Question:
Hello Dr Ramirez,
I hope you can help me.
I live in London England. And am a patient at Kings College Hospital London.I have recently miscarried for the fourth time.I had 3 previous miscarriages and following tests discovered i am heterozygous for factor v leiden.Following this I had a successful pregnancy using one low dose clexane and baby aspirin daily.I now have a beautiful baby daughter who is 8 months.I got pregnant quickly afterwards but miscarried recently at 10.5 wks again using clexane and aspirin.Can you shed any light on why I miscarried again.I thought I would be ok using the clexane etc,I thought this was the answer,but it didn't seem to work this time round.Is it likely this may happen again if I get pregnant?Is there anything else I should be trying?I hope you can advise.
Kind Regards
Hello Dr Ramirez,
I hope you can help me.
I live in London England. And am a patient at Kings College Hospital London.I have recently miscarried for the fourth time.I had 3 previous miscarriages and following tests discovered i am heterozygous for factor v leiden.Following this I had a successful pregnancy using one low dose clexane and baby aspirin daily.I now have a beautiful baby daughter who is 8 months.I got pregnant quickly afterwards but miscarried recently at 10.5 wks again using clexane and aspirin.Can you shed any light on why I miscarried again.I thought I would be ok using the clexane etc,I thought this was the answer,but it didn't seem to work this time round.Is it likely this may happen again if I get pregnant?Is there anything else I should be trying?I hope you can advise.
Kind Regards
Answer:
Hello Nicola from the U.K.
Factor V caused recurrent miscarriage through an increased risk of blood clots at the tiny vessels feeding the pregnancy. Therefore, the key to treatment is to use medications that decrease this clotting. Obviously the low dose aspiring was sufficient for your previous pregnancy. I don't think the Dexane (dexamethasone# contributed much. It is a steroid and used mainly to decrease the inflammatory response, however I also use it for my IVf patients to reduce the chances of rejection of the embryo. The recommended treatment is to use low dose heparin #2000 units twice per day) or Lovenox beginning at the start of the menstrual cycle or treatment cycle, in addition to the aspirin. I use both. I think that your overall chances for another successful pregnancy are good. You still might have additional miscarriages but that could be due to other reasons as well. There is an overall risk of miscarriage in 40% of pregnancies just due to random abnormalities. But don't worry about it too much. Keep trying, and I am confident that you will be successful.
Sincerely,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.blogger.com/www.montereybayivf.com
Monterey, California, U.S.A.
for additional information check out my blog at http://womenshealthandfertility.blogspot.com/ check me out on facebook and twitter with me at @montereybayivf
Hello Nicola from the U.K.
Factor V caused recurrent miscarriage through an increased risk of blood clots at the tiny vessels feeding the pregnancy. Therefore, the key to treatment is to use medications that decrease this clotting. Obviously the low dose aspiring was sufficient for your previous pregnancy. I don't think the Dexane (dexamethasone# contributed much. It is a steroid and used mainly to decrease the inflammatory response, however I also use it for my IVf patients to reduce the chances of rejection of the embryo. The recommended treatment is to use low dose heparin #2000 units twice per day) or Lovenox beginning at the start of the menstrual cycle or treatment cycle, in addition to the aspirin. I use both. I think that your overall chances for another successful pregnancy are good. You still might have additional miscarriages but that could be due to other reasons as well. There is an overall risk of miscarriage in 40% of pregnancies just due to random abnormalities. But don't worry about it too much. Keep trying, and I am confident that you will be successful.
Sincerely,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.blogger.com/www.montereybayivf.com
Monterey, California, U.S.A.
for additional information check out my blog at http://womenshealthandfertility.blogspot.com/ check me out on facebook and twitter with me at @montereybayivf
Hello Dr Ramirez,
ReplyDeleteThank you for your response above, which I found helpful. I was hoping you might be able to comment on my situation. I live in Australia and after 3 miscarriages, I have just lost another baby. I have found speaking with and discussing your recommendations, Obstetricians and Haematologists in Australia are reluctant to treat a heterozygous Factor V Leiden patient (which I am) during pregnancy at all. Could you shed light on why this might be the case? Is there medical research in America which might not be available in Australia? My preference would be to be treated as you have suggested and hopefully enjoy a successful pregnancy, but I don't know who to ask and with what exact information. I am hoping you can provide some advice? Many thanks,
There is medical research available and you could probably find it through the web. Another helpful source would be www.rialab.com. It is a practice in the U.S. made up of immunologists that specialize in recurrent miscarriages. I think they will do internet consultations but I am not absolutely sure. But you should check them out. You could probably use their site or advice to share with your doctors. Keep in mind, however, that many doctors are strongly tied to their own base of knowledge or training. Sometimes it is very difficult to get them to think outside of their comfort zone. In that case, you just have to keep checking around until you find the right doc. I, unfortunately, don't have the time to search for you and find the specific research that you are seeking.
ReplyDeleteGood luck.
Dr. Ramirez:
ReplyDeleteI am 35 and get easily pregenant on my own. I have had one normal healthy pregnancy 2 1/2 years ago, but ever since over a year and a half now I have had 4 miscarriages after the 3rd a saw a specialist that ran many blood tests and found that my antiphospholipids are high. Eventhough I was taking 1 lovenox shot every morning and a baby aspirin I still miscarried at about 8 weeks the pathology did not find any fetal tissue (human error) so we had no explanation. I am currently doing the same and they added an estrogen patch and my hcg levels went up in the 400's and then dropped 48hrs later to 69. I have to get betas tomorrow and am expecting the worst. Any suggestions, advice, should I see another doc? I also seem to have eczema or psoriasis on the scalp ( ever since I started misscarying hence another auto imunne issue) but no dermatlogist has confirmed, could my thyroid have something to do with any of this? Thanks.
I apologize for the delay in responding to this comment. It got lost in my myriad of emails. It sounds like you are doing what I would recommend if an immune cause of your recurrent miscarriages is suspected. I prefer to use Heparin 2000 units twice per day starting with the beginning of the menstrual cycle and continuing until 10 weeks of pregnancy, but Lovenox will do as well. If you are using Lovenox, I would recommend a dosage range from 30 mg per day to 40 mg twice per day beginning with the onset of the cycle and continuing until 10 weeks gestational age. Because there is a range, it will be a trial and error protocol to find the right dosage, but your doc might want to just move to the highest dose since you have evidence of an existing immunological disease. The other thing I would add is Medrol starting at 16 mg per day from the start of the cycle, then decreasing to 8 mg per day at the approximate time of ovulation until the pregnancy test. Then stop if positive.
ReplyDeleteGood Luck.
Dr. Ramirez, I would love your input please! I'm 29 years old. I have a five yr old daughter who is perfectly healthy. My pregnancy was natural and very smooth as well. I've been trying for a little over a year know for another but have had 3 miscarriages in 9 months. I have factor v which I found out after my 3rd mc. I am now seeing an IVF specialist here in Buffalo, Ny that also deals with recurrent miscarriages and have also found out I have MTHFR ( I believe that's how it's spelled). My husband also has factor v as well. I was on lovenox 40 mg but started a week after I found out I was pregnant. I seem to get pregnant very easily but my Doctor wants to put me on femara as well and I'm just confused on why. Please please please giver your professional opionion or let me know if I'm missing something I should be doing! Thanks for your time! Alicia
ReplyDeleteIt sounds like your RE wants to do a "super-ovulation induction cycle" to increase your per month chances of pregnancy. It may not be necessary in your case, but it may help to make things happen faster. The downside is that it increases your chances of a multiple pregnancy like twins. It will do nothing for your recurrent pregnancy losses.
DeleteI use a protocol in my RPL patients which include low dose heparin or lovenox, low dose aspirin, medrol, estrogen and progesterone. In MTHFR patiets I add an increased amount of Folic acid. The aspirin, heparin,medrol, folate and estrogen are started with the onset of the cycle. The progesterone is added after ovulation.
You need to make sure all the other causes of miscarriage have been ruled out as well.
Hello Dr Ramirez,
ReplyDeleteI had 5 failed ivfs and recently found out that I have homozygous Factor v Leiden in my blood.other than that my doctor said that my uterine condition is normal. My doctor put me on 40mg clexane and cartia everyday. This time I got 1 blastocyst and 1 morula which was put back in my uterus. But still it didn't work. I am heartbroken at the moment. Can you please advise what went wrong this time. At the moment I am 41 years old and I started ivf treatment when I was 34 years old. Still no luck.