Likely 3rd loss w/ Hashis, endo, PCOS, MTHFR (A1298C homo)

Lora

6 Posts
Reply Posted on: Jan 22, 2013 at 12:40pm
First, I apologize if this seems at all frantic, desperate, or disjointed. I'm only about an hour removed from this latest round of likely bad news.

I have been trying to conceive my first child since May 2010 (age 26 at the time) and now find myself on the verge of loss #3 at age 29.

Loss #1 was a suspected ectopic diagnosed while still under the care of an OB and treated with MTX at 6w2d in 11/2011. The PG was conceived naturally on a CD55 ovulation. I bleed from the day of my first positive home test and my HCG never rose normally. It plateaued at 490 just before the MTX injection.

In the 17 months leading up to that first PG I was diagnosed with Hashimoto's (TSH at time of DX 55.38) and PCOS (elevated androgens and anovulation, but normal u/s and LH:FSH ratio). I have been on Synthroid (various doses, currently 112mcg) and Metformin (2000mg) since spring 2011.

After the suspected ectopic we sought care with a local RE. The HSG he performed showed two blocked tubes (proximally) and we proceeded with a diagnostic laparoscopy in 2/2012 that revealed stage II endo on the ovaries, tubes, and (worst of all) bowels. All was removed and I began trying to conceive again with the aid of Clomid (first 50mg then 100mg).

Loss #2 was an early chemical (4w2d) in May 2012 while with RE#1 and on 100mg Clomid. The highest my serum progesterone got during the cycle was 8 while on 200mg progesterone suppositories.

Over the summer I relocated and am now with RE#2 who again repeated my HSG (all clear last month) and started me on Clomid (100mg CD 6-10 due to HSG on CD6), baby aspirin, and twice daily Crinone from 4dpo. (In addition to my normal Synthroid, Metformin, Folic acid (4mg), Vitamin D, Vitamin B12, and prenatal.)

I currently am 5w6d and though a 7.53mm gestational sac was visualized in utero this AM, my lab results just came back showing that my HCG has only risen from 1,113 to 1,479 in 1 week, and my P4 has dropped from 17.1 to 13.1 in the same amount of time. RE#2 is preparing me for another early loss.

My relocation this summer was to New York state, and I have been debating a consult with your practice for well over a year now. This loss (should it prove to be one) is certainly motivating me to find more answers.

In addition to my Hashi's (mostly well-controlled since summer 2011 with traditional T4 meds), PCOS, and endo, RE#1 also DX me with homozygous A1298C MTHFR after a traditional thrombophili RPL panel (all other results normal). A former endo also suggested several times I may have a very mild form of Raynaud's in addition to my Hashi's due to repeat bouts with blue fingers at times of high stress, but as we have been trying to become pregnant this entire time, she didn't see the sense in investigating further since 1. it was mild and not impacting my life, and 2. any meds for it would not be safe in pregnancy.

With all that said, I'm very concerned about immune issues and know you are my next step.

My specific questions:

1. What timing do you usual recommend for patients wishing to get the Reprosource panel done? Am I best suited to wait out this (likely) m/c before testing, or would some valuable diagnostic criteria be gained by doing ASAP irregardless of my current status?

2. I read with interest a blog post of yours that suggested in patients with diagnosed autoimmune issues that low serum P4 levels were concerning as they might mean fewer friendly helper immune cells get recruited to the uterine lining. My highest ever pregnancy P4 was last week's 17.1 and that was after nearly 3 weeks of twice daily Crinone 8%. (Highest leve during suspected ectopic was 7.8 on vaginal prometrium, 8.0 during the chemical on 200mg progesterone supps). I raised this concern to RE#2 and was told serum levels do not matter and denied PIO. Would it typically be your practice to treat with IM progesterone for someone with my issues?

3. When would be the best time to consult with your office? Do you advise waiting out this (likely) miscarriage and having my system return to baseline, or would it be worthwhile to call now (understanding you presummably have a decent wait list).

Thank you again and sorry for the length of this post.

Best to you.

Dr. Braverman

2026 Posts
RE: Likely 3rd loss w/ Hashis, endo, PCOS, MTHFR (A1298C homo) Posted on: Jan 22, 2013 at 7:13pm
Ok do not apologize , this is the state that most of my patients arrive in. You have been through quite a bit. We need to have a full consultation so I can go over all your history in detail , but a few answers. Yes I use IM progesterone quite often when I suspect an immune issue it does help with peripheral conversion to NK 16- cells (the precursors we beleive to the uterine natural killer cells) these are the ones you need to help establish implantation. Getting information while pregnant is very useful as we always want to see the immune systems reaction to your pregancy so earlier is better.
Please call my office , if you live in NY I will order these tests for you now so we will have them by the time I see you. Unfortunately I cant order them from outside NY per new regulations you would have to come here first. other than that you have clear signs in your history that dictate the correct and complete immune work up.

good luck I look forward to meeting you.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.

Lora

6 Posts
Reply RE: Likely 3rd loss w/ Hashis, endo, PCOS, MTHFR (A1298C homo) Posted on: Jan 23, 2013 at 5:44am
Thank you so very much. Just waiting for your office to open to call and get the ball rolling.

Lora

6 Posts
Reply RE: Likely 3rd loss w/ Hashis, endo, PCOS, MTHFR (A1298C homo) Posted on: Jan 25, 2013 at 7:35am
Dr. Braverman,

First off, thanks to you and your amazing staff for being so receptive to me at this stressful time. Thanks to the folks at Reprosource, I was able to have my blood drawn and shipped yesterday and eagerly await the results.

I write to update our situation which has raised yet more questions. To review, while a 7.53mm gestational sac was visualized in utero this Tuesday at 5w6d, my lab results that same day revealed that my HCG only rose from 1,113 to 1,479 in 1 week, and my P4 has dropped from 17.1 to 13.1 in the same amount of time. We were prepared for another early loss and I returned to my local RE for confirmation this morning.

This morning's ultrasound (6w2d) revealed a fetal pole measuring 3.93mm and a fetal heart rate of 105bpm. My lab results have yet to come back. To say I was stunned with the result is an understatement.

So, my primary question to you is, what (if any) cause would you typically associate with such slow and low beta HCG values at this stage of early pregnancy? Have you found any possible immunological explanations for unusual beta HCG levels? In your population of patients, do low/slow betas often have a positive pregnancy outcome? What, if anything, would you advise at this stage of the game as we wait for my Reprosource results and our consult with you?

I also plan on contacting your office this afternoon to update them on this situation, but wanted to reply here as well to keep my entire history within this post.

Best to you,

Lora

Dr. Braverman

2026 Posts
RE: Likely 3rd loss w/ Hashis, endo, PCOS, MTHFR (A1298C homo) Posted on: Jan 25, 2013 at 7:53am
My thoughts would have been the same as yours , with such a small rise I would not have expected to see a heart beat. I have also learned not to rely solely on lab tests. Your confirmation will come with your next sonogram , we must see a good change is size and an increasing rate with the fetal heart.
Keep me in the loop. Good Luck.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.

Lora

6 Posts
Reply RE: Likely 3rd loss w/ Hashis, endo, PCOS, MTHFR (A1298C homo) Posted on: Jan 29, 2013 at 12:57pm
So, the mystery continues as I await my first consult with you next week.

Last Friday (6w2d):
CRL: 3.93mm
Fetal heart rate: 105bpm
HCG: 1,857
P4: 9.5

Today (6w6d):
CRL: 5.62mm (local RE saying 6w2d which is still within a decent margin of error)
Fetal heart rate: 122bpm (nicely up)
HCG: 2,083
P4: 11.2

Local RE has consented to switch to PIO (1cc/50mg) daily, in addition to 1 Crinone 8% daily. (Currently taking Crinone 8% BID.) We will also be adding HCG boosters of 2,500U every three days starting this evening. These changes to protocol were mostly done to placate me and, in my REs opinion, represent a can't hurt, might help scenario.

I am eager to speak with you more at my consult, but wonder what your thoughts are regarding these results (understanding you don't know my entire history). Have you ever encountered patients that just don't produce HCG in expected quantities? Could there be any immunological explanation for these unusual lab values? Is it possible the assay used at my lab is not "jiving" with my blood?

We will not be doing any further HCG draws as the boosters will influence the results. My next ultrasound (and likely last before I see you) is this Friday (7w2d).

I am holding tight to the fact that both the CRL grew and the heart rate increased, and both of these are promising signs. That said, I'm a researcher at heart (to many years in grad school) and am just eager to hear what, if any, reason there may be to such abnormal HCG results. I have, in some ways, emotionally distanced myself from this process and am now just viewing this case as a medical mystery.

Dr. Braverman

2026 Posts
RE: Likely 3rd loss w/ Hashis, endo, PCOS, MTHFR (A1298C homo) Posted on: Jan 29, 2013 at 7:11pm
I would rather wait and see how you do before commenting on all my thoughts as we cant change the outcome at this point and remaining positive is so important.
dont distance your self yet, keep hopefull. Ill speak to you soon and we can reveiw all.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.