Tuesday, November 11, 2014

Miscarriage after IVF treatment

Anembryonic gestation.jpg



Transvaginal ultrasonography showing a gestational sac with a diameter of 28 mm, corresponding to a gestational age of approximately 7 weeks and 5 days. It contains a yolk sac (protruding from its lower part) but no embryo, even after scanning across all planes of the gestational sac, thus being diagnostic of an anembryonic gestation.


Patients are very excited when their HCG test is positive  ! They are on top of the world that their IVF treatment has succeeded, and they look forward to cradling their baby in their arms in a few months.

However, like any other pregnancy, 10% of all IVF pregnancies are also destined to have medical problems. The commonest problem is a miscarriage; and in some of these, the reason is because the embryo/fetus does not develop properly. This means that even though the woman is pregnant, and the pregnancy tests are all positive, there is no baby. This is a non-viable pregnancy, and many women get very confused - How can I be pregnant when there is no baby, doctor ?

A pregnancy consists of two tissues - the embryonic tissue, which gives rise to the baby; and the extraembryonic tissue, which gives rise to the placenta. In these pregnancies, only the tissue from which the placenta arises is formed properly. The tissue which gives rise to the embryo does not develop at all. This appears as an empty gestational sac on ultrasound scanning. This is called a "missed abortion" - presumably because the embryo is missing. The technical term is an anembryonic ( without an embryo) pregnancy.

In other women, the fetus continues to develop, and establishes a heart beat which can be seen on the scan at 7 weeks. However, on the next scan, this heart beat stops. This is called an IUFD, or intrauterine fetal death.

The commonest reason for a miscarriage is a genetic problem in the embryo, which prevents it from developing properly. This is a random event, and the risk of recurrence is low, which means patients can be reassured that their chances of having a healthy pregnancy for the future are actually quite good! However , older women, and those with poor ovarian reserve, have an increased risk of having a repeat miscarriage, because their eggs  have more genetically abnormalities, which we still cannot test for.

The medical term for a miscarriage is an abortion. Most miscarriages start with vaginal bleeding which is initially slight and painless. This is called a threatened abortion, because the pregnancy is threatened by the bleeding. This bleeding is from the mother, and is not fetal blood. About half the time this stops spontaneously and results in no harm to the pregnancy. At this stage, the most useful test is an ultrasound scan (usually done with a vaginal probe). If a fetal heartbeat can be seen, this means that there is a 95 % chance that the pregnancy will proceed normally. On the other hand, if the ultrasound scan shows that the fetus has not developed properly ("blighted ovum " or anembryonic pregnancy when no fetus can be seen; or a missed abortion or intrauterine fetal death when the fetus is seen but the heart is not beating, then nothing can be done to save the pregnancy.

In such cases, the bleeding progresses, and the uterus starts contracting. This is felt as painful cramps, and the mouth of the uterus ( the cervix) opens. This is called an inevitable abortion (because it cannot be stopped). If some of the pregnancy has already been pushed out by the contractions, this is called an incomplete abortion.

In patients with a blighted ovum, missed abortion, inevitable or incomplete abortion, the treatment in the past was a uterine curettage (D&C) - a short surgical procedure which is performed to empty the uterus and remove the pregnant tissue. However, in women with a missed abortion, a D&C can cause Asherman syndrome ( intrauterine adhesions) if the doctor scrapes the uterine lining too vigorously. Read more at www.drmalpani.com/asherman.htm . This is why these problems are now better treated with medical therapy.  These pregnancies can be terminated medically with mifegest
( anti-progestational agent) and misoprostol ( a prostaglandin). Your doctor will prescribe these for you.

The standard prescription is the following.

Tab Mifegest ( RU-486, Mifepristone), 200 mg, 1 - 3 tablets at one time. This is an anti-progestin.
After 48 hours, take Tab Misoprostol, 200 ug, 4 tablets at one time. This can be taken orally or vaginally.  This is a prostaglandin
You will start bleeding and cramping about 6-48 hours after the Misoprostol tablet.
You can take pain-killers for symptomatic relief

You need to do a check scan one week after the bleeding stops, to confirm the products of conception are completely evacuated.

It can be very hard to bounce back if you miscarry after IVF treatment after a miscarriage !  Lots of patients get disheartened and give up.  They lose faith in God because they feel he has been exceptionally unkind to them. Others blame themselves for the miscarriage and their self-esteem takes a further battering. They believe that they miscarried because they did not rest enough, or because they lifted a heavy weight ; or ate something which was “ too hot”. Many ill-informed relatives and friends also add to their misery by telling them that it was their lack of taking appropriate precautions ; or their excessive levels of “stress”, which caused them to lose their pregnancy.

All these myths and misconceptions just makes a bad situation even worse ! Please remember that nothing you can do can cause a miscarriage. Your fetus and safe and is well protected in your uterus and nothing you can do can harm in.

The commonest reason for a miscarriage is a genetic abnormality in the fetus, and this is Nature’s defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have “aged” and have genetic defects, which cannot be screened for.
Interestingly, many patients get even more determined to have a baby after a miscarriage . They feel that if they can carry a pregnancy to 8 weeks, they can carry one to 8 months as well – and the fact that their embryo did implant gives them a confidence boost ! The truth is that the fact you have conceived ( even though you did miscarry) means your chances of having a healthy baby are excellent, so please don’t get disheartened !


26 comments:

  1. Anonymous4:23 PM

    Very Useful material by Dr.Malpani. We, a relatively younger couple (35) had a similar experience in 2016 June with Beta HCG positive following 2 failed attempts in 2013. However, if the issue is somewhat genetic, should one consider opting donor egg/sperm or even Surrogacy? I am from Kolkata

    ReplyDelete
    Replies
    1. You do NOT need surrogacy !
      We have an active surrogacy program

      Read more at http://indiansurrogates.in

      However, surrogacy is an expensive and complex treatment option, which is best reserved for
      women without a uterus, or whose uterus has been irreparably damaged. Research shows that the reason for failed implantation is much more likely to
      be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem. The soil is passive - it is the seed which is active and is responsible for growth

      I need more information to be able to provide you with intelligent advice.

      Can you send me more details about your IVF cycles ?
      DO YOU HAVE PHOTOS OF YOUR EMBRYOS ?

      You can see what embryos should look like at http://www.drmalpani.com/knowledge-center/ivf/embryos

      What were the meds which were used for
      superovulation ? What was the dose used ? How many follicles did you grow ? How many eggs were collected ? What was the E2 ( estradiol) level in the blood ? What was the endometrial thickness ?
      How many embryos were transferred ?
      What was the embryo quality ?
      Can you please send me the printed treatment summary from your IVF clinic ?

      You can read about more about how we take care of our patients at http://www.drmalpani.com/ivf-treatment-at-malpani-ivf-clinic.htm

      You can talk to some of our patients by email at http://www.drmalpani.com/success-stories.htm

      Taking treatment at a world-class clinic will maximize your chances of success and give you peace of mind you did your best !

      Treatment can be expensive, but a baby is priceless. Our charges are very cost effective because of our high success rates !

      We look forward to helping you to have a baby !

      Dr Aniruddha Malpani, MD
      Malpani Infertility Clinic, Jamuna Sagar, SBS Road, Colaba
      Mumbai 400 005. India

      Clinic Mobile: 9867441589

      Tel: 91-22-22151065, 22151066, 2218 3270, 65527073

      Helping you to build your family !

      You can add a google review for us at https://plus.google.com/102706636605134081909/about

      My Facebook page is at https://www.facebook.com/aniruddha.malpani

      You can follow me on twitter at https://twitter.com/drmalpani

      Watch our infertility cartoon film at http://www.ivfindia.com

      Read our book, How to Have a Baby - A Guide for the Infertile Couple,
      online at www.DrMalpani.com !

      Read my blog about improving the doctor-patient
      relationship at http://blog.drmalpani.com

      Delete
  2. Anonymous7:50 PM

    I just had my 7weeks ultrasound and theres no heartbeat, just empty sac. Am terrified of d&c. Its my 2nd attempt of ivf i feel like my world is crumbling.i cant go back to work cos my workmates rub it on my face all the time that i dont have kids. I am broken.

    ReplyDelete
  3. I agree this is not good news and suggests you have an anembryonic pregnancy ( missed abortion)

    Read more at http://www.drmalpani.com/early_pregnancy_scans_atlas.htm


    Do NOT do a D&C for this. This can cause Asherman syndrome ( intrauterine adhesions).
    Read more at www.drmalpani.com/knowledge-center/articles/asherman
    Ask them to terminate it medically with mifegest and misoprostol

    The commonest reason for a miscarriage is a genetic abnormality in the fetus, and this is Nature’s defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have “aged” and have genetic defects, which cannot be screened for.

    The fact you have conceived once ( even though you did miscarry) means your chances
    Of having a healthy baby are excellent, so please don’t get disheartened !

    I need more information.

    Could you please send me your medical details by filling in the form at
    www.drmalpani.com/malpaniform.htm so I can guide you better ?

    Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

    Treatment can be expensive, but a baby is priceless. Our charges are very cost effective because of our high success rates !

    We look forward to helping you to have a baby !

    Dr Aniruddha Malpani, MD
    Malpani Infertility Clinic, Jamuna Sagar, SBS Road, Colaba
    Mumbai 400 005. India

    Clinic Mobile: 9867441589

    Tel: 91-22-22151065, 22151066, 2218 3270, 65527073

    Helping you to build your family !

    You can add a google review for us at https://plus.google.com/102706636605134081909/about

    My Facebook page is at https://www.facebook.com/aniruddha.malpani

    You can follow me on twitter at https://twitter.com/drmalpani

    Watch our infertility cartoon film at http://www.ivfindia.com

    Read our book, How to Have a Baby - A Guide for the Infertile Couple,
    online at www.DrMalpani.com !

    Read my blog about improving the doctor-patient
    relationship at http://blog.drmalpani.com

    ReplyDelete
  4. Anonymous10:18 AM

    Hello doctor, what could be the reason for implantation failure in donor egg cycles?
    Regards,
    US

    ReplyDelete
  5. Anonymous7:57 AM

    Dear Dr.,

    I had a donor egg IVF. Was transferred 4 eggs of A & B quality on 3 day.
    ET: 11th Oct
    My 15th day of transfer HCG-229
    17 th day of transfer HCG-558
    23rd day of transfer 4096
    24th day of transfer 2096
    25t day of transfer 667
    23rd Day of transfer: I started mild cramping,light bleeding and clotting.
    25th Day of transfer : scanned showed no gestational sac or residual of conception.
    I m having 2 intramural fibroids (8 & 18mm).
    Now,dr suggested laproscopy then second attempt.However,other dr I have consulted said that its better left.
    Do,you recommend second attempt with lap or after laproscopy.
    Shruti

    ReplyDelete
    Replies
    1. The drop in HCG confirms that you have miscarried

      The scan proves that your miscarriage is complete and you do not need any intervention

      I would not advise you to have a laparoscopy. Read more at http://www.drmalpani.com/knowledge-center/infertility-testing/laparoscopy-and-infertility

      The fact you have conceived in the past ( even though you did miscarry) means your chances
      of having a healthy baby are excellent, so please don't get disheartened !

      Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !
      You can talk to some of our patients by email at http://www.drmalpani.com/success-stories

      Treatment can be expensive, but a baby is priceless.
      We look forward to helping you to have a baby !

      Delete
  6. Dear Dr,
    I am 28yrs old n had IVF cYcle...
    ET: Nov 3rd with 2 embryos grades 2 n 3cc on day 5
    Reason for IVF,azoospermia which on SSA motile sperm cells where found
    Had my 7th week scan on the 8th of Dec n found no fetal pole...
    what could be the possible cause of the anembryonic gestation

    ReplyDelete
    Replies
    1. A blastocyst which is graded as 3CC has a poor inner cell mass, and is more likely to result in an anembryonic pregnancy

      You can see what blastocysts look like at http://www.drmalpani.com/blastocystimages

      Can you send me more details about your IVF cycle ?
      DO YOU HAVE PHOTOS OF YOUR EMBRYOS ?

      You can see what embryos should look like at http://www.drmalpani.com/knowledge-center/ivf/embryos

      What were the meds which were used for
      superovulation ? What was the dose used ? How many follicles did you grow ? How many eggs were collected ? What was the E2 ( estradiol) level in the blood ? What was the endometrial thickness ?
      How many embryos were transferred ?
      What was the embryo quality ?
      Can you please send me the printed treatment summary from your IVF clinic ?

      Delete
  7. Dear sir . I had adenomyosis which was resected after laproscopy. Then i went for ivf. After 5 week 5 day pregnancy i went for ultrasound. But immediately i started bleeding with large clots. I know it is miscarriage. I am very hurt and disappointed. I do not have any embryo left. The doctor has recommended for doing ivf again. Please advise me what should i do. I m 29 yrs old and married for the last 3 yrs.

    ReplyDelete
    Replies
    1. What was your beta HCG level ?

      Can you send me more details about your IVF cycle ?
      DO YOU HAVE PHOTOS OF YOUR EMBRYOS ?

      You can see what embryos should look like at http://www.drmalpani.com/knowledge-center/ivf/embryos

      What were the meds which were used for
      superovulation ? What was the dose used ? How many follicles did you grow ? How many eggs were collected ? What was the E2 ( estradiol) level in the blood at the time of the HCG trigger ? What was the endometrial thickness ?
      How many embryos were transferred ?
      What was the embryo quality ?
      Can you please send me the printed treatment summary from your IVF clinic ?

      Delete
    2. Sir, It was ANTAGONIST PROTOCOL. Dont have the pics of embryo not provided by hospital.
      Regarding Meds & dose used for superovulation, i have sent the scanned copy of full treatment prescriptions & test reports with ultrasound pics,etc. to your mail id.
      Ovum pick up done on 14.10.16.
      E2 level before HCG trigger (29.09.16)-20,
      E2 level during HCG trigger (06.10.16)-212
      No of follicles grown-11. No collected-10, Successful embryos-5 no. (Grade-1- 3 no., 4-cell & 2 no. 2-cell).
      Embryo transfer done on 23.12.16.
      No. of embryos transferred-3 no.
      The request for second opinion along with medical history of both of us sent to your mail id (as there was some network issue which applying for second opinion from your website).
      Kindly check & revert.

      Delete
  8. Anonymous6:13 PM

    dear sir,

    my wife had positive pregnancy test after 21 days of ET ,even after 24 days there is no gestational sac found what could be the reason

    ReplyDelete
    Replies
    1. I need more information to be able to provide you with intelligent advise.

      What's the beta HCG level in the blood ? If this is more than 1000 mIU/ml and there is no sac in the uterus, this means she has an ectopic


      Read more at http://www.drmalpani.com/knowledge-center/articles/ectopic

      Delete
    2. Anonymous10:24 PM

      HCG was 1686

      Delete
    3. This suggests she has an ectopic pregnancy
      This is a medical emergency

      Delete
    4. Anonymous12:43 PM

      No intra/extra uterine gestational sac found in ultra scan on 24th day

      Delete
    5. This means it is an ectopic. Please don't wait for it to rupture. We start treatment without waiting to see an extra-uterine sac.

      Read more at http://www.drmalpani.com/knowledge-center/articles/ectopic

      Delete
  9. Hello doctor. I did my 1st ivf last week . It was frozen et of a1 5 day blastocyts. After 14 th day of transfer my beta hcg was 1050 and 19 th day it was 3666 then next day i started bleeding n some flesh came out. It was miscarriage. Now we r planning for next transfer ...but how much is the chance live birth pregnancy. I hv pcos n my husband has appotosis 35 per

    ReplyDelete
    Replies
    1. The fact you have conceived ( even though you did miscarry) means your chances
      of having a healthy baby are excellent, so please don't get disheartened !

      Delete
  10. I had two miscarriage and I'm 26 years old.Doctor told it's blighted ovum and is due to chromosomal abnormalities.now planned to take blood test.what is the reason for this.much worried.

    ReplyDelete
    Replies
    1. The commonest reason for a miscarriage is a genetic abnormality in the fetus, and this is Nature's defense mechanism, to prevent the birth of an abnormal baby. These defects are random, and cannot be prevented, sorry

      The fact you have conceived in the past ( even though you did miscarry) means your chances
      of having a healthy baby are excellent, so please don't get disheartened !

      Delete
  11. Hi doctor. I am 33 years old. One year ago my AMH was 0.87. I had 4 IVF cycles. First one failed because the ovulation occured before the egg retrieval. I had 2 eggs in cycle. My dosis was 450 ui a day with menopur. On second cycle mt doctor went with the maximum dosage of menopur, 600 ui. In this cycle I had 4 eggs, 3 immature and 1 mature but even the mature one did not fertelize therefore the second ivf failed. On third cycle, the same dosage was applied, got 5 eggs, 3 mature and 2 immature, and only one fertelized (grade B). Embryo was frozen for the next cycle. The fourth cycle was recently with same disage and same result of eggs as third cycle. At he end, i had only one embryo from the fourth cycle (BC grade). When the transfer occured, the clinic only tranfered this last embryo (bc) whereas the previously frozen embryo was not tranfered as they said one embryo is of day 5 and the other of day 3 therefore cannot be transfered together. Now I have only one embryo bc transfered and on day 10 after the transfer, i performed ultrasound and a gestative sac was seen. One day 12 i did a urinal test and turned out negative. Still have not performed the beta hcg test. I would like to ask why we see a gestational sac, and is it true that the embryos od different days cannot be transfered together?

    ReplyDelete
    Replies
    1. You are getting poor quality care, sorry

      It is impossible to see a gestational sac 10 days after a transfer - your doctor is not telling you the truth !

      The Day 3 embryos could have thawed, cultured to Day 5, and both transferred together

      Do you have photos of your embryos ?

      Delete
  12. Thanks a lot doctor for you assistance. I have emailed you my embryo photo.
    Thanks again!

    ReplyDelete
  13. Anonymous12:16 PM

    Sir my wife gone through Ivf second time after failed first one before 3 months. She is 45 and this time tested positive with hcg and first ultrasound after 42 days of lmp
    We opted diner eggs. Single live embryo found heart beat 103 on day 41 .Size 14 mm on day 41 .Doctor suggested for next tvs after 2 weeks...... How is chances of ultimate success Sir. Plz tell.

    ReplyDelete

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