Secondary Infertility

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Reply Secondary Infertility Posted on: Oct 5, 2011 at 7:26pm
Hi Dr. Braverman,

I have a child that I conceived naturally with no problems. Since that time, I have had 7 miscarriages, 3 of which were tested for chromosomal abnormalities (and did have abnormalities). The other 4 were 'chemical' pregnancies and not tested. I am 42 years old so perhaps this is not surprisingly but I have also been tested for many issues and appear to have some auto-immune issues, for which I take lovenox, methanx, prednisone and low sugar/low carb diet. In brief, blood clotting issues (elevated IgM but the rest of the anti-phospholipid antibodies are negative, HPA-1 hetereozygous mutated, PAI-1 homozygous mutated, Factor XIII homozygous mutated). Also:

PAI - 1 4G/5G gene polymorphism - homozygous mutated
MTFHR - C677+
NK assay:
50:1 should be 15 or below (sometimes above, sometimes below)

Th1/Th2 cytokines:
TNF should be 30.6 or below (soemtimes above, sometimes below)

The last few cycles my endometrial lining has also been thin so I have been prescribed estradiol and progesterone.

I don't feel like I have a lot of time left (especially considering my ovarian lining thinning)... What do you recommend?

Thanks!

Dr. Braverman

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Re: Secondary Infertility Posted on: Oct 6, 2011 at 1:40am
I agree , although at this point age does begin to play a part, there is most likely another reason in addition for your losses. The lining alone could be an issue and you would need more aggressive therapy than just estradiol, we use viagra, vit E, and even G-CSF flushes with great success. Im not overly impressed with any of your immune findings but you do have some significant thrombophilia findings which are usually corrected with lovenox(you have to be sure your levels are tested and correct).
Of course my immune workup would be more complete than what you have had done already , but I dont get the sense that is where your problem lies. I would be happy to help guide you in your workup and treatment. If you wish you can call my office and schedule a consultation.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.

Dr. Braverman

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Re: Secondary Infertility Posted on: Oct 6, 2011 at 1:41am
I just wanted to be clear here, that it is the patients with the HLA issues that I most often see a complete failure to concieve at all which is why I suspect that first.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.

manyquestions

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Reply Re: Secondary Infertility Posted on: Oct 6, 2011 at 1:48pm
Thank you. To be clear, when you say HLA issues do you mean matching? What kind of treatment is there if that does turn out to be an issue?

I can set up a consultation but I am wondering how quickly we could get started on a more proactive regimen to deal with the endometrial lining issues.

Thank you!

Dr. Braverman

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Re: Secondary Infertility Posted on: Oct 7, 2011 at 7:11pm
There are many treatments for HLA matching issues, I have had great success with either IVIG/prednisone or neupogen. for lining issues try Vit E 600iu per day or viagra supp 50mg twice daily. at time of retrieval in IVF cycles or prior to ovulaiton with IUI cycles we have also used G-CSF flushes to help improve the lining as well with excellent results.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.

manyquestions

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Reply Re: Secondary Infertility Posted on: Oct 9, 2011 at 8:55pm
Thank you. I really appreciate that you take the time to respond to me and so many others on this board!

I am really looking forward to having our consultation. I had set up an appointment to meet with you last time I was in NYC but unfortunately our schedules didn't match. I am looking forward to the phone consult though, as I don't want to wait for my next trip there (having a birthday recently does that:). Is it possible to have a lab order for the HLA matching test before that time so that we'd be able to talk about that as well as the other results I already have when we have our initial consultation? Thanks again!

Dr. Braverman

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Re: Secondary Infertility Posted on: Oct 10, 2011 at 6:22pm
unfortunately I dont have a choice, I cant order testing until we have had a consultation, Im sorry , but the HLA comes back rather quickly.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.

manyquestions

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Reply Re: Secondary Infertility Posted on: Oct 11, 2011 at 4:07pm
Not a problem, I understand. A few other questions as I'm trying to plan ahead: All 8 pregnancies have been natural conceptions, though I am currently trying IUI with gonal-f (partly to help with estrogen production).

Do you think we should be considering IVF with PGD or is natural conception better when possible?

Also, do you ever go straight to G-CSF (depending on test results) or do you always try IVIG first?

Thanks so much!

Dr. Braverman

2016 Posts
Re: Secondary Infertility Posted on: Oct 13, 2011 at 12:37am
I see no need for IVF if you are concieving on your own , PGD is of no value here as they dont test for all chromosomes and results may incorreclty eliminate a normal embryo. I usually recommend IVIG prior to G-CSF as the latter must still be considered experimental. However if economics comes into play I have ordered the G-CSF as a first line therapy after all proper consents were obtained and Im sure the patient is available to me for close immune surviellence.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.