Three miscarriages at an advanced age two embryo dye normal, miscarriage causes so close so far?
Every woman is not easy to conceive, but there is a category of women especially not easy, because they want to have a child often pay more time and energy than ordinary people.
As my patient Xiaoqin said, having a baby on your own feels like building an atomic bomb!
Standing in front of me Xiaoqin 37 years old, clean face is still hard to hide the fatigue, you can see in order to this child, she has been so many years to pay how much effort, how many times the blow, but fortunately she did not give up.
01 three years and three miscarriages, embryo dye are normal?
37-year-old Xiaoqin, began menarche at the age of 13, menstrual cycle 28-30 days, menstrual period of 4-5 days, have done ovulation monitoring, ovulation is very normal, everything seems to be normal.
Her first pregnancy was in 2016, a little over 2 months pregnant, and when it was time for the foetal heart and buds to come out they did so normally.
Everything was without any warning, and when she was happy to go to the archive, she was ready to check another ultrasound on the way, but she didn’t expect to wait for the news of foetal arrest.
Xiaoqin was shocked as if she had been struck by a bolt from the blue, she listened to the doctor’s arrangement woodenly and didn’t even ask what the reason was, and certainly didn’t do the embryo dye test which seems to be very important now.
She had heard that all foetal arrests were due to eugenics, so she was sometimes even a little glad that the bad embryos had aborted themselves.
Xiaoqin was determined to wait until she had recuperated her body to have a proper preconception test, and to get her body in good shape before she got pregnant.
The results found that in the PGT-A group, nearly 70% of the 1809 embryos screened by genetic testing were aneuploid (aneuploidy increases the chance of failure of implantation or spontaneous abortion).
Live births were achieved in 468 women (77.2%) in the PGT-A group and 496 women (81.8%) in the conventional IVF group.
According to the statistical criteria of the trial protocol, the cumulative live birth rate of conventional IVF was not inferior to the PGT-A technique, and even slightly higher.
At the same time, the data showed that the average number of embryos needed to be transferred for live births was similar in the PGT-A group and the conventional IVF group (1.2 vs. 1.3 embryos), and slightly higher in the conventional fertilisation group, but the difference was not significant.
This is a good indication that for regular IVF patients, the advantage of the third generation IVF technology in the matter of holding a baby within one year is not obvious.
03 Additional benefits of third generation IVF
With the high cost of third generation IVF, does it really not work at all for the average patient?
This study actually found additional benefits to it as well.
That was a lower miscarriage rate, with a lower cumulative incidence of clinical miscarriage in the PGT-A group (8.7% vs 12.6%).
That is, the majority of patients in both groups had successful pregnancies after the first embryo transfer, but more women in the conventional IVF group required second and third embryo transfers for live births.
Therefore, it is up to the sisters to choose whether or not to use the third-generation IVF technique depending on their situation.
A concurrent editorial in the New England Journal of Medicine entitled ‘Reproductive Medicine Needs Responsible Innovation’ gave the study high marks.
02 Finding the Big Boss Behind the Fetal Arrests
I still remember the first time I saw Xiaoqin in the clinic, her face was waxy and yellow, with a layer of fine sweat on her forehead, and she was holding a thick pile of medical records because she had not registered in advance and she had come to see me for an additional number.
I helped her carefully comb through her medical records, and the main findings were as follows:
Basic condition: age 37, menarche at 13, menstrual cycle 28-30 days, period 4-5 days, medium amount;
Family history: father hypertensive, mother hypertensive, diabetic with history of cerebral infarction;
Fetal arrest experience:
January 2016, 8 weeks gestation plus foetal arrest, experienced from fetal heartbeat to no fetal heartbeat, no embryo dye test;
January 2017, 12 weeks gestation plus foetal arrest, experiencing from presence to absence of foetal heart, with normal embryo chromosomes;
April 2018, 16 weeks gestation plus foetal arrest, experiencing from presence to absence of foetal heart, with normal embryo chromosomes;
Past medical history:
Right iliac vein thrombosis was detected in April 2018 and was treated with thrombolysis.
Regarding the part of the tests for foetal arrest, in conjunction with her history above and the tests she already had, I prescribed some additional tests related to coagulation and immunity, and collated the results as follows:
Genetic factors: female chromosome 46,XX, male chromosome 46,XY;
Male factor: semen routine test was normal
Infectious factors: no abnormality in the eight items of infection, no abnormality in the TORCH examination;
Immunological factors: autoantibody anticardiolipin antibody persistently positive;
The blow after blow knocked her right out, but this time she didn’t cry, she knew it wasn’t the right time to cry, she kept the doctor’s instructions in mind and checked the foetal chromosomes!
Everything was no different from the last procedure, she had another empty month and waited for the results of a normal embryo chromosome.
Normal embryo dye means that the main cause is in the mother’s body, she made up her mind to wait for her body to recover, she must go for a thorough check-up.
Never thought that a flurry of tests would result in normal results!
Was it really bad luck?
Anxious about her age and the gossip of her friends and family around her, she didn’t have time to grieve for too long, so she could only continue to prepare for pregnancy.
At the end of 2018, she got pregnant again, this time she was more careful, she quit her job when she found out she was pregnant, and except for going to the toilet, she stayed in bed.
This time luck seemed to start favouring her, HCG doubled nicely, heart buds appeared at six weeks, placenta conversion went well at eight weeks, NT passed at twelve weeks, and she finally had a happy mid-pregnancy.
She also felt that she could finally breathe a sigh of relief. Little did she realise that the danger was approaching step by step, and she had an ultrasound done on the way when she was 16 weeks pregnant plus her mid-trimester don to see how the baby was growing.
Unexpectedly, what she waited for was the news that the foetus did not have a heartbeat. What was going on, the most dangerous early stage of pregnancy was over, why would it still be like this!
She really doesn’t understand anymore, it’s the same process as before, she had the operation, checked the embryo dye, and the baby is still normal!
What in the world caused the successive foetal stoppages, she decided that this time she must go to the provincial city to have a thorough examination.
02 Finding the Big Boss Behind the Fetal Arrests
I still remember the first time I saw Xiaoqin in the clinic, her face was waxy and yellow, with a layer of fine sweat on her forehead, and she was holding a thick pile of medical records because she had not registered in advance and she had come to see me for an additional number.
I helped her carefully comb through her medical records, and the main findings were as follows:
Basic condition: age 37, menarche at 13, menstrual cycle 28-30 days, period 4-5 days, medium amount;
Family history: father hypertensive, mother hypertensive, diabetic with history of cerebral infarction;
Fetal arrest experience:
January 2016, 8 weeks gestation plus foetal arrest, experienced from fetal heartbeat to no fetal heartbeat, no embryo dye test;
January 2017, 12 weeks gestation plus foetal arrest, experiencing from presence to absence of foetal heart, with normal embryo chromosomes;
April 2018, 16 weeks gestation plus foetal arrest, experiencing from presence to absence of foetal heart, with normal embryo chromosomes;
Past medical history:
Right iliac vein thrombosis was detected in April 2018 and was treated with thrombolysis.
Regarding the part of the tests for foetal arrest, in conjunction with her history above and the tests she already had, I prescribed some additional tests related to coagulation and immunity, and collated the results as follows:
Genetic factors: female chromosome 46,XX, male chromosome 46,XY;
Male factor: semen routine test was normal
Infectious factors: no abnormality in the eight items of infection, no abnormality in the TORCH examination;
Immunological factors: autoantibody anticardiolipin antibody persistently positive;
Coagulation factors: mildly elevated D2 polymer 0.58, negative genetic susceptibility to thrombosis screen, normal coagulation routine;
Anatomical factors: three-dimensional ultrasound showed no significant abnormalities;
Endocrine metabolic factors: normal blood glucose test, normal insulin screen, normal thyroid test, normal serum 25-hydroxyvitamin D test.
I judged her to have typical antiphospholipid syndrome.
03 How antiphospholipid syndrome affects the foetus
Phospholipid antibodies mainly act on the endothelium of blood vessels, inhibiting the release of arachidonic acid and the production of prostaglandins, thus promoting vasoconstriction and platelet aggregation.
In addition, phospholipid antibodies bind to β2GP1 and inhibit the anticoagulant activity of β2GP1, resulting in localised micro-thrombi.
This mechanism is manifested in pregnancy by affecting the expression of placental anticoagulant protein on the surface of placental villi, which decreases the local anticoagulant ability of the placenta, stimulates the synthesis of thromboxane by trophoblast cells, and promotes thrombus formation.
The placenta is the only place that provides nutritional supply to the fetus. The formation of placental thrombus seriously affects the nutritional supply of the fetus, which is a fatal threat to the fetus and a key cause of stillbirth.
Xiaoqin is very typical in that she has a history of venous thrombosis with at least one (two for Xiaoqin) unexplained, morphologically normal foetal death at 10 weeks or more.
Laboratory indices were more than 12 weeks apart, with more than two detections of positive plasma lupus anticoagulant or positive medium- to high-titer anticardiolipin antibodies or positive anti-beta2GP1 antibodies.
Typical antiphospholipid syndrome can be determined by at least one clinical symptom or one laboratory indicator, and Xiaoqin’s case is a very typical case.
04 Xiaoqin’s medication regimen
The drug regimen I gave Xiaoqin is the classic drug regimen for antiphospholipid syndrome, aspirin + prednisone + low molecular heparin.
Aspirin, the main role is to reduce the patient’s thrombotic tendency, improve hypercoagulability, reduce the local microcirculation of the uteroplacental, thus reducing the rate of miscarriage.
Low molecular heparin, a thromboprophylactic drug in conjunction with aspirin, has the greatest advantage of not passing through the placenta and thus has less impact on foetal and maternal safety, and is usually chosen in small or medium doses in clinical practice.
Low molecular heparin has the advantage of causing thrombocytopenia and osteoporosis is less likely to be used in pregnancy is safer.
Prednisone, which mainly exerts anti-inflammatory and anti-allergic effects, inhibits the proliferation of connective tissue, reduces capillaropathy, increases cell membrane permeability and reduces inflammatory exudation.
Prednisone, together with low molecular heparin, can play a synergistic role of drugs, improve hormone levels, balance the body’s immunity, and improve the success rate of treatment.
Of course, how the above medications are implemented, when to start using them before or during pregnancy, what are the contraindications, how to control the dosage, and how to discontinue the medication, all vary from person to person.
Please actively co-operate with the medication during pregnancy, take regular maternity check-ups and listen carefully to your doctor’s instructions.
