Sunday, December 27, 2009

43 yr. old Trying To Conceive Needs High Stim Protocol


My Medical History: TTC 4.5 yrs. (3.5 with RE) Many IUI's & IVF's. 3 chemical pregnancies - 2 with IUI 1 with IVF. AMA - 43ys young.

Had a Coagulation Panel done - Mutation found -
heterozygous MTHFR C677T
Results negative for Factor V mutation
Factor II DNA Analysis
Results WNL for
Lupus anticoagulant
Elevated levels for
Protein C Functional (187)
Factor II Activity (133)
Plasminogen (161)
B2 Glycoprotein (low positive)

Do I need to supplement my prenatal with extra folic acid and b vitamins? Baby aspirin? If so - can I just add extra supplements or do I need an Rx for something like Folgard?

Could this be the reason for all of my failed IUI's, IVF's and chemicals? Before finally agreeing to do this testing, my RE kept telling me that immune issues are too controversial and that the risks of their treatment outweighed their assumed potential benefits. I don't know what his thoughts are now as I couldn't get a Dr. callback for 3 weeks.

Many thanks, Dr. Ramirez, for so graciously donating your time in answering our questions! Your services are invaluable! Oh, yes - I am located on the east coast.


I'm afraid I am in agreement with your RE, although for slightly different reasons. We do know that the immune system does contribute to miscarriages, although I am not sure that is the problem that you have. There are definitely some very controversial treatments, such as IVIG, which are very expensive and have not been shown to be of benefit in multiple studies. However, the alternative, which I try with all my patients is low dose aspirin (81 mg) per day, progesterone (injections and suppositories) and low dose heparin 2000 U twice per day. This regimen has been shown to help with recurrent miscarriages and is very low risk. That is why I use it. I have had some successful pregnancies in patients with recurrent miscarriages using this cocktail.

However, although you are still very young in my book, your fertility age may be the basic problem. You have shown that you can get pregnant. The problem is an egg problem. It is what I call "age related egg factor." We know that because a woman is born with all her eggs, and they age with her, and the lifetime of the eggs are about 43 years old, they deteriorate with time and age. This deterioration causes internal problems in the egg, including fragile chromosomes. This leads to bad embryos that either don't progress in their development, don't implant or end in miscarriage. There is a 40% chance of miscarriage with each pregnancy in your age group. Chromosomal abnormalities is probably the major reason for your losses.

There are only two ways to mitigate this increased risk: you can keep trying until you are successful (and hopefully you will be eventually) as long as your ovaries are still functioning well, or you can do preimplantation genetic testing (PGD) to identify the normal embryos prior to transfer (however, keep in mind that this is a new experimental technology, is very expensive, and does lower the implantation rate because of the "injury" to the embryo.).

I think that if you were to present to me, I would continue to recommend IVF with a high stimulation protocol and put you on my cocktail. I don't necessarily recommend PGD. I think nature will take care of that. The key would be to keep trying if you are determined to have a baby. There have been successes in your age group but time is running out for you.

I hope this helps,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF program

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