Question:
I have been trying to conceive for 3 years, have had 3 miscarriages, all between 6-9 weeks (one was trisomy 22, the other two are unknown. Two pregnancies required progesterone suppository supplementation). I am 40 years old, hypothyroid, insulin resistant, have a bicornuate uterus, my DRVVT came back Borderline (lupus anticoagulant, recommended re-test in 12 weeks), positive for ANA's, 1:320 titer, speckled), and compound heterozygous MTHFR gene mutation (variants C677T and A1298C). I am getting ready to try again. I was already taking synthroid 88, and 850 mg metformin twice a day.
My doctor has put me on folgard in addition to my Prenate DHA prenatal vitamin, baby aspirin, 10 mg prednisone twice a day, and I am taking 1 tbs Maca Magic, as well as 1 tsp royal jelly. Should I be taking low dose heparin as well? Lovenox? Start the progesterone suppositories immediately after ovulation?
My high risk pregnancy doctor recommended I not do IVF, because he said that at 40, my eggs are much too fragile to undergo retrieval, fertilization, analysis and reimplantation. He also indicated I would have a harder time getting pregnant after this (likely) failed. Please let me know your thoughts on this. Also, do you have any research you can direct me to, indicating that only 1 in 40 or 50 of my eggs are normal at 40 years old?
Would love to know your thoughts. I can't bear to go through another miscarriage. Thank you.
Answer:
You seem to have lots of reasons for having miscarriages, but probably the most common and predominant reason is your age. This "age factor" leads to spontaneous chromosomal aberrations that lead to abnormal embryos and subsequent miscarriage.In terms of your immune factors, just to cover those bases I would recommend either low dose heparin or lovenox. The progesterone should be started right after ovulation and continued until the pregnancy test is negative or 10 weeks gestational age.
Although you are able to get pregnant naturally, the only method that would increase your chances of a successful pregnancy is IVF. The reason is that multiple eggs can be extracted thereby increasing the chances of having a good egg (normal). It is not for sure, but will statistically increase your chances. At your current age, you probably have 1 out of 40 to 50 eggs that are normal. (When this post was published in 2009 no one really knew how many "good" eggs exist in the 35+ woman...and although it is still not 100% certain, a recent 2013 study has come out with some answers. The study found that 2 out of 20 eggs retrieved from 40 yr old women were chromosomally sound and had the potential of fertilizing and implanting successfully.) When you go through a natural cycle, you are only ovulating one egg at a time, so you can see that your chances that it will be normal is low and the chances of being abnormal is high. That is where IVF can help. With IVF you could get anywhere from 10-20 eggs at a time, depending on your ovarian function. Because time is against you, that is what I would recommend. The aforementioned medications should be used in conjunction with the IVF cycle.
As far as what your high-risk (I assume perinatologist) ob/gyn has recommended, I think you need to decide who knows fertility better. A fertility specialist or a high risk pregnancy perinatologist. As a fertility specialist, I have to disagree with your perinatologist as to your chances of pregnancy. As mentioned previously, IVF is the treatment of choice at your age. He is correct in that the chances of pregnancy are reduced because of the age related egg factor, which means that the majority of your eggs are no longer viable and prone to genetic abnormalities (spontaneous breakages), but is incorrect in saying that IVF will worsen your chances because the "eggs are too fragile for retrieval, fertilization or implantation."
In order to educate yourself regarding age related infertility and egg quality, your best source is ASRM's new website, reproductivefacts.org, sart.org or the CDC website. Each of these have the information you are asking for regarding the age-related reduction in infertility.
Good luck in your journey and don't hesitate to look for the right approach by seeking a second opinion.
Sincerely,
Edward J. Ramirez, MD, FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF
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