Nine years ago, I was referred a patient by an OB. He had performed laparoscopic surgery on her and told her that her tubes were both blocked and were “unsalvageable”.  So, we did IVF and she got pregnant with twins on her first cycle. She came back a few years later to use her remaining frozen embryos, but nothing came from it.

Recently, I got a message from her that she wanted to share some good news about her new baby. When I returned the call, I was curious why she didn’t come back to us for THIS cycle of IVF. To my surprise, she bubbled enthusiastically about an amazing miracle. She shared that she had given birth to this recent baby after getting pregnant spontaneously without any medical treatment. She shared that her son (one of the original twins) had told her last year “Mommy, I’m going to pray real hard for a brother or sister this year”.

From a medical perspective, it is not entirely implausible for a woman diagnosed with blocked tubes to ever conceieve. Having blocked tubes diagnosed via laparoscopy or HSG does not mean 100% sure that they are blocked or will always stay blocked. Having said that, I would certainly put it at less than a 1% probability that a patient in this situation is going to get pregnant naturally. Put that together with the finding of all the years that went by without her getting pregnant and you have the occurrence of something that is estimated to have less than a 1 in 1000 chance of happening. No, I don’t recommend that women with blocked tubes should wait patiently for a miracle to happen, but I also recognize that sometimes, miracles DO happen.

A while back, when I was doing my monthly volunteer staffing at the indigent population clinic for the OB/Gyn residents, we came across a patient who came in for an ultrasound. She had delivered a baby seven years ago in her home country, but never got pregnant after that. Despite not getting pregnant naturally, she no longer wanted to get pregnant. In fact, she wanted to make sure of it and desired to get her tubes tied. It’s always a bit of a change of pace for me to see women who WANT to become infertile.

She was referred to us because she had been denied as a candidate for a tubal ligation because an ultrasound had shown her to have an IUD in her uterus. The story didn’t make sense. She fiercely denied ever having an IUD placed. She was from Central American and not from China. In China, there have been patients who have had IUD’s placed against their wishes, although not without their knowledge. We weren’t sure what to make of it, so we went ahead and did our own ultrasound. Sure enough, there were two very bright lines in her uterus, which did not look like anything natural. We did a pelvic exam and looked for the string to remove the IUD, but could not find one. After questioning her some more, I was leaning towards believing her story.

We set her up to get hysteroscopic surgery.

Today, I got an email from the residents. They had completed the surgery and fished out the objects. The pathology report identified them as being BONE, with some cartilage. It is a phenomenon described in the medical literature as heterotopic endometrial calcification. So she was telling the truth after all about never having an IUD placed. Although technically, the bone in her uterus would act as a very effective biological IUD. The source of this bone tissue is still controversial. The theories range from retained fetal bones to embryological development from stem cells after a pregnancy termination. So we still will never know exactly how they got there.

Now I am reminded to add “Bone Fragments in the Uterus” to the long list of thing that cause infertility.

Click here for episode 1

When patients make it to 12 or 13 weeks gestation, they graduate. We have a small ceremony and give them gifts. They celebrate freedom from taking their progesterone shots. We make a DVD of their baby doing back flips in their final first trimester ultrasound so they can watch it over and over. They say goodbye to us as they transition to their OB, relieved to be out of the first trimester, usually the most common period of pregnancy loss.

For Irene, she was not entirely free. She had to stay on her heparin and aspirin. Over the past two months, we had seen her every week and the pattern was consistent. We would show her the baby’s heartbeat on the ultrasound and she would be so relieved and happy. And then, at home, over the course of the week, the fear and anxiety would gradually gnaw at her insides so that by the time she came back for her next ultrasound, she was a complete nervous wreck.

Now on her last visit, she seemed panicked about saying goodbye to us. I knew it was because she realized that with her OB, she would be only getting visits every 3-4 weeks, which meant to her 3-4 weeks of not knowing how the baby was. I promised her she could drop by any day for a quick heartbeat check ultrasound all the way until 20 weeks when she would start feeling the baby move. At that time, she would have her own way of reassuring herself that the baby was fine.

We kept in touch with her less and less, until one day, we got the call from her husband that she had delivered a beautiful 7 pound 6 ounce baby girl, thanks to the benefits of heparin!

Click here for episode 1

Imagine that four times in your life, you have been pregnant and imagine that all four times have ended in miscarriage. It’s pretty understandable that now, in your fifth pregnancy, every twinge of abdominal pain can make your heart race with panic. Every time you use the restroom, you dread wiping for fear of discovering that first brown spot or even worse, that bright red flow. Your nights are sleepless as your mind fills up with the big question of when will disaster strike again? This is the predicament that Irene was in.

I got an instant message from my staff telling me that Harold was on the phone and he sounded very distraught. I took the call. He apologized for calling, but he didn’t know what to do. Irene was falling apart. She was not sleeping and not eating. I had them come in to talk in person.

ME: Thank you for coming in. What’s been going on?
IRENE: No, thank YOU for seeing us on short notice. I am embarrassed. I can’t believe that I’m acting this way.
ME: What way do you mean?
IRENE: I can’t sleep. All I can think about is losing this pregnancy. I know it’s not healthy for me to be like this. Everything panics me. Last night, I had a stomach ache after eating some ice cream and I immediately expected to start bleeding, even though it wasn’t the same cramping pain that I had with the miscarriages. I hate it.
ME: What you are feeling is very normal, considering what you’ve been through. Let me summarize your situation, OK? We have done a thorough investigation of your case and we have discovered a very significant finding, namely that you have a positive Lupus Anticoagulant test. You remember that, right?
IRENE and HAROLD nod.
ME: There is a good chance that this is the main contributor to your miscarriage history. We have the means to address this problem and we have instituted the right action. You are taking the heparin daily, correct?
IRENE: Yes. Every day.
ME: How’s that going, by the way?
IRENE: Not bad. I do have some bruising though.
ME: OK, I’ll take a look at it shortly, but a little bruising is normal. It’s not severe, right?
IRENE: Can I just show you? (raises the bottom of her blouse a little to expose some mild bruising on her abdomen)
ME: Yes, that looks fine. Anyway, as I said, we have this in place. You are on heparin and aspirin, which is intended to counteract the harmful effects of the clotting disorder. (I flip through the chart). Your first hCG level was 88. We then repeated it in two days and it was 169. This is an excellent rise. Then yesterday, we repeated it again. It was 625, which considering it was four days after the 169, is still a very good rise. At this point, all we can do is keep checking your hCG level every four days to give you the peace of mind that you need to know that everything is OK. At some time very shortly, I will do the first ultrasound. After that, we will do a second ultrasound in which we can see the heartbeat. I have a feeling you will feel a lot calmer after that. Meanwhile, we all just have to wait.
IRENE: Thank you. I feel a little better, but I know that when I get home, I’ll look around and be reminded of the places in the house where I experienced the other miscarriages and I’ll panic again. Is there anything safe for me to take that will calm me down?
ME: It’s best for you to avoid any tranquilizers or medicine. Unless you are feeling like hurting yourself or hurting Harold or you are totally unable to eat or to care for yourself, I would prefer not to prescribe anything. That’s not the case, right?
IRENE smiles.
HAROLD: Doctor, right now we are in your office and we feel safe, but I know that the moment we get home, it’s going to happen again. I have to get some sleep so I can do my work and I can’t spend every moment worried about this.
ME: Irene, what do you suggest? Do you have any ideas of what can make you more at peace, other than for us checking your levels and giving you reassurance with the results?
IRENE: In my mind, I trust what you are saying, but I can’t control my thoughts. Honestly, it just builds and  builds until I’m crying and ready to scream.
ME: I see. Well, let me think about this. I have two suggestions. One is for you to stay somewhere other than your home. It sounds to me that the environment is triggering bad memories because the rooms in your house are where you had the bleeding and the cramping that led to the bad outcomes. Can you stay with your parents or Harold’s parents or anyone?
IRENE: I see what you’re saying, but I’m not going to stay with Harold’s parents. His mom would drive me crazier and I don’t want her to force me to take that herbal stuff again.
ME: Hmm, OK. Well, I have another suggestion, but I have to warn you that it’s really silly.
IRENE: What is it? (almost smiling)
ME: It’s something that one of my patients taught me. She tried it and it helped her. Right now, you feel very safe in my office, right?
IRENE: Yes.
ME: What if I asked you to remember your miscarriages, to picture them in your mind right now, as vividly as you can? I know it sounds cruel and crazy, so you don’t have to if you don’t want to.
IRENE: I … I think I can do it right this moment, but how is this going to help?
ME: This is a little mind trick to help calm the association that you have between your memories and your emotions. Visualize your worst memories of the miscarriages and THEN I want you to replay the scenes over and over in your head like a movie, but I want you to shut out the sound and instead, insert a movie soundtrack. Choose music that is silly and happy, like something you would hear in the circus with clowns and animals running around. I bet you think I’m crazy, but maybe you could just try it.
IRENE: OK. It sounds so crazy I am thinking it might work, haha.
ME: OK, start now and do it over and over. You can do it too, Harold. Well, I’m going to go do some ultrasounds, but I’ll be back in 15 minutes to check on you.

When I came back, there was a sense that the tension in the room was greatly diminished. Both of them were smiling, although Irene was very obviously tearful. They left my office with hope.

My nurses checked on them the next day. Irene was still very anxious, but she admitted that things were a little bit better.

Click here for episode 9

Click here for episode 1

Irene had started her injections on day 3 of her cycle. After five days of injections, it brought us to day 8 and she was here for her ultrasound. This is what we saw:

RIGHT OVARY: (14×13) (15×14) (13×13)
LEFT OVARY: (16×14)

Lining = 8mm Triple Layer

This was a great stimulation. There were enough follicles to give a good chance of pregnancy, but not so many that we needed to be concerned about quadruplets. The follicles were not quite ripe yet, but they were close. I continued her on the same dose and brought her back after two more days.

This is what we saw:

RIGHT OVARY: (16×16) (17×16) (13×13)
LEFT OVARY: (21×18)

Lining = 8mm Triple Layer

It was a tossup whether to trigger the ovulation today or to wait one more day. I decided to go ahead and trigger and bring her back two days later for the insemination. In general, for first time patients, I trigger at around 5PM in anticipation of ovulation in the morning two days later.

Irene came back two days later and had her insemination. She was started on progesterone supplementation.

Twelve days later, she came for her pregnancy test. It was positive! Her hCG level was 88 IU/L !

For most first time pregnant women, this would be a great moment of joy. For Irene who had four miscarriages in four pregnancies, this was the beginning of the scary time.

As planned, she was started on daily injections of heparin.

Click here for episode 8.

Click here for episode 1

Six months had passed since Irene’s positive LAC (Lupus Anti Coagulant) test. The initial relief and excitement she had felt had gone away and she came in to discuss her options. After all, she had suffered four miscarriages, but then finally learned a reason for the miscarriages. We were ready with an intervention for her next pregnancy, but it had now been a year and a half and still no pregnancy. That had never been a problem in the past. She was surprised. She really thought she would have been pregnant already.

When they came in, I asked for an update on their lives. They were both still working the same jobs (nursing for her and the painting business for him), busy as always. They were paying attention to Irene’s ovulation dates and trying to be diligent about having intercourse during those days.

Their situation had now turned into a combination of infertility and recurrent pregnancy loss. They had gone a year and a half with no pregnancy and they still had their past track record of four pregnancies with four losses. I offered them a chance to boost their odds and speed up time to their next pregnancy. They enthusiastically agreed. I explained that we were going to do a standard cycle of ovulation induction to grow extra eggs. Then at the right time, we would inseminate Harold’s own healthy sperm into Irene’s uterus. Her instructions were to call with her next menses.

Three days after her period started, Irene came in. The baseline ultrasound was normal. The uterine lining was thin (not at all surprising because it had just bled out). I decided on a protocol of 150 IU daily injection of Follistim. She took the medication from days 3 to 7 and on day 8, we brought her back for evaluation to see what kind of follicular growth she had.

Click here for episode 7

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

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

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

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