Saturday, October 1, 2011

Patient On Metformin To Prevent Miscarriage: Is It Necessary?

Question:

HI Dr. Ramirez,

Sorry to keep this up about the Metformin, but you have been so helpful in the past...thought I would try your take on this.

I talked with my Doc about low dose heparin, and he told me that he does not prescribe this unless tested and confirmed thrombophilia is present, which he says I do not have. He would really like me to take the metformin. I have had one chemical pregnancy and one 9 week miscarriage and am currently 5 weeks pregnant. I took his advice and so far have taken 5 pills. I am extremely nauseated, which I know is from the Metformin as a few hours after it started. I REALLY DO NOT want to take this stuff after just recovering from OHSS. IS there any greater risk of miscarriage stopping now that I've started, and is there a greater risk of miscarriage if I don't take this med. I would love your thoughts on metformin and PCOS. Many sites are saying it really helps in the early stages of pregnancy for PCOS women to stay pregnant.

Thanks so much for your time....once again! C. from Canada

Answer:

Hello C. from Canada,

Metformin does nothing to help with a continuation of pregnancy and does not need to be continued once pregnant unless it was prescribed for diabetes. It is a pregnancy category B medication so is safe in pregnancy if your doctor insists that you continue it. If you were my patient, you would not be on it now. Metformin, given to help some PCO patients ovulate, is for that specific reason only. Once pregnant, the Metformin has done its job and is no longer required. If it is causing side effects, which it usually does, then I think I would recommend that you stop. There are absolutely NO recent studies that show that continuation of Metformin in PCO patients helps the pregnancy to survive or continue. Pregnancies continue or miscarry for many other reasons. Your doctor is mistaken but since he is the doctor you have chosen for your care, you have to decide if you are going to abide by his recommendations or not.

By the way, based on his comment about heparin, it is clear to me that he doesn't understand its use in recurrent miscarriage patients or infertility patients. It is obvious that he is not a specialist in that field. Please see my section on "Recurrent Pregnancy Loss".

P.S. Regardless of what many sites may be saying on the internet, you are wise to ask the advice of a medical professional.

Good luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

26 comments:

  1. Hello,

    Thanks for this great response. Is the mechanism behind how metformin induces ovulation in PCOS women known? And is this mechanism irrevalent when trying to prevent miscarriage?

    Thanks

    Jennifer

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  2. Metformin is an insulin blocker. In some PCO patients, there is elevated insulin and this leads to the ovarian or ovulation disorder. By blocking the insulin and getting the levels back to normal, the ovaries will sometimes return to normal function. This is not the case with all PCO patients or PCO patients with elevated insulin levels. Metformin does not influence or prevent miscarriage.

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  3. Dr. RamIrez,

    I am so relieved to find you site. I recently suffered a miscarriage at 6 weeks. I have PCOS and took metformin with my last two pregnancies. I had to stop metformin due to elevated liver function tests after a bile duct injury. After reading all the sites suggesting continuance of metformin in the first trimester, I've been blaming myself for not attempting the metformin again. I am not diabetic, but I do have insulin resistance. Your comments give me hope that maybe I did not cause my miscarriage.

    Thanks,
    Suzette

    ReplyDelete
    Replies
    1. You are welcome and I'm glad that the information was useful to you. However, I don't think that stopping the Metformin was the reason for the miscarriage. By 6 weeks gestational age, the pregnancy usually can support itself through the placenta and your insulin resistance should have no affect on the pregnancy. Good luck.

      Delete
  4. Hi I have pcos and insulin resistance. I had a miscarriage in December at 9 weeks. In march this month I found out im 5 weeks pregnant . I have hypothyroidism. I take levothryroxine every day. Do you suggest anything special for me to do or take?

    ReplyDelete
    Replies
    1. I would not make any suggestions at this point because there may not be any problems. One miscarriage does not indicate that here is any problems since we know that the natural chances of a miscarriage can be as high as 40% per pregnancy.

      That being said, there are some things that you should consider doing: (1) make sure you are on a good prenatal vitamin with at least 1 mg of folic acid, (2) I would recommend a progesterone supplement such as Crinone or Endometrin just as a little help with the implantation and early embryonic process, (3) make sure that your thyroid level is normal with a TSH of less than 2.0 (4) don't worry. The stress and anxiety might be detrimental and there is no sense in worrying over something you have no control of.

      Good Luck

      Delete
  5. Hello,

    I am so glad I found this. I am 6 weeks pregnant. I was diagnosed with PCOS in March of 2014 because I wasn't getting my period for the past 4 months after having normal periods on the pill for 9 years. I am not diabetic, she said I have a mild insulin sensitivity. I am 25 years old, 5'2" and was 172 pounds at the time. I started Metformin (500 mg 2x/day). My period resumed in April and I became pregnant immediately. Unfortunately that ended in an early miscarriage around 5 weeks. I became pregnant again in June after losing 15 pounds. So far I am 6 weeks and it has been confirmed by ultrasound (no heartbeat detected yet, she said still too early).

    She wants me to stop taking the Metformin because I was able to get pregnant, I lost weight, and I am not diabetic. I was a little apprehensive of this because of all the things I've read online saying that it can help prevent a miscarriage if taken the first twelve weeks of pregnancy. I told her my concern and she stated that as long as I continue to eat healthy that I should be fine and you don't want to expose the baby to anything unnecessarily. I still feel skeptical, but want to trust her as she is a very good doctor. I am so scared to have another miscarriage and will do anything to make it through the first trimester. I go back in a month for my next ultrasound. My hormones were always OK, I never had ovarian cysts--the only way she diagnosed my PCOS was based on the fact that I was a little overweight and that my periods had stopped. Any advice would be much appreciated!! Thank you,

    Stefanie

    ReplyDelete
    Replies
    1. Hi.
      As I've written in this post, Metformin is not necessary to prolong a pregnancy or prevent a miscarriage. Miscarriages usually occur for other reasons, the majority of which are caused by genetic abnormality. I think your doctor is giving you reasonable and proper advice. On the other hand, it will not hurt for you to continue the Metformin until 8 weeks gestational age (the highest risk period for miscarriages), if that makes you less stressed and more comfortable. So, using it would not be medically indicated but would only be for your peace of mind.

      Delete
  6. Hi, Dr. Ramirez. Thank you for answering this question, but I thought studies showed Metformin does reduce rates of miscarriage in women with PCOS when taken throughout the first trimester? http://www.ncbi.nlm.nih.gov/pubmed/20441061 http://www.ncbi.nlm.nih.gov/pubmed/18834342 I'm no doctor so I can't necessarily interpret these results. Do you have a problem with the way the studies were done? I feel like 2009 and 2008 are recently enough to be medically relevant. Trying to figure out what to do.

    ReplyDelete
  7. Hi Dr Ramirez,
    I have mild insulin resistance and my Dr advised me to take metformin. I have had 2 miscarriages this year (while taking metformin). Since the second miscarriage I have stopped taking the metformin. I am about to start another round of IVF and not sure whether to start taking the metformin again or try this time without it. Can you please advise what you would recommend.
    Thanks

    ReplyDelete
    Replies
    1. You should take the Metformin. It had nothing to do with the cause of the miscarriages.

      Delete
  8. Hi Dr Ramirez, after reading this thread I would also like to ask your opinion.. After doing research myself, I am starting to second guess my ob/gyn. After suffering from 2 miscarriages, one in May at 6.5 weeks and the other at 8.5 weeks in October, both were found through routine ultrasounds where there was no fetal heart beat and my body did not naturally miscarry either pregnancy, so I had to have a D&C for both. He then ordered extensive lab testing and chromosome testing for my husband as well. After getting the results back he determined that I was deficient in folic acid, a single mutation of MTHFR, and told me to start taking a supplement for it. After reading through the lab results and researching them myself, I also realized that I had elevated levels of antiphosphatidylserine IgM of 39, which normal levels are between 0-25. He stressed that this didn't really mean anything and wasn't anything of concern, even though the levels were elevated. After researching this myself it seems that it could be related to antiphospholipid syndrome among other issues.. Do you feel that a folic acid supplement is sufficient enough to help/fix my issues? And/or would you do anything differently? Such as more testing or prescribe a low dose of heparine, etc.
    Thanks!

    ReplyDelete
    Replies
    1. Hi. I would recommend Folic acid 4 mg per day, as well as, add aspirin 81 mg per day, medrol (prednisolone) 16 mg per day and decreased to 8 mg per day on the day of transfer, additional progesterone supplementation and some estrogen supplementation. I would also strongly consider using mini-dose heparin 2000 units twice per day. I make these recommendations based on the positive MTHFR and anti-phospholipid (phosphatidylserine).

      Keep in mind, however, that IVF and fertility treatments are highly dependent on the preferences, training and knowledge base of the doctor you are seeing. Also, there are NO gold standards, that is, we don't all do everything the same. Therefore, what I might do and recommend are not necessarily the way that it should be done and your doctor may not agree with them. You'll just have to make the decision how you want to proceed and whether or not you should seek the care of a doctor that provides the kind of care that you want.

      Delete
    2. Thank you for your insight. I'm actually not doing IVF though. We don't seem to be having any problems getting pregnant, the problem is in keeping the babies alive. We found out that both babies had passed through not finding fetal heart beats in routine ultrasounds, given their body measurements we discovered that they both passed the week prior to the ultrasounds, but my body was not miscarrying naturally. He hasn't referred me to a fertility specialist but I'm beginning to think that a second option certainly wouldn't hurt! I sure don't want to experience this for a 3rd time! I will definitely be contacting his office to meet with him about referring me to a specialist or doing more than just taking a folic acid supplement. Thanks again!

      Delete
    3. Hi. I hope this information will be of some help. I was not inferring that you were doing IVF, rather was giving it a more generic audience in the reply. However, it does apply to your situation as well. The protocol that I stated is an acceptable protocol for Recurrent Pregnancy Loss patients using any fertility treatment type and even if trying naturally. The point that I was making, however, is that this protocol may not be one that your doctor agrees with or uses, so be prepared.

      Delete
  9. Hello, I was diagnosed with PCOS when I was a whopping 16 years old because of an irregular cycle and large amounts of hirsutism. Since then I have had 2 healthy pregnancy and 1 loss, my cycles have regulated and I think this was a result of my diabetic grandmas cooking( miss her). I am currently in my mid-thirties and have been trying to conceive baby #3 with no luck for over a year. I have to admit that I am 40 lbs heavier than I was with my other two pregnancies but have been constantly eating right and working out with no results. When I was diagnosed I was not put on any medication whatsoever. Even though I have regular cycles I do not think I ovulate every month (BBT & opks). Fast forward to now, I see metformin as my only option until I read over this post. I have conducted my own research and I completely feel as though it’s my testosterone level and my question is will Metformin help with this issue Hirsutism and my male hormone? Or what would you recommend? Thanks in advance!

    ReplyDelete
    Replies
    1. Hello. Metformin is for insulin resistance that causes an elevated insulin level. Some PCOD patients have this and so by reducing the insulin to normal, the PCOD ovarian dysfunction resolves. Metformin has no effect of hirsuitism or elevated testosterone. The elevated testosterone is a consequence of the ovarian dysfunction due to PCOD and hirsuitism is the result of the elevated testosterone. The treatment for this is to correct the PCOD and block the testosterone, and in patients not desiring pregnancy, we use a specific birth control pill for that. For patients desiring pregnancy, ovulation inducing drugs are used.

      If you have regular menstrual cycles, YOU DO NOT HAVE PCOD. A diagnosis of PCO REQUIRES an ovarian dyfunction, i.e. problems with ovulation which leads to irregular cycles due to a lack of ovulation. If you have regular cycles and hirsuitism, then another cause has to be found, such as an adrenal problem. You need to see an endocrinologist or reproductive endocrinologist/infertility specialist.

      Delete
  10. I have PCOS but no idea about my insulin resistance or progesterone levels etc. I've been told to come off Metformin at 18 weeks pregnant by OB/GYN as he said to me the same info as you have stated.
    However because of this will my hormone imbalance affect my baby and cause a miscarriage even after 12 weeks? Are women with PCOS at high risk of miscarriage throughout or does it drop after 12 weeks like normal women?
    Do you think I need hormones monitored if I come off the met?
    Many thanks

    ReplyDelete
    Replies
    1. No. The pregnancy takes over making its own hormones so you needn't worry.

      Delete
  11. I have PCOS and I was pregnant, I stopped Met at 13 weeks and I miscarriaged at 14 weeks.

    ReplyDelete
    Replies
    1. It was probably not due to the PCOS or Metformin, rather it was coincidental. You can't draw conclusions on coincidence.

      Delete
  12. hello doc i am i am 25yrs old and had a preterm birth with my first child at 7mos..he is now 7yrs old..5yrs ago i was diagnose with pcos which i never thought will affect my fertility.. my husband is only here for 2 mos every year because he works overseas.. when he came back from work 2 mos ago i bought fertility blend for me and women and after we consume our first bottle we got pregnant..but reading blogs about it, some women miscarried after they got pregnant and stopped taking fertility blend so i got scared..i told my obgyne about it and she put me on duphaston and metformin both twice a day until my 16weeks...i am now 12 weeks pregnant..im also taking folic acid 5mg aday... i just wanna ask if i can stop taking these meds now? would it be ok even she wants me to take them till 16 weeks?? will i miscarry if i stop taking them? thanks doc

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    Replies
    1. I would think that you could stop those medications at 12 weeks. I usually stop my patients at 10 weeks gestational age. At 8 weeks, the placenta takes over and produces all the hormones that it needs.

      Delete
  13. I have PCOS But have concived naturally 3 times with 2 live births and now I'm 5 weeks 5 days. I've never been on any medication not had my progesterone checked with any pregnancy because I haven't had a loss or spent over a year trying to conceive. I keep reading my risk of loss is upwards of 65% with PCOS. Is this true? It's it based of early pregnancy or throughout the first trimester? I saw the heartbeat at 5 weeks 2 days and was simply told everyrhing points to a healthy pregnancy. But I'm clearly worried.

    ReplyDelete
    Replies
    1. No. You can't believe everything you hear or read on the internet. If a hearbeat was seen at 5+ weeks that is a very good sign, but too early to say it is a viable pregnancy yet. That ultrasound needs to be done at 7-8 weeks gestational age. If it shows good interval growth, good fetal heart motion and good gestational sac size, then the risk of miscarriage decreases to 5% from 40%. The problem with PCOD is getting pregnant. Maintaining the pregnancy is not usually a problem. The placental produces all the hormone that it needs.

      Delete
  14. I have PCOS and recurrent pregnancy loss. I ovulate regularly and conceive naturally but pregnancy fails prior 9 weeks. It was suggested I undergo IVF with PGS testing and I did. We transfered 2 day 5 PGS tested healthy embryos. I concieved and by 20 days poat transfer found my beta dropped and will miscarry. My husband and I underwent all preliminary fertility testing prior IVF. All tests including thyrpid, lupys, chromosome, blood clot issues, etc were normal. I am not insulin resistant. I found your page researching if metforim may have prevented my chemical pregnancy. I see it would not. my question is I'm going to ask my endocrinologistshe performing his to Scott B with endometrial biopsy in endometrial scrape. I was wondering if there may be any immune testing you would recommend? Considering I conceive and embryos were healthy I cant help but think my body is killing embryos when they try to implant. my follow up appointment with my reproductive endocrinologist is the fourth and I plan to discuss all options with him then. But found your site useful and wanted to ask for your suggestions too. Thank you.

    ReplyDelete

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