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Dr German Fernández
Medical Director at UR Vistahermosa Managua, PreGen (UR Vistahermosa)
Category:
Miscarriages and RPL
In this webinar session, Dr German Fernández, Medical Director, Gynaecologist specialising in Reproductive Endocrinology and Infertility at UR Vistahermosa Managua has discussed miscarriages causes, available diagnosis and treatment options.
Dr Fernández started by explaining that miscarriages are very common and around 10 to 20% of spontaneous pregnancies end in miscarriage. Most of them, around 80%, happen before 12 weeks and from 60% of a positive pregnancy test, 34% end in happy ending pregnancy. It is important to understand that even if you do an IVF treatment or not, there is a certain percentage probability of having a miscarriage. Many times people are wondering about how you can have a miscarriage if you are doing an IVF process, but even if you don’t use an IVF process, you can have a miscarriage as well as you can have, for example, preeclampsia, pre-term delivery, diabetes or whatever disease you may have in a normal pregnancy.
One of the main questions the patients ask: Is it me? Am I doing something wrong? And what is significant to remember is that egg quality is different from egg quantity. Sometimes even though you have a good AM level and Antral Follicle Count doesn’t mean you have a very good quality of those eggs. Another reason for miscarriages could be an underlying disease, such as untreated subclinical hypothyroidism, insulin resistance, or any previous diseases.
It is also known that if the progesterone levels are low in the luteal phase, the risk of miscarriage increases. Therefore, many times in an IVF process, we prescribe vaginal progesterone for patients to increase their levels.
It is also important to mention the male part. Sometimes we have a sperm analysis that says there is good concentration, very good motility and morphology, but we don’t know if this semen is indeed of very good quality. That’s the reason we do some other tests, for example, DNA fragmentation, and FISH, we also need to check if the partner has diabetes, ejaculation issues, if he smokes and if there were any previous miscarriages. Studying men is as significant as studying women.
Sometimes the cause can be found in both partners. The lab also has some responsibility, for example, creating an optimal environment for fertilization, and having an adequate preparation of patients, therefore, we always need to calculate the right dosage for each patient to obtain very good eggs. If we know, for example, that the progesterone levels are high, we freeze the embryos and do a transfer in a later cycle. Another crucial part is personalized treatment because not all patients need the same thing.
There are certain things that all patients undergoing IVF should remember and which can be crucial in their journey. These are:
I would also recommend all patients to take notes about their cycle because if you need to change your doctor, you will be able to provide thorough information. I would always ask how long you’ve been trying for, how was your egg retrieval, have you got mature eggs, did they fertilize, what grades your embryos were or if you had an easy or difficult transfer, etc. Thanks to that, I could probably provide a bit different prognosis. Those questions are very important to answer, and you have to take notes.
Another thing you should take into account is to find the answer if it’s better to transfer 1 embryo or more embryos at once. That always depends on the embryo classification, but also regulations in your country. Another thing is to consider the risk of twins or triplets if more embryos are transferred. At some point, you also might need to decide whether to change one of the gametes and also how far would you like to go through your process because if there’s a problem with let’s say your eggs or your partner’s sperm, you might need to change to egg donor or sperm donor to achieve a healthy baby.
It depends on the background of the patients. If you already had recurrent pregnancy losses or miscarriages, I would use, for example, I would use a very low dose of prednisolone until the 12th week of pregnancy. In donor eggs, we use estrogen, it usually depends on how much estrogen we’re going to use, we usually use up to 10 milligrams per day and progesterone around 800 per day, but some protocols use a 10000, it depends on the administration and also if you use this progesterone vaginally or if you use it in a shot. You may use estrogen from 6 to 10 milligrams without any problems, and progesterone you can use from 800 to 1000. In case a patient has recurrent miscarriages or previous implantation failures, we use prednisolone, and Viagra (sildenafil), we also use inositol, but it all depends on the patient.
Regarding taking progesterone until 30 weeks, it depends because if we have a patient who already knows that has uterine incompetence, you may use progesterone longer, but normally, in an IVF process, we use it until 12th weeks.
That’s a very important question because we have to understand, as I said at the beginning of the presentation, that miscarriages occur even though you do a natural cycle. People usually get confused about that. They think that if they have a 25 years old egg donor and husband’s or partner sperm, they will probably have some guarantee that nothing is going to happen, or they will have a certain guarantee that the fertility rate is going to be very high because they’re using an egg donor. However, it’s not like this because we have to understand that the semen of the husband may have DNA damage, and that is why that can cause or increase the miscarriages chances as well.
Unfortunately, we have to say that some patients have the same issue. At the moment, I also have a patient who has already gone through IVF with donor eggs, and she hasn’t been successful yet. What we do is change the donor, for example, that’s one option, another option is using an endometrial rejuvenation, you can use intra lipids to increase the chances of getting pregnant. But first, I would check if those eggs are from the same donor or if they are different, if not, I would say there might be something going on with the semen. If you already have 2 egg donations, perhaps you will need to pursue embryo donation at some point, and as I said at the end of my presentation, I believe everyone can get pregnant, the thing is, how far are you willing to go.
We do it all the time. Here in Nicaragua, you have to pay for every test, for example, if you want to get a genetic test, you have to pay for it, and if you want to go through an IVF, you need to pay. We don’t have a chance to do a thrombophilia test for everyone because if we do that, we’re making the process even more expensive. We use low doses of aspirin for every single patient, after COVID we have increased the dosage to 380 milligrams per day, but it depends on the country.
I would have some doubts about it because the implementation rate doesn’t depend on the bed rest, it depends on how the endometrium is prepared to receive an embryo. We don’t recommend bed rest much, it is not a regular recommendation. We just recommend 2 days of bed rest, but not like very restricted, you can do the dishes or prepare some food and things like that. We don’t want the patient to just lie down for 10 days.
Gradient, but it depends on the lab. Most of the time here, and we’re an international group, we always use gradient, but in some cases, we use swim-up if we have a very low-quality semen sample.
What we are doing now here is the endometrial rejuvenation, we use PRP in the endometrium and also intralipids. The other thing is you should try it for like 3 months, that’s usually the recommendation.
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