Click here for episode 1

Irene’s testing came back with a positive result, for a test called Lupus Anti-Coagulant (LAC). Instead of being depressed about having something abnormal, she was actually happy, especially when she learned that there was a way to address this problem.

The name, Lupus Anticoagulant, is paradoxically misleading. Most women with Lupus don’t have a positive LAC. Most women with a positive LAC don’t have lupus. Furthermore, it’s not truly an anti-coagulant. In fact, the miscarriage issues stem from it being a PRO-coagulant, meaning it causes excessive blood clotting. One way to think of this is that Irene’s immune system is overachieving. Instead of merely attacking germs and foreign substance invaders to her body, the immune system is also attacking her own cells, leading to unpredictable outcomes, one of which is recurrent pregnancy loss. The important thing to remember is this. Patient with a history of recurrent miscarriage and a positive LAC would most likely benefit from some form of true anticoagulation.

With a focus on the practical implications, we now had a plan. The next time Irene got pregnant, we would give her something to counteract the harmful effects of the positive LAC.

Irene now had the following concrete game plan. She would call us as soon as she missed a period and come in for a pregnancy test. If it was positive, then we would put her on heparin, a blood thinner. We had to also have a backup plan. In case she wasn’t pregnant within six months, we would re-evaluate to see if she would like us to do something to speed things up.

Click here for episode 6

Dear Dr , I have been through each and every section of your website and it
is really very informative for people like us who sometimes wish to know ,
why this treatment , what would it do? It has really encouraged me to ask my
RE politely about various things and treatments she suggests.

My goal is not to make extra work for my colleagues , but there are certainly times in which part of being an RE is communicating with patients and not just being an egg and sperm engineer. I personally get a lot of satisfaction from teaching, not just teaching medical students, but also teaching my patients and my blog readers.

There is this one thing about which I’ll like an opinion from you. I’ll
try to be brief but explanatory about my history , please advise me , I
really need your advice.

My Problems - TTC for 3.5 years now, I am 29 now.
- Irregular periods(since the age of 21, was on provera to get my periods)
- Married at age 25(BCP for 6 months)
- Detected with PCOS, Insulin resistance and hypothyroidism(currently on
metformin 1500 mg, synthroid 50mg) after 6 months of marriage
- Vaginismus - to top all the above problems , I have this, I sometimes
want to run away from this truth but I just cannot , my brain just does not
let my husband in and I don’t know whether we have ever had a successful
intercourse. I had a surgery to remove the hymen which the doctors thought
might be causing pain. I have been able to get all vaginal ultrasounds and
IUIs but I still can’t let him in. I just can’t state my helplesness and
wish somebody could understand it.

Infertility problems are divided into problems of sperm, eggs and anatomy. You haven’t mentioned sperm yet, but the irregular menses suggest an egg problem and the fact that you can’t effectively have sex creates an anatomical problem. Over the course of my practice, I have encountered quite a few married couples who never have sex. There are obviously many emotional implications in addition to the fertility implications. Dyspareunia is the medical term for painful sexual intercourse. This is further divided into deep dyspareunia and superficial dyspareunia depending on if the pain is felt deep in the pelvis or on the skin and surface. Vaginismus is a case of superficial dyspareunia. Your case, while severe is not as severe as those women who can’t even get ultrasounds.

I have been working on my above problems, I started with an aggressive
approach this year when my RE said that inseminations will overcome the
vaginismus factor. I have had 3 IUIs , 2 IUIs with clomid cycles and one
with Injectables. In both the clomid cycles , I had good mature follicles
always on my right ovary on cycle day 18 . The first cycle , I had 3 that
measured 2.1, 1.8 and 1.7 but my lining was only 0.5 cms. Next cycle with
clomid on my right ovary I had only one mature follicle on day 17 of 1.9 cm
and my lining was agin a 0.6. My RE said that clomid is causing the thin
lining and moved me to Injectables with the low dose of 75 IU. I had 5 good
follicles this time on cd12 and they were 1.9, 1.8, 1.8, 1.6, 1.5 and my
lining was 1.07 cms.I had the HCG shot at 12:00 in the night and went for
IUI at 9:30 on cd14.My doctor said the chances are very high and I was
started on progesterone on cd14 itself and on CD21 the progesterone levels
came as 38.3 but I wasn’t pregnant.

My questions
1) Is one IUI enough for me, knowing my situation that aur love making is
not successful , should we go for 2 IUIs in one cycle and if 2 what should
be the timings of them?

This type of detailed variation is an individual choice between the RE and the patient. There is no clear data showing that two IUI’s are that much better than just one. The timing of IUI’s is also a personal judgment call. Many RE’s don’t time it down to the hour, but just schedule it sometime either 1, 2 and/or 3 days after the hCG shot. I like IN GENERAL, to do the IUI about 40 hours after the hCG shot, but it varies especially in patients who have had previous IUI’s in which case you can go back and see what they have done in the past, so as to fine tune the plan for future cycles.

2) can inseminations truly overcome the vaginsimus factor, if so , why do
doctors say to make love that night and the following night ?

IUI’s get the sperm deep inside the uterus. For patients with vaginismus, the sperm often doesn’t even get into the vagina. So, yes, IUI’s are mechanically very effective for overcoming the vaginismus factor. I’m not sure what you mean in your second question. We don’t typically tell that to our IUI patients.

3) Also, I think that I took the HCG shot quite late at night(As in one of
your case studies you said it should be 35 hrs prior to iUI). Please tell me
when should the HCG shot be taken and when should the IUIs be done to have
most chances?

Again, refer to my answer to question #1. It is not set in stone. By the way, please point out where exactly did I said 35 hours for IUI. It might be a mistake. Or are you sure I wasn’t referring to IVF? In that case, it is indeed about 35 hours between hCG and egg retrieval.

3)Also, my RE didn’t do a HSG for me and she wants to do it this cycle, can
I do an HSG and an IUI in the same cycle? Also, as they say HSG improves
fertility , is that true , would that really help?

Yes, it’s possible and often done to have an HSG and an IUI in the same cycle. The drawback is if the HSG shows both tubes to be blocked, then you’ve wasted the ovarian stimulation. In some patients, an HSG does improve pregnancy, both through natural intercourse and through IUI. The thought is that the dye flushes debris and "junk" out of the tubes making them cleaner than ever.

4)If due to vaginismus my chances are very low with IUI,should I just move
to IVF ?

If your only problem is vaginismus, then IUI should overcome it. Bear in mind you might have other problems, such as egg quality issues, if you truly do have PCOS, as you suggested. In general, if the tubes are open, my patients undergo 1-3 cycles of IUI before going on to IVF, but there are so many factors to consider that you had best leave the recommendation up to your own RE.

Thanks
Pia

Click here for episode 1

Irene bravely finished sharing the stories behind her previous four miscarriages. She gathered herself together and we began going down the list of possibilities, searching for a reason to explain her many pregnancy losses, and more importantly, hoping to figure out the right interventions to minimize the chance of a fifth one.

In no particular order, we started by discussing ANATOMICAL causes. A baby needs a certain type of safe environment in which to grow. If the uterine cavity is an abnormal shape, is an abnormal size or if it contains a mass pushing in on it, this can create a suboptimal site of implantation, thereby increasing the odds of miscarriage. In general, for patients with anatomical factors, I’ve seen more pregnancy losses later on in the pregnancy, rather than in the very early first trimester, as Irene’s had been.

Next, we discussed GENETIC causes. Sometimes, a husband or a wife who looks normal, carries what’s called a translocation in their genes. This leads to an increased risk of miscarriage, so that rather than the usual 15% risk of miscarriage for average couples, the couple in question will have over a 60% risk of miscarriage. There is no cure for it, but there are solutions, such as IVF with PGD to help pick the normal embryos. Another choice which is rarely taken is to use someone else’s sperm or egg (depending on which spouse carries the translocation). The strategy I see adopted the most by these couple is just to get pregnant frequently and often so that despite many miscarriages, eventually one will take.

We then discussed INFECTIOUS causes. Some women don’t realize they have a low-level chronic infection that is causing them to have trouble getting pregnant and/or sustaining pregnancies.

We also discussed AUTOIMMUNE / BLOOD CLOTTING issues. I put these two broad areas together in one category, because their treatments are similar. Some people have abnormalities with how their blood clots. If the blood clots TOO easily, then the blood supply to the baby will be compromised as the vessels clot up.

Finally, there are HORMONAL issues. This, too, is a general category as there are many different hormonal abnormalities that can affect miscarriage risk. Not every patients should have all these investigated. There are costs and risks associated with every action, so we need to customize the plan according to what’s best for each individual. The following are the specific conclusions we reached and the decisions we made as a result.

ANATOMICAL: Irene’s regular ultrasound exam looked perfectly normal. I performed it myself. This means there are no whopping obvious anatomical problems. However, in order to see more subtle anatomical lesions, one needs to do either an HSG or a saline-contrast ultrasound, tests which involve putting liquid into the uterus in order to see a clearer contrasting view. So should we get one of those tests? It always depends. Irene’s insurance did not cover the test, which can run anywhere from $500 to 1000 dollars or so depending on the part of the country and the specific radiological facility. Our decision to put off this test was based on the fact that we found something else positive. If we had nothing abnormal in any of the other categories, or if her regular ultrasound had been suspicious, or if it was free for her to get an HSG, then she would have more likely chosen to get it.

GENETIC: This category is tested by getting a karyotype on each partner. This is also an expensive test and wasn’t covered by her insurance. The main reason we did not do this test was because there was nothing we could do if the results came back positive. Irene and Harold were opposed to using donor sperm nor donor eggs, in case one of them came back as having a translocation. They also could not afford to do IVF with PGD at this point. Therefore, we decided not to do a karyotype yet.

INFECTIOUS: Instead of testing for a chronic infection, it turns out to be more practical to just give antibiotics to both partners. First of all the cultures are not very sensitive, so it’s possible for someone to have an infection and for the test to wrongly suggest that they are negative for it. Also, the test turns out to be more expensive than the antibiotics. I prescribed doxycycline 100mg twice daily for both partners. The downside is potential stomach upset for both partners and and potential yeast infection for Irene. There is also the bigger ecological downside of introducing more antibiotic resistance to the world’s bacteria. However, Irene and Harold decided there were perfectly fine with this option.

AUTOIMMUNE / BLOOD CLOTTING: We ordered some tests. Specifically, we checked Lupus Anticoagulant and Anti-Cardiolipin Antibodies. There are the two most common tests. There are other ones such as factor V Leiden, Activated Protein C Resistance, a fasting Homocysteine level and Factor II, but for cost reasons, we held off on those for now.

HORMONAL: After reviewing Irene’s history, we did not order any hormonal tests. For example, if she would have admitted to feeling tired or low-energy, I would have checked her thyroid. If she had evidence of PCOS, I would have checked her for insulin resistance. She did not have anything in her history that warranted any other tests. Irene was scheduled to come back and discuss the results with me in two weeks, by which time everything should be back.

Click here for episode 5

A 61-year old Japanese woman gave birth with the help of her daughter’s donated eggs. She carried the pregnancy for her daughter, who has no uterus.

Because of the patients I get from Japan who come all the way over here to California to do donor egg cycles, I was under the assumption that donor eggs and surrogacy were illegal in Japan. I stand corrected. They are not illegal, but just not conventionally performed by the medical community except by defiant doctors like the one mentioned in this article.

One brilliant relationship psychologist, John Gottman, did an analysis of couples and their communication styles. He was able to find four no-no’s that when present consistently in a couple’s interactions predicted a high likelihood of divorce. I have embraced his findings and I try my best to avoid these four in my interactions with EVERYONE. The four no-no’s are CONTEMPT, CRITICISM, DEFENSIVENESS and STONEWALLING.

Yesterday, I was peripherally watching Olympics coverage with some friends when I overheard the US women’s volleyball players Branagh and Youngs having a “strategy discussion” on the sidelines as they were losing to the Chinese team. They were obviously getting their signals crossed and not playing as a cohesive team. One of them said to her teammate something to the effect that “you need to talk”, expressing that their miscommunication was hurting their play. Her teammate shot back with “I AM talking”. Being the communication guru nerd that I am, I took this chance to share with my friends some comments on the concept of defensiveness.

Defensiveness is one of the bigger communication problems present in our world. To me, I define it as spending more energy protecting oneself rather than really listening to what the other person is saying. You can see why this is a problem for couples. If a wife says to her husband “You never spend enough time with me,” the PROPER useful response is to inquire lovingly into why she feels that way and what he can do to address the problem. However, because those words are usually fired in such an accusatory tone, the most common response from the husband is to defend himself with replies like “What do you mean I don’t spend time with you? I spent all Wednesday night at home and before that, we were at your mother’s all weekend. And I’m with you now. What do you want from me?” But as you can see, while defensiveness is the natural response, it doesn’t lead us down productive pathways.

Once I heard the volleyball players interchange, I was pretty sure they were headed for defeat and that’s exactly what happened, as they had more unforced errors and moments of miscommunication. I would have loved to hear an alternate reply like this.

“You need to talk”.
“OK, you’re right. Let’s do it!”

Such a small simple difference changes the whole tone and feel of the situation.

Click here for episode 1

Irene and Harold continue their consultation appointment. They are here for help regarding their repeated miscarriages.

The fourth pregnancy occurred towards the end of their second year of marriage. Ironically, instead of being happy with her positive pregnancy test, Irene was terrified. She immediately made an appointment with her OB. This was a new doctor and not the one who cared for her during the first three miscarriages. Her insurance had changed and she was also wanted to switch doctors for personal reasons.

Her hCG test was positive and in the 400’s range. Her OB checked her levels again two days later and it was in the 600’s range. Two days after that, it was about 1000. By now, Irene was an expert on how to monitor an early pregnancy and her memory sure was excellent. She had her first ultrasound five days later. A 6mm sac was seen in the uterus. No fetus nor yolk sac were seen, but I agreed that this was acceptable at this stage. Irene continued her story. Her hCG level was about double of the previous test, but that was five days ago. Meanwhile, she was on complete bedrest and scared to do anything.

Then the bleeding began. She went to the emergency room. The ultrasound was unchanged. There was still a sac, but it hadn’t grown and there was still no yolk sac seen. The bleeding increased and her hCG levels dropped. She just had her fourth pregnancy loss. After Irene courageously told me the whole story, I handed her a box of tissue and took over the conversation.

ME: First of all, I thank you for sharing this with me. I realize it’s not easy to have to talk about such a painful three years. I’ll start by telling you that at this point, given your age and your situation, the odds still indicate that it’s much more likely that you will have a healthy baby eventually. You might find that hard to believe, but even patients with seven or eight miscarriages have gone on to have babies. Hopefully, over time, you will be able to believe me more, but I do understand if you are doubtful.

IRENE nods.

ME: With four miscarriages, there is a likelihood that there is a reason, something that is making your chance of miscarriage higher than the normal 15-20% that other women have. I’m going to start by telling you five major categories of problems that we have to consider. We will then decided which ones to pursue first.

IRENE excuses herself while she removes a notepad from her handbag. It is not uncommon for patients to play “medical student” and take notes while I explain things, so this action did not surprise me.

ME: One area of problem we have to consider is ANATOMICAL. Is there something wrong with your uterus that is giving pregnancies a difficult time to implant? Something like a small fibroid or polyp. We may or may not do some testing right away to see if this is the case. The second thing we have to consider is a GENETIC reason. I know you have had some testing in this area, but we’ll discuss if we should do any further testing at this point. A third category that I consider together are IMMUNE AND BLOOD CLOTTING issues. The fourth category consists of INFECTIOUS causes and the fifth would be HORMONAL issues. We are going to explore these one by one and choose which order we will test.

IRENE begins to smile with hope.

ME: The order of testing will depend on several factors, including how much the test costs, how invasive the testing is, how likely it is for us to find an abnormal result and finally, how likely we can intervene and change things in case we do find something wrong.

IRENE: This is so different and reassuring to hear. I feel like we finally have a clear direction and pathway to go.

Click here for episode 4

The following is an email sent from one of my favorite patients. After a tough journey, she has been blessed (abundantly) with triplets. While having three at a time is not the preferred way to be blessed, she is an inspiration in many ways. During her prolonged hospital stay prior to the delivery, she made the most of her time there, sharing her faith and giving inspiration to the other mothers on the hospital floor who were also on bedrest. After the babies were born, her family and friends rallied around and showed their love by helping out the new parents of three. The following is an actual email sent out to her family and friends (and to me). She has given permission to share this with the rest of the world in the hopes that it can be a reminder that loving family and friends are the most important treasures on earth.

To: (list of friends and family)
Sent: Wednesday, August 13, 2008 7:30 AM
Subject: Two home, one to go!

Well, I do not know if you all will believe me but I am sitting on the computer, kids are sleeping in their cribs, dishes are done and house looks pretty good. We have had a busy couple of days. Steve and I brought home Madeline and Nicklaus on Monday evening. We were both so excited to get them home, but very sad to leave our little Gracie. She is doing great she just gets so tired during her feeds that she needs a little more love in the NICU. It must be that she loves her nurses, especially Sally and Sheryl. As you can imagine things are slightly crazy. My Mom stayed the night with us the first night and we did not sleep but five minutes here and there. Madeline has a very odd breathing pattern and to be honest it is sometimes scary. Nicklaus just loves to look at the world and never wants to sleep. Thank goodness that is changing. We bathed them last night and I think that it wore them both out. My Mom and Dad both stayed last night and I was able to get six hours of sleep. I cannot say that my Mom has had that but I woke up early this morning and sent her to bed. Today we meet our Pediatrician for the first time. I am excited to see if the kids have gained any weight??? Then we will go visit Grace and back home for the night. Please pray that the kids continue to eat well and that Grace will be home with us soon. It is very hard to have a split family. I went to visit her yesterday and then Steve went after work to give her quality Daddy time. She is in great spirits but we want her home. Many of you have offered help. I thank you and yes I could use it. It would be helpful to me that if you call you tell me when you can do it. I am drawing up a calendar and scheduling people in. If you feel like you are a night owl and can handle a shift that would be great. My parents are here helping but I need to give them a break too. Day-time cuddlers are needed too. Thank you to everyone for everything. Steve and I realize that we could not do this alone and all the support has been so great. Christy

Click here for episode 1

Irene and Harold are here for help because all four of their pregnancies so far have ended in miscarriage.

We talked and elicited more information. Irene worked as a nurse. She liked her job and described it as being moderately stressful only. She did not work with any radiation or chemotherapy. Harold owned his own painting business. He described his stress level as an 8 out of 10. He clarified that he didn’t have much contact with the actual paint and chemicals, but rather did management. They lived in their own condo with Harold’s parents.

Their first pregnancy was conceived on their wedding night. It came as a surprise that it happened so easily. Irene, who had previously been regular, every 28 days, missed her first period a week after the honeymoon. She did a home pregnancy test and it was positive. Two weeks later, she noted some spotting, which progressed to moderate flow with cramping. By the time, she went to see her doctor, she was bleeding like a period. She remembers that her blood pregnancy test was positive at first, but then the values proceeded to drop. She wound up not getting a D&C, but rather just passing everything naturally. Harold attributed the miscarriage to the stresses of the honeymoon and the initial moving-in process.

Seven months later, Irene was pregnant again. She went to her OB immediately and her pregnancy was indeed confirmed with a blood test. The hCG numbers went up initially, but then she had bleeding again. When she went back for another exam, her cervix was open and the pregnancy was once again lost. No D&C was done. Her doctor had examined her uterus and found it to be normal size. There was no further testing done and Irene felt confused and depressed. Being a nurse, she tried to read up on miscarriages, but did not know what to do. Their doctor told them to avoid getting pregnant for three months, so they completely abstained from sexual intercourse.

After the three months were over, they hesitatingly started trying again. They were more fearful than excited when Irene was pregnant again in two months. Per Harold’s mother’s instructions, Irene cut her work hours significantly and avoided lifting anything. She also drank a daily concoction of herbal tea that her mother-in-law made for her. Things were more promising as she didn’t have any bleeding for two months. Then, one night, Irene was having a bad headache. Their neighbors were throwing some sort of party and the music was blaring. After lying down and trying to block the sound with pillows, Irene’s stress level built and she wound up sending Harold to tell them to please turn down the music. A mild confrontation ensued and things were eventually resolved by having the police come and talk to the neighbors. Meanwhile, the stress mounted and Irene felt panicked. All of a sudden, she started bleeding. They rushed to the emergency room. An ultrasound was done, which showed a sac in the uterus, but no fetus. Because of the heavy bleeding, Irene underwent a D&C. This time, her OB ordered some testing, which consisted of chromosome tests on Irene, but not on Harold. The test was normal. Before Irene could tell me about her fourth pregnancy, we took a break. She was tearing up too much for us to continue.

Click here for episode 3

No matter what all these anti-child news articles say, I strongly disagree with people who claim that having children is inherently bad for the earth or bad for the economy. Sure, they have a right to say whatever is on their mind, but I will fight them if they ever try to restrict the rights of other people to have children.

Back when I was interviewing for medical school, my views on people having a lot of children were influenced by a story that I read. It was a science-fiction short story that later got made into the 1973 movie  — SOYLENT GREEN, starring Charlton Heston and Edward G. Robinson. The story was set in a future where overpopulation was so out of control that there were massive food shortages. Rather than eating meats and vegetables, people were forced to eat nasty processed wafers made from plankton. With great desperation to reduce the population, people were given incentives to kill themselves by offering them a final deathbed view of wonderful nature scenery of the way earth WAS before overpopulation destroyed it. Once you got to watch the final nature show, you were given a poisonous drink and allowed to pass away in peace. Spoiler Alert: In case you want to rent this movie, skip to the next paragraph. Otherwise, I’ll share the kicker of the movie which was that Soylent Green was NOT made from plankton but rather from the recycled people after they were put to death! Yechh.

The movie made me a strong advocate of population control. When it came time for me to interview for med school at UCLA, I found myself talking to a doctor from their OB department and somehow the conversation wandered to the topic of contraception and sterilization and I let forth with a passionate unedited outpouring of my views on population control. I immediately sensed a strong negative reaction from my interviewer. In the end, I would up wait-listed at UCLA and eventually accepted. However, by that time I was accepted, it was so late that I had already decided to accept a spot at UC-Irvine. On the day I received my acceptance from UCLA, I had already moved and gotten settled in with a place to live in Irvine. It turned out to be one of the most fortunate turns of events in my life because UC-Irvine had the very best OB/Gyn program in the country, allowing me to meet a great mentor who would inspire me to enter the field of OB and eventually to specialize in Reproductive Endocrinology.

Later in my career, when I was an infertility Fellow at UCLA, I ran into that same doctor who interviewed me and found out that he was a fertility specialist who strongly advocated people having more kids.

So today, when I stumbled on yet another anti-child article, I took the time to reconsider what my stand is on this issue. My opinion has definitely evolved over the years.

Here goes: I believe that all potential parents have every right to have as many children as they want to, provided that they can raise them happy and healthy without reliance on the government or on other handouts. I believe that part of being a good parent, besides just caring for children is the ability to guide your kids into becoming adults who contribute to the world rather than just take from the world. Simple?

When I met Harold and Irene, I quickly learned that their story was different from those of other patients.  Unlike other couples who had trouble getting pregnant, Harold and Irene had gotten pregnant easily on their own four times in the past three years. Their problem was pregnancy losses.

Irene was 31 years old and Harold was 35. They were Korean, but had grown up for most of their lives in the US. After getting married three years ago, they immediately got pregnant. They lost that pregnancy and got pregnant again seven months later with similar results. In their second year of marriage, they once again had two pregnancies and losses. After a lot of frustration, their OB referred them to me.

We started by reviewing the concept of miscarriage. I explained that miscarriage was a very common part of life, with about 1 out of 6 pregnancies ending in miscarriage. So having ONE miscarriage was not anything unusual, sort of like getting into a minor car accident. However, if it gets to be a pattern, then it’s time to step back and see what’s wrong. Again, if someone gets into a minor traffic accident, you don’t make a big fuss, but if someone gets into four accidents in two years, then that raises many questions regarding their vision, judgment or driving ability. With four consecutive pregnancies all resulting in losses and not a single healthy baby born, it was definitely long overdue to explore the medical issues of this couple’s problem.

As you know, I like to structure all problem-solving in an organized fashion. For infertile couples, I divide the problems into issues of sperm, of eggs and of anatomy, as you can tell from our previous case stories. For recurrent miscarriage, I divide the problems into those of anatomy, genetics, hormones, blood clotting antibodies and infectious causes.

Check here for episode 2