Where to go from here?
7 Replies
Asunflower - August 10

My DH and I have been through 3 unsuccessful IVF cycles. First one in Jan. was BFN! We did a day 3 transfer of 2 6 cell embies and I was on an Antagon protocal where I produced 18 follices and 15 were mature, 11 fertilized with ICSI and we froze 2. Tried 2nd time in April. This time was on Lupron protocal. We got 28 follicles, 21 were mature and 19 fertilized and we got 3 frozen. We did a 5 day transfer of 2 grade 1 blastocysts this second time. We had a chemical pregnancy. Third time was just in July. We used the Lupron again and we got 18 follicles, 15 mature, 11 fertilized and we transferred 3 blastocysts on day 5 that were grade 2 and 1 was grade 3. We also got 1 to freeze. It was a BFN. We are going to try a FET of our 6 frozens in Sept. My question to you is if we get another BFN, what in your personla opinion would be our chances if we continued to try with IVF. I just don't know if it is worth it to keep going with IVF. When we went to our RE, I shared my history where I had an abortion when I was 17. He had me do the HGC test and it came back normal. We did a semen analysis and we have low count, low morphology. He diagnosed us with MF. That is why we use ICSI and AH. Do you think that there is some other testing that may need to be done on me? For example, should I be tested for NK cells or should I have my lining tested (biopsied)? I am just not sure why we got a chemical one time and no success the other times with such good cycles. Any suggestions or thoughts that you have would be helpful!

 

Dr Smith - August 14

I think there are two things that need to be looked into prior to the FET. One is testing for the level of NK cells and also the level of NK cell activiation. It is very common in cases such as yours to discover high levels of NK cells and abnormal NK cell activation. The second is to find out the thickness and pattern (i.e. triple) of your endometrial lining of the day of the hCG shot. If it was less than 7mm, or did not have a triple pattern, then that could be the cause of the chemical pregnancies. Both of these issues are treatable.

If these turn out to be normal, then I wouldn't suggest a fourth cycle at the same program. Seek out a second opinion and see of another doctor could take another approach. It looks like they tried valiantly and so have you. It just may not be in the cards.

 

Asunflower - August 14

Dr. Smith,
Thanks for your input. I appreciate it so much. I asked my RE about bothof these ane he does not see a need for NK testing since the Progesterone that I take would be what is used to treat it anyway. I also asked about my lining and he said it was great every time. It has always been around 9mm. What exactly is triple stripe? I have heard of this but my RE has never said anything about it with my cycles. What is used to help with lining issues?

 

Dr Smith - August 15

I disagree with your RE's dismisal of the NK issue. Sounds like he's out of touch with current thinking. Some old school RE's have difficultly in accepting the role of the immune system in reproduction or the rule of autoimmune disorders in early miscarriage. Although at one time this subject was controversial, more and more evidence is accumulating to support identifying and treaing autoimmune disorders (See references below).

Progesterone is ineffective in treating elevated NK cells and NK cell actvation. I have no idea what your RE was thinking (or not thinking). The tried-and-true treatment for NK cell problems is intravenous immunoglobulins (IVIg). Although effective, IVIg is very expensive. Less expensive treatments such as Solu-Cortef (hydrocortisone) and Intralipid (a solution used to nurish patients who cannot eat) are now being tested. Both of these new treatments show promise.

Time for a second opinion. Arm yourself with as much information about the role of NK cells in implantation and them bring it up at the consult. A good place to start is the Repromedix and Millenova laboratories websites:

http://www.repromedix.com/fo
rpatients/ourtests_patients.html

http:
//www.millenova.com/test.asp

REFERENCE
S
(and there's lots more where these came from):

Endocr Rev. 2005 Feb;26(1):44-62.

[b]Natural killer cells in pregnancy and recurrent pregnancy loss: endocrine and immunologic perspectives.[/b]
Dosiou C, Giudice LC.
Endocr Rev. 2005 Feb;26(1):44-62.

The endocrine system and the immune system interact closely during implantation and maintenance of pregnancy. One of the most striking examples of this communication is at the level of the decidua (endometrium of pregnancy). Here, under the influence of sex steroids, there is a dramatic increase of a unique population of lymphocytes, the uterine natural killer (uNK) cells, in early pregnancy. These cells derive predominantly from a subset of peripheral blood NK cells, which under hormonal influence gets recruited to the uterus. In mice, uNK cells play an important role in the development of placental vasculature. The role of these cells in human pregnancy is still not definitively established; however, they are believed to promote placental and trophoblast growth and provide immunomodulation at the maternal-fetal interface. [b]In contrast to their presumptive role in the maintenance of a healthy pregnancy, uNK cells and peripheral NK cells are dysregulated in unexplained recurrent pregnancy loss.[/b] Herein, we review NK cell populations, their changes in number and function in altered endocrine environments during the menstrual cycle and pregnancy, the current data on their potential role in unexplained recurrent pregnancy loss, and mechanisms for potential therapies targeted to NK cell function for this enigmatic disorder.


[b]Diagnostic evaluation of women experiencing repeated in vitro fertilization failure.[/b]
Vaquero E, Lazzarin N, Caserta D, Valensise H, Baldi M, Moscarini M, Arduini D.
Eur J Obstet Gynecol Reprod Biol. 2006 Mar 1;125(1):79-84.
CONCLUSIONS: A better understanding of reproductive failure mechanisms should allow an effective diagnostic flow chart and a focused therapeutic option for patients experiencing repeated IVF failure. [b]With this objective in mind, our data provide two important results: thyroid abnormalities, aPL and increased NK levels are more prevalent in women experiencing IVF failure...[/b]

 

Asunflower - August 15

Dr. Smith,
Thanks for your input and the data. I am meeting with my RE to talk about this and share the research and depending upon what he wants to do, we will seek help from someone else! I appreciate your time and efforts. I truly felt in my heart that the NK cell was an issue but it is hard to tell your RE what you want especially with no specific data. Thanks again!

 

Dr Smith - August 15

Please delete the first part of my post when you show it to your RE. I don't want to pi** off any more RE's than I already have.

 

Asunflower - August 15

Already taken care of! I understand your thoughts on that. I used only your data that you referenced when emailing him.

 

Dr Smith - August 23

Forgot to answer you question on the endometrium. The "triple" stripe refers to what the doc sees on US sound as the stimulation nears the end. A mature endometrium will exhibit a triple stripe pattern when the U/S probe is held in a specific way. Its a good sign. The optimal thickness for the endometrium is 8-10mm, so 9mm is fine.

 

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