Recurrent miscarriage

Recurrent miscarriage is when a couple have had three or more consecutive miscarriages. There are multiple factors that may cause miscarriage but often the cause of recurrent miscarriage is not identified.

At NeoFertility we look at up to 15 factors that can increase your risk of miscarriage. We have the ability to identify couples who are at risk of miscarriage even before the first miscarriage occurs. A review of our data from 2010 showed 80% of couples had successful pregnancies with a history of 3+ miscarriages. An abstract of our data is available here.

Couples with a history of ten previous miscarriages have had successful pregnancies with our treatment. Treatment with NeoFertility is safe and minimally invasive, with a low incidence of twins, premature births, or low birth weight. This is important to minimise health risks for babies conceived in our programme.

Our approach is to find the cause(s) of miscarriage and provide treatment before conceiving again. When the cycle is balanced and functioning optimally the couple are advised to conceive while taking the recommended treatment.

By charting your fertility cycle and getting timed blood tests, we identify biomarkers that increase your risk of miscarriage. These include abnormal bleeding patterns, short luteal phase, limited cervical mucus flow or if premenstrual symptoms persist for longer than four days.

In some cases we recommend surgical evaluation of the woman’s uterus (womb). Endometriosis can be a significant cause of recurrent miscarriage. In many cases this can be silent or symptom-free endometriosis.

We look at the possibility of a chronic low grade infection and treat this if appropriate. We send additional blood tests including for Natural killer cells, food antibodies, chromosomal or blood clotting abnormalities. Endorphin deficiency can also increase your risk of miscarriage. If we identify problems in any of these areas we commence treatment to correct the abnormalities.

Environmental and lifestyle factors are often very significant contributors to miscarriage.  In particular excessive alcohol and cigarette smoking together with a busy stressful working environment or other lifestyle stress may increase the risk of having miscarriages.

Once the couple conceive we monitor pregnancy closely and provide pregnancy hormone support. Dietary changes initiated while trying to conceive are important to maintain throughout the pregnancy to decrease the risk of miscarriage.

If a couple miscarry on their first attempt with our treatment, it is medically worthwhile trying a second time.  We often modify treatment further for subsequent attempts that improve the chances of success.

Treatment is not a guarantee of success, but we can significantly improve your chances with targeted medical and surgical intervention.

Fertility treatment age 35 years and above

What about Fertility treatment as you get older ? It is well known that fertility declines with advancing female age.

NeoFertility has a specific treatment strategy for both men and women of advanced reproductive age. This is helpful whether you have a history of infertility, recurrent miscarriage or you have just started trying to conceive.  We assess your fertility charting pattern, test the “quality of ovulation” based on timed blood tests for progesterone and oestradiol and prescribe whatever treatment is deemed necessary. The goal is to optimise your preconception environment and reduce the risk of infertility, miscarriage, ectopic pregnancy and premature delivery.

There is a “genetic clock” built into our DNA which causes us to age. From the age of 35 female fertility begins to decline. So far, we cannot influence this genetic ageing effect, but we can positively influence other aspects of ageing and improve pregnancy outcomes as a result. With NeoFertility we “Normal-stimulate” the follicle, provide hormone support to the luteal phase of the cycle and provide hormone support during the early stages of pregnancy. In addition we address diet, nutrition, supplements and lifestyle factors which all have an impact on your health and fertility.

This graph  shows declining live birth rates with advancing female age. It compares the declining live birth rates in the general population (green) compared to IVF (blue) and NeoFertility (Red) at the same age.

The green bars represent the expected live birth rate in the general population for the first year of trying to conceive without any fertility treatment. If a year passes without a pregnancy most authorities recommend evaluation and treatment for infertility.

The blue bars are the live birth data from HFEA UK in 2017 (Human Fertilisation and Embryology Authority). We looked at the live birth rate PTC (Per Treatment Cycle) of IVF.  This means for every 100 couples starting an IVF cycle, how many have a live birth. Fertility-treatment-2017-trends-and-figures-uderlying-graph-dataupdated.xlsx | 116KB opens in a new window

 Most IVF clinics quote the “clinical pregnancies per embryo transfer” which excludes miscarriages and those who never get to embryo transfer, giving the impression of a higher “success rate”.

The red bars are the expected live birth rates for completing NeoFertility treatment in 2015. The data is explained here. https://youtu.be/aDXWSWE4mbw

The graph compares one year of trying to conceive naturally with up to two years of NeoFertility and one round of IVF for different age groups.

It is assumed that once a year has passed and couples are not pregnant, the high numbers getting pregnant naturally diminishes greatly. NICE guidelines UK have shown that 50% of couples under 35 will conceive in the second year of trying without any fertility treatment. That is better than most fertility clinics. But this means some couples wait up to 2 years before investigating or treating fertility seriously. By tracking the signs of fertility with NeoFertility we can identify impaired fertility even before you try to conceive for 1 cycle. We then balance the cycle with targeted treatment to allow natural conception.

The majority of couples will conceive with NeoFertility treatment within the first 12 months, but if you persist for 12 balanced cycles or up to 24 months, pregnancy rates continue to improve

If you consider those with a limited budget of €5000, NeoFertility may take longer to achieve conception but yields a higher live birth rate compared to IVF.

With NeoFertility we aim to achieve the optimal potential available for each age group through our multifactorial treatment approach. When optimal cycles are achieved it is important to continue treatment for 12 effective cycles to ensure you have given yourself the best chance to conceive naturally.

Reduced Ovarian Reserve/Low AMH

Low AMH or reduced ovarian reserve can be treated successfully with NeoFertility.

AMH levels are commonly measured in fertility clinics to assess ovarian reserve and give an indication of female fertility potential. AMH is produced by the small antral follicles in the ovary. Low AMH is a condition where the number of antral follicles have diminished. This is especially relevant for IVF clinics as they aim to produce 8 to 12 follicles to obtain as many “good quality” embryos as possible. With a low AMH, the possibility of producing multiple eggs for an IVF cycle are reduced, making success less likely. If you produce a small number of eggs, it is less likely you will have enough good quality embryos to transfer, giving lower success rates for an IVF cycle.

Historically, antral follicles were counted during ultrasound scanning to give an indication of the ovarian reserve. In recent times a blood test for AMH is now widely used to determine a woman’s egg reserve. AMH levels are supposed to be constant throughout the cycle. Levels usually fall with advancing age, but AMH can rise for some women.

You need just one follicle and one egg per cycle for natural conception to occur. Because of our lower egg requirement we are able to achieve success with couples who have very low AMH levels and deemed unsuitable for IVF.  We have had success where donor eggs were advised or previously used unsuccessfully.

We normal-stimulate your cycle producing one good egg per cycle with the aim of achieving natural conception. We monitor your treatment using ultrasound follicle tracking and monthly timed blood tests in conjunction with your fertility chart, recorded on traditional paper or with the specially designed fertility tracking app we developed at www.ChartNeo.com .

The lowest AMH blood result we have achieved success with was for a 36 year old woman with 6 years of infertility who never conceived previously – her AMH was only 0.07pmol/l (0.009 ng/dl) and her FSH was 42iu/l. She conceived on her first cycle of treatment in our programme and delivered a 9lb baby boy.

Our YouTube presentation on Low AMH is available here and an abstract analysing our data on low AMH in 2015 is here.

Endometriosis

Endometriosis is a common cause of infertility. It is found in up to 50% of women trying to conceive. It can be mild, moderate, or severe.

The lining of the uterus is called the endometrium. This is usually found inside the uterine cavity. It thickens and grows every cycle to allow an embryo to implant resulting in a pregnancy.

Endometriosis is when the lining of the womb is found outside of the uterus. The lining can attach to ovaries, ligaments, bowel and the fallopian tubes.

Healthy endometrium is shed each cycle with menstruation, but with endometriosis, the endometrial shedding results in inflammation as it cannot be released when it grows in the pelvis. This commonly produces symptoms such as:

• Painful periods
• Constipation or diarrhoea during menstruation
• Sharp discomfort with penetration during intercourse

Interestingly for many women, endometriosis can be silent with none of the obvious symptoms. The only clue it may be present is infertility or recurrent miscarriage.

Endometriosis causes reduced fertility but you can still have a successful pregnancy even if it is not detected or treated. Just because you have had one previous pregnancy does not mean endometriosis is not present.

Women with untreated endometriosis will have a higher incidence of infertility and are 3 times more likely to miscarry compared to those who do not have endometriosis.

If you have not conceived after 6 months of NeoFertility treatment, we usually recommend a laparoscopy with a skilled gynaecologist as endometriosis is frequently missed by less specialised gynaecologists. Excision of the endometriotic lesions seems to be more effective than diathermy or laser ablation with a lower chance of recurrence.

Surgical treatment of endometriosis has been shown to improve the chance of conception and reduce the risk of miscarriage.

Every patient diagnosed with Endometriosis in our programme is advised to take Low Dose Naltrexone, supplements with vitamin D3, omega 3 and our dietary strategy to improve clinical well-being and optimise fertility.

Clinically, symptoms improve with treatment. Surgical intervention is the most effective treatment but symptom relief is enhanced with additional medical treatments.

MALE FACTOR INFERTILITY

Male factor infertility affects 40% of couples trying to conceive. It can be mild, moderate or severe. Many couples with severe male factor infertility may still conceive with appropriate medical intervention. If conception has not occurred after 6 to 12 months of regular intercourse during the “fertile days”, male factor is a possible cause and should be investigated.

In order to obtain a semen sample, we provide couples with a non-spermicidal, latex-free, perforated condom so the sample can be collected through normal intercourse. Abstaining from intercourse for 3 days prior to collection improves sperm concentration. Samples collected through intercourse with a suitable condom usually give more accurate results.

Semen Analysis Results

Interpretation

The above values from 2010 normal semen represent the lowest 5% of samples collected from a cohort of couples where conception occurred within 12 cycles of trying to conceive. An average sample should be higher than these values. In clinical practice conception can occur with samples lower than the above threshold. The lowest level acceptable for natural conception has not yet been determined. If a sample is sub-optimal this can be due to a number of transient events for example, a recent flu, illness, period of stress or following heavy alcohol or caffeine consumption. It is wise to consider repeating a sample after 10-12 weeks following any intervention to see if there is an improvement. If the sample result is around these lower limits, interventions to optimise male factor are worth considering and implementing. If you have a zero sperm count, azoospermia, natural conception is not possible with NeoFertility.

DNA Fragmentation Index

This is a new test to assess for DNA damage in sperm. It is not evaluated as part of routine testing and is not part of the WHO criteria to assess seminal fluid. The DNA result is impossible to predict from history or routine semen results.

DNA fragmentation occurs due to oxidative stress causing free radical damage to the sperm cells which are poorly protected because of sperm cell design with minimal cytoplasm. 

If you are older, a smoker, have a varicocele or chronic infection this will increase oxidative stress and therefore the DNA fragmentation index will be higher. There are several different kinds of DNA tests available with different reference ranges of normal values.

Generally if the DNA fragmentation index is:

• 15% or less natural conception is likely
• 15-25% Acceptable
• 25-50% Unsatisfactory
• >50% Natural conception is unlikely – unless it improves with treatment

Anti-Sperm Antibodies

With NeoFertility we can achieve success even with 100% anti-sperm antibodies.

Treatment Plan

Lifestyle Factors

For both the male and female we recommend:

1. No Smoking
2. Alcohol – 10 units per week, 4 max on any one day
3. Caffeine – 1 a day (Tea, coffee, cola)
4. Stress – control as far as possible
5. Exercise – keep it balanced – avoid doing too much or too little
6. Loose fitting cotton trousers
7. Weight reduction
8. Regular sleep – 7 hours minimum nightly

Supplements

Various supplements are recommended, depending on what problems are identified. It is important to know excessive supplements can damage sperm and impair fertility.

Treatment of chronic low-grade infection

Symptoms are not always obvious but a chronic low-grade infection can result in lower semen parameters. Treatment may be given empirically or following PCR-DNA testing for silent infection including chlamydia, mycoplasma, and ureaplasma.

Scrotal Ultrasound

We refer to a specialised radiologist to assess for possible varicocele. If found, embolization can correct the varicocele and improve fertility.

Other Treatments

• Tamoxifen
• Maca- Peruvian Herb

Treatment Outcomes

In our clinical experience we estimate over 50% of men will see an improvement in semen parameters with intervention.

We re-check semen analysis after intervention and if we do not see an improvement in semen parameters we alter our treatment strategy until all of our treatment options have been tried.

Premenstrual Syndrome

Pre-Menstrual Syndrome (PMS) and Pre-Menstrual Dysphoric Disorder (PMDD)

If you suffer from bloating, breast tenderness, mood changes, irritability, carb cravings, sleep disturbance and a cluster of negative symptoms for 4 or more days before the onset of menstruation you have Pre-Menstrual Syndrome or PMS. True PMS disappears with the onset of menstruation and is cyclical, recurring at the same time each month. Pre-Menstrual Dysphoric Disorder or PMDD is more severe with symptoms that interfere with your ability to function at home or at work.

Most women have a cluster of negative symptoms for 1 to 2 days which is normal. Symptoms become more severe after times of stress, illness, or sleep disturbance. If you notice symptoms are persisting for 4 more more days regularly it is likely you have PMS.

About 25% of women have PMS and 5% have PMDD. If you feel symptoms are problematic, NeoFertility can provide a range of medical treatments to solve the problem. Clinically these strong negative symptoms are associated with subfertility and poorer pregnancy outcomes and are worth treating to optimise conditions pre-conception.

It greatly helps if you track your fertility cycle with NeoFertility or with www.chartneo.com so you can document the symptoms, how severe they are, and in what stage of the cycle they occur.

Our treatment for PMS is:

1. Diet – avoid dairy, gluten, and fast carbohydrates (cakes, sweets, and biscuits)
2. Exercise – 30 minutes daily, 4 times a week
3. Supplements – B Vitamins, Omega 3
4. Low Dose Naltrexone – PMS/PMDD is associated with low endorphin levels in the luteal phase of the menstrual cycle. If you take a low dose of naltrexone 3 to 4.5mg nightly, you will get a 4-fold surge in endorphin levels. This will provide tremendous relief of PMS symptoms for 80% of women. The effects can be life-changing for PMDD where horrible symptoms disappear and life returns to normal.
5. Some 20% of PMS/PMDD are resistant and require additional investigations and treatment before symptoms improve. Treatments may include:

               a. Progesterone support in the luteal phase of the cycle

               b. Treatment of adrenal fatigue

               c. Treatment of thyroid dysfunction

               d. Sympathomimetic medication

If you continue to work with NeoFertility, we can successfully treat PMS/PMDD for the majority of women we see.

Post Natal Depression

It is common to feel a little low after the delivery of your baby.

Life is busy! You are sleep deprived, changing nappies, feeding, and baby is crying and waking at irregular times!

Finally you are living the dream – but it can be tough!

Baby blues are common. You had so much progesterone in your body for 9 months and all of a sudden it is gone and that calming, mood-enhancing happy hormone is gone……and your body feels it.

You do not need to dig deep and suffer on. Commonly we find re-introducing progesterone treatment after delivery can be very helpful to calm the mood, restore well-being, and help you feel more normal.

You do not have to have full-on post-natal depression. If you are not fully yourself, consider resuming progesterone and possibly naltrexone to get you on your feet again.

Remarkably, even if you have full-on depression, progesterone treatment will relieve negative symptoms for the majority of women.

Remember to call our practice if you need any support post-delivery. An anti-depressant is not the only option you have if you are feeling low after delivery. Progesterone is a faster and more effective solution for most women.