Category Archives: Recurrent pregnancy loss

A Cause for the IUGR

I had my 6 week postpartum appointment yesterday. Baby A came with me and screamed a lot. I ended up breastfeeding her while walking into the appointment room and during my pelvic exam…surreal. Everything looks good on my end!

We discussed several things throughout the appointment. 

•I expressed to her that I do not wish to be on birth control. Firstly, I am not convinced that it didn’t contribute to our difficulties TTC. Secondly, we plan to try again (although I cannot imagine that right now…more on that in another post). Lastly, I have switched to all natural products and I am not interested in introducing hormones into my body at this point. 

•She said that since I had an uncomplicated vaginal delivery we could try again as early as 6 months (I think that’s crazy).

•When my cycle returns and is regular, she can order a follow up FSH, AMH, and E2 so I don’t have to go back to my HMO fertility clinic right away. I am relieved about that (even though I had a pretty great experience with our RE). I’m wondering how those numbers will have changed a year or so after having them drawn. I also hope it will give us an idea of what to expect. 

•And now the main point of this post. The results of my placental pathology. It was small (as we already knew from looking at it after delivery). This could have been due to the UU (meaning the smaller size of my uterus) or uteroplacental insufficiency. The placenta showed signs of chronic uteroplacental insufficiency. Basically this means that the blood flow from my uterus to the placenta was insufficient for a good chunk of the pregnancy. Thus the IUGR diagnosis. I have lots of thoughts about this. 

Firstly, the baby was in the 38th percentile at the 20 week anatomy scan. That is normal. Then, right before 30 weeks at our growth scan, she was less than 3rd percentile. So things went wrong somewhere between 20-30 weeks. I stopped taking the baby aspirin at 28 weeks (which I was taking to hypothetically increase blood flow to my uterus…who knows if it helped. I feel it did help). I don’t think that would have affected growth that drastically in 2 weeks but I can’t help but wonder if I had stayed on it (or restarted it) if her growth would have been less restricted. 

Secondly, I wonder if the less than ideal blood flow had anything to do with my 3 miscarriages. I did not take aspirin until before the 4th pregnancy (which actually worked). I do have signs of poor egg quality with high FSH and boarderline AMH. All the miscarriages were missed, with no growth each time past 6-6.5 weeks. Could that have been due to poor blood flow and not egg quality? My gut says its egg quality. I guess we will never know but I wish we could. Too bad we were unable to test the embryos that miscarried.  

Thirdly, I wonder if the pregnancy being successful is because the embryo implanted in an area of the uterus that had better blood flow and the majority of my uterus has poorer blood flow. Those with a unicornuate uterus can have poor blood flow due to the abnormal formation of the uterus. Am I doomed to have tons of miscarriages? That remains to be seen.

Lastly, I wonder if I am lucky enough to get pregnant for a second time (and not miscarry) if this will happen again. And if not, how much more will my uterus grow? Can I make a bigger baby in my half uterus? It obviously stretched a ton this time but not like a normal sized uterus did. 

I made my OB cookies and wrote her a thank you note because she was so incredibly kind and supportive throughout the entire pregnancy. I know I was a high needs patient (for good reasons I think) and I wanted to let her know how thankful I am for her care. I ended the card saying “I am so thankful for my beautiful baby”, and I teared up as I wrote that. The gratitude I feel toward having her is immense and I don’t think I could put it into words. 

Today I Remember…

Today I remember…

My excitement at each positive pregnancy test. 

How I told my husband I was pregnant. 

All of the plans I made for each baby who was never meant to walk the earth. 

The anticipation of the first appointment, and then the nerves for the following pregnancy’s appointments. 

The incredibly heartbreaking power of the sentence “I’m sorry, there’s no heartbeat”.

The look on my husband’s face the first time we heard that sentence. 

The physical pain of each miscarriage, followed by the emotional turmoil. 

The thought that I may never become a mother to a living child. 

The fear of trying again only to face the same fate. 

That if I had never lost my three babies, baby A would not be in my arms today. 

Today, and every day, I remember my three angel babies, and I am grateful and thankful that I carried them for their short lives. I also remember all of the beautiful babies who were taken from our arms too soon. 

IUGR Update

I had my growth scan yesterday at the MFM’s office. Baby girl only gained 5oz and now weighs 3lb 1oz. Now she’s less than the 1st percentile. It’s great that she gained some weight, however tiny the amount, but I’m just so sad at how tiny she is. If she gains 5oz every two weeks and we are being induced at 37 weeks, I’m on track to have a baby who weighs around 3lb 11oz. That’s a TINY baby. I really hope the scan is off and she’s actually going to be bigger (not smaller). I also hope we can make it to 37 weeks without any issues. My MFM keeps telling me that it’s the gestational age that determines outcome, not weight. He’s glad we made it this far already (33 weeks tomorrow) and we are hoping everything continues to look good until induction. I’m still incredibly scared and sad that my body cannot nourish my baby appropriately. I’m so scared to have made it this far and then she doesn’t make it. My MFM also reassured me that with the close monitoring the risk of a still birth is quite low. I’m still scared, though. 

Thankfully, she’s still passing all of her NST’s, blood flow to the baby looks good, and the fluid levels are good. You could see her practice breathing on the ultrasound. It was really cool! 

We are looking at induction at 37 weeks, which we will schedule at my next appointment in 2 weeks. I’m scared of the induction itself, as I know labor that is induced has a higher risk of c-section. That, coupled with the fact that IUGR babies tend to tolerate induction poorly, makes me think I will end up with a c-section regardless. Ugh, I was really hoping for an unmedicated vaginal delivery but obviously whatever is best for the baby is what I want. I just know that pitocin contractions are supposed to hurt more and if I need a c-section right away for a problem it may be better to just have the epidural in place so I can be awake for the birth. So many things to consider. 

I’m really struggling with feelings of guilt and sadness. There has been lots of tears and I am really feeling blue. I know we all have our battles to fight but I just wish this wasn’t mine. I feel like my body sucks in general, with the poor egg quality, recurrent miscarriages, and the unicornuate uterus, and now it’s potentially contributing to lifelong issues for my little girl. 

In other news, I had my first baby shower, thrown by my husbands family. It was a joint baby shower as my SIL is expecting in December so we figured it made sense to combine them. It was wonderful to celebrate our baby, no matter what the outcome. I only got one “you’re so small” comment that I just brushed off. My SIL was 26 weeks to my 32 weeks and her bump is the same size as mine. Really great for my self esteem. We got a ton of clothes, and a lot of the stuff off of our registery. 

Speaking of the “you’re so small” comments, I really struggle hearing them. It just makes me feel bad about myself. I am also concerned about getting the “your baby is so tiny” comments after she is born, so much so that I don’t want any visitors after she is born. I’m sure this is unrealistic but it’s just how I feel. I don’t want to be judged as a poor mother because my baby is tiny. I already feel horrible about myself. These feelings concern me in general because I am concerned about post partum depression and anxiety and I feel like this may put me at a greater risk. I guess it’s good that I’m aware of the feelings already but it’s still scary. 

Thank you for reading if you made it this far. I hope everyone is doing well.

Cervix checks have begun and a few thoughts on Mother’s Day and death…

I had my 16 week appointment last Thursday (at 15w5d) and I got to have another vaginal ultrasound to check the length of my cervix. One of the more common complications of women with a unicornuate uterus is incompetent cervix. Because of that, I will be having cervix checks every two weeks from 16 until 24 weeks. 

My OB warned me before the scan that she is not the best at cervix measurements, and she ended up grabbing another OB to help her (I really appreciated the honesty). They took an average of three measurements and came up with 3.75cm. For someone with risk factors (like me), they start to worry at anything less than 2.5cm. So far so good! Fingers crossed this continues to be a non-issue. 

The baby is getting so big! It’s really crazy to see the growth progression since I have had soooo many ultrasounds. I also finally bought a Doppler to check the heartbeat at home. I’m just in need of a little extra reassurance and I feel like now that I’m this far along I shouldn’t have a hard time finding the heart beat (famous last words….). I’ll let you all know how it goes once it arrives. 

I also want to say a little something about Mother’s Day. To every women out there trying for their little miracle, you are a mother and I respect and admire you with all my being. To those mothers who have suffered pregnancy loss at any stage, my heart goes out to you. And to those mothers who have lost their baby or child too soon, I send you so much love. Life is not fair, and we are all mothers, no matter where we are in our journey. 

Today at work, a mother and father lost their little one. It’s a painful reminder that there are no guarantees in life, and I am honored to have cared for their baby. My heart is heavy for their family tonight. 

At least we are still heading in the right direction…

Today I am 12w3d pregnant. One week away from the second trimester (although that’s to be debated…I guess technically I could be there already by hitting 12 weeks or I could be 10 days away if I considered 14 weeks to be the start…I’ll go with the happy medium).@@

In general, this has been an incredibly uneventful first trimester, up until yesterday and today. I had an extra reassurance scan at 10w5d where everything looked on track. I weaned my progesterone suppositories to once a day with the plan of stopping after my NT scan on Friday. My pregnancy symptoms were mainly very mild cramping, and I usually had nausea and felt pretty poorly in the evenings up until last Wednesday. Then just very mild on/off cramping. Of course that made me nervous but a lot of googling convinced me it’s normal to have diminishing symptoms in weeks 11/12. My husband and I were preparing for the NT scan this Friday. Yesterday, I had about 8-9 hours of on/off period-like cramping fairly consistently. It was making me nervous but I was trying to convince myself it was normal and my uterus is just growing. I called the advice nurse in the evening and she set me up to see an OB this morning. She also suggested Tylenol which I held off on as I wanted to feel if the cramps got worse. My husband asked if I wanted him to come, and I told him no since he was already taking time off of work for Friday’s scan. I took a hot shower and curled up in bed feeling better and actually slept well and don’t remember cramping overnight.@@

When I woke up this morning, I used the restroom and when I wiped there was pink on the toilet paper and a little in the toilet. Cue freak out. I called my husband who immediately came home and took a hot shower and some Tylenol and proceeded to cry on and off convinced it’s over. I was again having period-like cramping. The pink spotting turned into brown discharge. We prepared ourselves for the worst. I didn’t see my regular OB but the woman I saw was incredibly kind. She checked my cervix, which was closed and she could see the old brown discharge on it. Then she did an abdominal scan where we were able to see the heartbeat and hear it (it sounded fast but she didn’t measure it). Lastly she did a vaginal scan and got a good CRL measuring on track for my dates. My cervix was around 2.5cm which she said was probably fine for now as her measurement could have been off. Since I’m seeing the high risk OB Friday (apparently with the NT you do see this OB) she will have them check again and they can give me more information on incompetent cervix and what the plan would be if I ended up with it. There was no obvious source of the (assumed old) bleed.@@

She then recommended that I go back to taking the progesterone suppositories twice a day and continue that through 34 weeks. It won’t hurt anything and in her experience she thinks it’s a good measure to take if we are worried about incompetent cervix. I also asked her to place me off work the rest of the week which she did. I just want to rest and not be on my feet all day in my occasionally stressful job. She said since I have a history of miscarriages my risk of having another one is obviously higher but she is highly optimistic that things will work out. I hope she’s right.@@

So now we wait until Friday to find out our risk of genetic issues and to see if the baby is still doing well. Both of us are obviously concerned but are trying to remain positive. I was actually starting to feel comfortable in this pregnancy, but that all changed this morning. I’m still having the period-like cramping although it’s not as bad as yesterday (but today I’m taking Tylenol so who knows how much pain that’s helping with). I had a lot of brown discharge after I went number two (sorry if TMI) but after that I’ve had nothing when wiping and a slight amount on my pad. I really hope this works out, as I cannot imagine the alternative at this point.@@

My husband has been amazingly supportive and loving throughout all of this. When we got home from the appointment, he gave me a beautiful necklace with matching earrings. It was originally supposed to be for Mother’s Day but he wanted me to have it now. I am so touched and lucky to have him by my side, through the good and the bad.@@

Thanks again everyone for the support! Sorry I’m such a sporadic writer. 

IVF is on my mind…

While I have been reading and keeping up with everyone’s blogs, I have been un-interested in writing about myself. There was nothing interesting to report. That has changed in that we have some progress after all of my second opinions. The writings below explore the opinions of the four doctors I have consulted with. Three of them are IVF doctors, and one is my RE. My RE is Dr. N, and the IVF doctors are Dr. H (#1), Dr. Z (#2), and Dr. ML (#3). I’m sure this post will get confusing, sorry!

Unicornuate Uterus

All four reproductive doctors concur that my uterus is not a likely cause of my miscarriages, although one of the four does think it could be a factor. I’m going to consider that good news, although I’m not fully convinced that it’s not part of the problem

IVF

My RE, Dr. N, is very pro-IVF for us due to my UU, as he felt doing a single embryo transfer was very important and I should not risk the chance of having twins naturally.

Our first IVF doctor, Dr. H (through Kai.ser), feels very strongly that doing IVF will be beneficial to us in that we can genetically test the embryos. His thought is that we would probably only get one genetically normal embryo based on my AFC and FSH (although we do run the risk of getting no normal embryos). His suggestion is the microdose Lupron flair protocol. I really liked his bedside manner, but I have huge problems with going on birth control for 2 months prior to cycling. I am very concerned about over-suppressing myself due to my borderline DOR. Kai.ser is an IVF machine that batches their patients and has great SART ratings, but I don’t think this approach is for me.

Dr. Z runs a private fertility clinic that only does IVF. He is a one man show. His big thing is that he also does immunology (something I am interested in because of my recurrent miscarriages). They are the most expensive option out of the three clinics, but I did have him run tests for my natural killer cells and my TH1:TH2 ratio (cytokines). After $800 for 4 vials of blood, my cytokine ratio was elevated but my NK cells were normal as far as I can tell. I do not understand what that means, even after consulting Google and reading some medical literature (I am able to wade pretty well through medical journals because my first undergraduate major was Chemistry…what was I thinking there, but that’s another story). If anyone has any insight into cytokines and recurrent miscarriage, please enlighten me. I am comfortable with his recommendations based on my results to have an intralipid infusion before my FET, and then do two more intralipid infusions upon confirmation of a positive pregnancy test. So what is my reservation with his clinic? I feel like they are just out there to make as much money as possible. The do a ton of unnecessary genetic testing that really adds to the cost (the overkill on the genetic testing is just my opinion). I realize that IVF is a business but I really didn’t like the feeling I got working with his clinic. I did like his protocol recommendation of a natural start IVF cycle (no BCP). I could see myself going back there someday if our plan doesn’t work out.

My final consult was with Dr. ML, who works in a large research hospital in SF (if you’re in the area, I’m sure you can figure out where this was, haha). I immediately loved her bedside manner and how well she knew my case. She does not quite agree with Kaiser’s diagnosis of DOR just yet, especially since I am still getting pregnant. Her suggestion was actually to keep trying naturally and if I miscarry again, have the embryo genetically tested so we can get an idea of why I’m miscarrying. However, she said if my husband and I wish to go forward with IVF, she would do an estrogen priming protocol, where I wear estrogen patches during my TWW prior to the IVF stims starting. And no BCP!

So what the heck are we doing with all this information? We’ve decided to keep trying naturally for the next couple of months and hope that we can just get pregnant on our own and it’ll work out for us. Lucky for me I have a lovely cyst on the left ovary (the side that is NOT connected to my uterus), so we are at least getting in good tries from the right side for the next couple of months. If we do get pregnant and I miscarry, we will try to get the embryo genetically tested.

We plan to start our IVF path with Dr. ML with my March cycle, with plans to actually do stims and retrieval with my April cycle. If we get a normal embryo, we will transfer it and see what happens. If there are no normal embryos, we will consider trying another cycle or possibly consider donor eggs. If I miscarry a normal embryo, then we will probably move onto surrogacy, or we may consider looking into doing some immune treatments with the Alan Beer Center, as we live close by.

I am not sure I want to keep miscarrying with no end in sight. Nor am I sure I want to do experimental treatments with no guarantees they will work (although if I’m saying that, IVF is a total experiment for us with no guarantees to give us a genetically normal embryo, so maybe I will be willing to try them). I’m not done yet, but I just don’t want to live my life from one miscarriage to the next, not knowing if it’ll ever work.

A Diagnosis? Sort-of…

As I write this, I am two tests away from a complete RPL work-up (according to my RE Dr. N). This is what I’ve had done (please note that my lab values normals are according to the Kaiser Lab and my RE). I have loosely grouped the tests below based in my understanding of them.

Genetic:
Chromosomal analysis on myself (normal)
Cystic fibrosis carrier (negative)
Chromosomal analysis on my husband (normal)

Clotting issues:
Lupus Anticoagulant (negative)
Cardiolipin Antibody (negative)
PT/APTT (13.3/30.1seconds, normal)
Factor V Leiden and prothrombin mutation (negative)
Homocysteine (5.7, normal)
Beta 2 glycoprotein IGG, IGM, IGA (all <9, normal)

Hormonal:
Testosterone (19, normal)
Hemoglobin A1C (5.1%, normal)
Fasting Glucose (83, normal)
Thyroperoxidase antibody (27, WNL)
TSH (2.11, my RE wants <2.5)
Prolactin (12, normal)
Vitamin D (25, normal)
AMH (1.24, low, want >2)
FSH (13, high, want <10)
Estradiol (<50, normal)
LH (3.6, normal)

My husband and I are taking a 10 day course of Doxycycline just in case there is an infectious component to our losses.

These are the two tests I have left to do:

Progesterone level at 7 DPO
Saline Infusion Sonohystogram (SIS) to evaluate for fibrosis and polyps

After I ovulate this month I’ll do the progesterone and I’ll be doing the SIS hopefully next month (there were no openings this month and the test apparently has to be done after your period stops but before CD 12…obnoxiously short window). Hopefully these will be normal. I will update once I have those test results.

So, what does my RE have to say about all this? Basically, he thinks the reason for my miscarriages is due to poor egg quality. Since my AMH and FSH are abnormal, my ovarian reserve is low and my egg quality is on the poor side. His exact words are: “When the [AMH] level is between 1 and 2, this shows egg quality is starting to change. It’s what we call the “gray zone”. It’s not bad, but makes it harder to conceive. Once the level drops under 1, we know that the number of quality eggs remaining are much lower. It is harder to conceive and we tend to see more miscarriages.” And “Your FSH of 13 is high (over 10), showing hormonal evidence of ovarian aging.” His recommendation is to start taking 75 mg/day of DHEA since research shows this helps improve egg quality and reduce the risk of miscarriage.

Of course I was freaking out and immediately asked him if we should proceed directly to IVF because I would really like to have a child that is genetically mine. He, however, says “Since you are still young, I think your egg quality is better than the AMH level.” I guess he thinks we should be ok with these numbers, but only time will tell.

I visited an acupuncturist recommended to me by co-workers who gave me some dietary tips, supplements, and will start my treatments next week. He does not think the DHEA is necessary at this time but did not tell me to stop it since my doctor told me to take it. He does not think my AMH is too terrible but is hoping to work to lower my FSH and my TSH. His plan is to relax me and increase blood flow to my uterus and ovaries in hopes to improve my egg quality and help with implantation.

My plan is as follows for the next 3 months (we will still continue to try naturally as I make these changes): DHEA per my RE, Co-q 10, vitamin e, vitamin c, prenatal vitamins, b-complex vitamins per the book “It Starts With The Egg”, and 81mg aspirin, diet changes, and acupuncture per my acupuncturist. I am also continuing to exercise. At the end of three months I will ask for a repeat of my AMH and CD 3 FSH/LH/estradiol to see if there are any changes. As long as they are not worse, I will probably continue on this supplement regime as we keep trying naturally. If the numbers are worse, I am going to start exploring the idea of IVF with PGS. I may also start exploring the use of medicated cycles to maybe try and ovulate more than one egg to increase our monthly chances but from what I am reading, using these types of medications is not great for people with increased FSH (since my ovaries are already working harder to ovulate each month). That’s something I will need to discuss more in depth with Dr. N after three months. If we do happen to conceive, we will see what happens and if we have another miscarriage I will strongly consider proceeding to IVF (my hubby isn’t wild about this option).

My long term plan if I cannot successfully have a baby is to do donor eggs, so at least my husband can have a biological child. I would still like to be pregnant/breastfeed if possible.

Obviously this could all change but it’s the plan for the moment.

I’m not sure how I feel about all this. I was convinced that something was wrong, but I was not expecting it to be ovarian reserve or egg quality because I am still relatively young (32 next month). Also, it really does feel like a “sort of” diagnosis since I’m getting pregnant. And I’m not wild about my TSH. I wish I could convince my doctor to treat it as I think it could only help. But it’s not my realm of expertise. I’ve done a ton of reading and it seems like there is a chance we will be able to have a baby, it will just take longer. Honestly, being well versed in medical crap is more like a curse because I can’t just listen to the doctor. I’m constantly researching and asking questions but if there is anything I’ve learned in my nursing career it’s that you have to be your own advocate in the health care world or you will never get what you want or need.

Any thoughts? Or any suggestions? Or can anyone point me in the direction of bloggers with a similar problem?