Implantation Problems & Causes Of Chemical Pregnancy

Question:

Hi again, it's K. in NY. I have written to you in the past about my difficulties staying pregnant. I have had 7 chemical pregnancies in the past 18 months and one miscarriage at 9 weeks after using femara (you felt it was probably due to a respiratory virus I contrated around 6 weeks). I tested positive for MTHFR mutation heterozygous but also this didn't appear to be the issue.

I guess I have a 2 part question for you. The first would be related to causes of chemical pregnancies. My progesterone levels have been on the low side of normal (even during the pregnancy that ended in miscarrige) and I really thought that was the cause. I was placed on 50 mg suppositories 2 months ago and I did get a positive result this month (8 DPO Hcg 12, progesterone 18.8, took femara and progesterone) but my HCG level was back to <5 on 10 DPO.

Are there other implantation issues that could be my problem besides chromosomal abnormalities and low progesterone that lead to a pregnancy not progressing? I know I shouldn't test early, but I was trying to establish if low progesterone levels were the cause of my losses.

Part 2: is it possible to just have an underlying HCG level that elevates above 5 regularly, and if so, what would that signify? As you may remember, my old RE wrote off the HCG values as me eating too much cereal and developing an antibody to HCG that triggers pregnancy tests. I will be visiting a new RE soon and want to be sure to ask the right questions and supply the best information.Thank you very much for all of your insight and for volunteering your services. Merry Christmas!

Answer:
Hello K. from the U.S. (New York),

Let me take the second question first since it is the easier of the two to answer. The answer is NO, you can't have an underlying HCG level from cereal or any other source other than pregnancy. Serum pregnancy tests are very sensitive and testing for the beta subtype (bHCG), so there is no cross reaction even if the cows you were using the milk from were given hormones for some reason (I presume that is what your old RE was thinking as a source. A little far fetched if you ask me).

In terms of your chemical pregnancies, that is a difficult problem to answer. If you have already undergone a complete recurrent miscarriage evaluation (hormones, infectious diseases, anatomical, genetic, immunologic) then we may not have the technology to find the exact cause. However, the hormonal is easy to check through blood tests, and I automatically place my patients on progesterone supplementation just in case; anatomical testing would take an ultrasound and hysteroscopy, again an easy test; and infectious diseases and genetic are also easy to test. The only one that is difficult and not completely understood is the immunologic component. Many authorities have looked into many different immune factors.

If you look at a website by Reproductive Immunology Associates, who have made a practice of the immunologic causes of miscarriage, you will see lots of different test that they recommend. Because this component is so difficult to define, experts have conflicting opinions.

If you were my patient, I would put you on a protocol that I use and, for the most part, have been successful with. It involves taking aspirin 81 mg per day starting at the beginning of the cycle, medrol (prednisone) 16 mg per day taken from the beginning of the cycle then decreasing to 8 mg after ovulation, progesterone vaginal suppositories beginning after ovulation and, finally, heparin 2000 units twice per day subcutaneously beginning at the start of the cycle. The aspirin, medrol and heparin treat for subclinical immunologic problems and the aspirin and heparin also help to increase blood flow at the microvascular level at the implantation.

Good Luck & Merry Christmas to you too :) ,

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.

Comment: Thank you SO much for your opinion. I will definitely have to look into these additional things. Glad to hear that I am doing all that I can do on my own and that I am advocating for the right things. It makes a HUGE difference when you have an idea what direction you should be headed so that you can work with a doctor to get there. Merry Christmas!

Progesterone After IVF

Question:

My wife had IVF (in vitro fertilization) in Canada. She was prescribed Gonal-F, Repronex and Orgalutran for the stimulation phase. Two blastocysts were transferred at day 5 and yesterday our day-14 serum HCG pregnancy test was positive.

We were told by the nurses at the fertility center to stop taking the Prometrium pessaries now that the pregnancy test is positive. From reading, Progesterone seems to have many beneficial effect to the fetus, with minimal adverse effects. I think continuing progesterone supplements until the 10-12th wk is important. I am not sure why they want my wife to stop this!

Can you advise? A. from Canada

Answer:

Hello A. from Canada,

Your research is correct. Most IVF programs, if not all, will continue the progesterone until at least 8 weeks. I continue until 10 weeks and some programs will continue until 12 weeks.

I see that your center had your wife on progesterone pessaries (suppositories). For those others reading this post, there are different forms of progesterone to choose from:
• Daily oral progesterone
• Daily intramuscular injections (IM)
• Daily vaginal pessaries. These are mounted in wax, which melts as progesterone is absorbed causing discharge. It may be necessary to wear a panty liner.
• Daily vaginal tablets
• Daily vaginal gel

There are several formulations of vaginal progesterone: Crinone 8%, Prochieve 8%, Endometrin 100mg and pharmacy formulated versions. Several very good studies have shown equal efficacy to IM injectable progesterone. However, most RE's are trained on IM Prog and so don't want to make any drastic changes. I happen to use both. If a patient cannot tolerate the IM Prog or has an allergic reaction to it, then they can switch to the vaginal version.

Bottom line: There is no harm in continuing the progesterone, but if removed prematurely, it could jeopardize the pregnancy.

Good Luck and Congratulations,

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

Estrogen Patches Vs. Estrogen Injections: Which Is Better For Pregnancy Success?

Question:

I have four frozen embryos which I would like to have transferred. My question is what has a better success rate with prepping the uterus, the Vivelle dot 0.1mg patches vs. the delestrogen injections? I had a baby two years ago from a donor egg and how they prepped me was with the delestrogen. I have since moved away from that IVF Clinic who used this protocol. I have recently consulted with a different clinic where I presently live and they would rather use the patches.

This makes me wary since I am not sure if this will hinder my success rate. Please advise.

Thank you. B. from the United States

Answer:

Hello B. from the U.S.,

There is no difference in pregnancy rates between these two forms of estrogen. Any estrogen can be used. Some clinics will use oral tablets, others will use vaginal suppositories, in addition to the patches or injections. The key is to make sure that enough estrogen is being delivered to form an adequate uterine lining. Certainly protocols can vary, and it is the specifics of the protocols that are important i.e. are they using enough estrogen with the patches vs the injections. Without looking at the two protocols, I cannot tell you if the patch protocol is adequate. You would have to send them to me in order for me to review them and give an opinion on those specifics.

Keep in mind that frozen embryo transfers have a lower pregnancy rate than fresh transfers, so that may affect your chances of pregnancy. The rates are roughly 50% less (30% vs 60%). Let me hear from you if you have further questions.

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, USA