Dear Professor Winston,
I am searching for an explanation for recurrent second trimester missed miscarriages following IVF with egg donation. I have a daughter, aged three who was conceived naturally when I was 40. We tried unsuccessfully for another natural pregnancy from when I was 41. We turned to IVF first with my frozen eggs and then through egg donation. I am now 44.
Aged 34 I was diagnosed with immune thrombocytopenia purpura
(IPT) and a steady platelet count of +/- 100.000 – which is asymptomatic. Aged 37 I was diagnosed with triple negative breast cancer. I had chemotherapy (3xFEC, 3xtaxotere) and radiotherapy. I have been in
remission since. I had eggs frozen prior to chemotherapy and at that point a low egg reserve was detected, 3 eggs were collected.
Aged 40, despite low egg reserve and AMH/FSH all in the wrong direction, we conceived naturally and had an uncomplicated pregnancy, except for heavy bleeding at 13 weeks including passing a blood clot the size of my palm. I took progesterone for 3 days and had no further issues. A baby girl was born at 39w1d weighing 3.120kg. My platelet count dropped towards the end of pregnancy, it was treated unsuccessfully with steroids and then IVIG. Platelet count was less than 50.000 at delivery so I had a platelet transfusion following the delivery. There were no complications with the vaginal birth, no excessive bleeding, no problem with the infant.
Aged 42 we did IVF with our frozen eggs. Two embryos were transferred at day 3. This was unsuccessful.
Aged 43 we did IVF with donor eggs (donor was 27 years old). At a routine scan at 16w6d no heartbeat was detected. I had no miscarriage symptoms.
Autopsy showed the pregnancy appeared to have ended at 16w. There was no explanation, no viruses detected, placenta was the correct size for the term.
Aged 43, we did IVF again with frozen embryos from egg donation. I started bleeding and miscarried at 5w.
Aged 44, we did IVF again with frozen embryos from egg donation. Supplementary medication (in addition to usual fertility medication): Prednisone, Plaquenil and Lovenox (Heparine) taken daily. At a 16w scan, no heartbeat was detected and the baby appeared to have died at 13w just after a 12w scan that showed all was normal. I had no miscarriage symptoms and had to have a D&C from which we are awaiting the results.
We have done all the tests that would normally be done in this situation, all came back negative (antiphospholipid syndrome negative for example) and my husband’s sperm is also normal. I have a healthy BMI (height 1m73, weight 60kg) and a healthy diet.
We are wondering what to do next and if it is worth trying one more time with a different egg donor?
Your sad and difficult story underlines something I have repeatedly suggested on this website. So often when there is a poor ovarian reserve or clear evidence of ovarian failure developing in one’s late thirties, IVF is much less successful than natural conception. So many people desperate to conceive, enter IVF in their later reproductive years and by doing so, possibly reduce the chance of conception rather than increase it. Whilst a person is undergoing IVF and both before and after treatment, this whole process decreases fertility and thereby reduces conception. Moreover, as you have clearly shown, egg freezing is not as nearly reliable as is often made out and undergoing egg freezing when the ovaries are already no longer producing viable oocytes is mostly very unlikely to produce a pregnancy.
Admittedly your particular situation is different as you did manage to conceive after IVF with donor eggs but then had the shock of two lost pregnancies. It is difficult to explain this on the information you give me though I suppose the systemic illness you have had and all the cancer treatment may possibly have contributed. One thing that does strike me is that from what you say, your uterus has not been fully investigated and ultrasound and HyCoSy is an completely inadequate way of looking at the uterine cavity where the baby grows, as well as the uterine wall in any kind of detail.
I may be a bit old-fashioned and am now retired from clinical work, though I still am an active researcher, in our IVF service we never undertook an IVF treatment without full assessment of the uterus and its cavity first. The gold standard was (and to my mind undoubtedly still is) a carfully done X-ray – a hysterosalpingogram (HSG) using dye – to assess the uterus.. In a women of your age and with your history it is not at all unlikely that there may be an abnormality, possibly treatable, inside the uterus and unquestionably my first step would be for an HSG.
I agree that the the other issue (which you appear to have considered) is, of course, what is the fertility history of your egg donor. That clearly is vital information. I would suggest you consider doing the x-ray as a start.
With best wishes
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