Possible Uterine Abnormality Or Immunologic Disorder Causing Four Miscarriages In 32 Year Old: IVF With Surrogate Again?

Question:

Background: I am 32 as is my husband. We had an ectopic pregnancy 10/2005, 8.5 week miscarriage 3/2006, 10 week miscarriage 8/2006, 9 week miscarriage 2/2007 (genetic testing done - female/chromosomally normal), and 9 week miscarriage 8/2007 (male/chromosomally normal).

We had a healthy son via gestational surrogacy with my egg in 2008. During the IVF (in vitro fertilization) procedure for this surrogacy, I only produced 6 eggs and only 1 blastocyte made it to the 5 day transfer as an 8 cell blastocyte. I have Hashimoto's Disease (on medication since 2000), diagnosed with Endometriosis in 2005 (2nd lap in 1/2010 showed it is gone) and diagnosed with Adenomyosis in 1/2010, after which I took Depot Lupron for 4 months.

I have had every genetic test I've heard of and the only issue is one copy of the MTHFR gene. I took 81 ASA and Heperin with my last two pregnancies, and progesteronne with the last four. I even did IVIG with the 5th pregnancy. Two weeks ago I tested my FSH and it was normal. I also had an AMH test and it was 0.2, very low.

My RE has told me that I should try IVF (with me being the carrier) but I'm not sure. I know they are concerned about the number of eggs I have left and the quality of the eggs that are left. What I want to know is if my 2nd through 5th pregnancies could progress to 8-10 weeks with normal hearbeats and the last two we know were chromosomally normal, does this have anything to do with poor egg quality? How could these last two pregnancies test normal but be of poor quality? Is that possible?

Thanks! D. from the U.S.

Answer:

Hello D. from the U.S.,

To answer one of your last questions, since your pregnancies were know to be genetically normal, this is not an indication that you have poor egg quality. Poor egg quality leads to abnormal embryos (genetically) because the chromosomes within are fragile and break during division. It is most likely that you have either an immunologic disorder or a uterine abnormality. The latter might be the case because a surrogate was successful with your eggs.

I don't see any reason for you not to try with your own uterus if you can afford it financially. The only downside is if the uterus is a problem, you will end up miscarrying again and will have spent the money for that IVF cycle. I am not sure that I am convinced that it is a uterine problem, however, because the previous pregnancies progressed as far as they did. I would recommend that you go the gamut with the next in vitro fertilization cycle, using aspirin, heparin and IVIG if you decide to use your own uterus. That may be what it takes. If finances is an issue, then I would recommend that you use a surrogate again.

I know these are tough decisions but your young age, the positives that you have had, in addition to the child you have already had via surrogate two years ago, make your chances for another pregnancy very likely.

Good Luck,

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.

Low Ovarian Reserve & Previous Placenta Accreta

Question:

Hi, I had placenta accreta with my son's delivery in 2007 and lost quite a bit of blood. I did keep my uterus but had to have uterine embolization to stop the bleeding. My doctors alsways said to wait 2 years before trying to conceive, but after seeing numerous doctors recently, I was told I would be risking my life again to consider another pregnancy. I also have a large fibroid about 4 centimeters in my uterus along with a distorted uterus.

The doctors feel the embolization probably caused my ovaries to stop functioning, or even the massive blood loss could have caused it.

We have looked into surrogacy but found out that I have very small ovaries, about 1 centimeter each and low ovarian reserve. The doctor did an ultrasound and said there was blood flow, but feels I am pre menopausal. I went off birth control pills in January and was tested in February. My FSH was 9 and my estradiol was 9. I did 3 days of injections (45) and the doctor only saw one follicle so said to stop treatment. In March, My FSH was 16.75 and E2 was 10. The doctor saw 2 follicles on day 2. The doctor said if I did a full round of IVF the chances would be very low and the quality most likely low. The plan was to do IVF and then have a surrogate. I went to a doctor this week that said I could try knowing the chances are low and to retrieve the eggs, even if there were only 1 or 2.

I am not quite ready to give up, we have also considered egg donor. I am 36 years old. Any suggestions or success rates would be great. Thanks so much!

Answer:

Hello,

I am sorry to hear about your experience. It sounds like you have very low ovarian reserve as demonstated by an elevated FSH level and poor response to stimulation. Certainly, your best option would be donor eggs. That would have a 34 - 63% pregnancy rate per IVF attempt depending on the clinic (our program is 63%). Of course, there is the alternative of trying with your own eggs. Because the stimulation would be low i.e. few eggs retrieved, the chances would go down, but there is still a chance. I have done many older (older than you) patients that have only had one egg produced, one retrieved, one fertilized and one transferred and gotten pregnant and had a baby. So in my opinion, it is more a personal decision on whether to try with your own eggs, al long as you know that the chances are reduced. There is not a specific statistic for your case that I can quote as no one has looked at pregnancy rates based on the number of eggs retrieved. In your age group, I average replacing 3 embryos with a pregnancy rate of 50%. It would probably be less if only one was replaced. European data, where they only transfer 1 embryo, shows pregnancy rates of approximately 33% in your age group. That assumes a higher number of eggs retrieved, fertilized and available to choose from. In any case, I think that if money were not an issue, and you were willing to try with your eggs at least three times (you might even need more), knowing that the chances are significantly reduced, then you should give it a try. If it fails, at least you know that you gave it your best shot, and will be ready to go to donor eggs. I certainly would allow you to have that opportunity in my program.

In terms of your pregnancy risks, you are certainly at risk for a recurrent placenta accreta if you were to become pregnant. However, that can be mitigated by being followed closely and planning for a hysterectomy at the time of cesarean delivery. I would not recommend an attempt at natural delivery in your case. I would also recommend that you consider having the fibroid removed prior to any IVF cycle to maximize the chances that they will not interfere with the IVF cycle or pregnancy. Regarding the surrogacy option. Certainly surrugacy is a good alternative and would eliminate the problems with your uterus, whether you choose to use your eggs or donor eggs. If you go this route, be sure you go with a reputable agency and retain the services of a surrogacy lawyer.

I hope this helps!

Edward J. Ramirez, M.D.,FACOGExecutive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

Check me out on Facebook and Twitter with me at @montereybayivf

Pregnancy after endometrial ablation?

Question:
Is there any possible way of conceiving after an endometrial ablation? Is there any way of repairing the uterine lining?

Answer:
Hello Leah from Canada,
　
If the endometrial ablation was performed correctly, which destroys and scars the endometrial lining/cavity, pregnancy is not possible. However, sometimes pregnancies occur where some area of the endometrium has not been ablated, which is an error in technique. In these cases, the patient will usually continue to have menstrual cycles. There is absolutely no way to repair the uterine lining. The only option would be to use a surrogate if pregnancy were desired and the ovaries were still functioning.

Sincerely,

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

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on facebook and twitter with me at @montereybayivf.