Four Weeks Post First IVF & Positive BHCG: Not Rising Adequately & Possible Ectopic

Question:

Hi Dr. R. -

I am 39 years old and we have male factor infertility. In our first completed IVF cycle we had 27 eggs retrieved, 20 good, 14 fertilized, and 3 - day 5 blasts transferred. I had a very light implantation bleed and a positive Hcg at day 14 post retrieval.

1st Hcg 132 14 days post retrieval (this was 2 days early as I had to go out of town)

2nd Hcg 183 19 days post (this was a few days late since I was out of town)

3rd Hcg 278 21 days post (also requested a progest test which was 119 or so, can't remember exact #).

4th Hcg 479 23 days post

Had a u/s 23 days post which showed nothing other than very large ovaries. I understand the data on Hcg doubling but am curious about the 10-20% of women who do not have doubling - not a lot of literature on these patients. My RE said there is zero chance of the pregnancy progressing and said it was a chemical pregnancy and would monitor for an eptopic, I was advised to stop progesterone supps. Also, I had preg symptoms day 12-18 post but they have become less this past week. I have had no bleeding or cramping during the entire process. Any thoughts on my prognosis would be appreciated. Are my levels just too low and too slow?

One other question, my ovaries are "as big as grapefruits", is the only option to wait until they resolve and how long can that expect to take? Again, I am 4.5 wks post retrieval.

Thank you! J. from the U.S.A.

Answer:

Hello J. from the U.S.,

The minimum requirement for HCG rising in a normal pregnancy is an 80% rise, not 100% (doubling). However, your bHCG's have not been rising adequately. For example, the first bhCG at 132 should have risen to 238. The fact that your bHCG's are not rising adequately means that it is unlikely to be a normal progressing pregnancy, but you are still pregnant. In addition, an ectopic (tubal) pregnancy cannot be ruled out yet because the level is not high enough to see a pregnancy in the uterus. The level generally has to be above 2500. It is wise to keep a close eye on your situation.

The ovarian size is due to the increased stimulation you received. It will take up to two weeks to resolve in size from the cessation of the pregnancy. Remember, even though your first cycle has not been successful, you and your husband were able to go through all the steps needed to accomplish IVF, with some good embryos to transfer. I hope that you will consider trying again.

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.

Positive Beta But I Missed Dose Of Prometrium, Now Spotting: Am I Miscarrying?

Hello Dr. Ramirez,

I am on prometrium 200mg/1morning and 2evening. I forgot evening dose on my 12th dpo. Experienced spotting and pencil line blood in mucus next 3 days. Since I forgot to take the prometruim could I be miscarrying? Today it's 16dpo and my beta came back + but at 77. Thanks! M. from the U.S.A.

Answer:

Hello M. from the U.S.,

It is unlikely that this missed dose would cause you to miscarry. Remember, the progesterone you are taking (prometrium) is a supplement and not the only source of progesterone. Your ovary, or follicle that you ovulated from, becomes a corpus luteum cyst and is the natural source of progesterone to support implantation and an early pregnancy. Once the placental develops, it takes over the production of progesterone.

The number for your first bHCG is fine. It should double approximately every other day (48 hrs) and the trend gives a good indication of how the pregnancy is progressing until an ultrasound can be done at 6 weeks gestational age. The actual amount of rise of the bHCG is at least 80% so if it doesn't double completely, don't be worried as long as it is going up.

Good Luck and don't worry too much,

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 the information! I appreciate the advice. I am actually moving to santa clara county and will see if it is feasible to use Dr. Ramirez as my physician!

IVF Patient's Early BetaHCG Levels Show Drop In Estrogen

Question:

On January 12th, I discovered I was pregnant following IVF. My HCG numbers have been excellent. However, on January 21st I learned that my estrogen levels had dropped to 259 (from 400 on Jan 15). My progesterone and HCG continued to do well (HCG 569 on Jan 15, 3616 on Jan 21st). My Doctor has indicated that I should plan a D&C imminently as the pregnancy is unlikely to be viable.

Would you share this view? How significant is an estrogen drop? Thank you.

Answer:

Thank you for your question.

In the early pregnancy, less than 6 weeks gestational age, estrogen is derived almost completely from the ovary. Placental estrogen production has not started. Based on your first BHCG, I estimated that you are less than 6 weeks gestational age (assuming your BHCG was drawn at 8-10 weeks post transfer). If that is the case, and you are not taking exogenous estrogen (from another source), then the drop is concerning because it is an essential hormone of pregnancy.

Your doctor might want to consider adding estrogen in some form. Estrogen alone is not sufficient to diagnose an impending miscarriage. If all three hormones are dropping, then that would be significant. I would continue to follow the BHCG levels, which is the most sensitive to make that diagnosis.

In such an early pregnancy, a D&C is generally not required. Good luck and hang in there!

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com