Question

Hi, I am 30 years old and have had 4 miscariages in the last 2 years (no live births). During my first pregnancy, at 7 weeks, I began to bleed heavy and pass clots. I was put on bed rest for the following 6 weeks(bled entire time), but miscarried at 13 weeks. It was very painful, both emotionally and physically. I had an hsg and was told that I may have a bicornuate uterus. January 2006 had a hysteroscopy/laparoscopy and found that it was only a uterine septum and that the surgery corrected the problem. April 2006, got pregnant again, had basically the same thing happen, started bleeding at 6 weeks and continued until I miscarried at 8 weeks. My doctor wasn't concerned, stating it was probably just "bad luck". October 2006 got pregnant for the 3rd time, all was well until around 8 weeks. One Friday afternoon while at work, I began to bleed. I went straight to the doctor. My ultrasound showed nothing there. My doctor examined me and was able to retrieve the fetal tissue from my cervix. This miscarrige happened very quickly. Now, it was more than just "bad luck". My doctor tested the fetal tissue for defects and those tests all came back ok. It was a heathly girl. My husband and I began the genetic testing that my obgyn offered and it was found that I had a clotting factor, prothrombin gene mutation. I began taking a baby asprin daily and was told that once I got pregnant again that I would also be taking heparin injections and progesterone suppositories. The end of January 2007 got pregnant again. I began all of the medications, 5000 units of heparin injections twice a day and 2 progesterone capsules twice a day. I knew that this time everything would be ok. Everything had been going perfect up until 5 days ago. On Wednesday (exactly 8 weeks) I went for my first ultrasound. I was very excited to see the baby.I was feeling great and had no bleeding whatsoever!! Well, my scan showed that the baby was measuring 6 weeks and was told it wasn't good. I had my hcg levels tested Wed. and Thurs. and they were 11,000 on Wed. and dropped to 9,000 the next day. On Friday my doctor called and told me that I would be miscarring soon and as I write this letter, I sit here and wait for the process to begin. I feel ok, haven't had any cramps or bleeding, nothing but emotional pain. I thought that this time, and with all I've done, that I would have a positive outcome. With this, I ask of you to please help me in determining what is going on. My doctor told me that there was nothing more that he was able to do for me and he would send me to a fertility clinic.

Is there any help out there for me???? I feel like I have hit a brick wall and that there is no hope. Thank you for taking time out to listen.

Sincerely, Marie

Answer

Dear Marie,

I am sorry you are having such a difficult time. It is harder if you have multiple problems. Each one needs to be treated systematically. If you have a prothrombin gene mutation, heparin (or Lovenox) is the proper therapy for this problem. Your doctor has corrected your uterine septum, which will help your chances for carrying a baby to term.

I would make sure you get a test for mycoplasma/ureaplasma. If this is present, you and your husband should undergo antibiotic therapy before conception. You should also make sure your thyroid is functioning in the high normal range (TSH below 2) even though some labs say that TSH values between 2.0 and 5.5 are normal. As thyroid hormone levels get higher, the TSH gets lower. I would also get testing for anti-thyroid antibodies. Also very important are optimizing blood sugar and fasting insulin. Supplements such as OptiVite, omega-3 fatty acid, ans folic can also be helpful.

You do not say what your cycles are like. It would be important to make sure your uterine lining and estrogen and progesterone levels are optimal pre-conception. One week after ovulation, your estradiol should be above 110 pg/ml and your progesterone above 15 ng/ml. It would be even better to have a more complete evaluation of your cycle with at least three estradiol and progesterone values in the luteal phase. An ultrasound to check your uterine lining at the appropriate time should be done. If the hormones and lining are not ideal, there are therapies that can improve them.

Aditionally, it is important to identify pregnancy very early (no later than two weeks after ovulation), and obtain early progesterone and HCG levels. Progesterone therapy (as well as the heparin or Lovenox) should also be started at the earliest possible time. The best protocol for progesterone I have found is the one from the Pope Paul VI institute utilizing progesterone injections. HCG levels obtained very early can give you an idea if it is a healthy pregnancy. Usually you can see an embryo at six weeks from the last menstrual period, as well as a heart beat. Eight weeks is a bit late to get the first ultrasound in your situation.

If you have more miscarriages, I would be sure to get chromosomal studies, as was done with one for your pregnancy losses, so you have a better idea of what went wrong. It is possible at least some of the others were due to abnormal chromosomes which would be beyond your control. Finally, there are experimental therapies such as IVIG and possibly low-dose naltrexone that can be used if all else fails.

Mary L. Davenport, M.D.

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