Sunday, July 3, 2011

4 Weeks Pregnant, Hypothyroid, At 43 After Clomid Cycle: How Are My Levels? What To Do If I Miscarry?

Hello, I’m in California.

I just found out I’m pregnant, about 4weeks 4days. I had my first beta; it was only 18 at 14 dpo and 24 at 15 dpo. I took another yesterday at 17 dpo, but I won’t know the results until tomorrow. Either way, a very poor prognosis for a viable pregnancy.

I know I should just wait until tomorrow, but I want another opinion. This is an agonizing waiting period – I feel like I don’t know if I’m coming or going. This is the 5th or 6th time I’ve been pregnant, but I’ve never had a pregnancy like this, where I have no symptoms whatsoever. I can unhappily handle a miscarriage, but I do NOT want it to turn out to be ectopic, which is what I fear the lack of symptoms means.

Question 1:
I am on Crinone 8% 1/day. Would that “mask” a miscarriage? I know it won’t stop a miscarriage, but what I’m trying to find out is if the progesterone will stop the bleeding I would have if I were to miscarry? Will I not start bleeding until I stop using the Crinone? (Which I’m not going to do until I find out for sure what’s going on.)

It turns out that my TSH is high, about 5.7. And from what I understand, that number may actually have been higher prior to pregnancy. I should have been medicated for this problem before getting pregnant, but the multitude of doctors I’ve been to never had me get this test done, as a matter of a fact, I actually added this test to the beta lab slip myself.

Question 2:
I have been told that the rate of early miscarriage is high in women with untreated hypothyroidism – IF they can get pregnant at all. Do you have any information on this?

I am going to ask to be put on thyroid medication tomorrow at my appointment. Is there a specific medication that I should be on while trying to get pregnant that is more effective for fertility and safer for a growing fetus?

I am assuming an upcoming miscarriage (I’m a realist). I am also 43, so I literally do not have a second to spare. I got pregnant on my first round of 50mg Clomid (I also added Soy Isoflavones and Black Cohosh), which says to me that I was either previously not ovulating – or my follicles were not rupturing (exact 30 day cycles). If/when I miscarry I will immediately begin trying again.

Question 3:
Should I try the Clomid again because it worked, or try something a bit stronger, injectables with an IUI perhaps?

Question 4:
Can I use fertility drugs immediately after miscarrying, i.e. before I get another period? I know that often a woman will conceive immediately after a miscarriage.

Thank you so much for your help. I wish you weren’t so far away, it would take me about three hours each way to get to you! J. from California


Hello J. from the U.S. (California),

The reason you are not feeling any pregnancy symptoms at this time is because the bHCG levels are still very low. The symptoms may come on if the levels risk over time but not all patients have pregnancy symptoms even with normal pregnancies.

The fact that the levels are increasing is a good sign. They cannot be interpreted in less than 48 hr intervals so I don't know why your doctor ordered them that way. Basically the bHCG should increase by 80% in 48 hrs. If the next level is still going up, I would continue to follow them. I caution against drawing any conclusions based on these results. They are a guide only.

Your TSH level is indeed elevated and is an indication of hypothyroidism. That means that you need thyroid supplementation. I would recommend that you see an endocrinologist or reproductive endocrinologist to have this done.

The fact that you got pregnant on Clomid is a very, very good sign! It shows that you have the ability to get pregnant! However, your obstacle is the "age factor" i.e. decreased egg quality and viability due to age. You certainly got very lucky on your first Clomid cycle but I would not expect that each time. Your natural chances of pregnancy per month (Clomid, injectables and IUI fall into this category) is approximately 0.2% per month. Using fertility medications to increase the number of eggs that you ovulate is the only way to increase your chances per month. If you are determined to continue the natural pathway, then I would strongly recommend injectables with a closely monitored cycle. Ideally, you should be going directly to IVF to give you the highest chances per attempt of 33%.

You will not be able to go directly into another ovulation inductions cycle after the miscarriage. You will need the miscarriage to resolve completely, as determined by following the bHCG's. Once this has resolved, then you can induce ovulation.

Good Luck,

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

Monterey, California, U.S.A.

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