Wednesday, December 23, 2009

40 Year Old With Multiple Miscarriages Needs Correct Specialist


I have been trying to conceive for 3 years, have had 3 miscarriages, all between 6-9 weeks (one was trisomy 22, the other two are unknown. Two pregnancies required progesterone suppository supplementation). I am 40 years old, hypothyroid, insulin resistant, have a bicornuate uterus, my DRVVT came back Borderline (lupus anticoagulant, recommended re-test in 12 weeks), positive for ANA's, 1:320 titer, speckled), and compound heterozygous MTHFR gene mutation (variants C677T and A1298C). I am getting ready to try again. I was already taking synthroid 88, and 850 mg metformin twice a day.

My doctor has put me on folgard in addition to my Prenate DHA prenatal vitamin, baby aspirin, 10 mg prednisone twice a day, and I am taking 1 tbs Maca Magic, as well as 1 tsp royal jelly. Should I be taking low dose heparin as well? Lovenox? Start the progesterone suppositories immediately after ovulation?

My high risk pregnancy doctor recommended I not do IVF, because he said that at 40, my eggs are much too fragile to undergo retrieval, fertilization, analysis and reimplantation. He also indicated I would have a harder time getting pregnant after this (likely) failed. Please let me know your thoughts on this. Also, do you have any research you can direct me to, indicating that only 1 in 40 or 50 of my eggs are normal at 40 years old?

Would love to know your thoughts. I can't bear to go through another miscarriage. Thank you.


You seem to have lots of reasons for having miscarriages, but probably the most common and predominant reason is your age. This "age factor" leads to spontaneous chromosomal aberrations that lead to abnormal embryos and subsequent miscarriage.In terms of your immune factors, just to cover those bases I would recommend either low dose heparin or lovenox. The progesterone should be started right after ovulation and continued until the pregnancy test is negative or 10 weeks gestational age.

Although you are able to get pregnant naturally, the only method that would increase your chances of a successful pregnancy is IVF. The reason is that multiple eggs can be extracted thereby increasing the chances of having a good egg (normal). It is not for sure, but will statistically increase your chances. At your current age, you probably have 1 out of 40 to 50 eggs that are normal. (When this post was published in 2009 no one really knew how many "good" eggs exist in the 35+ woman...and although it is still not 100% certain, a recent 2013 study has come out with some answers. The study found that 2 out of 20 eggs retrieved from 40 yr old women were chromosomally sound and had the potential of fertilizing and implanting successfully.) When you go through a natural cycle, you are only ovulating one egg at a time, so you can see that your chances that it will be normal is low and the chances of being abnormal is high. That is where IVF can help. With IVF you could get anywhere from 10-20 eggs at a time, depending on your ovarian function. Because time is against you, that is what I would recommend. The aforementioned medications should be used in conjunction with the IVF cycle.

As far as what your high-risk (I assume perinatologist) ob/gyn has recommended, I think you need to decide who knows fertility better. A fertility specialist or a high risk pregnancy perinatologist. As a fertility specialist, I have to disagree with your perinatologist as to your chances of pregnancy. As mentioned previously, IVF is the treatment of choice at your age. He is correct in that the chances of pregnancy are reduced because of the age related egg factor, which means that the majority of your eggs are no longer viable and prone to genetic abnormalities (spontaneous breakages), but is incorrect in saying that IVF will worsen your chances because the "eggs are too fragile for retrieval, fertilization or implantation."

In order to educate yourself regarding age related infertility and egg quality, your best source is ASRM's new website,, or the CDC website. Each of these have the information you are asking for regarding the age-related reduction in infertility.

Good luck in your journey and don't hesitate to look for the right approach by seeking a second opinion.


Edward J. Ramirez, MD, FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF

1 comment:

  1. My oocytes left on one of the ovaries may cause the ICSI procedure falling?
    I had two failed ICSI procedures. I am going to do 44 years in a couple of months.
    First of all, I apologies for the English (I am writing from Portugal) and thank you very much for the attention as I am very afraid that is almost too late for me as I already have 43 years old, and 2 ICSI protocols were I did not conceived.
    Me and my husband, have a 10 years old sun, resulted from a natural conception. After 3 years trying to conceived, we discover that the sperm number and mobility was too low: 1.05x10^6/ml; 3.57x10^6 total; 0% normal morphology; 35% progressive motility; 10% non progressive mobility. For that we tried on January the 1st ICSI and after 6 months later the second ICSI.
    On both cases it was not possible to retrieve oocytes from the left ovary, on the first case because the intestine was in front of it, on the second because an important artery was in front of it.
    On the fisrt cycle i received 300IU Gonalf (for 11 days) and Cetrotid (0.25 after 6 days of starting Gonal F). 36h before oocyte retrievel 10 000 IU Pregnyl. These resulted in 3 oocytes on each ovary. The estradiol levels were OK.
    The 3 oocytes retrieved from the right ovary, resulted in 2 fertilizations, and "two good" embryos that were implanted after 2 days. My endometrium presented 7mm at the implantation day. I started Progesteron 2 times a day of 300IU.
    After 10 days of embryo transfer, I start to bleed. My hCG blood at 14th day was 1 IU.
    On the second protocol: I received ELonva 150 IU (I have 60Kg) a plus Menopur (150 IU) a 7 days after ELonva. The Cetrotide was as previously. This time tI received only 5000 IU Pregnyl instead of 10 000 as before.
    The doctor give-me also Lovenox 20/ day till the Pregnyl addition 36h before occyte retrievel, that restarted 4 days after oocyte retrieval. [My blood levels at the third day of the period were: anti-tiroglobulin (Tg) is 122 KIU/L instead of 60; hFSH is 16.3 UI/L; Antinuclear antibodies 160; S functional protein 127%, the remaining blood results were normal. Since 10 years ago I start to experience some alergic reactions: red skin and itch in my back and neck.]
    This resulted in 5 oocytes in the right ovary, and at least one on the left ovary. My d left ovary was very difficult to visualize and was smaller than the right one. As an artery was very near of it, this oocyte was not retrieved, as happen of the first ICSI.
    From the 5 oocytes retrieved, 4 were fertilized. One presented as "anormal": as it was observed an extra nucleus ?? The second fertilized egg, only presented 5 cells after 3 days after fertilization. The other two embryos, after 3 days, presented 6-7 cells, "some" fragmentation", but were consider good. These two embryos were implanted after 3 days of the fertilization.My endometrium was 10.7mm instead of 7mm as before.
    From January to May I restart to do some gymnastic, that resulted in 5 Kg lost, and diminish body mass index from 28.4 to 26.1. I feel much better with more energy, and my period that was in January from 26 days increased to 28 days. (My period was always 28 days till 2 years ago, and now with my return to the gymnasium it return to the 28days as before).
    For this time the Progefick, that was also started on the day of oocyte retrieved, was given 3 timesinstead 2 times/ day, but maintaining a total 600IU dose/day.
    My period came on the 15th day after oocytes retrieved, instead on 12day as on the first ICSI.
    My blood hCG test made on the 17day gave 1 IU :(
    My oocytes that remaining in the left ovary could difficult the implantation?
    What protocol would you advise for a third (and last) ICVI attempt......
    Thank you a lot.



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