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Thread: Miscarriage and planned treatment due to immmunological problems

  1. #1
    Join Date
    Aug 2012
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    7

    Default Miscarriage and planned treatment due to immmunological problems

    Dear Dr. Coulam,
    I would like to ask you for your kind advice about my future treatment in case I get pregnant again.
    I am 34 (as well as my husband), have no chlidren, no gynaecological problems in the past (except 1 episode of asymptomatic mycoplasma infection succesfully treated with ATB and findings of high risk HPV- I underwent vaccination against HPV as I was recommended). I had no interruption in the past.
    We started to TTC last year and I got pregnant after 4 month. At the end of 6th and beginning of 7th week I started to bleed and my gyneacologist prescribed me Dydrogesterone. I kept on bleedind and having cramps and after a week I had ultrasonography done, where no heart action was present I had to undergo curretage.
    After recommended 3-month break we started to TTC again, now it is 5 month and I am not pregnant yet.

    During that time I had several tests done and here are the results :

    My uterus is RV/RF, other gynaecological finding are normal, menstrual cycle regular, ovulation present, hormonal profile normal.
    Trombophilia panel : MTHFR 677t homozygote mutation found, Leyden heterozygote mutation found, others normal. Homocysteine lelev normal.
    APLA : ACLA negative, anti B2gp negative, anti annexine V IgM slightly positive (twice), IgG negative.
    Anti TPO, anti TSK, TRAK negative, thyroidal hormones normal (including TSH which was 1.9), but according to the ultrasonography I was told I have chronic autoimmune thyreoiditis. No treatment.
    Immunological tests : anti ovarian antibodies negative, anti zona pellucida negative, anti spermatozoa not interpretable (planned to be done again).
    Anti nuclear antibodies (also found repeatedly) slightly positive - granular fluorescence of nucleus, once also cytoplasmatic fluorescence found).
    CD3+ T-Ly, CD4+ T-Ly, CD8+ T-Ly, B-Ly normal, NK cells elevated 26.7%.

    At the moment I take active folates (800 mg), coenzymated B6 (25 mg),methylcobalamin (1000mg) and DHA and Aspirin 50 mg/day.

    And here is my planned treatment : LWMH from positive pregnancy test till the end of pregnancy, Aspirin till 34-35 th week, thyroidal hormones if needed (accordind to thyroidal function), Dydrogesterone 6th-12th (14th) week and probably Prednisone - used at least 6 week before conceiving, 4 weeks 5 mg/day, then 2.5 mg /day, at least till 14th week of pregnancy. So I was told to stop for 6 week TTC, after that I should use condom except of my fertile days.

    What is your opinion about the treatment? Is it ok (including dosages)? I am willing to do anything to gave birth to a healthy child, but so meny medication seems too much for me. My imunologist is also not very sure about the corticoids, as they can worsen my blood coagulation. I read about intralipids, could I use them instead? (IVIG is not affordable for me..). If yes, what dosage do you recommend (I found recommendation saying that 1 infusion should be administered at positive pregnancy test (100 ml 20% IL diluted in 250 or 500 ml of normal saline infused over 1-2 hours), 2nd at 8th week and 3rd at 12th week. Is it ok and is it enough or is there a way how to find out wheter I am supposed to take another infusion (some tests probably)?
    Should I have some other tests done or are these suficcient?
    Thanks very much for your answer in advance.
    Best wishes,
    Beata

  2. #2
    Join Date
    Sep 2008
    Posts
    677

    Default

    Intralippids will help to treat your elevated NK cells. Depending on the results of you NK activation assay including suppression tests with intralipid, we would start with different dilutions of intralipid. The most common doses is 4ml of 20% intralipid solution in 250 ml of noraml saline but this can vary depending on the individual. We give the first dose prior to expected implantation and the socond dose with the first positive pregnancy test. We then reck your NK cells and treat according to that result. You should talk with your docotor about his/her protocol. Dr. Coulam

  3. #3
    Join Date
    Aug 2012
    Posts
    7

    Default

    Thank you a lot for your advice.
    I have one more question : Is there a possibility, that my elevated NK cells are the cause why I am not getting pregnant again?
    Thanks.
    B.

  4. #4
    Join Date
    Sep 2008
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    677

    Default

    Yes, we have shown an association between elevated NK cells and implantation failure. Dr. Coulam

  5. #5
    Join Date
    Aug 2012
    Posts
    7

    Default

    Thank you very much for your time and your answers.
    I apreciate it very much also because it is very hard to find someone who can give me an advice in this field of medicine. IL are not administered in our coutry as a treatment of fertility and pregnancy loss problems, or at least I did not find anyone using them for this purpose, so I think I will be probably one of the first experimental patients here.
    Thanks again, hope IL will help
    Beata

  6. #6
    Join Date
    Aug 2012
    Posts
    7

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    If you donīt mind I would like to ask 2 more questions :

    What are the normal ranges for activated NK cells and activated T cells in testing activated reproductive phenotype?

    And when do you use to start giving low dose aspirin adn how long do you recommend to use it (in case of TTC natural way)?

    Thank you.
    B.

  7. #7
    Join Date
    Sep 2008
    Posts
    677

    Default

    Normal values for activated T cells are as follows:
    CD3 51 - 79%
    CD4 30 - 52%
    CD8 16 - 40%
    Activated NK cells depends on the lab and which activation marker they are using.
    We recommend aspirin on in those at riak for blood clotting and start it prior to pregnancy. Dr. Coulam

  8. #8
    Join Date
    Aug 2012
    Posts
    7

    Default

    Thanks again very much for all your answers Dr. Coulam.

    I will be tested for CD69 on NK cells. Can you pls tell me the normal range of this test? (I am asking because when tested on number of NK cells the normal laboratory range was up to 19%, but then I found out that in women with reproduction problems it should be lower than 10%, so I would liek to be sure about the proper range this time too.)

    Thank you.
    I apreciate your time and answers very much.
    Best regards,
    K.

  9. #9
    Join Date
    Sep 2008
    Posts
    677

    Default

    You need to check what the normal range is for the lab peerforming the test. Dr. Coulam

  10. #10
    Join Date
    Aug 2012
    Posts
    7

    Default

    Thank yuo. I will check it for sure.
    Best regards.
    B.

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