RE for recurrent miscarriage- advice?

coco2787

I made an RE appointment for next week and was hoping those of you who have seen an RE for RPL could offer some insight.  *TW fertility*  I get pregnant easily, but I've lost 4 pregnancies in the last 7 months.  Two CPs and two MMC (one at 9 weeks and one at 14 weeks).  Because my losses were all at different times and the basic RPL testing I've had done has all been normal, my biggest concern is that my egg quality is bad.  I don't plan on making any decisions at the first appointment, but I'm wondering if there's any questions I should definitely ask or any testing that I should make sure to pursue.  Also curious, for those of you who have a known or suspected egg quality issue, did your RE suggest any treatment ideas other than IVF with PGS?  It feels like an extreme solution when I don't have a fertility problem, but at this point I'm willing to do whatever it takes to avoid going through another loss.  

char245

@coco2787 you and I seem to have very similar issues. *TW* I have a DD and prior to having her I had one CP and then got pregnant with her the next month. This time around I had a MC at 9weeks and have had two CPs since. When I went to the RE we discussed my whole history and then she laid out all the tests that would be done over a two month period (pretty sure they are all standard tests). From there the only thing that came back low was my egg quality. My RE suggested we try for a couple more months on our own and then move straight to IVF. She’s very open minded and willing to discuss other options but she said since our issue isn’t getting pregnant the only intervention that really makes sense is IVF. If it doesn’t happen for us this month we start IVF in the beginning of July. 

offtoneverland

*lurking--hope you guys don't mind*
@coco2787 When I began seeing an RE after my 3rd early loss, she said if we absolutely couldn't comprehend the idea of having another loss, IVF with PGS would pretty much be our only option. And even that is not guaranteed, unfortunately, although it usually works out much better, as far as I understand. We felt the same way as you (that it was an extreme option) since we were in a similar position. 

I can't remember how old you are, but unfortunately there is no way to test egg quality (again, as far as I understand). If you're not AMA, it's probably very unlikely that your egg quality is bad (this is what my RE told me, at least) but you never know. My first appt with my RE was very good, but interesting because she stressed that my losses were probably just due to really bad luck. She equated getting pregnant with a healthy egg like a roll of the dice. Some people get very lucky, others don't. So that was kind of disheartening to hear. 

I can't remember all the testing you've done. I would ask about an HSG and getting your cd3 bloodwork done for AMH, FSH, estrogen, etc, just as a starting point. You could also ask about a baseline ultrasound. I think those are done around cd3 as well. They will look at your ovaries and follicles to see what's up or if there's anything concerning. 

@char245 By low egg quality, were you talking about AMH? It's been explained to me by others that that's only an indicator of how many eggs you have left, and not of their quality. Or is there another way your egg quality was tested? Just curious because my AMH came back extremely low, but my RE said there was really no way to know what my egg quality was. Wishing you the best of luck so you don't have to move on to IVF. 

Forgive me for barging in here, please. I hoped my experience would be helpful to @coco2787 since I've been in a similar position.

char245

@offtoneverland yes, you’re right. I misstated that, my low number was on AMH level which is just the indicator of follicle production so not necessarily quality. That was another reason she only wanted to give us a few more months of trying on our own and then move straight to IVF. Since I had that tested ten years ago for donating eggs and it was on the lower side then and has only dropped from there she was concerned about it continuing to lower. 

offtoneverland

@char245 Gotcha! I just wanted to make sure you knew because when I first found out about my low AMH, I was freaking out thinking it meant my egg quality was bad, until my friends on the Bump talked to me and explained it. Regardless, it still is a pretty alarming diagnosis, because it makes the future uncertain as you may have a timeline to be working with, but there's just no way to know what that timeline is. It's really stressful. 

olivemomma

@coco2787 good luck with your Apt! I would love to know what they recommend as I have a similar situation and have had 3 losses (1 cp and 2 MMC) in the past 6 months. My 2 later losses were at roughly the same point in my pregnancy so I don’t know if that hints at a possible different explanation than if they are all at different points. 

zamoraspin

@coco2787 Well this turned out very long because I have been in a very similar boat for a long time except I've never had a live birth and have some years on you. 

I think it's a good idea to go to the RE. I'm not sure how comprehensive your testing has been to date but an RE will run a full recurrent loss panel which is 18+ tests, and also do genetic testing on you (and possibly YH) to see if you have a normal karyotype or are a carrier for a slew of genetic disorders. If you have not had one already they will also do a cavity examination - usually an HSG or saline sono. I'll be honest, for most people they do not find anything and you end up "unexplained RPL". 

Given how late your most recent loss was, and knowing you did do NIPT, I would ask questions about clotting disorders if I were you, especially if the testing on the baby you lost does show all normal genetics. There is also a possible immune component to recurrent loss that you should talk to your RE about - specifically what my RE has said is if we had documented that any of my losses were genetically normal, even though the immune stuff they can test for has been negative, she would want to try low-molecular weight heparin to suppress my immune system in subsequent pregnancies. I know dr's vary in their recommendations but the immune issue is something to ask about also if the most recent loss did not have a genetic issue.

When you are unexplained RPL (and to their knowledge have not lost a genetically normal baby) the implication is the losses are due to embryo quality. This can be caused by egg quality (there is no test for egg quality, age is the most informative factor), or sperm quality. Sperm quality can be tested using DNA fragmentation tests. It is pricier than a normal SA, and my RE doesn't think it's worth doing in most cases because her recommendation to reduce risk of loss remains the same if it is an egg or sperm issue - IVF with PGS. When she first told us this, last October, I thought that was a very extreme solution as well. At the time I was pregnant for the third time in six months, and even after that loss, our RE said that women who have had even 5 mc's still have at least a 50% chance of a live birth in subsequent pregnancy. Given the rates of IVF success, that doesn't seem like terrible odds, and we decided to try again for either 5 more months or one more pregnancy. As I've mentioned my fourth baby stopped growing at about 8w and had T22. So here I am, waiting to find out when we can do IVF with PGS. If I were younger, maybe we would feel differently, but I'm 36 and there's no chance I'll have a first child before I'm 37. 

*Allegedly* there are things you can do to improve egg and sperm quality. It Starts With the Egg is the leading book on this topic. Things like smoking and heavy alcohol use are things to cut out if you are concerned about egg/sperm quality (don't know if this applies). Less obvious stuff like CoQ10, avoiding BPAs, avoiding phthalates, etc, are also recommended by ISTE. I have done all the suggestions except I have not been super reliable on the low carb diet rec - that is a tough one for me - and we have not seen better results. I also have DH on supplements and we did do a DNAF test through Episona (kind of a OTC thing) and his sperm came back normal risk, so it seems likely I'm producing not so great eggs, likely because of age. 

Aside from IVF with PGS another idea that we tested out was clomid - I did a couple cycles on it to see if I could produce more eggs/more shots at one good one. I didn't get ku at all on clomid and I didn't produce tons of eggs. I understand this is possibly controversial because of risk of multiples but I'm glad we gave it a shot, even if it turned out to be a counterproductive measure for me. 

*TW for those struggling with IF - talking about super-fertility. Like you, I get pregnant pretty easily. I have talked about this on the board before - there is an actual phenomena termed "super-fertility" or "hyper-fertility". Women who are above average in fertility tend to have more miscarriages. The uteruses (uteri?) of women with average fertility who have had only live births will not allow a non-euploid embryo to implant, but women with super-fertility have un-choosey uteruses which leads to more mc's. My RE has never said this is what is going on with me although she has referred to me as "super-fertile" before, and I have come to my own conclusion that this is what is going on - we are not making great embryos (likely egg quality) and my uterus is kind of a slut. Here's a blurb, there's more out there on it: https://www.livescience.com/22706-super-fertility-recurrent-miscarriages.html 

Because I am "so fertile" I am hopeful that if we do IVF with PGS we can have a good outcome - but I do worry we will have zero good embryos to put in. end TW*

coco2787

thank you @zamora_spin, that's all helpful.  I've seen that study before about "super fertile" women and I feel like that definitely applies to me, and it made sense that my first 3 losses might have been an issue with embryo quality.  I'm almost hoping the NIPT results were a false negative so that I have some answers that maybe I can work with.  

olivemomma

@zamora_spin @coco2787 I think I also fall into the ‘super-fertile’ area for women. I have had 5 total pregnancies and only 1 month in all 5 where I possibly could have gotten a BFP and did not (and that was my first cycle coming off of over 10 years on BC right before my first pregnancy). I asked my Dr about this phenomenon of a more ‘slutty uterus’ and she seemed completely unaware! But it makes so much sense to me from what I have read. I’m really hoping that is the case with me and that the overall quality of the next embryo will be higher and will stick around. I feel so lucky to be fertile but man is there a negative for every positive thing in life!