DOCTORS'

Medical Case Studies

Recurrent miscarriage

Short Summary

42-year-old patient with hypothyroidism (Hashimoto's) with a history of primary recurrent abortions, probably due to a uterine septum. She underwent 2 IVF cycle, the 2nd – with poor response. The expert suggests some diagnostic and therapeutic strategies.

Patient's Questions

What is your diagnosis?
What further treatment, if any, do you suggest?
Centers of excellence in Italy?

Medical Background

Reports the common exanthematic diseases.

Menarche at 12 years of age; cycles of 27-29 days, 5-6 days, regular.

Hypothyroidism (Hashimoto's Thyroiditis), being treated with Eutirox, 100 mcg/day.

Hysteroscopic metroplasty in 2005 for uterine septum.

Last Pap smear in 2006 reported negative.

Last pelvic ultrasound in 2006 reported negative.

Para 4400: 2003 spontaneous miscarriage 11th week  D&C (Dilation and Curettage) 2004, 3 spontaneous miscarriages, 5th-6th week, D&C not performed. Estroprogestogen therapy for contraception from 1986 to 1992 (Triminulet), suspended voluntarily. The patient has been attempting pregnancy since 2001.

Attached are the available blood test reports (not recent) to help frame the case.

In 2002, 5 cycles of Clomid, 50 mg/day.

In May 2006, diagnostic laparoscopy and diagnostic hysteroscopy which concluded with: bilateral tubal patency with severe morphological changes to the right tube and slight changes in the left tube.

In the early months of 2007, a cycle of treatment with Gonal-F 900 at posology of 450 UI subcutaneous for 4 days.

IVF performed in May 2007, unsuccessfully.

Additional IVF in November 2007 with microinjection, unsuccessful, and in particular: "oocytes were withdrawn on September 2007, echo-guided transvaginally, with intravenous anesthesia. Follicles were aspirated from the right ovary and from the left ovary. In total, four oocytes were drawn, which had the following characteristics under stereomicroscopic evaluation:

immature 0

mature 4

somewhat mature 0

post-mature 0

irregular 0

1 oocyte was unsuitable for freezing.

On September 2007, three oocytes were microinjected, of which 3 fertilized.

In total two embryos were achieved.

The seminal fluid had the following parameters:

1st sample 1st sample treated with Percoll

Volume ml: 0.1 Volume ml: 1

Initial count (x10^6/ml): 15.2 Initial count (x10^6/ml): 0.7

Total number: 1.52 Total number: 0.7

Initial motility: 60% Initial motility: 95%

Rapid prog.: 5% Rapid prog.: 40%

Slow prog.: 40% Slow prog.: 45%

Tot. num. motile: 0.912 Tot. num. motile: 0.665

Normal shaped: 16% Normal shaped: 28%

On September 2007 the following embryos were transferred:

1 embryo of 4 cells and level 1

1 embryo of 4 cells and level 3

An Intrauterine Transfer was performed.

The luteal phase was supplemented with Crinone".

The medical history for Ms. xxxx partner, Mr. xxxxxx, contains the following:

common childhood exanthem;
HCV+, microcythaemia, now recovered, including serologically, allergic to aspirin.
Spermiogram not found to be pathological.

Expert's Opinion

In light of the aforementioned observations, I would suggest the following diagnostic/ therapeutic strategy:

Confirm a normal hysteroscopy (has already been done on May 2006)
Assess thyroid function and verify euthyroid
Does the patient have any evidence of thyroid auto-antibodies?- If yes, she might benefit from the addition of Dexamethasone 0.5mg from the start of gonadotropin stimulation and until a week post ET.
The husband should be tested for viral load, and treated accordingly. This, due to the possible negative correlation between HCV and implantation and pregnancy rates.
I suggest another IVF-ICSI cycle, using either the mictodose-flare GnRH agonist or the Ultrashort GnTH-agonist-GnRH antagonist controlled ovarian hyperstimulation protocol . Stimulation should consist of daily: 450 unit of Gonal-F and 150 units of hMG.
Use ICSI and AHA, for the oocytes and embryos, respectively.
Due to the Italian law, which allows the insemination of only 3 oocytes, I think that they should look for a center of excellence outside Italy.
For luteal support, in addition to crinone, I would add estradiol 2mg/day and probably also hCG 2500 units, twice a week.