Results 1 to 6 of 6

Thread: PCOS and miscarriage

  1. #1
    Join Date
    Jul 2011
    Posts
    6

    Default PCOS and miscarriage

    Dear Dr. Williams,

    I was diagnosed with PCOS in 2007 and went on to conceive my twins through IVF. After that, my husband and I decided we did not want to pursue any future fertility treatment. At that time, my Reproductive Endocrinologist suggested that I stay on Metformin (1500 mg per day) as he has seen PCOS women have spontaneous pregnancies.

    My husband and I were shocked and elated to find this happen to us this summer, only to be devastated 7 weeks later to learn that we had lost our baby, just days after seeing a heartbeat on ultrasound.

    During this pregnancy I stayed on the Metformin as recommended, and my doctor prescribed progesterone suppositories (100mg 3 times daily). I did not ask for this until I was already 5 weeks and I am blaming myself, thinking that I knew progesterone can be low in PCOS women and I should have asked for it sooner. They never gave me a reason for the miscarriage, but I have been beating myself up ever since.

    I do take some peace in knowing that I can get pregnant on my own. I am just wondering what I can do in the future to make my miscarriage risk lower? I still do not know if I can ever go through this again, but want to be prepared if I change my mind in the future. I read somewhere that progesterone is only effective if taken BEFORE pregnancy, but cannot be taken until after ovulation? Should I be monitoring my cycles more closely and use progesterone after ovulation until pregnancy is confirmed?

    I am just sad and want to move forward. I would appreciate any advice you are willing to share.

    Sincerely,
    Katie

  2. #2
    Join Date
    Oct 2008
    Posts
    103

    Default

    Katie,

    I am so sorry that you experienced this loss, especially after all you have had to go through in the past. We see early miscarriages quite often, but hopefully this will be the only time this will happen to you.

    It is encouraging that conception occurred on its own. If you are having regular menses while on metformin, then it is working to help allow ovulation to take place. Some studies have suggested that miscarriages occur more commonly in women with PCOS, and that metformin can decrease that risk, but the exact mechanisms remain unclear, if present at all.

    Progesterone production can be abnormal, and it can be a cause for miscarriage. With poor progesterone production we usually see a normally developing embryo, but early bleeding and cramping as the uterus begins to contract due to the progesterone drop. If what was seen was a loss of embryo growth while your uterus remained quiet, then progesterone may not be an issue.

    However, progesterone is necessary for changes in the uterine lining that allow the embryo to attach, implant, and establish the placenta. It is theoretical that early implantation problems involving the initial invasion of the uterus by the placenta may not allow normal placental function once the embryo has increased in size. This may also lead to poor growth and embryo loss at a later stage. Again, it is theoretical. But progesteone use during the luteal phase (after ovulation) can help supplement the normal progesterone production, and we know that this is necessary during IVF cycles. If you cannot know when you are ovulating, it makes using progesterone more difficult--if you use the progesterone PRIOR to ovulation, it may prevent ovulation or cause changes that may not allow an embryo to implant (which is the basis for the "morning after pill").

    I usually recommend progesterone use starting 2-3 days after ovulation. For women with a regular 28 day cycle, this begins on day 17. Progesterone use in the luteal phase may also delay the start of a period, so you may need to check a pregnancy test when one is due, and stop the progesterone after a negative test. Talk to your physician about this.

  3. #3
    Join Date
    Jul 2011
    Posts
    6

    Default

    Dear Dr. Williams,

    Thank you so much for responding so quickly and your thoughtful response. This has been really difficult and I feel that knowledge helps me to deal with this sad situation.

    A week prior to the loss, I did have some bleeding, but they were able to see a heart beat of 135 and everything "looked great". They determined that the bleeding was likely due to the progesterone suppositories. But maybe it was just that my progesterone was already too low?

    A week later on ultrasound they determined that the crown to rump length measurement looked good, but the gestational sac was "slightly small", measuring about a week behind the crown to rump. They told me that it was possible for the baby to progress, but it was also possible that the pregnancy could end in miscarriage. One day later the bleeding increased and there was no longer a detectable heartbeat.

    I guess my question is, could low progesterone contribute to the gestational sac being small and subsequent fetal demise, or is that likely as separate issue? Also, in regards to progesterone, are you comfortable with the suppositories, or do you prefer injections (this is what I used in my IVF cycle)? It is interesting to note that in my first successful pregnancy, I had bleeding as well after stopping progesterone in my 12 week. They attributed it to a low lying placenta and twin pregnancy. But when I was put on oral progesterone a few weeks later the bleeding stopped. I am not sure if those two things are related either. One of the twins ended up having a poor functioning placenta and we delivered prematurely because of that issue.

    Also, I have very regular cycles on the metformin, but they are longer at 35 days. Can I use ovulation predictor monitors? I have heard these do not work in women with PCOS due to high levels of LH. I am ususally fairly certain when I am ovulating as I monitor my cycles closely so I can also start taking the progesterone on approximately day 25.

    I plan on seeing a reproductive endocrinologist soon to move forward, I am just not ready to do so quite yet. I need some more time to heal. Thank you so much for your time and consideration. Learning from this experience is really helping my grieving process.

    Warm regards,
    Katie

  4. #4
    Join Date
    Oct 2008
    Posts
    103

    Default

    The specifics of your loss are concerning for a progesterone influence. It is impossible to know, however. The bleeding with a normal sized embryo with a good heartbeat can be consistent with low progesterone levels, but the small gestational sac is not necessarily due to progesterone.

    The vaginal suppositories are fine for normal ovulatory cycles--this form may not increase serum levels much, but it is absorbed into the uterus very well. The injectable form is not used as often--if you can remember, it is quite uncomfortable, but it does increase serum levels to a comfortable and measurable level.

    LH kits can be effective, but it is true that for some women with LH elevations due to PCOS, it may not be accurate, but if you can detect a positive result at an appropriate time based on your cycle length, then starting progesterone a few days later can be helpful. It depends on whether you want to start paying attention to every day of your menstrual cycle again--if you remember, during treatments and IVF the process can be all-consuming, with expectations and disappointments with attention paid to every day. Hope this is helpful.

  5. #5
    Join Date
    Jul 2011
    Posts
    6

    Default

    You have been incredibly helpful. Thank you so much for your kindness and consideration. I appreciate it very much.

  6. #6
    Join Date
    Jul 2011
    Posts
    6

    Default

    Dear Dr. Williams,

    I met with a reproductive endocrinologist who was very willing to treat with clomid, injectibles, or IVF (because of my history) or let me try and conceive spontaneously in the future. He is willing to prescribe progesterone in the luteal phase if I decide to try on my own.

    The one question I still do not have an understanding of, if on Metformin, I have fairly regular cycles (although slightly long at 35-40 days) and I know that I ovulate (I obviously got pregnant the last cycle, and I randomly had an ultrasound the cycle before due to suspected cyst which turned out to be a kidney stone, but I saw the large follicle and it correlated to my cervical mucous, which I use along with temperature to make sure I am ovulating), how will clomid or injectibles help increase my chance of conceiving? Does it shorten the cycle creating higher quality eggs and boost hormones to ensure that a luteal phase defect does not occur? Or does it just give more predictability to make sure the timing is right?

    If I try on my own, I plan on using a baby comp, which you probably know predicts ovulation according to temperature in conjunction with LH strips. Then I will start progesterone 3-4 days after the increase in temperature and stay on the progesterone if I am pregnant or stop at 12 days if not.

    How would you recommend proceeding? Also, do you have any opinions on Clomid verses Femera (Letrozole)? I have read a couple of studies which have showed promise for Femera in women with PCOS. I have also read that it does have an effect on cervical mucous like Clomid. My doctor also states that injectibles have a higher success, but I am terrified of multiples after the premature delivery of my twins (although my Doctor said that the complication we experienced is just a risk of twins and I do not have a higher chance than anyone else of this happening again).

    I am just so confused about how to proceed. The only thing I do know is the pure joy I felt knowing I was pregnant and that I definitely want more children. I would really appreciate any advice that you are willing to offer. Thank you so much for all of your help.

    Warm regards,
    katie

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •