The plot thickens…my phone consult with Dr. S

I had a phone consultation today with Dr. S.  This doctor treats all of the hard cases like me and most of his patients are from out-of-state and abroad.

He feels absolutely confident that I have an immune problem.  He is ordering the proper tests for Erick and I both to confirm his suspicions.  Those tests will include antiphospholipid antibodies (anticardiolipins, APA, etc.), NK activation with IVIg, HLA and DQa, reproductive immunophenotype, thyroperoxidase and thryoglobulin.

There are two types of Immunologic Implantation Dysfunction:

1. Autoimmune – This is where your body produces an immunologic response to your body.  Easy to treat.  Accounts for 90% of problems.
2. Alloimmune – This is where your body has an immunologic response to cell components from someone else, as in the male contribution to the embryo.  This one is more tricky to treat and possibly not treatable.  Accounts for 10% of problems.

Anyone want to guess which he thinks is our problem?  Yes, that’s right – alloimmune.  He says this is rare.  Well, I suspected immune issues could be my problem, but I didn’t exactly expect this. If he’s right, at least we’ll finally know what we’re dealing with.

Controversy?

I should also point out that many doctors do not believe in this, including my current RE.  Camp #1 says there’s not enough research.  Camp #2 says it’s very complicated and many doctors do not understand it.  Also, it’s been hard to prove with so many variables, but now with embryo chromosomal testing, conclusive research will be possible.

I’m having zero luck with the non-believers at this point, so I choose to believe in this.  This is on the forefront of this field. Just think about how many people were thought to be crazy with their ground-breaking ideas at first.  Also, there are tons of people for whom this has worked.

He thinks I have this for the following reasons:

1. He thinks I have immune problems because I have had 11 mostly good embryos transferred over the last several years.  None have resulted in a baby.  He says that typically 1 out of every 2 blastocysts is normal, so there should have been five good ones.
2. Repeat miscarriages – I can get pregnant, I just can’t stay that way.
3. Most (if not all) immune problems result in first trimester losses.
4. He specifically thinks allo-immune because my ability to hang on to an embryo or fetus keeps getting shorter.  First miscarriage at 10 weeks, then 7 weeks and now 4 weeks.

What happens with alloimmune

This is all very complicated stuff and I’m trying to learn as much as I can.  But basically your body attacks the embryos.  In normal pregnancy, it’s paradoxical that a mother’s body allows something foreign (an embryo) in her body, but that’s how it works.  A pregnancy must be recognized by the mother’s body as a foreign object to trigger the appropriate immunologic mechanisms which allow the embryo to implant and grow. But in this case, when the man transmits via his sperm certain genes that are too similar to the mother’s genetic make-up, the immune system rejects the embryo.

From Dr. S’s blog:

So it is that in less than 10% of IVF cases that are associated with ID the embryo (through the contribution made by the sperm) shares too many genetically similar characteristics with the host (the mother). When this happens, repeated exposures to such an embryo will over time evoke an imbalance in the cytokines released by the uterine immune cells. This is characterized by activation of uterine NK cells (Nka). In such cases the “root system” of the embryo” can be compromised and the the embryo may be destroyed immediately but most often will instead “limp” along only to miscarry when its supply of nutrients and oxygen is outstripped by demand.

Thus alloimmune ID usually does not destroy the embryo immediately. Rather, after sustained erosion of its reserve, the conceptus will miscarry.

We diagnose alloimmune ID by testing the male and female partners for shared of genetic markers known as of as DQa and HLA. A sufficient degree of matching clinches the diagnosis.

Subsequently over time, with repeated exposures of matching embryos to the mother’s uterus, NK cells will become activated and the couple will find themselves miscarrying. Eventually the NKa will become permanently established and the couple will fail to conceive.

Other comments:

• Dr. S said it was a real shame that NONE of our products of conception have ever been tested.  In number one, the hospital could have but didn’t and we didn’t know any better at the time.  It was not necessary for the second one because it was genetic (blighted ovum).  And, for the third, by the time I got to the hospital there was nothing left to test and I was so distraught that I didn’t collect anything at home.  And, the fourth, too early.  So, girls, if you miscarry, please try to save what you can and get it tested.
• Another interesting thing he said is that he doesn’t think I should have had the uterine septum removed.  He said it will not cause implantation failure and only could pose a risk for a late miscarriage.  But, without justification, says it should not be performed because it can leave scar tissue, which in turn could be a real problem and absolutely cause implantation issues.  Hmm…great.

So, he said if we have alloimmune, he does think we still have good chances.  But whereas autoimmune problems are 100% reversible, this is not and is harder.  It all depends on how much the male and female partners DQa genes “match”, whether the male’s DQa genes are identical and the severity of uterine NK cell activation.  In these scenarios, it would not be treatable.

So, now we get the blood tests and go from there.  I really hope he’s wrong and even if it is immune issues, I hope it’s auto-immune, which can absolutely be treated.  But, regardless, at least we’ll know for sure.  Information is good.

Do any of you have this problem or know someone who does?  Thoughts? Comments?