Recurrent Pregnancy Loss

March 21, 2007 - Wednesday
12:50 PM to (EST)
Guest Speakers: Edward Illions, MD
Albert Einstein College of Medicine

Categories
Acupuncture • Donor Egg • Endometriosis • IUI • IVF • PCOS • PGD • Pregnancy • Pregnancy Loss

	Corey_Whelan joined.
	Ed_Illions joined.
	Krisbill122703 joined.
	nlaurente joined.
Corey_Whelan	Welcome everyone to The American Fertility Association's online educational session. Tonight's session is on recurrent pregnancy loss. We are very lucky to have with us tonight, one of the most renowned experts in this field - Dr. Edward Illions.
	gina36 joined.
Corey_Whelan	Dr. Illions is with the Albert EInstein College of Medicine. He is here to answer all of your questions on this topic.
Corey_Whelan	So let me say welcome to all of you! I am Corey Whelan, your chat moderator and The American Fertility Association's Director of Development. I welcome you to ask your questions now.
	Dolores joined.
	Suzi joined.
	Caitlin joined.
	Janie joined.
	Scandia joined.
gina36	Hello, I currently just suffered my second miscarriage in Dec. it was a missed m/c at 8weeks...I was supposed to be 8w5d and the baby stopped growing around 6w5d.....I did have some genetic type bloodwork done along with my husband and everything came back normal....my doctor seems to think that I have had 2 rounds of bad luckhe doesn't really feel that I need any testing.....do you think I should get any testing or as he has told me "try again." (sorry this is so long)
	Corey_Whelan left.
	Corey_Whelan joined.
	shaymer01 joined.
	jdravis joined.
shaymer01	hello
Ed_Illions	currently, a full scall evaluation for RPL is warranted after 3 consecutive losses. However, most physicians in the field will offer testing after two losses. This is your choice. Fortunately, 65% of couples have normal testing.
nlaurente	I understand that there are several factors causing pregnancy loss. But,why is it very common in late pregnancy, i.e. women pregnant in later age such as 40s?
gina36	Oh, and I also had the bloodwork that tests the "blood clotting factor" and that came back normal too.
Krisbill122703	After now my husband and I's 5th miscarriage we have sought help through a fertility specialist (I am only 25). They found I have a blood clotting disorder - at what point in a pregnancy would I want to begin taking a blood thinner of sorts? Will IUI improve our chances of not miscarrying again?
Ed_Illions	women in their late thirties and early forties have diminished ovarian reserve which meas that there is an age related effect on the eggs. The eggs may have inferior quality and hence the majority of embryos that develop suffer from genetic abnormalites which result in losses.
jdravis	Hi Dr., I am 30 years old and have had 3 miscarriages, no successful pregnancies. All tests have come back indicating no problems. All miscarriages happened between week 4 and 5, is there nothing that can explain these very early pregnancies that a test result wouldn't find?
Krisbill122703	Oh, and are blood thinners harmful to a fetus?
shaymer01	Have you heard of taking DHEA and acupuncture to increase egg quality and quantity in older women? What is your opinion on this?
gina36	Yeah, I actually wanted to know if acupuncture will help with fertility too
Ed_Illions	With a documented blood clot disorder; many physicians would treat with a blood thinner after the first positive pregnancy test. Of course, many people can begin aspirin therapy prior to pregnancy; but heparin usually starts with a positive pregnancy test. IUI should not affect your chance.
Corey_Whelan	Dr. Illions, can you address the comments on acupuncture for us?
nlaurente	Pardon my ignorance, but what's DHEA again?
	lanitraj joined.
Ed_Illions	Depending on the completeness of your evaluation; usually couples with normal test results eventually have successful outcomes. I think it is important to obtain tissue from the pregnancy losses if possible for genetic testing. Your losses are too early for that testing. I would need to see which tests were actually done in your case to determine if a complete evaluation was performed.
Corey_Whelan	DHEA stands for dehydroepiandrosterone. It's the most prevalent hormone in the body
	Stacie joined.
	MSimon joined.
Corey_Whelan	welcome Stacie and MSimon
	shenderson joined.
	pauline joined.
Corey_Whelan	welcome all.
Ed_Illions	Regarding DHEA and acupunture; I am not aware of any good data which supports DHEA. Acupuncture may be beneficial in the setting of infertility patients. We counsel our patients to utilize acupuncture during IVF cycles (may relax the patient and reduce stress levels.) Less infor available for RPL patients. I would support its use.
Janie	Hi Dr. Illions. I am 36 and suffered 2 losses from IVF. I moved onto donor egg and the fresh cycle resulted in a chemical preg. and now the FET pregnancy is over at 6 weeks. I have had recurrent loss testing and endometrial biopsies. My testing mostly consisted on anticardiolipins etc. All test results were negative. What else would you recommend? My donor was very proven so these miscarriages are shocking.
Krisbill122703	I have heard good things about acupuncture and prenancy but negative things about the herbal supplements the acupuncturists may push. Any thoughts on herbal supplements?
	lstocks joined.
Corey_Whelan	hang on guys. Let Dr. Illions catch up with Janie and then Krisbill
Stacie	I have had 5 miscarriages over the last three years. I am 34 with a day 3 FSH of 11.6 so I have been diagnosed with diminished ovarian reserve. I am currently in my 3rd round of IVF (1st two were 4th & 5th miscarriage). We have been suggested to move on to donor egg and may go this route in the future. I have two questions... I am borderline positive APS and my RE does not think this is my issue therefore does not suggest my Lovenox injections... thoughts?
Stacie	Also, what do you think about Natural Killer Cells playing a part in all this?
Ed_Illions	Regarding the failed IVF cycles including with donor eggs (fresh and FET); I would be interested in the uterine environment. It seems that there is failure to establish implantation in any setting thus far. There are unfortunately no good markers for uterine receptivity. Possiblyl a gestational surrogacy situation may work.
	lanitraj left.
Ed_Illions	I agree with you. We support acupuncture but we do NOT advoacte the herbal supplements. There are some herbal supplements that have proven harmful effects. We do not advocate their use.
	KManzi joined.
gina36	I have also heard people going to the chiropractor for fertility issues too. Is this proven or not?
Corey_Whelan	Janie, if you live in the NY area, you should definately attend the AFA's conference on April 29th. There will be a lot of surrogacy agencies represented there and Dr. Illions will also be speaking in person. 100 faculty members talking about various topics and 60 exhibitors. in NYC at the Grand Hyatt hotel
Krisbill122703	Are herbal supplements not advocated for just the female or male as well?
Ed_Illions	Most MDs would probably agree with donor oocytes. I beleive PGD (preimplantation genetic diagnosis) may be useful in this setting. Transfer only the genetically normal embryos. Regarding use of heparin; usually we treat when multiple determinations of APS are moderately or strongly positive. this is a borderline call. I would support PGD over use of lovenox.
Ed_Illions	I do not have any personal knowledge of a particular practice that a chiropracter may offer which would benefit patients with RPL.
Corey_Whelan	Dr. Illions, do you have any insights for us on what Stacie calls natural killer cells?
Ed_Illions	We do not recommend herbal supplements for either male or female.
MSimon	Dr. Illions. I am 40 and have had 2 miscarriages. Test revealed that the first miscarriage was chromosomal but the tests for the 2nd miscarriage were inconclusive. I have hypothyroidism, which is being regulated with meds and stage II endometriosis. What procedures and/or tests would you recommend?
gina36	Thank you for you insight. It has been a pleasure chatting with you .
KManzi	Dr. How many cycles would you suggest with PGD & poor egg quality before moving on to donor egg? My last PGD cycle had 2 genetically normal and 14 had a problem.
	gina36 left.
Stacie	I don't produce enough eggs to allow for PGD. 1st cycle IVF only 3 eggs fertilized, transferred all three, miscarried. 2nd IVF 2 eggs fertilized, tsfd both, miscarried. I am now ready for my HCG shot with 7 follicles which will probably yield 4-5 eggs.
lstocks	I am 16 and have had 10 miscarriages all of them occuring between the 9th and 10th week of pregnancy. THe sonograms have all shown health pregnancies with normal heart beats and growth up until the 9th or 10th week. I have tried IVF with PGD and lovenox. The doctors do not know what else to try. All of my test results are normal.
Corey_Whelan	lstocks, I think your age is wrong?
Ed_Illions	Some centers which specialize in immunology will evaluate natural killer cell activity in patients with RPL. this literature is mixed in this area. those centers will often use IVIG (intravenous immunoglobulin therapy) which is expensive and does not always work. There are side effects with this therapy as well. We do not routinely check NKC activity.
lstocks	You are right. I'm sorry. I am 36 ::smile
Corey_Whelan	don't be sorry. I just wanted the doctor to get the right info!!!!!
	melijane joined.
pauline	I am 41 yrs old. Conceived naturally, had 2 miscarriages at 9 and 4 weeks. Failed 1st IVF; miscarried at 9 weeks after second IVF. One D & C showed trisomy 18. Any suggestions?
Ed_Illions	Endometriosis may adversely affect egg qualtiy in some cases. You may want to consider surgical correction of endometriosis. Other options include use of PGD. Hypothyroidism will adversely affect fertility if uncorrected.
melijane	Hello,
Corey_Whelan	hi melijane
Ed_Illions	Regarding the number of PGD cycles; I would move on to donor eggs is the egg quality is poor.
Corey_Whelan	folks, we are at the 1/2 way point, so please don't wait to ask your questions
shaymer01	At 39, my doc has advised against pgd unless looking for a genetic disease such as CF. He said it would be a waste of money since all cells cannot be tested or something like this. Do you agree?
Ed_Illions	You may have enough eggs this cycle for PGD. Most centers would do PGD with 5 embryos. You need to have great fertilization this cycle.
lstocks	I would like to know is there a relationship between recurring miscarriages and fibroids. That is the only thing left that my doctor thinks could be possibly the cause.
Corey_Whelan	Shaymer, how many misses have you had?
shaymer01	three
shaymer01	have had all kinds of blood testing...nothing abnormal.
melijane	Sorry I am 32 yrs old. No live children 3 miscarriages within the past 2 years. MTHFR homozygous treated with Lovenox 40 mg starting CD 6. History of extremely low progesterone and beta hcg. Currently being treated with crinone 1dpo. Current Dr has me on Clomid to increase natural hormones. last unmedicated cycle largets follie was 16.5 mm on CD 15. This cycle with Clomid largest follie is 22.5 mm and 2nd at 19 mm. Taking Ovidrel tonight. What are your thoughts on this treaytment. Would you recommend immune testing should this cycle not work out?
shaymer01	had ashermans, and a uterine septum (minor), corrected.
Ed_Illions	with 9 or 10 losses, there may be an underlying disorder of clotting which is not being detected. Lovenox in that setting was reasonable even with normal testing. If that fails; other scenarios include gestational surrogacy or even donor gametes.
melijane	Normal hsg no other thrombophilias
	Zimgirl joined.
melijane	Also not sure if this matters but needed to get methotrexate to get hcg to normal after 2 losses(all losses at 7 weeks or less) One loss was more of a chemical with low levels and a long period following.
Ed_Illions	In the case of the failed IVF cycles in the 41 yo patient; I am assuming that the entire RPL evaluation is normal. If not performed; I would complete that evaluation. PGD is an option if you produce enough embryos for biopsy.
KManzi	Dr. I have one son 3.5 years conceived naturally. Since then, I have had 3 IUI's, 3 IVF's (one with PGD), and two miscarriages. Since the PGD showed poor data... should I be concerned if I try to get pregnant naturally again? I would think my chances are slim to carry a normal pregnancy given the PGD data we received?
lstocks	Do you recommend any other treatments for clotting disorders? I have tried the lovenox 3 times and it did not work.
Ed_Illions	Regarding RPL and myoma; this is almost always a diagnosis of exclulsion. I would need to rule out all other casues. If the fibroids affect or come near the uterine cavity; then you may consider surgery. Keep in mind; myomectomies may also cause scar tissue.
Ed_Illions	some recent data has not been terribly supportive of PGD for purpose of ruling out aneuploidy; in that regard your doctor is correct. If the genetic center tests for 10 probes during PGD; they are evaluating about 85% of genetic causes of early losses.
	moondreams joined.
	shenderson left.
Ed_Illions	I agree with Lovenox in the setting of homozygous MTHFR mutation given your history. Ofcourse; it is important to take folic acid which I am sure that you are doing. I believe that gonadotropin injections may be more helpful in terms of developing better follicles in order to improve your progesterone level.
Ed_Illions	With poor PGD data in your IVF cycles ( I am assuming that majority of embryos were abnormal); I would support donor oocytes in that setting.
melijane	I am also on Metanx(like Folgard no one seems to have heard of it but it supposedly is a broken down form of FA better for mTHFR. What is your opion on NK cells and the other immune testing? Also how about dexamethasone? What is the brand name of gonadatropin? Thank you!!
	Janie left.
MSimon	Thank you Dr. Good luck everyone
	MSimon left.
melijane	Also, last question I promise! what is your opinion on Dr. Toth relating RPL with infection/bacteria
	Elle140 joined.
Ed_Illions	There are other forms of LMWH in addition to Lovenox. I do not know the results of your tests in terms of which clotting disorder you have. Unfractioned heparin is another choice but Lovenox has less side effects.
melijane	No other clotting disorders
melijane	Sory just realize that wasn't directed to me.
Krisbill122703	Do trigger (ie: ovidrel) injectables always work to release?
Ed_Illions	Metanx contains 2.8mg of folic acid in addition to vitamins B6 and B12. I use it when I need to increase folic acid supplementation. Our center does not routinely test NKC since we are not convinced that the data shows benefits with use of IVIG. Some studies have shown benefit in these patients when treated with IVIG. I would refer a couple interested in IVIG to a center of immunology. I am not aware of any role for dexamethasome in preventing RPL. we sometimes use it to lower androgen levels in a stimulation cycle but that is rare.
moondreams	Sorry, I jumped in late and hope this question isn't too basic. I had one 9 week miscarriage with a fresh cycle and a chemical pregnancy with a frozen cycle. I'm about to do another frozen. Embryos were high grades, my lining was and levels were great. Since it's too late to do PGD, any suggestions on other tests that I should undergo before trying again?
Ed_Illions	Regarding RPL and bacteria; the data is mixed. We test for ureaplasma and mycoplasma since it is easy to do. If we detect it; we treat with antibiotics. Usually if a pregnancy is lost to infections; there are obvious clinical signs. An exceptio may be with listeria
	Elle140 left.
Ed_Illions	In my experience; Ovidrel is effective; I prefer to use IM hCG injections to trigger my IVF patients; I have had 2 or 3 IVF patients who failed to yield adequate egg numbers at retrieval.
	jdravis left.
shaymer01	5 follies, no eggs on retrieval, could this be due to bad hcg injection?
Ed_Illions	I would proceed with FET. There are some tests to evaluate endometrial receptivity but are somewhat unreliable. One such test is doing an endo biopsy for integrins. I rarely do that anymore. Consider PGD for future fresh cycles.
lstocks	None of my test showed a clotting disorder. The doctor treated as if using the lovenox. Could there be a possibility of clotting disorders that do not show up in the test? Ive been told that unless they know of a specific disorder to test for that they don't know other test to do. Do you have any other suggestions.? I'm not sure what basic clotting test were done.
Krisbill122703	Does PCOS effect pregnancy (ie: any higher chance of miscarriage). What about teh Ovidrel while doing IUI?
nlaurente	Dr. Illions, I have no history of pregnancy and RPL and currently in my 40s trying natural pregnancy with acupuncture. If pregnancy occurs, would complete bed rest be benifitial, though a lot of RPL factors are chemical and egg quality realted?
	Zimgirl left.
Corey_Whelan	folks, we have just five minutes left.
moondreams	Thanks. Good luck to everyone.
Ed_Illions	5 follicles and no eggs; the problem could be do to hCG. Did they measure hCG levels the morning after the hCG trigger. Other possibility is difficult retrieval but that would be unusual. Consider using IM hCG trigger.
	kari_coppinger joined.
	Stacie left.
kari_coppinger	I just saw the notice about this. Is there still time to ask questions?
Corey_Whelan	Kari, type fast
kari_coppinger	Can do, thanks.
kari_coppinger	I've had four losses. two at 8 weeks. Two at 18 1/2 weeks.
kari_coppinger	The first two and second two don't seem related. Have had some specialist consulations.
kari_coppinger	Newest diagnosis is incompetent cervix but showed no signs of that before.
kari_coppinger	One obgyn has suggested possibly there is an immunological problem. Any ideas on how to research or follow that up?
kari_coppinger	I live in the Los Angeles area.
Ed_Illions	Regarding the clotting tests being normal; some patients may have an underlying subtle clotting disorder that may not be detected. I would make sure that B2-glycoprotein 1 antibodies were tested and if they were normal (in addition to the usual tests we do); consider testing for annexin V
melijane	Thank you for your time. Good luck everyone
Corey_Whelan	Kari, please email me tomorrow at corey@theafa.org
melijane	Karu have you called SIRM?
Corey_Whelan	No more questions, folks. Let's let Dr. Illions catch up
melijane	Kari I mean
kari_coppinger	Sorry, don't know SIRM. Corey, I'll be glad to email you tomorrow, thank you for the offer.
lstocks	Thank you for your time and assistance.
	KManzi left.
Ed_Illions	Regarding 4 losses; two in first trimester and two in second trimester; sorry to hear of your problems; usually we think of different causes in this setting. Incompetent cervix is usually diagnosed clinically based on the history of the loss. If suspected; your Md would place a suture in the cervix. The early losses are usually genetic. Obviously, in this case; disorders of clotting and coagulation can cause a similar picture. I would need to see test results.
nlaurente	Thanks Dr. Illions for the very informative session!
Corey_Whelan	Dr. Illions, I want to thank you so very much for all of your thoughtful insights here tonight, and for taking the time to be with us! And thanks to all of you for being here and asking your questions as well - when you ask we all learn. And of course, I wish you all so much luck on your journey. And joy. Good night everyone, our chat is officially over.
	nlaurente left.
	mruss joined.
	Krisbill122703 left.
	Corey_Whelan left.
	Scandia left.
	Caitlin left.
	Suzi left.
	Krisbill122703 joined.
	Dolores left.
	Ed_Illions left.
	lstocks left.
Krisbill122703	good luck and goodnight to all!!!
	Krisbill122703 left.
	pauline left.
	kari_coppinger left.
	melijane left.
shaymer01	Thank yuou!!!
	shaymer01 left.
	moondreams left.
	mruss left.

Recurrent Pregnancy Loss

Categories

Chat Archives