Dear Professor Winston,
I have just been told by a friend that you provide a question answering service. Unfortunately all the specialists I see have different suggestions and theories and I am at a loss as to what to think and do. So if you could take the time to read my story and let me know your thoughts I would be incredibly grateful. I have a 4 year old daughter who was conceived naturally and was born (in Feb 2010) at 40 weeks in water after a 3 hour labour and an uncomplicated pregnancy. Since June 2011 I have had 6 miscarriages. With regards to getting pregnant this has always been natural and straight forward, however the difficulties lie with maintaining the pregnancy. In brief: June 2011 – Miscarriage 1 – 6.5 weeks (this was a missed miscarriage and discovered at a 12 week scan and required an ERPC.) Jan 2012 – Miscarriage 2 – 6.5 week (missed miscarriage and discovered at 12 weeks although I had a 6 week scan where everything was normal. I had an ERPC.) March 2012 – Miscarriage 3 – 5.5 weeks – I bled naturally. Jan 2013 – Miscarriage 4 – 6.5 weeks (discovered at 8 weeks, I had an ERPC. In this miscarriage I was taking cyclogest 400 x1 per day, baby aspirin, prednisolone 25mg a day). PoC was done and it was 46XY June 2013 – I discovered I had Asherman’s Syndrome, I had a hysteroscopy, during the procedure my womb was perforated. Oct 2013 – I had another hysteroscopy as the Asherman’s hadnt been cleared up and a coil was put in for 2 months. April 2014 – Miscarriage 5 – 6.3 weeks (discovered at 8 weeks – ERPC) During this pregnancy I took no medication. PoC was done – 46XX June 2014 – Asherman’s returned so another hysteroscopy and a coil for 2 months. Dec 2014 – Miscarriage 6 – 9 weeks. (In this pregnancy I took: baby aspirin daily metformim – I have polycystic ovaries cyclogest 400 3x per day gestone 100mg 1xper day dexamethasone 1mg per day claxane 20 2x per day. ERPC carried out – 45X – Turner Syndrome.) Some results: In my most recent monitoring cycle the month before I was last pregnant: Day 4 – FSH 5.5 and LH 5.5 Day 25 LH 31 (my cycles are around 32 days) AMH from June 2013 – 69.5 I have had thyroid tested, blood clotting test, thrombo elastogram, NK cells tests – all of which have been normal. With all that in mind I have a few questions: 1) Do you think low progesterone could account for the miscarriages (apart from miscarriage no 6)? 2) Do you think the Asherman’s could account for the miscarriages (apart from miscarriage no 6)? 3) It has recently been suggested to me that the reason I get Asherman’s so easily could account for miscarriages so have been advised to have a PAI1 test – do you think this could be a possible explanation? 4) I turn 40 next month so with that in mind would you advise IVF with embryo screening? 5) My gut feeling is that the treatment I was taking in my 6th pregnancy was possibly working as I got to 9 weeks and miscarried for chromosome reasons so would you recommend taking the same treatment but to also do IVF with embryo screening? Sorry for such a long email and for so many questions and thank you so much for the time you have taken to read this and for your patience. CS

Reply…

Dear CS,

I think it is most likely the whole of your problem is most likely to be due to adhesions in your uterine cavity. These adhesions (so-called Asherman’s syndrome) are really quite common and most frequently occur after a miscarriage treated by a curettage to remove bits of the conceptus or membranes, or after delivery when the obstetrician has to do difficult manoeuvres to remove the placenta from the uterine cavity. Such adhesions are also much more likely if there has been some infection associated with the pregnancy, particularly after a miscarriage and very occasionally after a birth or a Caesarean section. Sometimes such infection is completely silent and does not cause symptoms. There are a number of other causes including some tropical infections, tuberculosis, malformation of the womb, or some operations to remove fibroids or a uterine perforation. But the commonest cause is following miscarriage.

Though very distressing, I doubt if the Turner syndrome pregnancy is very meaningful – this is tricky to decide but Turner syndrome is such an extremely common cause of miscarriage and it does not cause recurrent problems except in rather rare cases. I am willing to bet that Asherman’s is still quite likely to be your problem and I would suggest, that if you haven’t had one, then an hysterosalpingogram is the best investigation. It is a simple, very safe, cost effective, sensitive, and a relatively uninvasive procedure. Sometimes you will be able to tell if you are likely to have Ashermans because your periods may have changed. Classically, though not always, people with uterine adhesions have reduced menstrual flow. Less commonly they may have more colicky pains during menstruation. I should add that, often, successful treatment of Asherman’s tends to be quite specialised.

Of course, I hope your Asherman’s has indeed gone as you suggest but I would be a bit dubious. You have been offered all kinds of fancy treatments, aspirin, prednisolone, NK cells etc. To be honest I think all this is most likely to be completely irrelevant. I am not too sure what you mean by the PAl1 test you mention – I am unaware of this but would be happy if you could let me know what you have been told. There is such a test for some allergic reactions but I can’t believe that’s likely in your case. There is also a gene called Pal1 but I have no knowledge of any association with infertility. Let me know if you have information.

But frankly, I haven’t got good news. I think at the age of 40 with recurrent Asherman’s the prognosis is not good and I would hesitate to suggest going through many more complex and expensive treatments – seeing as you have a daughter whom I am sure you treasure. Of course, if you do have the HSG, I would be very happy to review scanned copies of these x-rays to try to give some assessment of the likelihood of successful treatment.

My apologies if this is depressing but I think realism is important if you are to come through all this extremely unpleasant and worrying experience unscathed.

My best wishes
Robert Winston

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