July 2012
Question:
Hello Dr. Ramirez,
I am writing from the United States. I have been TTC for 2 years. I began RE treatment 6 months after trying to
conceive naturally at 34 yrs old. I am 36 now. I have failed 6 Intra Uterine
Inseminations and Three IVF (in vitro fertilization) cycles. Below are the
details: (for privacy purposes I have omitted the precise details of each cycle…except
for the transfer details)
First IVF: 7
mature eggs, All ICSI 1 fertilized, transferred 4 cell Grade AB on day 3
Second IVF: 17
mature eggs, 9 fertilized, transferred 2 Grade AA on Day 3, one made it to
blast and freeze (poor quality)
Third IVF - 18
mature eggs, 14 fertilized, 9 made it to blast, transferred 2 Grade AA, froze 6
good quality blasts ranging from Grades AA - BB
I never had a positive beta or urine test. I've done all the preliminary testing, water
sono, bloodwork, HSG, etc. everything is normal. My husband’s tests and sperm are also normal.
I asked about immunology testing and Doctor said there is
nothing to support that treating it helps.
I don't believe the early bleeding is normal. My luteal
phase naturally is about 11 days long.
Dr said the PIO is plenty for me and would not recommend increasing it.
I asked about baby aspirin and heparin. They said baby aspirin
is ok, but heparin can be dangerous.
I've read in your posts that you recommend that if there is one IVF
failure.
Is there harm in taking heparin? I don't know what else to
do to make them implant. What are your
thoughts considering my history? I do
not want to transfer any frozens unless the protocol is changed. I feel like
continuing the same PIO / medrol protocol is setting me up for failure
again. I appreciate your advice. Thank
you!
Answer:
Hello,
Since you have had decent embryos to transfer in at least
two of your three IVF cycles, this would be regarded as implantation failure. Thanks for reading my posts. I also discuss these issues in my blog.
Your doctor is right in that the correct general opinion,
kind of like being politically correct, is that the studies do not show any
benefit to treating for immunologic problems in IVF. However, it remains to be seen and depends
which studies you prefer to believe.
There are certainly studies that show that immunology plays a role in
miscarriages and some studies that show immunological treatments help with
IVF. I don't think it can be discounted
completely but at the same time, don't believe in every treatment that is
offered.
I certainly advocate
low dose aspirin, low dose medrol and low dose heparin in my patients that fail
two cycles of IVF for no clear reason. I
have had many be successful thereafter with that protocol, which I have been
using for the past 18 years. There is NO
danger in using low dose heparin. Full
dose heparin is another matter.
I think that the dilemma you now face is whether to continue
with this doctor or not. If you want
more, such as using the protocol mentioned, then you'll probably have to find a
doctor that will provide that to you. I
certainly think your doctor needs to reevaluate and consider what else he/she
can do since what is being done so far has failed.
You certainly can always fly out to California. :) For an FET cycle, you would only need to be
here for one day.
Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
Follow-Up Question:
Hello again,
We consulted with our RE again regarding the transfer and he
suggested doing nothing differently
and chalked it up to bad embryo genetics.
Again he reiterated no baby
aspirin so we pleaded for him to do immunologic testing, cytogenetics (on
us) and blood clotting work ups to which he agreed.
Everything came back normal, including cytogenetics on my
husband, with the exception of my protein s free antigen level. It was 151 and
regarded as "high" by the lab that ran it. He referred me to a hematologist who ran
protein s activity testing which thankfully came back normal. He said a high
level protein s is not concerning and that only a low level would be.
So here we are again with his recommendation of transferring
with the same protocol. I asked again
how about baby aspirin and he remained firm on "no". I told him 3 doctors, including one at his
practice, the hematologist and an online doctor i have emailed have said there
is no harm in using it along with my friends who have used it with no pre-existing
blood clotting disorders and went on to have successful IVFs.
He said taking baby
aspirin with no blood clotting problem can cause more complications than help. He said it can interfere with the growth of
the placenta. Is this true? So far he is the only doctor that has said no
to baby aspirin including the doctors of everybody I know who has gone through
ivf unexplained.
Are there any facts you know of with baby aspirin and
placental defects?
Again, I truly appreciate your knowledge and advice and
thank you for your responses. There
should be more doctors like you who help others online with honest,
professional opinions!
Follow –Up Answer:
Hello Again,
There are no studies that show any adverse affects of low
dose aspirin on embryo or placental development. In fact, and either you or he can look this
up in any Infertility textbook, low dose aspirin is an approved and advocated
treatment for recurrent pregnancy loss (now why would they endorse it if it
caused placental problems?). We have
extrapolated its use in failed IVF with the same idea that it increases blood
flow to the implantation site and reduces the formation of micro-clots in the
tiny vessels supplying the implantation site.
There is no way to test for these.
Since this doctor is not willing to work with you on this
very simple and innocuous treatment, which may or may not help, I think you
should seriously re-consider using him.
Good Luck,
Edward J. Ramirez, M.D.
Follow-Up Question:
QUESTION: Hello again
Have you noticed this email is more than nine months after
your last reply?
Our RE did not budge again on the baby aspirin so we decided
to wait on the next transfer and try naturally with baby aspirin.
That month I became pregnant for the first time. I went to my
RE and he confirmed it with blood though the levels were low and I was bleeding
and he did not offer progesterone cream. He said he doubted the pregnancy was
due to the baby aspirin. At 5 weeks I miscarried, and although it was sad, I
was elated at the fact that I did get pregnant. So we tried again naturally the
following cycle with baby aspirin (2 weeks after miscarriage) and what do you
know?
I got pregnant again. I went back to RE and he confirmed with
a blood test. I started bleeding again so he suggested progesterone cream. I told him we did the baby aspirin thing
again and if I should continue taking it and he said YES!
He followed my progress until 2 months and referred me to my
obgyn to monitor the pregnancy. I continued the progesterone cream until the
end of the 3 months and continued taking baby aspirin until 37 weeks. Yes, 37
weeks.
Our healthy baby boy
was born at 41 weeks, weighing 9lbs, 4oz and measuring 20.5 inches.
If I did not read your
blog, he would not exist. My husband and I attribute his existence to your blog
and cannot thank you enough. Please
continue your public advisement as it made our dreams come true.
Thank you!!!!!!
Follow-up Answer:
Hello,
I am absolutely delighted for you. Congratulations :) I'm saddened to see that you had to prescribe
a therapy for yourself, but glad that it might have done the trick. No one will ever know for sure if it helped
or not and what the mechanism is, but it seems to help many people with your
type of history. I now put all my
infertility patients on low dose aspirin from the beginning, IVF or not. Another possible factor is that you tried soon after your miscarriage--studies show that there is a higher chance of pregnancy after a miscarriage.
I'm shocked and a little disappointed that your Ob doctor
allowed you to go post-dates (41+ weeks) because that posed significant risk to
the baby such as a fetal demise, fetal distress, etc. I
NEVER let my infertility or IVF patients go past 40 weeks. The sooner the baby was out the safer it was
at that point.
Thank you for reading my blog and using this service (AllExperts) as well. I do it in tribute to the task and gifts that
God has given me, which is a part of the love he has for us. Your baby is also a gift from God for you to
treasure and teach of his ways. Devote
your love to this son and shower him with Goodness so that when he grows up, he
will shower others with goodness as well, and thereby contribute toward making
this world a better place. It is not
often that I get feedback of successes attributed to my writings, but know that
your feedback reinforces my dedication to this task.
Congratulations!
