Posts Tagged ‘implantation issues’

We’ve had multiple losses – what should we be asking about?

Wednesday, October 14th, 2009

“We seem to have no trouble getting pregnant, but we’ve had several first trimester losses.” Or, “We put back good-looking embryos every time, but they just don’t stick.” If this sounds like you, here are a few ideas you might want to discuss with your doctor.

Miscarriages can be caused by any one or more of the following factors:

  • structural
  • hormonal
  • immunological/autoimmune
  • environmental
  • genetic

Let’s start (as the drs often do) with the fairly basic hormonal tests. One of the first that’s included in a fertility workup is testing progesterone in the luteal phase. Most drs order this for CD21 (Day 21 of your cycle), but actually you should really have it done at 7dpo (7 days past ovulation). Of course, 7dpo=CD21 if you ovulate on Day 14 of your cycle, but if you usually ovulate late or early, or if it’s unpredictable, you might want to track your ovulation using BBTs (basal body temperatures) and go at 7dpo. If your progesterone (P4) levels aren’t high enough, you may need progesterone supplements (like utrogestan pessaries) after ovulation (O). Some specialists believe this is a VERY common problem with older women and that if you’re over 40 and ttc naturally you should take P4 after O every cycle.

Another important one to test early, especially if you have any family history or tend to feel tired a lot, is thyroid conditions. Hypothyroid (underactive thyroid) does pop up reasonably often as a cause for conception and sometimes miscarriage problems and is easy to test for. You can ask your GP for this if you’re not seeing a specialist.

If you’re ttc naturally you should also check whether you have a luteal phase defect, i.e. once you ovulate it takes fewer than 12 days for AF (your period) to arrive. You can usually figure this out by charting your basal body temperatures (BBTs) – and a really good site for learning how is Fertility Friend. Again, if your LP is too short, this can be easily fixed with progesterone support after O.

There’s a panel of blood tests you can ask for that are used to diagnose some of the possible causes of “recurrent pregnancy loss” (RPL) or “recurrent implantation failure” (when those embies just don’t stick). Broadly speaking, they cover three categories of issues – autoimmune issues (your body may be rejecting embryos as foreign bodies), clotting issues (not sure the exact mechanism for this, but if your blood clots too much, this makes pregnancy loss more likely – some clotting issues are caused by autoimmune problems) and some genetic issues. Here’s the list that we were sent for, and I think it’s a pretty typical list for New Zealand (some countries like the States seem to test for half a dozen kitchen sinks, several of which aren’t available in NZ):

  • Coagulation screen
  • Thrombophilia screen
  • Autoantibody screen incl.
  • antithyroid antibodies,
  • anti-gliaden antibodies
  • Factor V Leiden
  • Karotype
  • MTHFR mutation
  • Anticardiolipin antibodies
  • Lupus anticoagulant
  • … and a karotype for DH (who gets off easy, as usual).

Probably the next logical step is to get either a saline sono (ultrasound during which they squirt saline solution into your uterus to help them see better) or an HSG (similar, but it’s an X-ray procedure where they shoot iodine dye into your uterus and can also check whether you have blocked tubes). Either of these should tell you whether you have any structural issues in the uterus that might be preventing you from achieving or holding onto a pregnancy. Examples include uterine polyps, fibroids, scar tissue, and an unusual shaped uterus. The most likely issues can often be treated with some fairly minor surgery.

The main environmental causes of miscarriages are not usually tested for, but things you should look around you to check your exposure. Some to keep an eye out for include lead, mercury, organic solvents and ionising radiation. Other more common culprits like cigarettes, alcohol, coffee and other drugs should be cut right out (or, down as much as possible) while ttc. Some naturopaths will do things like send a sample of your hair for analysis for heavy metals, which can highlight things you are exposing yourself to without knowing it. They also advise avoiding those forms of radiation and related exposure that we are not often aware of. These include long-haul flights (which expose the body to as much radiation as a full-body X-ray, or so they say) and keeping a cell phone in your pocket right next to your ovaries – think about it!! Well, who knows which of these various things are real causes, but if you want to make sure you try everything you can to prevent another loss, you’ll probably do what I did and take the ideas pretty seriously.

But what if my specialist won’t run all these tests?

This is quite a common comment from a lot of women/couples dealing with RPL (recurrent pregnancy loss). It may be frustrating, but there is another way to look at this. OK, you may not be able to test for the entire kitchen sink, but maybe you can ask your specialist to consider treating you as if you did have several of these issues going on but they just may well be undiagnosed. That may sound nuts, but there are actually quite a few low-tech options you can ask about that many doctors will agree fall into the “won’t hurt, might help” category. These include:

  • low-dose aspirin (usually 100mg/day) – addresses clotting issues
  • high-dose folic acid (4-5mg/day) – helps prevent neural tube defects
  • progesterone support (usually Utrogestan pessaries) after O on every cycle you are ttc
  • low-dose estrogen support after O too (2mg estradiol valerate, for example)

If you’re doing IVF, each cycle is a bit more high stakes, so you may be able to push for a bit more of a kitchen sink approach. Some other things that people are often allowed to try even if there hasn’t been a definitive diagnosis of a particular cause for repeated losses/failures include:

  • progesterone shots instead of (or as well as) the pessaries – for after egg collection
  • a low-dose steroid such as Dexamethasone – to address any undiagnosed immune issues
  • Heparin shots – Heparin is a blood thinner, so this also addresses clotting factors

Finally, don’t forget that there’s good evidence that acupuncture improves pregnancy and live birth rates for patients undergoing IVF – and good reason to believe this is also true for couples trying to conceive naturally or with IUI. Click on the category Acupuncture and Chinese Medicine in the left-hand column to see more posts on this topic.

Our IVF/IUI/TI cycle just failed … What should we be asking at the review?

Thursday, September 24th, 2009

After all the waiting to GET on the waiting list and then all the waiting ON the waiting list, finally you got to try the “big guns.” You’ve somehow overcome your fear of needles, vaginal scans and then (for IVF) the dreaded egg collection procedure; you’ve survived the harrowing 2ww … and it’s a BFN. Or a chemical pregnancy. Or a pregnancy and then a miscarriage.

After all that anxiety, fear, hope and expectation, a failed cycle is just devastating. You’re booked for a review appointment with your specialist – but what should you be asking about now?

The most important question, of course, is WHY your cycle failed. There could be many possible explanations, some of which are just guesses and some of which are backed by concrete evidence or could be investigated further.

You don’t want to go through the expense and stress of another IVF cycle and only afterwards find out there was something else you should have addressed first. Here’s a quick list of other things you should be sure to have checked out if you haven’t already:

  • Male Factors. A full semen analysis is necessary – not just counts/motility/morphology but also tests for antisperm antibodies and SCSA (tests for DNA fragmentation).
  • Polyps and Fibroids. Uterine polyps and fibroids, even if they’re small, can influence the menstrual cycle and can interfere with implantation. They can typically be seen via ultrasound and can be removed through a relatively simple surgical procedure.
  • Thyroid Issues. Thyroid issues can impact fertility and need to be ruled out as a contributing factor. A thorough thyroid test needs to include TSH, free T3/T4 and anti-thyroid antibodies.
  • Ureaplasma. Ureaplasma is an infection for which you should be tested. “Ureaplasma may cause the formation of sperm antibodies and an inflammation of the uterine lining, either of which may interfere with implantation of the embryo” (Source)
  • Factor V Leiden. Testing for Factor V Leiden is also important. “Factor V Leiden is a relatively common hereditary blood coagualtion disorder and can lead to stillbirth or unexplained recurrent miscarriage” (Source)
  • Hysterosalpingogram (HSG). An HSG is a test to determine whether the fallopian tubes are open. Even if you’re doing IVF this is important because you could have a hydrosalpinx, which is a blocked tube that leaks toxic fluid into the uterus and can affect implantation. (More info)
  • Recurrent miscarriage/recurrent implantation failure testing panel. In New Zealand, the usual procedure is to run a set of blood tests (on the female partner) such as:
    • Coagulation screen
    • Thrombophilia screen
    • Autoantibody screen incl.
    • antithyroid antibodies,
    • anti-gliaden antibodies
    • Factor V Leiden
    • Karotype
    • MTHFR mutation
    • Anticardiolipin antibodies
    • Lupus anticoagulant
    • … and a karotype for the man

Follow this link for a very comprehensive list of possible causes of recurrent miscarriage that can be investigated systematically if you need to do some more serious digging.

  • Endometriosis. If you have period pain that requires more than a couple of Panadol (or any other of the possible symptoms of endometriosis), ask for a laparoscopy to investigate. Endometriosis is quite common and often missed or misdiagnosed, e.g. because women think their period pain is normal. For more information, check out Endometriosis New Zealand’s excellent website.

OK, nice laundry list, but what should I be asking my doctor?

Before your review appointment, if you did IVF, call the embryologist who worked with you during your cycle and ask him or her what they thought about the quality and maturity of your eggs, the fertilisation rates and the quality and development of your embryos. If you can, it’s best to do this soon after (or, the day you go in for) embryo transfer so that it’s fresh in the embryologist’s mind. Pump them for any information you can get.

When you see your doctor, start with an open-ended question about what he or she thought went well in your cycle and what didn’t. Summarise what the embryologist told you as well and ask the doctor to comment.

Your next question should be around the various other possible causes of cycle failure listed in the bullet points above. How many of these have we eliminated as a possible cause, how did we do so, and which of them should we investigate before leaping into another cycle? Make sure you study these beforehand and think whether you recognise any relevant symptoms.

You may find yourself in a situation where the doctor pronounces you have an egg quality problem. Now, this is a difficult one because, from a Western medicine perspective it’s seen as untreatable and just the hand you’ve been dealt. Further, this is really little more than an “eyeball” assessment, assuming you haven’t done a PGD (preimplantation genetic diagnosis) IVF cycle where the embryos are actually tested for chromosome abnormalities. Visual egg and embryo quality is correlated with chromosomal normality/abnormality and pregnancy rates, but it isn’t a direct assessment of these things. You can definitely have great looking eggs/embryos that are abnormal. And there are a few instances where very scrappy, sad-looking eggs and embryos turn into perfectly normal babies, but unfortunately not very often.

If you do get the “bad eggs” speech, there are a couple of questions you should raise. One is whether you can try a different protocol that might be better suited to your delicate eggs. For example, some specialists argue (and have evidence) that higher doses of stims can “fry” some women’s eggs, so that a lower dose may be more gentle and damage them less. [I personally had a dramatic improvement in embryo quality when I dropped my dose from 450IU to 150IU, and I know others who have experienced the same.]

The other thing to insist is that “bad eggs” isn’t just assumed to be the ONLY cause of your failure. Even if it’s true and you are looking at moving forward with donor eggs, you need to be sure you don’t have uterine or autoimmune issues or endometriosis (etc) that could jeopardise the success of that cycle.

Most fertility specialists in New Zealand don’t really buy into the idea of alternative medicines, but if you’ve been given the “bad eggs” or “old eggs” speech, I’d strongly recommend reading the following piece by Dr. Randine Lewis about the Chinese medicine perspectives on “poor egg quality” and whether there’s anything you can do to address it.

This website/blog also has several posts on acupuncture and Chinese medicine – see the menu at left to find items on that topic.