry. Naturally I'm concerned about doing anything that will put my pregnancy at risk, but feel like I can't continue without knowing a bit more.
I asked to have the bloodwork redone, but they don't normally do that. BTW...my HCG levels went from 89000 - 91992, then dropped down to 73000 in the last week, which was part of the reason they wanted to do an ultrasound. Apparently that isn't a very high peak...could this be a further indicator that something is going on?
Thanks for your help.
A
At Sat Aug 22, 05:57:00 AM 2009,
Anonymous said…
DR. T- I am so sorry to hear about what you are going through but I am living proof that the Lord will never put more on you than you can bear. I delivered a stillborn in Feb. 2009 at 21 weeks gestation. I became pregnant in March and miscarried at 15 weeks gestation in June 2009. My membranes keep on rupturing due to colonization of bacteria. I am 28 years old with two college degrees and i work in the medical field so i have so knowledge on my condition. My husband has two kids from a previous relationship that he doesn't get to see that often and he wants a family with me but the thought of burying another child is heartbreaking for me. I feel like something is wrong with me and i really want 3 kids but my ob or the fmm specialist can tell me what the problem actually is. Can you please help me!!!! Will I every carry a child to term without having premature rupturing of the membranes????
At Mon Nov 02, 03:39:00 PM 2009,
zoliepup said…
Dr. T-
I just found your site because of a very low PAPP-a, but am sorry to hear about what you are going through.
It brought up the question about your own PAPP-a and whether it was elevated when you were evaluated or if you didn't screen :)
(I stumbled upon the cardiac implications).
Now I just wait for my CVS to tell me what's going on with me!
38 yo
11 4/7 wk
CRL 80 mm
NT 1.1
PAPP-a 0.22 (yikes)
HCG 1.07
Most importantly, I'm glad you are doing well! My best to you and your family!
At Tue Nov 03, 06:15:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To zoliepup: The CRL (crown rump length) of the baby is on the large side for 11 4/7 weeks. I am wondering if that might not be skewing the results somewhat. Reassuring are the NT and hCG measurements. I'm betting on a chromosomally normal baby! Please let us know. Best wishes with the CVS!
Dr T
At Fri Nov 06, 10:45:00 AM 2009,
zoliepup said…
Dr. T-
I really didn't expect a response, but thank you so much :)
The CRL discrepancy came because the OB didn't trust my EDC based on ovulation, so she bumped me back based on her initial US (which was pretty cursory).
Regardless, FISH from the CVS is back and normal. Happy dance! Ancillary info was that we found out that it's a girl!
I'll still be closely monitored for placental insufficiency, pre-e, and other complications... but truth be told, I'm thrilled and much more relaxed.
I hope you are doing well and taking care.
At Wed Nov 25, 07:47:00 AM 2009,
hewb said…
Dr. T:
This blog has been extremely helpful for me, and I know I, like many other women, appreciate the time you take to answer women's questions. I wish you the best in your recovery and health!
I had a bad result from the combined first trimester screening done at 12 weeks 4 days - NT was high at 6.5 (mult. mean of 3.46), HCG was high (168317, Mult. mean of 2.59), PAPP-A was normal (966, Mult. mean of .40). They gave me 1/2 odds of the baby having a serious disorder, but lower risk of Trisomy 18 (1/130). I am 36, 5'9" and 140 lbs, have had only one previous pregnancy and from that a healthy 13-month-old son. I went in today (14 weeks 5 days) and with the doppler they found a heart rate of about 60 bpm, and said the baby probably won't survive. Is there any hope for this baby? How long could it survive in utero? Do you have any recommendations about how to proceed? I have an u/s scheduled for next Tuesday at a high-risk OB and had tentatively planned an amnio for that time, however I'm not sure now if the baby will still be alive, and if so whether I should have an amnio, and how long the baby might survive.
I am also wondering about trying to get pregnant again assuming this loss. I have very irregular periods, ranging from 28-70 days, but had no problem getting pregnant either time we tried (got pregnant during my first cycle both times) and have no health problems. Should I have any testing done on this baby or before trying to conceive again; should I consider any medications? I read that you recommend waiting 2-3 months after D&C (or D&E as looks likely in my case) before trying again, and we'll certainly do that.
Thank you very much for any advice about this pregnancy and the future.
Elizabeth
At Sat Nov 28, 11:31:00 AM 2009,
Anonymous said…
Dr. T
Glad you are on the road to recovery.
I am 40 and pregnant for the 8th and almost certainly the last time. I am trying to understand my integrated screening results.
My pregnancy history is this:
# 1: Miscarriage with D and C at 13 weeks (2002)
#2: Healthy boy 9lb 3oz by C section (no pregnancy complications) (2004) (HCG, AFP and uE3 all 1.0 MoM in second trimester screen)
#3: Miscarriage at 6 weeks (2005)
#4: Healthy boy 9lb by C section (I did have a subchorionic hematoma which bled from weeks 7-10 with this pregnancy). (2006)
#5 Miscarriage at 6 weeks (2007)
#6 Fetal demise 10 weeks-D and C (July 2008)
#7 Pregnancy terminated for T21 at 17 weeks in March 2009 via D and E. My first trimester results for this pregnancy gave me 1:10 odds of T21 (HCG 2.0MoM, Papp-a 0.49 MoM, NT 1.2 MoM, nasal bone identified). T21 diagnosed by amnio.
With this new pregnancy (LPM 8/5/09) my first trimester screening was awesome. The bloodwork was done at 10 weeks 3 days and NT at 12 weeks 1 day)
HCG 0.9MoM,
Papp-a 1.1MoM,
NT 0.77MoM
with odds of 1 in 1300 for T21. Given my previous history I was very happy with those results. But since then its gone downhill and I don't know what to think.
Firstly I JUST read the report from the 12 week ultrasound at my OB visit and it states that the nasal bone "could not be demonstrated". No one told me this at the time and I don't know if that statement means it is actually absent or the tech just couldn't get a good view as the baby was moving so much. I might have considered CVS if I'd been told.
and secondly I got my second trimester bloodwork (taken at 15 weeks 2 days):
HCG 2.4 MoM
Inhibin A 2.0 MoM
AFP 2.0 MoM
The HCG and inhibin A are worrying and my odds are now 1 in 560 for T21 which is worse but still not bad for may age. The nasal bone is an unknown so I don't know how to factor that in. The AFP doesn't fit for T21. I have an ultrasound coming up prior to deciding on an amnio. Is there anything I should ask the US tech to look for specifically? The nasal bone? neural tube defects? I'm also worried given the number of procedures I have that I am at risk for placenta accreta. Would that explain the elevated numbers for the second trimester and the discrepancy between the 1st and 2nd trimeter results? I should also mention that I have a synechia (which must have resulted from the D and E in March) and a sub chorionic hematoma (which bled from 7 to 9 weeks and was still visible on US at 12 weeks).
In case it matters I was on progesterone until 14 weeks and take daily aspirin.
Thank you for reading this and good health.
At Mon Nov 30, 09:17:00 AM 2009,
hewb said…
This is Elizabeth again -- posted on 11/25. One more thing I thought I'd mention. I had an ultrasound at 8 weeks, all looked good and fetal heart rate was about 150. I had another OB visit; the heartbeat (heard by doppler) was again around 150. I received the H1N1 vaccine at 12 weeks and 24 hours later got sick with something flu-like that has lasted ever since (has been better since about 2 weeks after getting sick; it started with a cough which is still sometimes productive; I had exhaustion and body aches toward the beginning, but never had fever). As mentioned above, I then had my 1st trimester screening at 12 weeks 4 days, when there were the first signs of problems and low heart rate. Could the problems with the baby stem from either my illness or the vaccine? My OB told me this was probably mild flu-like symptoms brought on by the vaccine, but it was NOT mild, and I received the shot which is supposed to have only a dead virus. My primary care physician told me after 10 days of illness that since I was pregnant, he didn't want to prescribe anything, to tough it out and take Benadryl. Prior to that I had taken only occasionally Robitussin, which was on my approved OB list.
At Mon Nov 30, 02:00:00 PM 2009,
Anonymous said…
Dear Dr,
I have been reading your posts which are excellent and very informtive and I am glad you are now feeling better. I hope you are still well.
I am however, feeling absolutley sick with worry after reading your posts about ultrasond scanning and its safety record. I tried to be so careful in my pregnancy to do everything right to give my baby the best chance, I didnt drink any caffiene, ate so healthily, took vitamins etc etc but I did have very two early scans as well as two at 12 and 22 weeks -it never occured to me they may be so dangerous down the line. My little boy is very well and healthy but when people talk of 'long term damage' I literally feel sick to my stomach and I just dont know why this didnt occur to me before. I just trusted it was safe but now realise this was very niave. Do you have any advice for me? This has been bugging me for so long now I just dont know what to do.
Thank you for takng the time to read this.
At Tue Dec 01, 12:00:00 PM 2009,
Anonymous said…
As a follow up to my last post I spoke with the ultrasound doc who said they couldn't get a view of the nasal bone as the baby was lying face down.
Thanks again for reading.
Anon of 11/28
At Tue Dec 29, 02:09:00 AM 2009,
Anonymous said…
Dr T - I am 39 and have had 6 miscarriages in total and one successful pregnancy and normal birth.Miscarriages have all been early between 6 and 12 weeks.Most after we have seen a heartbeat. I was put on uterogestan and baby asprin for the last 4 pregnancies from about 5 weeks.Both husband and I were tested and nothing abnormal found. I went for bloodtests and was found to have Factor V Leiden blood clotting disorder. Dr suggested I go on heparin immediately as I was already 5 weeks. Gynae disagreed and kept me on baby asprin. Everything went well and saw heartbeat at 9 weeks and then at 10weeks no heartbeat. Had d&c couple of days later. Is there any advice of suggestions you are able to give me with having another healthy pregnancy, please.
Thanks Anie
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