* Author Topic: Immune FAQ  (Read 331614 times)

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Offline agate

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Re: Immune FAQ - Continuously updated and added to.
« Reply #10 on: 15/07/10, 22:29 »
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    Offline agate

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    Re: Immune FAQ - Continuously updated and added to.
    « Reply #11 on: 15/07/10, 22:29 »
    12   K
    12.1   Karyotyping tests?
    12.1.1   What is karyotyping?
    Karyotyping is done by taking a very high magnification photo of the chromosomes from one of your cells (from a blood sample).  The laboratory can look at the image for any visual anomalies.  Anomalies are rare but they may reveal something that means that one partner may never be able to have children (explaining recurrent IVF failure or miscarriage) or that any children are at high risk of a serious genetic disorder that could be avoided by having PGD screening of embryos.

    Example normal results:
    Karyotype: 46, xx.  An apparently normal female chromosome complement and banding pattern.
    Karyotype: 46, xy.  An apparently normal male chromosome complement and banding pattern.


    12.1.2   Where can I get karyotyping tests done?
    These tests are expensive (approximately £400 for both partners) and need to be done for both prospective genetic parents.  Your GP may agree to do them on the NHS particularly if you have had multiple miscarriages, or you may be able to get them done through an NHS miscarriage clinic if your GP will agree to refer you, otherwise they can be done privately, e.g., at TDL (through Dr G), via many fertility or miscarriage clinics or at private hospitals.

    Offline agate

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    Re: Immune FAQ - Continuously updated and added to.
    « Reply #12 on: 15/07/10, 22:29 »
    13   L
    13.1   LAD test
    13.1.1.1   What is the LAD (Lymphocyte Antibody Detection ) test?
    LAD measures the level of anti-paternal antibodies in your blood - this is supposed to give an indication of the level of protective blocking antibodies in the blood.  A sample of serum from your blood is mixed with a sample of live white cells (T and B cells) from your partner (or sperm donor – if using known donor).  Where antibodies are present in your blood they will bind to your partner’s white cells and the percentage which have been ‘tagged’ in this way can be measured using flow cytometry. 

    The LAD test cannot be performed with just the host mother’s blood – it needs to use the mother’s blood (regardless of whether she is using donor eggs or not) AND fresh blood from whoever is providing the sperm.  If the sperm donor cannot provide blood, you can perform the LAD test with, say, the partner’s blood – but it may not be a meaningful result, because it won’t tell you whether the mother’s body is specifically hospitable to an embryo containing the sperm donor’s DNA or not.

    The results are reported for IgG and IgM antibodies for both T and B cells as percentage.  For RFU Chicago, if the average of the 4 measurements is above 30%, the overall result will be recorded as positive and if its lower than this, it will be recorded as negative.

    IgM is usually seen as an ‘early antibody’ which reflects the body’s initial response to an antigen (foreign protein) whereas IgG takes over as a more ‘mature’ response to a particular antibody.  This is presumably why IgG is seen as a more important measurement that IgM.

    Dr Beer said that the B cell IgG measurement was more important than the other measurements.  He said ladies should be aiming for B cells IgG to be over 30% and preferably over 50%.  It is possible to have excellent B cell IgG measurements but still get a ‘negative’ overall result if, say, your T cell measurements are low.

    In your body, NK cells as constantly on patrol against viruses and pre-cancerous cells.  Viruses are recognised as being ‘foreign’ and ‘hostile’, pre-cancerous cells are recognised as being ‘self’ but ‘altered’.  NK cells are programmed to attack both of these classes to protect the body from viruses and cancer. 

    As half the embryo’s DNA comes from the mother, the theory is that if the body cannot recognise the father’s DNA, it will treat the embryonic cells as ‘altered self’ and trigger an aggressive NK response which will increase NK numbers, NK activity and/or TNFalpha levels.  High levels of anti-paternal blocking antibodies should mean that the body recognises embryonic cells as ‘foreign’ but ‘benign’.  Low levels of anti-paternal antibodies are associated with repeat miscarriages (which are believed to be the result of NK and TNFalpha responses to embryonic cells), and are also thought to be associated with repeated failed implantations.

    Antipaternal antibodies are probably only generated during pregnancy (or as a result of blood mixing events e.g., blood transfusions).  So it is probably normal for them to fall to low levels within 6-9 months of pregnancy.   Some doctors theorise that if they don't start to fall, then that in itself is abnormal and more of a problem than having low LAD.

    Low LAD is usually treated with LIT (see below).

    Example results:
    Leukocyte Antibody Detection

    Flowcytometry         negative
    (T-cells) IgM+         12.2         % this is low – but probably the least important measurement
    (T-cells) IgG+         2.4         % this is low – but not quite as important as the B cell figures
    (B-cells) IgM+         12.9         % if you are part-way through a course of LIT, a high number here may eventually increase your B cells IgG+
    (B-cells) IgG+         11.1         % this is low

    13.1.2   Should I have the LAD test?
    I think Dr Gorgy and AEB recommend this to all their patients.   As far as I know, Dr Nduwke only offers it to patients who request it and Dr Sher doesn’t use it.  I think that ARGC don’t use this test.  It probably has little value unless you are going to consider LIT treatment if the result is low.   Some doctors think that the test is irrelevant unless you have been pregnant within the last 6-9 months, but most agree that the test will be most relevant if you have had multiple miscarriages past the 3 month point within the last year.  If you have never been pregnant, you may not want to prioritise having this test - but different doctors have very different opinions about it.

    13.1.3   How much does the LAD test cost?
    I think it is £200 with Dr Gorgy

    I think its £282 with Care

    I think its €130 with Serum

    13.1.4   What are the sample requirements for the LAD test at RFU Chicago?
    From the male partner:30-40mls of blood collected in green top (lithium heparin additive) tubes – mixed well before posting (tubes rolled end over end about 10 times).  Not refrigerated.  Must be received by RFU within 48 hours of blood being drawn during working hours. 

    From the female partner/host mother: 10mls of blood collected in yellow top (SST) tube (the sample requirements for the female partner are not as critical as for the male partner because the female partner's sample does not need to still contain live cells when it is received by RFU).

    The yellow top SST tube contains a few millilitres of gel which helps to split off the serum (the liquid part of the blood which contains the antibodies) away from the red and white cells.  The green top tubes have a much smaller (i.e,, invisible) amount of lithium heparin in the tubes.  A red top tube (no additive) can be used as an alternative to the yellow SST tube for the female partner. 

    You can have the blood drawn at TDL (on Wimpole St, two doors from Dr Gorgy). You can arrange to get a post pack from Dr Gorgy/TDL and have the blood drawn at your GP (or local hospital) on Monday/Tuesday afternoon and then post it back to TDL special delivery before 9am so that they add it to their fedex pick up on Tuesday/Wednesday in time to get it to Chicago within 48 hours.  To do this, you pay the test fee to Dr Gorgy's receptionist over the phone with a debit/credit card and ask for a post pack (this includes empty tubes, referral form, plastic protector and padded envelope), she will arrange for TDL to post it to you and then you arrange with your GP or local private hospital to draw the blood into the tubes, then you arrange for postage/courier back to TDL (special delivery before 9am next day is usually ok).  The cost will be the normal Dr Gorgy charges plus any charge your GP/local hospital makes to draw the blood, plus the post/courier cost back to TDL - but this may still be cheaper than travelling to London depending where you live.

    If you want to have the LAD test run at Serum, Serum can provide you with instructions for bringing your partner's blood (freshly drawn) to Athens so that you can test LAD.

    13.2   Level 1 tests
    These are basically tests that provide some fertility immune information but are available through any doctor (e.g., your GP if they will agree to do them) .  They include:
    •   Thyroid panel (TSH, free-T3, free T4 and antithyroid antibodies) – to test for under/over active thyroid and to test for the presence of antithyroid antibodies (untreated antithyroid antibodies or untreated under/over active thyroid have been shown to significantly reduce the chance of pregnancy/IVF success).
    •   Insulin resistance (ideally the glucose tolerance test (GTT) - untreated insulin resistance raises the risk of untreated diabetes in pregnancy which can be harmful for baby and increases the risk of PCOS which hinders fertility)
    •   Thrombophilia panel (ideally including Factor V Leiden, MTHFR, PAI-1 and Prothrobin factor II  - although these are rarely available on the NHS) and Antiphospholipid panel (including anticardioplipin IgG and IgA) – to test for ‘sticky blood’ signs  (untreated 'sticky blood' reduces the chance of pregnancy success)
    •   FBC and liver function tests (basic check on your overall health)
    •   Lupus and Rheumatoid arthritis panel (including anti nuclear antibodies and anti-mitochondrial antibodies – may signal undiagnosed auto immune conditions)

    You may also want to ask for
    •   Vitamin D level (deficiency is likely to lead to immune regulation problems)
    •   Immunoglobulin panel (IgG, IgM and IgA) (- may signal some rare immune issues - and is also a necessary screening test before you can have ivig treatment if applicable)
    •      Karyotyping for both partners (in rare cases, genetic problems are apparent from the karyotyping test which might mean that the chances for one of the partners having a healthy baby are very much reduced - see above) - but this is an expensive test, so your GP may not agree to do it.

    Note that the level 1 tests may indicate that you have problems e.g., with your thyroid, with insulin resistance, with ‘sticky blood’ or that you are at higher risk of having autoimmune issues, but they don’t really give you much indication of what you might find on your level 2 (Chicago tests).

    You should ask for a copy of all the results in case you need them.

    My understanding is that Care Fertility's level one package is:

    1. Full blood count, Fasting glucose, Urea and Electrolytes, liver function tests
    2. Thyroid function tests (must include both free T4 and TSH)
    3. Anticardiolipin antibodies (both IgG and IgM)
    4. Thrombophilia screen (must include lupus anticoagulant, Activated Protein C resistance, Factor V Leiden, Protein C, Protein S, PAl-1 Gene Polymorphism, Antithrombin III and Factor II Prothrombin gene mutation, Methylene Tetrahydrofolate Reductase (MTHFR) Gene Mutation (most NHS hospitals will be unable to do these).
    5. Autoimmune antibodies (must include anti-nuclear antibodies, thyroid peroxidase and anti-mitochondrial antibodies)
    6. Karyotype (both partners)

    This package costs about £1,200 at Care.

    13.3   Level 2 tests
    Different clinics will include different tests in their immune testing.  The common tests are:
    •   NK Assay (see below) & immunophenotype
    •   Cytokine ratio (see above)
    •   DQa (see above)
    •   LAD (see above)
    •   Tests for inherited thrombophilia (see below)
    •   Uterine NK biopsy (see below).

    13.4   Lining issues

    13.4.1   What treatments are available for a thin uterine lining?
    In my opinion, the first thing to rule out is any infection which may be preventing growth of a healthy lining (see Chlamydia).   

    The next thing to try is prognynova/cyclacur white (estrodial valerate - see below) - and possibly sildenafil (Viagra) ideally both as a vaginal pessary (available from US pharmacies e.g., http://www.metrodrugs.com/Home/Ordering/CompoundingServices/tabid/97/Default.aspx  or KRAUPNER PHARMACY in NewYork
       
    Tel: 001 718 821 1313
    (Ask for the pharmacist Anthony or sally)
     
    Fax: 001- 718 821 2665
    ( fax prescription, with dose, your phone number email etc, and pay by credit card))

    Or MDR pharmacy in Encino USA: https://www.mdrusa.com/services

    Sildenafil (viagra, cialis) is used by Sher at a dose of 25mg (vaginally) 4 times per day.  It is normally only available as an oral tablet and the specially compounded pessaries are very difficult to get hold of from the UK (the only US pharmacies I know of who might supply a UK prescription are those mentioned above), but according to Dr Sher, it is much more effective if it is absorbed close to the uterus rather than having to go through the gut and bloodstream as much of the oral dose is metabolised before it can reach the uterus.  Studies suggest that this regime is effective in thickening the lining for 70% of women who try it.  In one study, 42% of those women who responded to vaginal viagra had a baby.

    Viagra pessaries are made by the pharmacies above in the US by:
    1: preparing a standard polyethylene glycol (PEG) base.  Bases are usually made from a mix of a solid PEG (e.g., PEG 3350 or 4000) with a liquid PEG (e.g., PEG 400). For example, a 1:1 mix of PEG 400:4000 or a 6:4 mix of PEG 400:3350.    The solid PEG is weighed out and melted (at about 60degC) and the liquid PEG is mixed in.
    2: oral sildenafil tablets are crushed and sieved.
    3: the crushed sildenafil is mixed into the molten PEG at about 55-60degC and stirred to distribute it.
    4: the mixture is poured into disposable plastic pesssary molds (similar to the ones that cyclogest is made and distributed in).
    5: the pessaries are allowed to cool and the molds are taped shut with PVC tape.
    6: the pessaries are stable for about 3 months at room temperature.
    7: the pessaries are dampened with water prior to insertion. 

    The ingredients and supplies for making viagra pessaries are available in the UK. Making up tablets and pessaries (called 'compounding') used to be a skill all pharmacists were trained in, but it has now become rare outside of hospitals and research pharmacies.   Pessary molds and other supplies are available from medical suppliers like www.distinctive-medical.com.   PEG bases in pharmaceutical grade quality are available ready mixed from specialist suppliers in the US e.g., www.apothecary-products.com or as single ingredients from www.sigmaaldritch.com in the UK but only to pharmacists, research organisations etc, or from fagron in the uk.  The pessary bases commonly available to the general public in the UK e.g., for aromatherapy (e.g., for making tea tree oil pessaries) are made of cocoa butter (theobroma - as used in cyclogest pessaries) but are unlikely to suitable for making viagra pessaries because viagra is soluble in water rather than in fat.   Glycerin/gelatin pessaries are also sometimes used in the US for viagra pessaries but are much less convenient because they are not stable (need to be kept refrigerated, do not keep for very long and have to sealed from water in the air as the glycerin/gelatin mixture is strongly hygroscopic).  Pharmaceutical grade glycerin is readily available from large branches of Boots etc but pharmaceutical grade gelatin can only be bought from chemical suppliers like sigma aldritch.

    Another FF was able to find pharmacies who will do compounding of the pessaries in the UK see:
    click here

    According to Dr Sher, inserting oral tablets into the vagina is unlikely to be helpful as they do not disperse readily.    It has been suggested that it might be possible to crush the tablets and mix with a suitable vaginal carrier gel e.g., biofemactive or rephresh (to increase the volume for vaginal dispersal and absorption), e.g., about 3-4mls of gel and then insert that mixture vaginally (a vaginal applicator that screws onto the tube of gel e.g., ortho/gynest, may make this easier - and you may want to invest in a packet of medicine crush bags, to crush individual tablets cleanly, and then tip the powder directly into the part filled applicator (the easiest way to do this is to attach the applicator to the tube and then squeeze about 1.5cm of gel into the applicator, remove the tube and draw back the plunger to give 2cm of space in the applicator, then tip the crushed tablets from a crush bag into the applicator, then reconnect the applicator onto the tube and top up with another 1.5cm of gel - then remove the tube and insert the applicator high up in your vagina and apply the gel by pushing the plunger of the applicator quickly (which seems to leave less residue of tablet in the applicator) - you can use sterilise the applicator etc with milton and then rinse with boiled water)- so this may be a possiblity to discuss with your clinic if pessaries continue to be unavailable in the UK.  Used in this way, a dose of 100mg is normally used twice daily.

    'Generic' viagra is also available as a citrus flavoured oral jelly which some docs have suggested could be applied vaginally. 

    Serum Athens have been in discussion with a Malaysian pharmacy to make a specially formulated vaginal viagra jelly together with applicators - this should be much more effective and convenient than starting with oral formulas which have excipients designed for your gut and not your vagina - ***I understand its now available **** and needs to be ordered and sent direct to you from the manufacturer (not from Serum themselves).  The cost is about Eu100 for a course of medication including the applicators excluding shipping costs (approx Eu40).  To order, contact the manufacturer: [email protected].  It can take up to about 20 days to receive it from Malaysia so you do need to allow enough time to order it and you might want to post on the Serum thread (on the greece section) to see if anyone wants to order with you and share the postage (I believe, John can post 2 courses together for shippping costs of Eu50 and 3 courses for a little more than that).  Some women have had problems with their parcels getting through customs or having to pay extra taxes.

    Information on the viagra cream from John Bowen - what is the expiry/use by date?
    "There is no expiry date for any practical purposes as this cream can be kept for years if stored under the proper conditions. As a guideline, you can easily keep it for a year under normal conditions, ie by nor storing it in a palce over 28 degrees celcius."
     
    - What are the ingredients/excipients and what dose of viagra is there per tube?
    "Ingredients: Deionized water, Ethylene Glycol, Cetyl Alcohol, Monostearate, Steareth 2, Steareth 21, Polysorbate 20, Potassium sorbate, Propylene Glycol, Carboxymethylcellulose, Sildenafil.

    Each applicator contains 2 grams of cream with an active ingredient of 100 mg of Sildenafil. Sidenafil is the active ingredient in Viagra."


    - What are the usage instructions?

    "To apply just remove the applicator from its sealed plastic packaging, insert it into the vagina and press the plunger to deliver the cream."


    Dr Sher prescribes 5mg oral terbutaline (bricanyl - another vasodilator) three times daily alongside 25mg vaginal viagra four times daily from the first day of stimulation for fresh IVF or the first day of estrogen medication for FET/DE (until HCG trigger or 3 days before ET) for patients with thin uterine lining although he has mentioned on his forum several times that some ladies have to stop the terbutaline because they experience unpleasant side effects.   For women who find out they have a lining below 9mm within 2 to 3 days of planned HCG administration for fresh IVF (or a few days before FET/DE), he suggests 'rescue viagra/terbutaline therapy' which is to start his viagra/terbutaline programme immediately so long as it can be taken for at least 48 hours before egg collection.

    G-CSF given as a single shot intrauterine infusion as 'rescue therapy' for thin lining has shown some promise in this very small study http://www.fertstert.org/article/S0015-0282(11)00177-4/abstract (also see G-CSF).

    If lining fails to thicken for a lady who is down regulated for donor egg treatment, HCG shots given at the donor's trigger shot has also been shown to have a beneficial effect on lining growth (see HCG shots).
     
    Trental (Pentoxiphylline) is another drug with some vasodilation effects which has been used in studies but is less favoured by SIRM/Dr Sher.  In studies by other clinics it was used successfully at 400mg twice a day doses together with vitamin E (in a study with patients who had diagnosed thin lining and elevated NK cells. Trental is used by some immunology clinics particularly for endometriosis patients because of its immunosuppressive effects.

    Vitamin E (600mg/day) and L arginine (6g/day) have also been shown to improve uterine artery bloodflow and endometrial thickness but seem to be less effective than viagra.  Vitamin E is available in supermarkets and health food shops.  L arginine is available in healthfood shops - please see the comments below under Supplements.

    http://www.ncbi.nlm.nih.gov/pubmed/19200982

    Adequate protein and selenium intake is also important for lining growth, so some ladies take extra protein in the form of protein powder, chicken, eggs etc and selenium (see supplements) as a supplement or perhaps as extra pineapple or brazil nuts which tend to be fairly high in selenium content.

    From a chinese medicine point of view, keeping your feet (and belly) warm is supposed to be essential for lining growth, so unless the weather is hot, it is suggested that you always wear socks and try to wear a long vest.

    Caffeine is thought to reduce bloodflow to the lining - so its best avoided.

    http://www.bellaonline.com/articles/art25467.asp/zzz

    Progynova (estrodial valerate, an HRT medication - the white pills from a cyclacur packet) is manufactured as an oral tablet, but many clinics use it vaginally - either for the whole dose or part of the dose.    The tablets are then inserted as a very tiny pessary close to the cervix.  Many clinics step up the dose of estrodial as treatment proceeds.   Some ladies do not absorb oral progynova very well or metabolise it too quickly or convert it to masculinising hormones (which may be apparent from blood tests to check the estrodial level whilst you are taking the medication).  In which case, they may get better results switching to some or part of the dose vaginally (like a very tiny pessary) or using skin patches (e.g., estrofem), or injections of estrodial valerate (not available in the UK, but available in the US).    Where estrogen medication is needed to grow the lining, it will usually need to be continued until about 12 weeks of pregnancy to avoid a sudden drop in hormones when the placenta is small and vulnerable.

    Whether or not your lining responds to estrogen by thickening appropriately will depend partly on the numbers of estrogen receptors you have in your lining tissue.   Some doctors think that the number of estrogen receptors can be up-regulated in some ladies by treating them for, say, 3 months before their fertility treatment with supplementary estrogen e.g., cyclo-progynova.

    Estrogen medication may increase the risk of clotting (as do the natural high levels of estrogen during pregnancy) which can also contribute to poor lining thickness, as well as being a health risk, so you may need to discuss clexane or other blood thinners like aspirin with your clinic.    Clexane and other blood thinners have been shown to improve bloodflow in the uterine artery (by doppler ultrasound), so most immune docs use blood thinners as standard for almost all their patients.

    Dr Braverman states on his website that he has had some success with thin lining for some patients using G-CSF (see above).

    Progesterone (cyclogest, utrogestan, gestone, crinone, agolutin, prontogest etc) is usually given to improve and mature the lining, but is unlikely to actually thicken a very thin lining. The lining has to be grown and thickened first under the influence of estrogen before progesterone is started.   Once started, progesterone is also continued until around 12 weeks of pregnancy (see Gestone, above).

    Follow on from promising studies at other clinics, Serum Athens have introduced PBMC treatment (see PBMC below) for IVF implantation failure.   During the initial studies at Serum, it has been noted that the appearance of the lining also appeared much improved - so for some ladies with lining issues, it may be worth looking into PBMC treatment.

    Very unlucky ladies will not respond to these medications and, in that case, particularly if there has been previous gynae surgery e.g., D&C, Asherman’s syndrome may be likely which is difficult to treat.

    Conversely, if your lining is found to be too thick on ultrasound scan, you may be given medication to try and shed the lining before restarting your fertility treatment.

    13.4.2   What is a good lining and how is poor lining diagnosed?

    According to Dr Sher a good lining is triple layered (trilaminar) on ultrasound and around 9-14mm.  He says that below 9mm, pregnancy is possible but the chances are lower and the miscarriage rate is higher.  Apparently, he does not perform ET if the lining is less than 8mm.  Many clinics quote 15mm as the upper limit for an acceptable lining thickness - but some docs say there is no upper limit, provided the appearance is normal (and it has recently been shed properly before treatment began).  Some have a cut off of 7.5mm for the lower limit of acceptable.

    A thin lining may be due to:

    hormonal issues (e.g., estrogen being too low - which can be improved with estrodial valearate supplements e.g., oral or vaginal progynova (cyclacur white pills), skin patches e.g., estrofem, or injections of estrodial valearate - and tested by having a series of blood tests whilst you are approaching ovulation during your natural cycle if you are trying naturally or whilst taking estrogen medication if you are trying with embryo transfer (FET, IVF, DE etc)),

    compromised blood flow - which can be tested for directly using a doppler ultrasound of the uterine artery (to measure RI - resistance index and to look for something called 'notching' on the doppler which indicates reduced flow), or which can be suggested by clotting issues (see Thrombophilia below), or by increased immune activity e.g, elevated NK activity which could increase the likelihood of microscopic clotting in the uterine lining tissue.   Compromised blood flow can be improved with clexane and, potentially with vasodilating medication like terbutaline and viagra (sildafinil)

    endometritis (inflammation of the lining) - usually due to an infection e.g., chlamydia, mycoplasma, ureaplasma.   Sometimes apparent from a hysteroscopy as a red, spotty 'strawberry-like' lining.  Usually easy to treat with antibiotics although if the bacteria can be successfully identified (e.g., by taking a biopsy sample and culturing it, or potentially, using the greek menstrual blood tests, it may be easier to choose an appropriate antibiotic.

    One study has suggested tamoxifen to increase lining thickness http://www.omicsgroup.org/journals/successful-pregnancy-in-recurrent-thin-endometrium-with-new-uses-for-an-old-drug-jfiv.1000110.pdf

    Permanent damage to the endometrium after an STD, PID or pregnancy related infection (post-abortal or post-delivery endometritis) or damage caused by scarring after instrumentation e.g., a D&C.  Such scarring (e.g., Asherman's syndrome where scar tissue joins the uterine surfaces in a series of adhesions) is usually visible by hysteroscopy, but not always.     Scar tissue can often be resected (cut away) in a surgical hysteroscopy but some ladies are prone to recurrence of the scar tissues after the surgery.   Some surgeons leave 'balloons' or coils in the uterus temporarily after surgery for Ashermans's to try and stop adhesions reforming.  Most doctors will prescribe estrodial medication after uterine surgery to reduce the chance of adhesion formation.

    If there is severe Asherman's scarring that resists resection, then Sher recommends that the only solution is surrogacy.  To determine whether lining issues are permanent, he suggests doing a trial run of estrogen plus viagra pessaries and then using ultrasound to check whether the lining is then triple lined and at least 8mm.  If the trial run fails, he suggests that patients move on to surrogacy (presumably after investigating surgery first?).

    Dr Sher has various blog items on his site (www.ivfauthority.com) about Asherman's and lining issues.

    Thick linings are sometimes seen with PCOS or perhaps adenomyosis (experienced docs should be able to identify adenomyosis from the appearance of an ultrasound scan but most docs probably cannot) , or sometimes due to the presence of a cyst which is releasing hormones and preventing the normal drop in hormones.   Providing a thick lining has a normal appearance on ultrasound (uniform, tri-laminar) and has been shed recently (bear in mind that if you are post menopausal or have down regulated, lining does not start to grow until you start estrogen medication so it is 'fresh' at the point of starting estrogen meds), they are not thought to cause a problem, but an old, thick, patchy lining needs to be shed and regrown to give a better chance at embryo transfer.   Studies have shown a significantly reduced pregnancy rate where DE recipients have been kept on estrogen for more than 5 weeks prior to ET (showing the effect of an old lining).


    The rest of section L is currently in an overspill section right at the bottom of this thread - I need to work out how to insert it up here - but the L section currently exceeds the maximum size for a single post

    Offline agate

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    Re: Immune FAQ - Continuously updated and added to.
    « Reply #13 on: 15/07/10, 22:30 »
    14   M
    14.1   Miscarriage
    14.1.1   Are there any tests I should be doing if I know I am going to lose this embryo?
    If you contact Dr Gorgy (or your consultant) he should be able to arrange for you to have the tissue tested for karyotyping/chromosome testing (to confirm whether the embryo was genetically normal), and/or for placental histology (the microscopic appearance of the placenta (which may shed light on what caused the failure e.g., it may show evidence of clotting issues or other compromised growth which may indicate immune issues, and elevated numbers of uNKs may be apparent on a slide of the placenta material).   In some cases, it may be too early in pregnancy to do this (usually if its before about 7 weeks), and you may need the co-operation of your local hospital (if it’s an ERPC (D&C or D&E) situation) and they may try and discourage you from receiving a tissue sample (as it is extra work for them and they may take the view that ‘its just bad luck’) so if you really want this, you may have to be persistent which is difficult at a time when you are really upset.  Speaking to your consultant or getting your partner to advocate for you before you deal with the NHS may help you feel stronger and decide what you want to do. 

    You may be give the options of:
    waiting to miscarry naturally
    medical management (being given drugs to encourage miscarriage)
    surgical management (ERPC)

    A D&C carries a risk of encouraging infection and/or Asherman's syndrome which could affect your uterine lining in the future but most first trimester miscarriages can be dealt with using a D&E procedure which carries less risk of Asherman's.   There may be cases where an ERPC is necessary because natural miscarriage or medical management is incomplete.   If you opt to miscarry naturally or with medical management but want tests run, you will need to speak to your consultant about how to preserve a tissue sample.  This testing may have to be run privately as the NHS may be reluctant to pay for it unless you have had multiple miscarriages or its a late miscarriage.

    14.1.2   What are the standard tests for recurrent miscarriage?
    Different clinics will have different procedures, but essentially they are generally similar to the ‘level 1’ tests (see above), so you could expect
    •   Thyroid screening
    •   Tests for thrombophilia (‘sticky blood’) and antiphospholipid antibodies
    •   Karyotyping (see above)
    •   Physical screening of the uterus (e.g., by hysteroscopy or ultrasound) for septa, polyps, fibroids etc
    •   Basic hormone checks (e.g., FSH, LH, prolactin, estrodial on day 1-3 and progesterone 7 days after ovulation).
    •   Some clinics will perform a uterine biopsy for uterine NKs.

    A specialist immune doc would be likely to suggest similar tests, but with the addition of the ‘level 2’ tests (see above) and, possibly, additional tests, e.g., infection screening.

    14.2   MTHFR (see thrombophilia – below or click here)

    14.3   Mycology/chinese mushroom therapy
    I'm aware of a few ladies who have had several IVF failures or early miscarriages associated with elevated TNFa and/or NKa and/or history of endometrial infection with chlamydia/mycoplasma/ureaplasma resulting in endometritis and thin uterine lining or implantation failure associated with raised immune activity.   Dr Trevor Wing has treated them with 3 or more months of a standardised mycology/herbal formula for autoimmune activation comprising

    1.5g Reishi (latin name: Ganoderma lucidum, chinese name: LingZhi or Lingzhi) (http://www.purehealthonline.co.uk/product.php?catID=25&opener=0-2-25&productID=509) - a mushroom with antiinflammatory properties,
    1.5g Cordyceps sinensis (chinese name: Dong Chong Xia Cao) e.g., http://www.purehealthonline.co.uk/product.php?catID=26&opener=0-2-26&productID=650) - a mushroom with immuno-modulatory/stimulatory properties as well as estrogenic/testerosteronegenic properties,
    1.5g Coriolus versicolour (Turkey Tail / Yun Zhi)(http://www.purehealthonline.co.uk/product.php?catID=28&opener=0-2-28&productID=507) - a mushroom with immuno-stimulatory properties (3 mushrooms) and often,

    2 herbs, Qin Jiao/Qin Jhao (gentiana macrophylla)1.5g (available from purehealthonline) and Huang Qi 1.5g (astralagus).  Purehealth have just introduced a combined capsule of 0.5g each (so 3 capsules a day) to satisfy requests from ladies on FF!  60 caps for £9 http://www.purehealthonline.co.uk/product.php?catID=275&opener=0-275&productID=828 or 300 caps for £36.   These 2 herbs are supposed to help with male and female fertility generally.  So I guess they are a possible alternative to John's vitality herbs but I cannot possibly guess whether they are similar/as good or not.

    Be careful not to confuse these with chinese wormwood which has a similar sounding chinese name to one of these herbs!

    Some practitioners suggest cordyceps on their own but, anecdotally, according to Wing, the results for ladies with elevated inflammatory pattern immunes (e.g., NKactivity) are supposed to be better with the combination of 3 mushrooms (& 2 herbs). I think this might be because the Reishi mushroom in particular seems to be an anti-inflammatory. 

    Information on Wing's website (http://www.naturalgynae.com/downloads/nav6_fact25.pdf) says:
    "Patients with raised natural killer cells (CD69 - CD56 - CD16) respond will with treatment by medical
    mushrooms.  These have been well proven in Japan to moderate the immune system of HIV patients
    and form a mainstream part of conventional medicine treatment in japan for AIDS patients.  The same
    action has been observed in women with raised NK cell levels.   Patients are given a combination of
    three mushroom types (Cordyceps, Reishi and Coriolus) in tablet form."

    Cordyceps is often cited as increasing NKactivity - although it is prescribed by Wing's group to do precisely the opposite (reducing NKa for ladies whose NKa has tested as elevated - although perhaps that is partly because Wing uses it alongside Reishi mushroom).  Many supplements appear to be immunoregulatory rather than immunosuppressive (they seem to reduce aspects of the immune system which are overactive and to increase aspects of the immune system which are underactive) - but I expect combining cordyceps with reishi is possibly quite important for ladies with elevated NKa as it has a documented anti-inflammatory effect.

    On Dr Wing's clinic website http://www.naturalgynae.com/nav14.html  he has a list of 'associates' who are all chinese medicine practitioners who have completed some sort of training course into chinese herbal medicine for gynaecology.  Dr Wing is based in Surrey, but ladies in other areas might find it more convenient to see one of his associates.  Wing usually has a waiting list for appointments, but some of his associates don't have long waiting lists. I don't know how extensive the training that he provides is - but the associates can email him for advice.

    A supplier recommended by Serum in Malaysia is John Bowen - [email protected].  He suggests 30 days of cordyceps sinensis 2g per day prior to ET and 30 days post ET cordyceps 1.2g for implantation failure.   For egg quality problems he seems to suggest the same programme but with 30 days of 'vitality herbs' prior to egg collection (1 capsule per day for 12 days and then 18 days of 1 capsule every other day).  The vitality herbs contain:
    Chinese ginseng root  50mg
    Cynomorium (Suo Yang) 130mg
    Epimedium Sagittatum (Yin Yang Huo, Horny goat weed) 120mg
    Cnidium Monniem (She Chuang Zi) 100mg

    So are a different combination to the herbs used by Wing - but still based on cordyceps mushrooms.   The cordyceps provided by John are wild cordyceps from China and Tibet. The cordyceps available in the UK from mushroomnutrition.com (purehealthonline) are farmed in the US by Aloha medicals who are a very reputable supplier.  Suppliers of wild chinese cordyceps insist that farmed products will be inferior to wild gathered mushrooms, but suppliers of the reputable brands of farmed products insist that their product is safer (as its source is easily traceable), standardised for potency, and is ethically and ecologically better because of concerns about over gathering of wild mushrooms leading to their extinction.   I don't have any way to judge whether the cordyceps supplied by John from China/Tibet is better than the myco nutri brand of farmed cordyceps but I know that the myco nutri brand is widely used and is used by Trevor Wing's group in the UK, so my assumption would be that it is a safe choice to buy.  Its probably quite possible to buy 'dodgy' cordyceps off the net that isn't cordyceps sinensis at all, or contains impurities that you don't want - but I don't have any specific information about brands to avoid - I would stick to the mushrooms supplied by purehealth because they are trusted by Trevor Wing or the ones from John Bowen because I wouldn't know how to determine whether other brands are of good quality.

    For male sperm problems John Bowen suggests (at least) 60 days of cordyceps 2g per day and 1 capsule per day of 'vitality herbs' prior to IVF.

    John currently charges €0.6 per 0.4g capsule of cordyceps and €1.5 per 0.4g capsule of vitality herbs, but there is also the cost of shipping to the UK (about €40 per package).   I think that if you just want cordyceps, it should be cheaper and easier to order it from the UK e.g., 300 0.5g capsules from mushroomnutrition.com/purehealthonline are about £40 plus postage), but if you want to buy the vitality herbs as well, it may be easier to order everything together from Malaysia.

    Purehealthonline have a main website at purehealthonline.co.uk and also a mushroom specific site at mushroomnutrition.com.   They do stock a combined cordyceps/reishi/coriolus 0.5g capsule (on the purehealthonline site) of which you would need 9 capsules per day to equate to a 1.5g dose of each mushroom.  On the mushroomnutrition site, they stock a cordyceps/reishi/maitake 0.5g capsule which is the replacement product for cordyceps/reishi/coriolus (as new legislation puts coriolus in a different category to maitake, so the company are having to gradually phase out supplying coriolus).  My understanding is that maitake and coriolus are supposed to have similar properties but are not the same mushroom so I do not know whether the two different formulas are interchangeable - although both Coriolus and Maitake seems to be associated with immunostimulatory effects - increasing NKa and TNFa (particularly maitake) - my assumption is that the more important mushrooms for ladies with implantation failure due to elevated NKa and or TH1 are the cordyceps and reishi rather than the coriolus/maitake.   

    Purehealthonline do have their own in-house herbalist called Martin Powell- so I guess if you wanted to discuss it with him, you could call him - at the moment though, you can still buy the coriolus formula, but this is likely to change at some point.

    If you want to follow Wing's programme of 3 mushrooms (& 2 herbs) because you know you have inflammatory pattern immunes (high NKa) then it would be easiest and probably cheapest to buy them from the UK from purehealthonline, but if you need a diagnosis for your issues and proper advice you might need to see an associate practitioner of Wing who can give advice and supply the mushrooms and herbs from pure.

    I would not suggest taking any chinese herbs or mushrooms without the agreement and knowledge of your clinic, especially if you are intending to take them at the same time as your IVF medication.

    Wing seems to think its safe to continue to take the 3 mushrooms and 2 herbs up until ET, but if you are taking corticosteroids (prednisolone, dexamethasone, medrol etc), he seems to advise some patients stopping the mushrooms and herbs when they start the steroids, but not always, although he is concerned that the effect of the mushrooms might be up or down regulated when taking them at the same time as steroids.

    There aren't a huge number of published studies in english - I don't know if there are more that are in chinese - but this information might be of interest:

    http://www.biolreprod.org/content/70/5/1358.full

    Martin Powell (the herbalist at purehealthonline) says this on his mushroomnutrition website (quoted from his own book) "Fertility - C.sinensis is increasingly being used by leading specialists in the field of infertility and clinical evidence suggests that cordyceps has a beneficial impact on female fertility and the success of IVF. In part this may be due to its ability to stimulate 17β-estradiol (oestrogen) production, through increased StAR (steroidogenic acute regulatory protein) and aromatase expression20. In common with other mushrooms, cordyceps' ability to regulate immune function and in particular NK cell activity may also play a part."

    Reishi seems a useful mushroom to be taking with cordyceps for ladies with an inflammatory immune pattern i.e., elevated TH1:TH2 as it appears to suppress excessive TNFa - without reducing CD8 (Tregs, foxP3 etc) - so for known raised NKa/TNFa issues, a formula including Reishi rather than just cordyceps seems a logical choice.

    This information is from http://www.raysahelian.com/reishi.html

    "Reishi Research studies
    Effects of ganopoly (a Ganoderma lucidum polysaccharide extract) on the immune functions in advanced-stage cancer patients.
    Immunol Invest. 2003.
    Preclinical studies have established that the Ganoderma lucidum polysaccharide (reishi) fractions have potent anti-tumor activity, which has been associated with the immuno-stimulating effects of reishi. However, it is unclear whether reishi has immuno-modulating effects in humans in vivo. This study aimed to investigate the effects of Ganopoly, the polysaccharides fractions extracted from reishi, on the immune function of advanced-stage cancer patients. Thirty-four advance-stage cancer patients were entered onto this study, and treated with 1800 mg Ganopoly (reishi), three times daily orally before meals for 12 weeks. Immune parameters (cytokines, T cell subsets, and natural killer activity) were compared between baseline and after 12-week treatment. Thirty patients are assessable for their immune functions. Treatment of reishi for 12 weeks resulted in a significant increase in the mean plasma concentrations of interleukin (IL-2), IL-6, and interferon (IFN)-gamma, whereas the levels of IL-1 and tumor necrosis factor (TNF-alpha) were significantly decreased. A marked variability among patients with advanced-stage cancer was observed in the numbers of each lymphocyte subset at baseline. The mean absolute number of CD56+ cells was significantly increased after 12-week treatment of reishi, whereas the numbers of CD3+, CD4+, and CD8+ were just marginally increased compared to baseline levels, with the CD4:CD8 T cell ratios unchanged. In addition, reishi treatment resulted in a significant increase in the mean NK activity compared to baselines. The present study indicates that Ganopoly enhanced the immune responses in patients with advanced-stage cancer. Clinical evaluations of response and toxicity are ongoing.

    Mechanism of the antiulcerogenic effect of Ganoderma lucidum polysaccharides (reishi) on indomethacin-induced lesions in the rat.
    Life Sci. 2002 .
    Many cytokines, in particular tumor necrosis factor (TNF)-alpha have been known to play an important role in the pathogenesis of gastric mucosal lesions caused by various factors such as drugs and Helicobacter pylori infection. Our previous studies have shown that the polysaccharide fractions isolated from the fruiting bodies of Ganoderma lucidum (reishi) prevented indomethacin- and acetic acid-induced gastric mucosal lesions in the rat. However, the mechanisms remain unclear. This study aimed to investigate whether reishi had a direct mucosal healing effect in the indomethacin-treated rat, and to explore the possible mechanisms by determining the gastric mucosal mRNA and protein levels of TNF-alpha and ornithine decarboxylase activity. These findings indicated that reishi produced a mucosal healing effect in the rat model, perhaps due partly to the suppression of TNF-alpha."

    Maitake mushroom might not be a good choice for ladies with elevated NKa and/or elevated TNFa. This information is from http://www.raysahelian.com/maitakemushroom.html

    "Effects of D-Fraction, a polysaccharide from Grifola frondosa on tumor growth involve activation of NK cells.
    Biol Pharm Bull. 2002.
    Natural killer (NK) cells are directly cytotoxic for tumor cells and play a primary role in regulating immune responses. We monitored levels of NK cell cytotoxic activity in cancer patients receiving maitake D-Fraction extracted from maitake mushrooms (Grifola frondosa). Elevated levels of cytotoxic activity were maintained for one year. To elucidate the mechanisms underlying long-term activation of NK cells during treatment with maitake D-Fraction, we examined tumor volume and levels of IFN-gamma and TNF-alpha in MM46-bearing C3H/HeN mice to which D-Fraction was administered for 19 d. Maitake D-Fraction markedly suppressed tumor growth, corresponding with increases in TNF-alpha and IFN-gamma released from spleen cells and a significant increase in TNF-alpha expressed in NK cells. This suggests that the maitake D-Fraction activates NK cells even on the 20th day after treatment. Furthermore, D-Fraction increased macrophage-derived interleukin (IL)-12, which serves to activate NK cells. These results suggest that NK cells are not only responsible for the early effects of D-Fraction on tumor growth, but also for the long-term tumor-suppressive effects of maitake D-Fraction through increased IL-12 released from macrophages."

    Please don't ask me whether the mushrooms from pure are better/as good as the ones from John Bowen - I have no way to know.  I am not a herbalist.

    14.4   Mycoplasma genitalium, Mycoplasma hominis
    14.4.1   What is mycoplasma?
    They are common STDs that are rarely tested for unless there are overt symptoms which are rare and all other STDs have been ruled out.  Because they are so common, some doctors believe that it is normal to carry them in the vagina, and that they are (usually) harmless. However, they are associated with higher rates of infertility and miscarriage in the few studies that have been done, and may cause infections in the newborn.  They may also cause bacterial vaginosis (an infection of the vagina that tends to smell fishy, particularly after sex).  One theory is that, provided they are kept in check by the normal acidity of the vagina they are harmless, but that if the acidity is disrupted e.g., by loss of the healthy lactobacillae in the vagina, these bugs can become more dominant leading to BV in the vagina or endometritis (inflammation and possibly scarring) if they reach the uterus and take hold there.    They are also believed to cause urethritis (inflammation of the urethra) in some men and possibly reduced sperm quality if they cause inflammation in the testes.

    14.4.2   How is mycoplasma tested for?
    In women, the most accurate test for mycoplasma in the vagina is a PCR vaginal swab specifically for mycoplasma.  A swab culture test is an alternative but is slightly less sensitive - as it relies on the lab being able to grow (culture) live bacteria from the swab.  In men, the most accurate test is a semen PCR test specifically for mycoplasma.  A semen culture (and antibiotic sensitivity test) is an alternative but it is slightly less sensitive.  A high vaginal swab test through Dr Gorgy for mycoplasma and ureaplasma (together) is currently about £75.  Semen PCR tests are about £75 and semen culture tests are £50.  Locus Medicus in Athens will also test menstrual fluid samples for mycoplasma and ureaplasma (see under Chlamydia, above) for approximately 90Eu each.  In theory, the menstrual fluid test may obtain a sample not just from the vagina, but from higher up e.g,. in the uterine lining, so it may reveal bacteria that have moved higher up in the genital tract.
    ***Serum have introduced a new 7 in 1 PCR test from LifeCode laboratory in Athens.  This tests for Mycoplasma hominis, Mycoplasma genitalium, Ureaplasmas, Gardnerella vaginalis and Atopobium vaginae as well as an 'ordinary' test for Chlamydia and a test of total bacterial load which measures whether there is a normal population level of 'good bugs' (lactobacillae).   The 7 in 1 test can be done on menstrual fluid or semen and can be sent by post.  It costs €170 so its probably better value for money than doing the locus medicus tests for Mycoplasma and ureaplasma separately.***

    14.4.3   How is mycoplasma treated?
    Getting rid of mycoplasma should be easier if the vagina is kept acidic. The cheapest way to do this is to use natural live yoghurt and apply it to the vagina using clean fingers.   However, most pharmacies sell specially formulated vaginal acidity gels which are sold as products for preventing recurrence of BV e.g., Biofem acti-gel or Rephresh.   These need to be applied over several days to have a good effect as aim is to return the vagina to its normal acidic state and make it a more hostile environment for BV bugs.   Acidity is likely to be reduced if you are close to ovulation (or stimming for IVF etc) as fertile egg white cervical mucus is not as acidic as mucus at other times of the month.  Acidity can also be compromised if you have reduced cervical mucus or after having sex as semen is not acidic.

    Many strains of M genitalium and some strains of M hominis are resistant to tetracyclines (e.g., doxycycline) and metronidazole (flagyl) and M hominis is also strongly resistant to macrolides (e.g., erythromycin, clarithromycin and azithromycin).  Moxifloxacin is much more effective against M hominis than either tetracyclines or macrolides but clindamycin appears to be a more effective agent against M hominis than moxifloxacin.  Studies suggest that 1g of azithromycin kills about 79% of cases of M genitalium.  A longer course of 500mg azithromycin followed by 4 days of 250mg azithromycin kills about 95% of cases of M genitalium.  If M genitalium is still present after azithromycin treatment, then 10 days of moxifloxacin (400mg for 10 days) is supposed to kill those strains which are resistant to azithromycin but you should only be offered moxifloxacin if azithromycin has failed (to reduce the risk of developing moxifloxacin resistant strains, moxifloxacin is an antibiotic of 'last resort').   When taking moxifloxacin you should avoid aspririn, ibuprofen and diclofenac as well as medication containing aluminium and magnesium (e.g., ant-acids).  Serum's approach is to use an azithromycin erythromycin 'sandwich course' (the same as the 28 day course for chlamydia but with erythromycin substituted instead of doxycycline) where mycoplasma is detected alongside chlamydia.  But if the mycoplasma proves resistant they use a 'last resort' antibiotic similar to moxifloxacin called Prurifloxacin (Prixina).

    http://sti.bmj.com/content/82/4/269.full
    http://ijsa.rsmjournals.com/cgi/content/abstract/19/10/676
    http://ukpmc.ac.uk/articles/PMC2572837;jsessionid=D64CC885565737546C5B7FE0EDCB27C7.jvm1

    For stubborn M hominis infection that has persisted after oral moxifloxacin, some ladies are trying:

    day 1-10 of menstrual cycle - intramuscular clindamycin injections combined with
    day 1-14 of menstrual cycle - moxifloxacin 400mg
     

    Offline agate

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    Re: Immune FAQ - Continuously updated and added to.
    « Reply #14 on: 15/07/10, 22:30 »
    15   N
    15.1   Natural conception with immune treatment
    15.1.1   Can I try naturally with immune treatment or do I have to do IVF?
    Some clinics e.g., Dr Gorgy and Care, will offer immune treatment to you whilst you continue to try naturally.  This is particularly appropriate for ladies who get pregnant quickly but, without immune/clotting treatment suffer repeat losses. 

    Paying for immune treatment alongside trying naturally may be less appropriate/cost effective for ladies who are older, have known egg or sperm quality problems or have not been achieving any kind of pregnancy, even if you believe your tubes are intact and have a normal hormone profile for your age and/or a healthy previous pregnancy.  Immune medications are expensive, and for some ladies their chance of achieving pregnancy will be significantly higher per cycle with IVF than per cycle with natural conception, so you may be advised that to reach the same chance of pregnancy you would have to be trying for say, 3-6 cycles naturally (with all the immune costs) just to have the same odds as 1 cycle of IVF (with the immune drugs).   Personally, I would think that this is a decision you should defer until you have done any fertility/immune testing you are going to do, and then get at least 1 opinion on your chances of natural versus IVF conception. 

    Some ladies may consider IUI or ovarian stimulation with immunes – but again, this is something that I think you should try to ask for advice on the likelihood of success compared to trying naturally or with IVF before you proceed.  Particularly for older ladies, or for couples with poor sperm parameters, IUI tends to have a low chance of success.


    15.2   NK assay/K562 test/NK cytoxicity assay
    15.2.1   What is the NK assay (K562 test, cytoxicity test)? 

    The NK assay from RFU has three components.  The lab mix a sample of NK cells from your blood with a sample of target K562 cells (specimen cells).  They incubate the sample for two hours and then measure what percentage of the K562s have been killed by your NKs.   They perform the same test at three dilutions.  50:1 (50 NK cells to every K562 cell), 25:1 (25 NK cells to every K562) and 12.5:1 (12.5 NKs to every K562).  For normal fertility you want all three of these measurements to be below 15% i.e., you want your NKs to kill off less than 15% of the target cells in two hours.  This would mean you would have a normal level of NKactivity/killing power.  Elevated levels mean that your NKs are more aggressive/active than ideal for fertility.

    The second part of the assay is the same test but with a solution of IVIG added at two concentrations.   If your basic levels are elevated, you would want to see them reduced to below 15% (i.e., brought into the normal range) when IVIG is added.  Dr Sher disputes the value of the second part of the test as he feels it may not reflect how your NKs would behave with IVIG in the body, but Beer Centre, ARGC and Dr Gorgy do believe that it gives a good indication.   If it shows that your levels do come down it shows that a) your NKs do appear to respond to medication and b) they specifically seem to respond to IVIG.

    The third part of the assay is a basic immunophenotype – a measure of the relative concentration in your blood of CD3+ cells (all T cells apart from NKs), CD19+ (all B cells), CD56+ (all NK cells) and CD19+5+ (B cells associated with autoimmunity).

    When Dr Gorgy runs this test, he tends to request a fourth part of the assay (usually shown on a separate sheet) where the 50:1 is repeated but with a solution of intralipid added, to see if that produces a suppression in NKa in the test tube.

    Example test results:
    NK Assay (% killed) panel
    50:1                               27.3         10-40% note that for fertility, the normal range is below 15%
    25:1                               22.0         5-30% note that for fertility, the normal range is below 15%
    12.5:1                            14.1          3-20% note that for fertility, the normal range is below 15%

    IgG conc 12.5 50:1                   21.4 note that this result shows some suppression – but not down to below 15%
    IgG conc 12.5 25:1                   17.0 note that this result shows some suppression – but not down to below 15%
    IgG conc 6.25 50:1                   18.4 note that this result shows some suppression – but not down to below 15%
    IgG conc 6.25 25:1                   12.4

    % CD3+                                        69.0         60 – 85% note that this result is normal
    % CD19+                                        5.9         2 – 12% note that this result is normal
    % CD56+                                     25.2         2 – 12% note that this result is elevated
    % of CD19+ cells, CD5+            17.5         5 – 10%  note that this result is elevated

    NK Assay w/intralipid
    50 :1 w/intralipid 1.5 mg/ml      13.9% note that this result shows suppression down to below 15% which is a good sign
    25 :1 w/intralipid 1.5 mg/ml      7.4% note that this result shows suppression down to below 15% which is a good sign

    15.2.2   How is the NK assay different from NK measurement/absolute NK level? How is it different from a uterine biopsy for NKs?
    Most immune docs agree that an NK cytotoxicity assay is more useful than merely measuring the concentration of NKs in your blood because it is the aggressiveness (killing power) of your NKs that is important rather than how many of them there are in your blood stream.  It is more likely to indicate how hostile an environment your uterus is likely to be. 

    All tests on peripheral blood (blood from your veins) are an indirect measurement because they cannot look at the actual NKs in the uterus.  A uterine biopsy (see below) does but it is an invasive test so it cannot be used during fertility treatment and pregnancy (only before treatment starts), so it cannot be used to monitor what is happening in your body during that process.  Some patients prefer to do both a cytotoxicity assay and a uterine biopsy before treatment starts to get as much information as possible and then rely on blood assays only once treatment starts, but many ladies decide to stick to the blood test (see uterine biopsy, below).

    An alternative NK test to the cytotoxicity is a CD69 blood test.   This test measures your absolute NK level (the concentration of NKs in your blood), as well as measuring your absolute level of NKs carrying marker CD69.  High CD69 concentrations are supposed to correlate with higher cytoxicity (killing power) so the CD69 is an indirect way of estimating whether you might have a high cytoxicity.   Its significantly cheaper than an NK assay and its relatively easy to access in the UK through RIC (see under Resources, below).

    Other ways of measuring the state of the NK immune system for fertility include looking at variations of the immunophenotype - particularly the ratio of CD4/CD8 (as diminished CD 8 regulatory cells compared to CD4 T helper cells results in an increased CD4/CD8 which is associated with increased risk of IVF failure or miscarriage), the ratio of CD56bright/dim (as diminished CD56 bright regulatory cells compared to CD56dim cytotoxic cells tends to be associated with increased cytotoxicity and increased risk of implantation failure or miscarriage) and also the absolute count of CD56dim (CD56dim are associated with increased cytotoxicity and increased CD69).  The NK assay used by Dr Economou in Athens relies on the immunophenotype rather than cytotoxicity.

    15.2.3   What is the K562 test plus immunophenotype?
    It is the same test as the Chicago NK assay, but Dr Sher (in Las Vegas) prefers to use RIA labs in California for it rather than RFU so the output format is different.  I believe we tend to use RFU in the UK partly because it has been established for longer, but also because the flight time to Chicago is shorter/more convenient for shipping bloods.

    15.2.4   Please explain my RFU NK assay results?

    The first part of the test, the cytotoxicity (50:1, 25:1, 12.5:1) shows what percentage of target cells your NKs killed off within two hours.  You want all these numbers to be below 15% for normal fertility. (Higher levels may be great for fighting viruses or cancer but not good for fertility.) 

    The second part of the test shows whether adding a solution of IVIG to your samples modified the results.  If the first part of test shows elevated NKa, you want this part of the test to show that adding IVIG successfully reduced your NKa to normal (below 15%).   

    The third part of the test (the immunophenotype) shows the relative concentration of various types of cells in your blood.  CD3+ cells are supposed to be 60-85%.  According to Dr Beer, elevated levels are likely to be associated with autoimmune conditions and infertility issues.  Most T cells carry marker CD3 so this marker is called a 'pan' T cell marker.   This category will include several subcategories of cells e.g., cytotoxic T cell, T memory cells (CD4+ and CD8+), T helper (CD4+), T regulatory (CD8+ including FoxP3).
    CD19+ are supposed to be 2-12%.   CD19+ are B cells - the cells that make antibodies.
    CD56+ are supposed to be 2-12%. CD56+ are total natural killer cells.  Different markers are associated with higher levels of killing power/activation.  E.g., cells carrying marker CD69 are supposed to tend to be of higher killing power as those that don't carry that marker. 
    CD19+5+ are supposed to be 5-10%. These are a sub-class of CD19 cells that are associated with autoimmune activity including antihormonal antibodies.  Accordingly, Dr Gorgy tends to prescribe additional progesterone e.g., gestone, to ladies with elevated levels of CD19+5+ in case the activity includes anti-progesterone activity.  CD19+5+ make 'generalised' antibodies that are active against many different proteins, so it is difficult to test for a specific antiprogesterone antibody.  Progesterone will not bring the CD19+5+ level down, but is precautionary against one of the consequences of a high level.

    The CD3+, CD19+ and CD56+ are all given as a percentage of total lymphocytes, so the three results taken together should always add up to about 100% because, taken together, most lymphocytes will carry one (and only one) of markers CD3+, CD19+ or CD56+. As they are given as a percentage rather than an absolute measurement, it is not possible to tell from the immunophenotype whether you have a high overall number of a particular type of cells, only that a particular class of cells is relatively out of balance compared to the total number of lymphocytes.  Additionally, if one (or two) classes of cells in the immunophenotype is elevated, the other class(es) of cells will, mathematically, have to be relatively reduced, so if you have a very high CD3+ and CD56+, you would expect to see a relatively low CD19+ and this would not necessarily mean that you have a low absolute concentration of CD19+ cells in your blood (as the immunophenotype does not give the absolute concentrations of any of these cells), only that there is a poor balance between the classes.    If you have an FBC run at the same time, in theory you would be able to convert the CD3+, CD19+ and CD56+ to absolute measurements because you would have the total number of lymphocytes (and the relative proportions of T, B and NK lymphocytes from the immunophenotype) - but I have never done this.

    The CD19+5+ measurement is given as a percentage of total CD19+ because it is a subclass of CD19+ cells.

    15.2.5   What is the difference between the NK assay and the NK retest (at RFU Chicago)?
    The NK assay includes an assay with IVIG to see whether IVIG suppresses your NKa in the test tube.  The retest does not include that part of the test, but does include the NKa (50:1 etc) and the basic immunophenotype (CD3+, CD19+, CD56+ and CD19+5+).  The retest does not include the assay with intralipids.

    15.2.6   How much does the NK assay cost?
    I think it’s about £465 (RFU) Dr Gorgy (the cut-down follow up assay is £325).

    I think its about £532 (RFU) with Care (the cut-down follow up assay is £470).

    I think its about €170 with Dr Economou in Athens (see my thread on serum clinic) but does not include a cytotoxicity

    15.2.7   How do I get an NK assay run with intralipids as well as with IVIG?
    Dr Gorgy tends to get this run as standard.  I don’t think the other doctors currently offer this.  Bear in mind that the cytotoxicity assays with medication only give an indication of what might happen in your body.  In the test, the NK cells used are separated from the rest of your immune system and it only looks at what happens at the 2 hour point.  The cells in your body may react differently, especially over a longer period.  The most accurate way to find out what medication helps you is to try the medication for at least 10 days and then repeat the NK assay.

    15.2.8   What are the sample requirements for the NK assay (RFU)?
    30-40mls of blood collected in green top (lithium heparin additive) tubes – mixed well before posting.  Not refrigerated.  Must be received by RFU within 48 hours of blood being drawn during working hours.  You can have the blood drawn at TDL on Monday/Tuesday/Wednesday mornings.  You can also arrange to get a post pack from Dr Gorgy/TDL and get the blood drawn at your GP on Monday/Tuesday afternoon and then post it back to TDL special delivery before 9am so that they add it to their fedex pick up on Tuesday/Wednesday just in time to get it to Chicago within 48 hours.  To do this, you pay the test fee to Dr Gorgy's receptionist over the phone with a debit/credit card and ask for a post pack (this includes empty tubes, referral form, plastic protector and padded envelope), she will arrange for TDL to post it to you and then you arrange with your GP or local private hospital to draw the blood into the tubes, then you arrange for postage/courier back to TDL (special delivery before 9am next day is usually ok).  The cost will be the normal Dr Gorgy charges plus any charge your GP/local hospital makes to draw the blood, plus the post/courier cost back to TDL - but this may still be cheaper than travelling to London depending where you live.

    15.2.9   Should I have the NK assay test?
    Of all the immune tests, this test is probably the most important and is the most widely used.  NKa is high for most ladies that need immune treatment.

    15.2.10   How long do the results take to come back?
    About three days after the sample arrives in Chicago.  Dr Gorgy’s patients will need to phone the clinic for a copy of the results.

    15.2.11   What are the treatment options for elevated NKa?
    The most basic treatment is corticosteroids. Usually a low dose of clexane is added on the grounds that NKa may compromise blood flow to the uterine lining or the placenta.   Most immune docs will then use intralipids and/or IVIG drips on top of the basic treatment.

    For elevated CD19+5+ B cells, Dr Gorgy tends to prescribe additional progesterone.

    Where elevated NKa is associated with a low LAD or with an infection e.g., Chlamydia, some docs believe that the elevation will reduce if the infection is treated or the low LAD is addressed with LIT.

    During pregnancy, some docs will want to retest your NKa periodically to determine which treatment to give you and to monitor for any immune flares.   A lot of immune Tx ladies seem to experience a flare in immune activity at around 18-22 weeks of pregnancy whereas, in ‘normal’ ladies, immune activity is usually suppressed during pregnancy (see Pregnancy).  However, some immune docs stop treating NKa before 18-22 weeks and most ladies on that regime get through pregnancy without any problems.   Studies suggest that there is a only a small increase in live birth rate for ladies who continue their immune treatment (IVIG drips) past 12 weeks, so the implication is that most pregnancies can cope with an immune flare in the later stages of pregnancy.  The difficulty is not being able to know whether you are in the tiny minority whose pregnancy wouldn't cope so well with a late immune flare.


    15.2.12   What alternative NK tests are there?

    As well as the RFU type assay which has a cytoxicity (killing power test) plus immunophenotype (relative concentration of T, B and NK cells).  Other tests are:
    - endometrial biopsy - to physically count the NK (CD57) cells in a sample of uterine lining
    - CD69 - to measure the concentration of cells in the blood that carry marker CD69 - this is a proxy for cytotoxicity because where the proportion of NK cells carrying marker CD69 is high, this tends to be associated with higher cytotoxicity.
    - ratio of CD4/CD8 - this tends to be higher where cytotoxicity is higher because CD8 immunoregulatory cells tend to be reduced when the immune system is disposed towards high killing power
    - ratio of CD56bright/CD56dim - this tends to be lower when cytotoxicity is higher because CD56bright cells tend to be immunoregulatory (helpful for fertility) whereas CD56dim cells tend to be cytotoxic (less helpful for fertility)
    - total NK (CD56) count - this tends to be higher when cytotoxicity is higher, but unfortunately it cannot distinguish between helpful immunoregulatory NKs and unhelpful cytotoxic NKs.

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    Re: Immune FAQ - Continuously updated and added to.
    « Reply #15 on: 15/07/10, 22:31 »
    16   O
    16.1   Omeprazole – see Chlamydia - above or click here

    16.2   OHSS (ovarian hyperstimulation syndrome)

    16.2.1      How can I improve my chances?[/i]
    See IVF strategies under I, above.

    16.2.2   I think I have OHSS?
    During stimulation, after egg collection, during two week wait or in very early pregnancy if you think you have OHSS (severe bloating, abdominal pain, nausea, breathlessness etc), phone your clinic to get urgent advice.   If you have difficulty breathing, feel very sick and/or cannot urinate and cannot get hold of your clinic go to A&E.   OHSS is rarely life threatening so long as it is promptly treated (this means having a drip if necessary to keep you hydrated, and having a catheter put in if you cannot urinate).    If you start to show indications that you might develop OHSS during stimulation (high estrogen, high follicle numbers), ask your clinic whether you should be prescribed cabergoline (a drug which has been shown to reduce the symptoms of OHSS without reducing your chance of pregnancy).  Equally, if you have a tendency towards OHSS (high antral follicle counts, PCO etc), you should be careful to eat a high protein diet and drink plenty of fluid during stimulation and after egg collection as this helps to cushion your system agains OHSS.

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    « Reply #16 on: 15/07/10, 22:31 »
    17   P

    17.1   PCOS – see insulin resistance - above or click here

    - also see under IVF (for IVF strategies for PCO/OHSS)
    - also see under thrombophilias - PAI-1 because some studies have suggested ladies with PCOS are more likely than average to have elevated PAI-1 levels.

    17.2   PBMC - peripheral blood mononuclear cells

    This is an experimental therapy designed to improve implantation rates.   PBMCs include T cells, B cells, NK cells, monocytes, macrophages, basophils and dendritic cells (so most white blood cells apart from neutrophils and eosinophils).  PBMCs can be separated from other blood cells and plasma using a commercially available reagent called ficoll which separates PBMCs from plasma, red cells etc - a fresh blood sample is poured into a tube containing the ficoll and then the tube is spun in a centrifuge.  The liquid part of the blood (the serum and the substances dissolved in it) spin up to the top of the tube because they are less dense.  Dense red blood cells spin down to the bottom of the tube, and the lighter PBMCs move to the middle in a layer called the 'buffy' layer.   The PBMCs are extracted from the tube using a syringe.

    The theory behind PBMC infusion into the uterus is that immune cells from the bloodstream are part of the normal communication and signalling to the uterine tissue to make it receptive to an embryo.  PBMCs from the human blood stream have been shown to promote blastocyst 'invasion' into the uterine lining cells of hamsters and to increase the rate at which the trophoblast grows in cows http://onlinelibrary.wiley.com/doi/10.1002/mrd.21243/abstract;jsessionid=D86F45296B8BE6B09260788D5D786C91.d02t04

    http://www.jstage.jst.go.jp/article/jmor/26/3/122/_pdf

    So the theory is that introducing extra PBMCs into the uterus might promote uterine receptivity - perhaps by secreting proteases (enzymes) that make the lining more receptive or more complicated processes that change the signalling to the immune cells in the lining shifting the environment towards TH2 cytokines (e.g. TNFa) from TH1 (e.g. IL10) cytokines, or perhaps that cause local inflammation which is actually helpful for implantation.  It appears they also seem to promote the release of G-CSF (a natural chemical that seems to promote a tolorogenic ('embryo-friendly') response from the dendritic cells in the uterine lining.

    Early studies found that PBMCs from pregnant women made animal uterine lining more receptive, so for autologous PBMC treatment (using PBMCs from the IVF patient's own blood), the PBMCs are 'activated' by incubating them with a solution containing HCG (the pregnancy hormone).   The ideal treatment might be to use donor PBMCs from pregnant women but, as this treatment was developed in Japan where it hard to get official approval to use donor cells, it has not been investigated.   Obviously, using donor blood would increase the risk of infection and obtaining blood from pregnant ladies might be ethically difficult.    However, studies using autologous blood (own blood) seem to show good results in any case.  Some clinics give the patient additional HCG shots, presumably to try to prime the PBMCs to act as though they were from a pregnant lady.  Where PBMC is given to OE patients, they would have received the HCG trigger shot about 36 hours before they give their blood for PBMC.

    For PBMC treatment, about 10-30mls of blood is drawn from the patient and the mononuclear cells are separated out using the methods outlined in this paper :http://humrep.oxfordjournals.org/content/21/12/3290.long - by adding the blood to a commercial reagent called ficoll and then centrifuging so that the red cells move into the ficoll and the plasma spins to the top, leaving the pbmcs in a layer in the middle of the tube.   Care needs to be taken to exclude neutrophils as it is not normal to find neutrophils in the uterus.

    10mls of whole blood yields about 1 x 10^7 (70 million) PBMCs.  One batch of blood is drawn and prepared on egg collection day and cultured in the laboratory in a commercial reagent solution called Roswell Park Memorial solution with HCG 5IU/ml for 48 hours, before another 10mls of blood is drawn from the patient to prepare a fresh batch of pbmcs, then the two batches are infused into the uterus on day 2 after egg collection using a small syringe attached to a catheter (a similar procedure to ET), prior to embryo transfer on day 3 or 5.  http://humrep.oxfordjournals.org/content/21/12/3290.long - in a Japanese study of OE patients who had 4 or more IVF failures, this improved the live birth rate from 6% to 35%.    The method using two blood draws 48 hours apart should theoretically be more helpful because the first batch of PBMC has been incubated with HCG, and in lab experiments, HCG activated PBMCs showed an increased effect on uterine lining cells compared to PBMCs that had not been exposed to HCG.  The Japanese researchers noted that ensuring that all neutrophils are removed from the PBMC sample may be important because, unlike T cells, B cells and NK cells, it is not normal to find neutrophils in uterine lining tissue.  No statistical improvement was seen for the patient group who were over 40 (but the study was small and the numbers of +40 patients presumably very small).  It should be noted that donor egg treatment is illegal in Japan - and embryo quality was not a criteria for exclusion/inclusion in the study - Japanese ladies whose egg quality is poor have no option but to give up treatment or keep going with OE.   So I would expect that for ladies over 40 in this study egg quality was probably very significant.  Unfortunately, average rates of success for OE patients over 40 (especially after previous OE failures) are never very high. I would expect DE patients over 40 who had multiple IVF failures to benefit from PBMC.

    A recent Japanese study used a triple quantity (3 x 10^7) of freshly obtained PBMCs suspended in phosphate buffered saline without any addition or incubation with HCG and immediately infused into the uterus through a catheter about 2 days before embryo transfer http://www.jrijournal.org/article/S0165-0378(11)00278-6/abstract - in this study for a small group of patients who had 3 or more failed IVFs and were having frozen blastocyst transfer, this improved the (OE IVF) pregnancy rate from 17% to 32%, but didn't make a statistically signficant difference to a patient group who had only 2 failed IVFs or who were doing frozen day 3 transfer.  This study seems to confirm that HCG activation of the PBMCs is more helpful than using fresh PBMC without any HCG incubation step.

    The authors of these studies have pointed out that there may be a beneficial effect simply to inserting a catheter prior to ET (local injury effect similar to endometrial scratches but more gentle - so, potentially it can be carried out only a few days before ET, unlike scratches which have to be done at least 2 weeks before ET allow the lining to recover) which hasn't been ruled out.  Other studies showed an increase in implanation rate where an infusion of embryology culture medium (the solution that is used for incubating embryos in the embryology laboratory) was made prior to embryo transfer which also suggests that a degree of local injury/inflammation prior to ET may improve uterine receptivity.

    In this 50 patient study from Ukraine (Feskov clinic), which also used cultured PBMC's combined with fresh PBMC with a uterine infusion given 2 days after egg collection, the OE IVF clinical pregnancy rate improved from 18% to 36% in a patient group who had 2 or more previous IVF failures.

    http://eshre2010.abstractsondemand.com/showabstract.php?congress=ESHRE2010&id=627

    In another Ukrainian study with 80 women (Nadiya clinic), which used PBMC's cultured for 48 hours with HCG combined with fresh PBMCs with a uterine infusion given 2 days after egg collection, the OE IVF pregnancy rate for ladies with at least 4 previous failed IVFs improved from 10% to 37% in a patient group who had 4 or more previous IVF failures.  This last study is also interesting because the doctors took samples of the reshly obtained PBMCs and the PBMCs after they had been incubated for 2 days with HCG and compared the expression of cytokines.  They found that the levels of IL-8, TNFa and IFN-g expressed in the PBMCs of those women who went on to get pregnant were unchanged after HCG incubation, but in some of those who failed to get pregnant, their PBMCs showed initially low levels of IL-6, IL-4 and IFN-g which were raised significantly after exposure to HCG.  The researchers thought it was particularly signficant that these women showed raised IFN-g (a pro-inflammatory TH1 cytokine) in response to HCG - as uterine lining tissue which is receptive to embryos apparently shows no change in IFN-g.

    http://eshre2010.abstractsondemand.com/showabstract.php?congress=ESHRE2010&id=637

    As PBMC is done after egg collection, it cannot influence the pregnancy rate by changing egg/embryo quality, only by affecting implantation rate and the early growth of the embryo in the uterus.  The published PBMC studies so far show impressive improvements in pregnancy and live birth rate for some ladies with repeat IVF failure who are doing OE IVF.  I would hope that the improvement in pregnancy rate for ladies who have had repeat IVF failure using DE IVF might be even higher as embryo quality should be less of a factor as DE embryos tend to be very high quality.

    My understanding is that PBMC treatment is available at clinic Nadiya (300Eu www.ivf.com.ua/en) and clinic Feskov ($312 http://sana-med.com.ua/eng/) in Ukraine and that Serum (approx 500Eu) in Athens are starting to offer PBMC as well.  So far, the number of patients who have received PBMC at Serum is small (and it is only recommended to patients who have had several IVF failures or have problems with lining).   Anecdotally, Serum have observed an improvement in lining shown on ultrasound 2 days after the PBMC was given and, on biopsy, an increase in the expression of G-CSF.

    The Kinderwuncentrum in Austria also offers PBMC.  Interestingly, the Austrian clinic give injections of HCG to the patient, presumably to try to prime the white cells.   For OE IVF, most ladies would have had a trigger injection of 5000-10000IU of HCG 36 hours before egg collection, but in addition, the Austrian clinic prefers to give a 'top up' injection of 1500 IU of HCG on the day after the first blood draw for PBMC (the day after egg collection) and another 'top up' of 1500 IU on day 5.

    17.3   Poor egg/embryo quality - see IVF strategies above

    17.4   Poor ovarian response - also see IVF strategies above

    17.4.1 What is a poor response to IVF?  What is a good response?

    There isn’t a single definition, but some docs have suggested that a good response is where you get more than 6 eggs recovered.   An excellent response is 8-15 eggs recovered.  More than 15 eggs recovered tends to be seen as over response (as the patient will often have a risk of OHSS, more discomfort and possibly reduced egg quality and/or a reduced window of time for successful implantation in the uterine lining).   Where less than 4 eggs are recovered on a typical dose of stimulation drugs (e.g,. 225-300 IU) for a typical stimulation time (e.g., 10 days), then some docs would call this a poor response, as statistically, the chance of pregnancy is less than for a patient group where more than 4 eggs are recovered.   

    On a first cycle of IVF, some docs will be very cautious about the risk of over-response, and might use a relatively low dose of stimulation drugs (e.g,. 150IU), or they might be deliberately aiming to use a low dose to simulate more of a ‘natural cycle’ type of IVF.  In which case, recovering less than 4 eggs would not be a poor response (because it is proportionate to the reduced dose of stimulation drugs).

    Among poor responders, there will still be big differences in the chance of pregnancy due to differing egg quality.   Obviously, it only takes 1 good quality egg to make a healthy pregnancy.  Younger ladies are more likely to get pregnant with only 1 or 2 eggs recovered because their egg quality will tend to be better.   

    17.4.2 I had a poor response on my last IVF?  Will it be poor next time?

    Statistically, if you have poor response on your first cycle, you are more likely than not to have poor response on future cycles, but for a minority of patients, the first cycle may be uncharacteristic i.e. it took place in a month where the starting crop of antral follicles just happened to be unusually poor for that lady, or the dose/protocol did not suit your body.  Unfortunately, until you do at least 2 IVFs it is impossible to know whether your response is characteristically poor or if it was just a particularly bad month for your body.

    17.4.3 My last IVF response was poor.  Is there still a chance to get pregnant naturally?

    If you are ovulating regularly, your tubes are open and you are having sex with a man who has some live sperm there is always a chance of getting pregnant.   The chances will diminish if your partner has a very low sperm count or sperm with very poor parameters, if you have a blocked tube, if you are not ovulating regularly or you aren't having sex in the couple of days before you ovulate.  However, some poor responders may actually have the same chance of getting pregnant naturally as on an IVF cycle e.g., if the sperm is good quality and both tubes are open (or your dominant ovary is the one on the side with an open tube).  This is because, sometimes the high doses of meds used for IVF can tend to reduce egg quality or shorten the implantation window (the time when the lining will accept an embryo).

    17.4.4 My last IVF response was poor.  Do I still have a chance with IUI?
    IUI tends to have a lower success rate per cycle than IVF.   Its success relies on having fairly good sperm, and being able to trigger ovulation of 1-3 mature eggs at about the same time as the IUI is done.   Accordingly, if you can consider switching to donor sperm (if your partner has poor sperm parameters) then it might be worth a try, provided your doc thinks there would a reasonable chance of you being able to ovulate with a fairly low dose of stimulation meds and your tubes are open.

    17.4.4 My last IVF response was poor.  Should I try clomid?
    If you are fairly young, it might be worth a try.   For older ladies whose egg quality is probably more fragile, then it might be less likely to help.  This is because clomid is a fairly 'harsh' and unpredictable drug compared to injectable FSH.   If you want to try 'naturally' or with IUI, then injectable FSH is a bit more predictable because it doesn't rely on your body producing its own FSH.

    17.4.4 My last IVF response was poor.  What can I do to reduce the risk next time?

    The aim is to improve response to get more eggs but not at the expense of reducing egg quality.     Some interventions may reduce egg quality so they may not work for particular patients.   Other interventions may not improve response, but might help the egg quality.  Some clinics will not tailor their protocols well to individual patients, so if your own clinic are not ready to discuss tailoring your protocol after a poor response cycle, you might want to get at least 1 second opinion from a more specialist clinic.   These are my suggestions to investigate and discuss with your clinic.

    1) switching protocol
    Numbers of eggs recovered tends to be higher on the long protocol for normal responders – but some ladies have sensitive ovaries that don’t ‘bounce back’ well after having down regulated for the long protocol – so they may respond better to a short protocol starting on a natural period.   Additionally, some ladies experience better egg quality on a short protocol.  Accordingly, if you have had no success on the long protocol, it would probably be worth switching to the short protocol and vice versa.

    Some ladies’ egg quality improves if their ovaries are ‘rested’ by a month or more on the pill before they start IVF – but other ladies have ovaries that don’t ‘bounce back’ well after having been on the pill – in which case, they may benefit from either a natural period start to their IVF, or using the agonist/antagonist conversion protocol overlapping with the pill (you start a daily dose of agonist about 5 days before stopping the pill – then on about day 2 of your bleed you stop the agonist and start an antagonist at half dose along with your stimms).

    Some ladies experience better response on a flare protocol (a short protocol where you start agonist at about the same time as stims so that the agonist produces a 'flare' of your own FSH to add to the FSH in the stims) – but sometimes this is at the expense of reduced egg quality – so again, you would probably have to try it to find out whether it suits your body - although some clinics avoid using flare protocols for all ladies because of the flare protocol's reputation for reducing egg quality (particularly in older ladies) and because the level of FSH that your body will experience on a flare protocol is unpredictable (the flare protocol relies on pushing your body to produce its own FSH as well as giving the FSH in the stimms).  Clinics who rely on tailoring your FSH and LH level very carefully by monitoring your bloods and adjusting your doses to get your FSH and LH into a particular target zone (e.g., ARGC) are less likely to use the flare protocol because of its unpredictability, but clinics who try to keep the costs of meds down as low as possible, sometimes use flare protocols for all/most of their patients, especially for normal responders, because using your body to produce some of the FSH needed reduces the number of ampoules of stims that need to be paid for.

    For poor responders who do ovulate naturally, and particularly for older poor responders, some docs believe that although the chance of pregnancy with IVF is never going to be as high as for a normal responder of the same age, it is not improved by using high doses of stimulation meds, and and that natural cycle IVF may give the same chance or better as conventional IVF.   Their approach is to try 2 or 3 cycles of natural cycle IVF instead of challenging the ovaries with medication.   This means taking no FSH or LH medication at all and aiming to monitor the natural development of follicles on ultrasound (often starting with a scan 4 days before ovulation is predicted - ovulation is often predicted to happen 14 days before you expect your period).  A trigger shot of HCG is then taken about 3 days before ovulation and egg collection happens 3 days after ovulation with the aim of collecting only 1 or 2 eggs, with embryo transfer happening usually on day 2 after egg collection.   The aim of the natural cycle approach is to be as gentle as possible to the ovaries and keep your hormone levels as normal as possible in the hope of getting the best possible egg quality.


    2) switching stimulation meds
    Stimulation drugs can be pure FSH (e.g., gonal F, puregon, follistim) or mixed FSH and LH (merional, menopur, pergoveris) and can be natural (derived from human urine e.g, menopur, merional) or synthetic (e.g, gonal F, pergoveris). Most docs agree that we need some LH for good follicle growth, but some think that too much LH can be detrimental to egg quality.   So if you have previously had a poor response on the long protocol with pure FSH, you may get a better response if you switch to short protocol (where you have some natural LH remaining in your system) or a long protocol with some LH (all or part merional/menopur). Some docs prefer natural stimulation drugs because they have a reputation for being more 'gentle' on the ovaries and often cheaper, but others prefer the synthetics which have a reputation for being more 'intense' - but so far, studies haven't shown natural or synthetic to be clearly better for all patients, so its probably a question of which meds your body responds to better. 

    3) Pretreatment with DHEA
    Older ladies tend to have lower levels of DHEAS and a reduced ovarian response.  Some studies suggest that, if  DHEAS levels in the blood are proven to be low, then taking DHEA as a supplement can get the level back into the normal range which sometimes improves ovarian response after about 3-6 months.  Therefore, if you have had one poor response cycle, you might want to ask your GP to run the following bloods (ideally on day 1-3 of your cycle): DHEAS, free testosterone, estrodial, SHBG, FSH, LH and prolactin.  If your DHEAS is low and your testosterone and LH are not already high and your SHBG not already low, then you might want to discuss taking DHEA e.g,. 25mg micronised DHEAS from a reputable brand e.g., biovea, 3 times a day for 3 months before your IVF cycle.   After the first month, you should repeat the blood test to check you haven’t under or overshot the normal ranges.  You do not want to have excessive DHEAS, testosterone, LH or low SHBG as this might reduce your egg quality.

    4) Estrogen priming protocols
    Good response tends to be associated with relatively low FSH levels, which is why some clinics suggest that poor responders should wait for a month when your FSH is at its lowest on day 1-3 to do your IVF cycle.  Taking estrogen will tend to suppress FSH, so some doctors think that priming your body with estrogen injections or skin patches for about 1 week before starting stimms can help poor responder patients.
     
    5) Increasing the dose of FSH
    Increasing the dose of FSH can often help recruit more follicles so reduce the risk of poor response – but some studies suggest that higher doses may reduce egg quality.   Accordingly, some docs are reluctant to use high doses for some or all patients – or where they do use high doses (doses more than 300 IU), they will use a step down approach – where the patient starts on the high dose but only for the first few days before stepping down to a lower dose.  If on your last cycle, you used a particularly low dose of FSH for your age group (e.g,. 225IU or 150IU for age 35), and your response was poor, its reasonable for your clinic to suggest trying a higher dose e.g,. 450IU stepping down after 4 days to 300 IU, but I would be wary of docs whose only suggestion when faced with a poor responder patient is to give enormous doses of FSH (e.g, 600 IU) unless perhaps the patient is a young poor responder who is likely to have excellent egg quality, or to keep trying high doses after it has already failed for the same patient.

    6) Lifestyle/supplements
    Some supplements are supposed to help with poor response.  For example, estrogenic/estrogen-like supplements may help reduce your FSH, which may help improve your response (e.g., wheatgrass, spirulina).   Other supplements or lifestyle changes may just help your body cope better with the demands on it which might improve your egg quality e.g., royal jelly, extra protein.  It is bound to be more difficult for your body to produce good eggs if you are tired and under nourished.

    7) Thyroid problems
    Undiagnosed thyroid conditions can increase the risk of poor response.  So you may want to see your GP and ask for TSH, FT4 and antithryoid antibodies to be tested for.   Do not accept that the results are ok without seeing the actual numbers for yourself because the optimal range for your health that your GP will accept is wider than the range which seems to be optimum for trying to conceive.  You want to aim to get your TSH around 1 and your FT4 into the top third of the normal range.   If antithyroid antibodies are detected it means you are at higher risk for developing thyroid problems even if your hormone levels are normal now.   Some studies suggest that your chances of pregnancy can be improved if antithyroid antibodies are treated with a small dose of thyroxine, blood thinners and steroids (see Thyroid).

    8) Immune issues
    If you are relatively young and are experiencing poor response suggesting diminished ovarian reserve without an obvious explanation, it could be that your ovaries are suffering from attack by anti-ovarian antibodies.   These are difficult to test for, but they are associated with premature ovarian failure and poor response to IVF.   Some studies suggest that taking immune meds e.g., steroids (see corticosteroids) may help to reduce antiovarian antibodies, which might help the chance of pregnancy.   However, where response is diminished due to immune issues, it is difficult to know whether the situation is reversible without trying it – logically, though, younger ladies are more likely to have reversible problems.

    9) You may not be ready to consider donor egg treatment, but be aware that it does exist, and if you are prepared to wait or can travel overseas, its not difficult to arrange, or particularly expensive compared to own egg treatment.   Even if it is something that you could not think about until you have tried several different OE approaches and still been unsuccessful, at least know that it exists, and that its readily available until age 50.   So even if OE never works, and adoption isn't possible for you, with DE there is still a good chance of having a baby (e.g., 70% after 2 cycles of DE) for most ladies until age 50.

    17.5   Pregnancy (also see two week wait and pregnancy - below)
    17.5.1   What immune testing and treatment protocols are typically followed in pregnancy?
    Humira treatment is normally completed before pregnancy or at least in early pregnancy because it’s a fairly new drug and there is not much safety data for how it affects the fetus.

    LIT treatment is often aimed to be complete before pregnancy, but some ladies LAD levels do not stay elevated as well as others, or they may discover a low LAD after they find out they are pregnant (Dr Gorgy recommends retesting LAD in early pregnancy unless levels have already been shown to be good) and ‘booster’ LIT may be recommended in pregnancy with or without follow up LAD retests.  LIT is not normally required after 18-22 weeks of pregnancy.

    Steroids are often discontinued around or before twelve weeks of pregnancy (but this may vary depending on the severity of immune issues).

    Progesterones (e.g., gestone) are also normally discontinued around twelve weeks of pregnancy (but this may vary depending on severity of immune issues).

    The duration of clexane treatment varies depending on the severity of immune and clotting issues.  Some ladies may be advised they can stop it earlier in pregnancy, but often its at 22 or 31 weeks.  Other ladies are advised to continue it after the baby arrives for, say, six weeks.

    Dr Gorgy tends to prescribes IVIG/Intralipids (during stimulation and) on a positive pregnancy test and then again on the first heartbeat ultrasound scan.  He then tends to suggest an NK retest 7-10 days after the drip after which you have a consult to discuss his advice for when you should have the next drip.  I think the rationale for this approach is that for most immune issues, the drip should be effective for about 4 weeks (Dr Sher thinks this timescale may be shorter e.g., 2 weeks, for severe issues like a sensitised DQa match).  So by the time you get your positive pregnancy test the effects of your first drip(s) may be starting to wear off, so it could introduce a significant delay if you then waited to retest your NKa before organising a drip.   The earliest time that a first heartbeat ultrasound scan is usually done is 6.5 weeks of pregnancy (i.e., 4.5 weeks after egg collection) – if the initial scan is inconclusive a repeat scan a few days later may be necessary. So this will probably be at least 2.5 weeks after your first pregnancy drip.  After consultation with Dr Gorgy, many ladies have another drip at this point before their first NKa retest in pregnancy (7-10 days after the drip – only on a day where fedex to Chicago is possible (see above)).

    My understanding is that in early pregnancy ‘flares’ in immune activity are more critical than later in pregnancy because the uterine lining, placenta and the embryo are smaller, so damage done at that stage may end the pregnancy or cause irreparable damage leading to miscarriage later.  Immune ‘flares’ later in pregnancy are less likely to be critical because the placenta and the fetus are larger and better established and therefore more able to repair any damage.   

    It therefore seems reasonable to be more cautious about the interval between drips in early pregnancy and to wait until after the first heartbeat scan to retest your NKs.  After sending off the blood for retest, Dr Gorgy’s patients will have to phone his clinic (about a week later) to ask for a copy of the results and then will want to consult with him to decide what to do.

    Depending on the severity of your immune issues, your medical history and anything else that increases your pregnancy risk e.g., having twins or bleeding, Dr Gorgy may recommend regular ultrasound scans to check for hematoma and normal development/growth rate.

    Other clinics take different approaches to drips and retests in pregnancy.  My understanding is that the AEB advise frequent and comprehensive retests (not just NKa) on which they base their treatment recommendations in pregnancy.  Dr Ndukwe tends to follow Dr Sher’s protocols so advocates regular intralipid drips without NKa retests.  I think ARGC tend to do more retests than Dr Gorgy (e.g., of cytokines plus NKa) and then advise on drips.   Dr Gorgy’s approach is in between these – suggesting initial drips automatically and then deciding what to do next based on retests.    As retests are expensive (costing more than, say, an intralipid drip), where intralipids are used as the only treatment option, and where it is practical to have them regularly, it makes economic sense not to do (m)any retests and just have regular intralipid drips especially later in pregnancy, although if your body does behave unexpectedly, the only way to tell might be from repeat ultrasound scans (although any slowing down in growth due to immune flare will take time to become apparent (by which time, the placenta may already be damaged - although bear in mind that scan measurements are difficult to do and consequently, a single bad scan result may not always be meaningful) whereas in the blood it will be immediately detectable).  Ultrasound scans are cheaper than NKa retests though.  Where IVIG is a possibility, retests may have additional value as IVIG drips are very expensive.  Dr Beer used to suggest continuing to have monthly retests until there were two consecutive retests without a problem (although my my impression from talking to other patients, is that it is quite rare for two retests in a row to show no issues).  Dr Gorgy tends to prefer regular retests at least until 22 weeks, even if the patient is not keen to have IVIG because in his experience, if there is a serious problem starting to appear on retests, many ladies will change their mind and decide to have IVIG if intralipids are not normalising their retests.  He also has apparently had a small number of patients who decided not to continue with retests and/or opted not to have IVIG when he felt their retests required it around the 18-22 week mark (where he believes immune flares are common - my experience from discussion with other patients is that most do have a flare at this point) who went on to have a stillbirth, so consequently he is extremely cautious about deciding to stop retests or not to give IVIG if there are any issues showing up on retests.  AEB tend to insist on regular retests for most of pregnancy.   SIRM and Care (who rarely, if ever, use IVIG anymore), rarely suggest many retests during pregnancy.

    17.5.2   My NKa has gone up in pregnancy – is this normal?  What do I do?  Will it harm my pregnancy?
    Obviously, you will want to speak to your consultant to get his advice and he may suggest you have another drip fairly quickly to try and bring your NKa down.  He may suggest increasing your progesterone (e.g., gestone) or even your clexane or steroids.  He may suggest you try IVIG instead if you have been using intralipids or vice versa.

    In the meantime, you should try and keep calm and relax as getting stressed about the result will not help lower your immune activity.    You may also want to try and rest with your feet up to improve blood flow to the uterus, making sure you do some gentle walking from time to time to push blood around your body, and you should try and keep well hydrated and avoid saturated fats.

    It is not normal for NKa or NK (CD56) numbers to increase in pregnancy. The immune profile for ‘normal’ ladies shows suppression of NKa and NK (CD56) numbers during pregnancy (which is one of the reasons why pregnant ladies are more vulnerable to infections like ‘flu during pregnancy).  However, ladies with immune issues do often see flares in their NKa retests, which is precisely the reason why they are having immune treatment and retests.  Because CD56, CD19 and CD3 are given as a percentage of total lymphocytes on the RFU immunophenotype (part of the NK assay), ideally you would like the levels to remain in the normal range during pregnancy and possibly for the CD56 and CD19 to fall slightly as pregnancy progresses.   As CD56 and CD19 fall, CD3 has to rise because the proportions of these three cell classes have to add up to approximately 100%.

    In early pregnancy, immune flares can be very damaging to the embryo, but later on, the fetus and placenta are bigger and more able to withstand immune attack.  According to Dr Beer the fetus does not start to show significant damage from immune attack until after the immune activity has continued for about 4 weeks (although this will probably be a shorter period in early pregnancy).  The most obvious sign of damage would be for the fetus’ growth to slow on an ultrasound scan.  If your growth scans have been reassuring and/or you are past 12 weeks, personally I would be fairly relaxed about seeing a flare in your NK retests during pregnancy but of course, I would follow up with any drips that my consultant advised as soon as reasonably practical.


    17.5.3   My pregnancy test after immune Tx was positive, what do I need to do?
    •   Arrange a repeat bHCG blood test if you haven’t done already - preferably ask for a progesterone blood test (P4) at the same time (to make sure your progesterone levels are adequate and not falling).
    •   Contact your consultant as soon as possible to get his advice on any drips (intralipid/IVIG) he suggests you have urgently and confirm whether you need to make arrangements for drips now and straight after first ultrasound scan, and whether and when you need retests of NKa, LAD etc .
    •   Make arrangements for your first ultrasound scan, and make sure you have enough medication to last until then (with enough extra to cover you until you can get another prescription).
    •   After your first ultrasound scan (and any drip that you might need, with any follow up retests), it may be a good idea to see your GP to see if she will now prescribe your medication on the NHS (e.g., prednisolone, clexane, gestone, cyclogest), and to ask to be referred into the NHS OB (obstetrics system) – this will usually mean seeing a midwife at around 10 weeks and an NHS ultrasound and often non-invasive tests for Down’s syndrome at 12 weeks.   A more comprehensive ‘anomaly’ scan will normally be offered at 20 weeks.

    17.5.4   What is ‘low risk’ and ‘high risk’ NHS pregnancy care?
    NHS pregnancy care is often divided into ‘low risk’ and ‘high risk’ care pathways.  On a ‘low risk’ pathway you will mainly see a midwife and may give birth under midwife care (at home or in a midwifery lead unit).  On a ‘high risk’ pathway, you will usually see a midwife, but also an OB (obstetrician) and you may be restricted in your options for where you can have the baby (to an OB lead hospital unit).  During a ‘high risk’ route pregnancy, the OB may provide extra scans and blood tests as part of his monitoring of your pregnancy (your immune consultant may also suggest additional private scans and tests if he feels the NHS testing is not sufficient for him to judge his ongoing immune treatment of you).   Many immune treatment ladies will end up on an NHS ‘high risk’ pathway, e.g., due to:
    •   Being older and/or overweight
    •   Having other medical issues e.g., autoimmune diseases, diabetes, diagnosed clotting disorders
    •   Carrying twins/triplets
    •   Being on additional medication that the midwife is not comfortable to monitor/advise on (e.g., clexane)
    •   Potential issues that may show up on their additional private scans
    •   Fibroids, endometriosis, previous uterine or abdominal surgery, cervical problems
    •   Previous history of late miscarriage/stillbirth/fetal problems

    If you are initially designated as ‘low risk’ that may change if any new problems or abnormal results are found during your pregnancy.

    The ‘high risk’ route has its disadvantageous in that you are less likely to be deemed suitable for a midwifery birth, and are more likely to end up with a surgical outcome (forceps/ventouse/C section/induction), but you are more likely to receive more frequent ultrasound scans and monitoring.  For a lady with immune issues, this could make a significant difference as immune attack on the baby could be revealed by a slowing in baby’s growth or a subchorionic haematoma, that your immune consultant may be able to address by additional immune treatment.

    A high risk pregnancy is more likely to result in a premature birth, a C section, or a growth restricted baby.  One recent innovation being explored by some NHS hospitals for high risk mums is ante-natal expressing of colustrum (expressing early breast milk to freeze so that you have a stock of it in your freezer to take to hospital with you).   The advantage of doing this is that if your baby needs extra food in a hurry you already have some which takes the pressure off you and makes sure you have the perfect food ready in case, for example, your baby's weight is dangerously low, his blood sugar drops, you have multiples to feed, or he develops a neonatal problem like hemolytic disease or baby jaundice that requires a high intake of milk at the same time as your baby is not really well enough to breast feed.  Not all hospitals know about this option yet, but its something you can explore and if you start to hand express a few mls a few weeks before you expect baby to be delivered, you may be able to increase your supply signficantly to have a good stock of frozen colustrum ready, and have your breasts ready to supply slightly larger quantities when your baby comes.  The first few days after birth are very important for getting breast milk to the baby rather than formula because there is a short window of time when the baby's gut is very 'porous' which allows maternal antibodies to get through.  With time, the baby's gut gets less and less porous so fewer protective maternal antibodies can cross the placenta.

    From my personal experience, if you are a high risk lady, I would suggest not buying a breast pump until you are ready to leave hospital after baby is born, purely because if there are medical issues, the hospital may recommend a particular garde/type of pump to make sure you can express enough to meet your baby's need.  There is a big difference in performance between the type of pump that you can buy from a high street shop and the kind that you get from a specialist medical supply shop.  A high vacuum medical grade pump may be required if you need to try and get your milk supply up quickly e.g., Ardo Calypso or Ameda Elite and depending on your plans it may make more sense to hire a pump rather buy one if you are not planning to breastfeed longer term.  I've put the contact details for Ardo in the Resources section because I found them very helpful.

    High risk ladies are also likely to find that their NHS OB wants them to start/continue clexane until 1-6 weeks post-partum and after a C section are likely to find themselves wearing electric bootees which are followed up by compression stockings to reduce their risk of blood clots (DVT).  Even if your immune doc signs you off from taking clexane at 31 weeks (from the point of view of risk to the baby), your NHS OB may want you to continue it from the point of view of risk to you.

    17.5.5   Do I need to keep having retests during pregnancy?

    see 17.5.1 (above)

    17.5.6   What are adequate progesterone levels in early pregnancy?

    Check out the graph of average levels on this page:

    http://repro-med.net/repro-med-site2/index.php?option=com_content&view=article&id=25&Itemid=54

    Bear in mind the graph is shown in ng/ml.  If your results are in nmol/L you will need to divide your figure by 3.18 (or take Dr Beer's figure and multiply it by 3.18) to get comparable results.

    At 4 weeks(14dpo) you want your progesterone to be about 22ng/ml=70nmol/L, at 5 weeks about 24 ng/ml = 76 nmol/L and 26 ng/ml=83 nmol/L at 6 weeks(28 dpo).

    N.B., ng/ml is the same thing as mcg/L (ug/L)

    17.5.7   Where can I see normal embryonic/fetal growth charts?  Is my scan normal?

    This site has example ultrasound pictures for each week of early pregnancy and info on sizes, sacs, yolk sac etc http://www.baby2see.com/development/ultrasound_sonogram/first_trimester_scans.html#week5

    This paper gives the charts used by most UK antenatal clinics for dating pregnancies
    http://www.bmus.org/policies-guides/23-17-3-161_ultBMUS.pdf

    17.5.8   Is my bHCG normal?

    Remember that a single bHCG measurement is not particularly meaningful - its the growth rate between two measurements taken at least 24 hours (ideally 48 hours) apart that matters.

    This site is very helpful for understanding the ranges of normal bHCGs
    http://www.betabase.info

    17.5.8   What is my due date? How many weeks pregnant am I?

    When you do IVF, to work out how many weeks pregnant you are you count from egg collection day and add on 2 weeks (because in the UK natural pregnancies are worked out from your last period, so we assume that ovulation would normally take place on day 14).   If it was FET, count from embryo transfer day, add on 2 weeks and add on how many days old your embryos were e.g., for a blastocyst transfer add on 5 days.

    To work out your due date its easiest to use an IVF calculator.
    http://www.ivfconnections.com/forums/content.php/749-IVF-Due-Date-Calculator-by-Date-of-Transfer-Retrieval-Ovulation-or-Insemination

    17.5.8   My bHCG has risen less than 66% in 48 hours - can I do anything?

    Probably not, but some clinics will retest your NKa and may prescribe IVIG if they think there is still a chance but the pregnancy is suffering from immune attack - its a gamble whether to do it because of the cost.  Its possibly not worth trying unless you are close to test date as the later its given, the less chance it will be able to help by then.

    Some clinics will try 3 shots of pregnyl/HCG 1500IU given on alternate days in case its a transient issue with the trophoblast that might respond to extra HCG.  It may not have a particular high chance of success but it is a very cheap treatment (about £2 per shot), although finding a chemist to buy it from (on prescription) at short notice is tricky (its not usually kept in stock so has to be ordered in) and to have a chance of working it has to be given as early in pregnancy as possible.   The disadvantages of giving HCG are that it will interfere with bHCG monitoring shots - each shot will have raised your levels by about 45-60 units 24 hours later and about 25-40 units 48 hours later (2 days), and about 8-12 units 48 hours after that (4 days) , falling to about 3-5 units 48 hours after that (6 days) and there is some risk that you will make the trophoblast of a non-viable embryo more persistent raising the risk of needing a D&C or possibly methotrexate to resolve the situation.  However, its very hard not to take this option if you are given it because its cheap and might just work.

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    Re: Immune FAQ - Continuously updated and added to.
    « Reply #17 on: 15/07/10, 22:31 »
    18   Q

    18.1   Question lists
    18.1.1   How do I make sure I get all my questions and concerns answered?

    See Appointments (above) but I recommend reading and planning before your appointments and writing up a list of your questions that you can check off during your appointment.   If you are having a telephone appointment, you may want to fax a copy of your questions to the Consultant so he has them in front of him.   You might also want to take a few minutes in the waiting room after your appointment just to check that you did cover everything and understand the advice you have been given. If the consultant is not too busy, you might be able to deal with any points you missed saving a separate trip/call.

    Some questions may be around timing or doses of medication.   I would recommend that for every medication you are prescribed you write down the dose, the time of day to take it, the day to start it and the day to stop it.   You may find it helpful either to create your own calendar in a spreadsheet that you can easily amend and print off to take to appointments or make several copies of a ready made calendar so that you can check/change timings easily (and can easily see when weekends fall etc during your treatment).

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    Re: Immune FAQ - Continuously updated and added to.
    « Reply #18 on: 15/07/10, 22:31 »
    19   R
    19.1   Recurrent pregnancy loss – see miscarriage (above or click here)

    19.2   Resources and links

    Most patients find Dr Alan Beer’s book “Is Your Body Baby Friendly” very useful as a reference book.  It is available from Amazon.

    The Beer centre http://www.repro-med.net/repro-med-site2/
    The FGA (Dr Gorgy) http://www.fertility-academy.co.uk/
    The ARGC http://www.argc.co.uk/
    Care Fertility http://www.carefertility.com/
    SIRM (Dr Sher)  www.haveababy.com
    The Lister http://www.ivf.org.uk/
    TDL pathology www.tdlpathology.com
    The Path lab, welbeck street london (has an online price list of all the lab tests they offer) http://www.thepathlab.co.uk/
    Dr Toth’s website http://www.fertilitysolution.com/
    Fetal medicine centre, Harley St (for private ultrasound scans during pregnancy – no referral needed) http://www.fetalmedicine.com/fmc/
    British national formulary (for info and list prices of UK prescription medicines) www.bnf.org
    Clinicheck London www.cliniccheck.com
    RIA lab, California  www.rialab.com/index.php
    Ardo breastpumps www.ardomums.co.uk/ ardo.ch.everest.ch-meta.net/www/ch_muk.php?SP=EN - really helpful, hospital quality breastpumps - a million times better than the stuff from high street shops
    Locus Medicus (laboratory in Athens which offers testing for Chlamydia, ureaplasma and mycoplasma in menstrual tissues samples sent by post) http://translate.google.co.uk/translate?hl=en&sl=el&u=http://www.locus-medicus.gr/&ei=922LTMTCMc2pjAeP5ZnVDA&sa=X&oi=translate&ct=result&resnum=1&sqi=2&ved=0CBgQ7gEwAA&prev=/search%3Fq%3Dlocus%2Bmedicus%26hl%3Den%26rlz%3D1R2SNYS_enGB347%26prmd%3Div
    for Serum clinic, Athens and Peny Abatzi http://www.serum-ivf.com/index.html and [email protected] [email protected]
    Yasser Latif at Rigcharm pharmacy (used to be called Ali's pharmacy), London yasser latif <[email protected]>  0207 790 9150.  07957472457 or email [email protected]
    Central Homecare pharmacy (mail order pharmacy - tend to be cheap for IVF drugs) 01420 543400
    Healthcare at Home fertility  (Jade Herrington) 08702 400518


    The ARGC and FGA (Dr Gorgy) ladies on fertilityfriends.co.uk have their own chat threads as do Care and Lister.   There are also many immune related threads in the ‘Investigations and Immunology’ section of the fertilityfriends.co.uk board e.g., a thread for Humira, a thread for thyroid issues, and a thread for LIT.  In the Greece section of the board there is a thread for the Greek Chlamydia test.  In the general pregnancy chat section you will find a ‘pregnant with immune treatment’ chat thread.

    Care Fertility have their own bulletin board at www.carefertility.com/ivf/

    Dr Sher from SIRM in the US has a blog with some immune articles at www.ivfauthority.com.    SIRM also has a forum at forums.haveababy.com where Dr Sher answers questions in the Las Vegas part of the board.   This can be a very useful way of obtaining free advice from a knowledgeable doc but I would suggest making sure you read his blogs first, otherwise Dr Sher will probably reply ‘read my blog’.  Likewise, Dr Fisch who has written books on hormones for fertility and pregnancy may reply suggesting you read his books.  I would also suggest keeping your questions very short and specific as they tend not to go into long accounts of medical histories or give detailed advice on the forum, and if you ask multiple questions, he may only answer 1 or 2 of them which can be confusing.   However, he does offer free telephone consults to provide more in depth advice, although obviously there is an element of sales-pitch to these consults and, like a lot of doctors, he can put his opinions very strongly which, as often happens in fertility treatment, may be very different to the views of other doctors in the same field.    You can also post questions to other doctors in the SIRM group on different areas of the SIRM forum and compare their views.

    Yahoo groups has a reproductive immunology forum at http://health.groups.yahoo.com/group/immunologysupport/
    which has a good files (FAQ etc) section.

    There is also a TTC/pregnancy with MTHFR group
    http://health.groups.yahoo.com/group/MTHFRPG/

    Dr Toth’s patients have a forum at http://health.groups.yahoo.com/group/FertilitySolution_TothPatients/

    19.3   RFU Chicago and RIC (UK)
    19.3.1   How do I check which tubes I need for my Chicago tests?
    You can check the test manual here:
    [http://www.rosalindfranklin.edu/cms/Microbiology/DiagnosticTestMenu.aspx]http://www.rosalindfranklin.edu/cms/Microbiology/DiagnosticTestMenu.aspx[/url]

    19.3.2   Where can I find contact details for RFU Chicago?
    http://www.rosalindfranklin.edu/cms/Microbiology/DiagnosticTestMenu.aspx

    19.3.3   How do the tests on offer at RIC (UK) compare to those at RFU (Chicago)?

    There are a number of differences.

    RIC does not offer the LAD or DQa tests.

    RIC do offer a TH1:TH2 cytokine ratio test which is significantly cheaper (cost is £190 with RIC) than with RFU via Dr Gorgy, but I do not know if they test the same cytokines as RFU i.e., I do not know if they are testing TNFalpha or another TH1 cytokine.

    RIC offer a CD69 count assay for only £110, which although it is not a direct measure of NK activity, is hopefully a good indicator (NK cells which express the CD69 marker are associated with a higher level of killing power than NK cells in general, so measuring the concentration of NKs which have CD69 expression is an indirect indicator of killing power) and is a lot cheaper than a full NK assay with cytotoxicity.  However, SIRM, Dr Gorgy, Care and ARGC do not seem to think the CD69 test is sufficient to determine NK activity.
    RIC offer an NK cytoxicity assay for £360 which is similar to an NK cytoxicity retest from RFU (but cheaper) although the RIC assay does not include the basic immunophenotype (count of CD56+, CD3+, CD19+ and CD19+5+).  RIC offers a separate lymphocyte subset assay for £75 but I do not know exactly which cell types are counted and therefore whether it is similar to RFU's immunophenotype or not.  The cost of RIC's NK cytoxicity plus immunosuppression (£450) appears to be similar to RFU's full NK assay except RFU only test suppression with IVIG (and intralipid) whereas RIC also test with steroids, but RIC don't include an immunophenotype (lymphocyte subset testing is an extra £75).  Dr Gorgy, Care and ARGC rely heavily on the CD19+5+ count included in the immunophenotype.

    RIC will accept samples of blood drawn elsewhere - but only if the blood is less than 8 hours old (rather than 48 hours at RFU), or you can have blood drawn at Quest on Wimpole Street in London. RIC require a blood test consent form signed by the patient and by the 'requesting doctor'.  Test results will only be sent out to the doctor.   

    Contact details for RIC are available here http://ri-centre.co.uk (as well as request forms, price lists, details for where blood can be drawn and the number and type of tubes to be used).

    RIC have some interesting information on their website where they state the causes of repeat miscarriage as being

    immune problems 30%
    clotting problems 10-13%
    hormonal problems 20%
    infection 1%
    uterine/cervical anomalies 5-10%
    unexplained 10-15%
    chromosomal defects unknown%

    They also state that 20-40% of patients with repeat IVF failure or repeat miscarriage have antithyroid antibodies (an indication of autoimmune issues) and 55% of patients with repeat miscarriage have antiphospholipid antibodies. However, there is no information given on the source of this data.

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    Re: Immune FAQ - Continuously updated and added to.
    « Reply #19 on: 15/07/10, 22:32 »
    20   S


    20.1   Secondary infertility
    20.1.1   Can I have immune or clotting problems if I have previously had a healthy pregnancy?
    Having previously had a baby does not rule out immune, infection or clotting issues, for example being/becoming a problem, although due to the natural immune suppressive effects of pregnancy, some ladies with immune issues may find that they improve significantly for about one year after a successful pregnancy (according to Dr Beer).

    In particular, if you have a DQa match with your partner or with your previous partner, the first pregnancy could actually have triggered alloimmune senstisation leading to NKa/TNFa surges on new implantations or to acquired thrombophilias like antiphospholipid antibodies.  Infections that did not stand in the way of your first pregnancy may become a more serious barrier to pregnancy as you become older and generally less fertile.  Similarly, as we get older, we are more likely to have immune/inflammatory related problems as we have had more time to develop them and we reach a point where our body prioritises immune defence over uterine receptivity.

    20.2   Sequential double transfer/Interval double transfer

    This means doing a embryo transfer on day 3 and on day 5.     In all studies, blastocyst (day 5) transfer shows a better statistical pregnancy rate than day 3 transfer however,  for some groups of patients there are 2 reasons why a day 3 transfer may give a better result for them

    1) none of their embryos may survive to blast giving nothing to transfer and no chance of pregnancy
    2) they may have a very short implantation window (a shorter than usual time when the lining can receive an embryo) and a day 3 embryo might just catch this when a day 5 embryo just misses it - some studies suggest that embryo development is slightly slower in the lab than inside the body.

    However, because day 5 gives a better chance for most patients, we tend to want to do a day 5 rather than a day 3.   

    A few studies have suggested that taking the best 1 or 2 embryos and transferring them to the uterus on day 3 and then letting the rest of the batch develop until day 5 and transferring 1 or 2 more might give a better pregnancy rate than just doing a transfer on day 3 and, possibly a better pregnancy rate than just doing a transfer on day 5. 

    However, the overall number of embryos transferred needs to be born in mind - as obviously there are legal limits on the total number of embryos that can be transferred per cycle and, higher numbers of embryos are more likely to result in a risky multiple pregnancy.

    The following studies may be of interest though:

    http://humrep.oxfordjournals.org/content/26/suppl_1/i160.short
     P-193 Effect of blastocyst and sequential embryo transfer on pregnancy rate
    M. Stojkovic1,  M. Ilic1,  N. Markovic1 and  P. Stojkovic1

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582122/
     
    http://www.ncbi.nlm.nih.gov/pubmed/14998193
    http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8400288
     
    http://connection.ebscohost.com/c/articles/22922933/sequential-transfer-day-3-embryos-blastocysts-after-previous-ivf-failures-despite-adequate-ovarian-response
     
    http://www.ncbi.nlm.nih.gov/pubmed/14714825


    20.3   Steroids

    See Corticosteroids (above)

    20.4   Stimulation for IVF
    20.4.1   Any dos and don’ts during stimulation?
    Don’t exercise too much – your ovaries may be swollen and can twist causing damage if you try to do more than your body is very used to.
    Do drink plenty of water and ensure a good protein intake to help egg production and to prevent OHSS.
    Do try and avoid anyone you know is ill with anything contagious like colds or flu– especially someone with chickenpox (unless you have checked that are immune with a blood test).  You may be slightly immunosuppressed due to steroids or Humira, and if not, you don’t want to catch anything that will then cause your NKa and TNFa to rise.

    20.5   Subchorionic hematoma – see bleeding in pregnancy above or

    20.6   Supplements

    20.6.1   In general
    You should check with your clinic about any supplements that you propose to take during your treatment.   There are so many different supplements being marketed as having fertility benefits that its impossible for me to consider all of them – however, I would generally be sceptical of the many of the claims being made and would suggest you look for actual research studies that back them up and check whether they have any likely unhelpful effects for your own medical and immune situation before you decide to spend money on them.  Supplements should be considered on an individual basis bearing in mind your own medical situation, immune levels, diet etc.  For most ladies, the best value for money supplements are likely to include - a prenatal multivitamin (e.g., from any supermarket), vitamin D3 (25-50mcg - but see below), Omega 3 fish oil (at least 1000mg - but see below), and possibly an extra B vitamin complex (including 400mcg folic acid) if you have the most common MTHFR mutation (which most of us do).   Many ladies might decide to take one or more antioxidants for anti-inflammatory and egg quality reasons (e.g., resveratrol, pycnogenol, lycopene).   You would probably want to start the prenatal vits, any extra folic acid, antioxidants and the vitamin D3 well in advance of fertility treatment e.g., 3 months before.  For most men, the best value for money supplements are likely to be - a men's multivitamin (e.g., from any supermarket), Omega 3 fish oil (at least 1000mg) and an antioxidant (e.g, lycopene, pycnogenol etc).  Men need to start any supplements at least 3 months before fertility treatment.

    20.6.2   Agnus Castus/Cohosh/soya isoflavones/yam etc
    Some of these e.g., Agnus Castus may be helpful if you are trying to conceive naturally as they reduce prolactin levels which can help regulate ovulation, particularly for ladies with PCOS but they all affect hormone levels so it is very unlikely that your clinic would approve their use during fertility treatment as they may interfere with treatment.  I haven't read anything suggesting that Cohosh would be safe for trying to conceive.   Soya is probably safe, but its not clear that there would be a benefit - one study showed a benefit for IVF patients in taking soya http://www.fertstert.org/article/S0015-0282(04)02356-8/abstract, but it was suggested that the benefit was due to soya's estrogenic activity which might be helpful particularly for poor responder patients who will tend to have lower circulating estrogen levels in response to IVF stimulation, in which case, estrogen supplements like progynova may give more reliable dosing.   Yam is suggested as a natural source of progesterone and is available as tablets and also creams.  However, my understanding is that the progesterone used in fertility drugs comes from the same source and given that it is more likely to be a good quality and have a more certain concentration and absorbability, I canot see why there would be any reason to resort to using yam tablets or progesterone creams if conventional progesterone supplements like cyclogest/utrogestan/gestone/crinone etc are available.

    20.6.3   Bee pollen/propolis/Royal Jelly
    Some ladies take this on the grounds that they may improve egg quality (as they contain various minerals and amino acids - but I am not aware of any scientific trials that prove any impact on egg quality).  They are often marketed as boosting the immune system (which may be disadvantageous for immune Tx ladies). It is not clear whether these claims are true as the research is sketchy, and even if they do boost immune activity whether that still applies in ladies who already have excessive activity or if it is only in immunosuppressed patients.  Bee products are unlikely to be suitable for ladies who are allergic to bee stings.

    20.6.4   Bromelain/Pineapple extract
    This is marketed on the grounds that it may improve the chances of implantation and/or improve digestion.  For the same reason, some ladies take it from egg collection to pregnancy test date, although herbalists also say raw pineapple can be used to bring on labour which implies it could cause unhelpful uterine contractions around implantation or early pregnancy – so for that reason, some ladies stick to UHT pineapple juice rather than fresh pineapple/fresh juice.  I have not seen any scientific evidence for it either way.

    20.6.5   Calcium
    Calcium supplements will generally benefit any women taking clexane or steroids or during pregnancy and breastfeeding.  Certain medical conditions do cause problems with calcium build-up (hypercalcaemia e.g., sarcoidosis, kidney stones) so in those situations you would need to check with your GP.

    20.6.6   Chinese herbal medicine
    To determine what knock-on effects these medicines have, you first need to know exactly what is in them (which is often difficult to be sure), then you have to get advice on every ingredient to find out its effects for fertility treatment and for your immune system.  Very few fertility clinics would approve their use because its too complicated to do this and there have been many reports about the labelling on Chinese medicines being inaccurate and in rare cases, the bottles containing ingredients that are very dangerous e.g., lead or banned pharmaceuticals.  See Mycology for information on chinese mushrooms.

    20.6.7   Coenzyme Q10
    Some practitioners e.g., Zita West recommend taking coenzyme Q10 during stimulation and up until embryo transfer in the hope of improving egg quality.  Personally, I would not take it after embryo transfer or during pregnancy because there is insufficient evidence that it is safe.

    20.6.8   DHEA
    Some small studies have shown that it may benefit ladies with poor ovarian reserve as they may have reduced blood DHEA levels and some improvement in egg numbers and quality has been shown for such ladies in pilot studies.  Full clinical trials have not, to my knowledge, been published yet but typical doses are 25mg micronised DHEA three times a day for three months before treatment (stopping at egg collection in case it compromises implantation).  In my opinion, it is not advisable for ladies with good ovarian reserve, and particularly for ladies with PCOS, to supplement with DHEA as it may lower Sex Hormone Binding Globulin (SHBG) and raise LH and testosterone levels leading to reduced egg quality.  In general, I think its better to have your DHEA levels tested to see if you have reduced levels or not before deciding to take DHEA, and if you do take it, to have your DHEA, SHBG, LH and testosterone levels monitored whilst you try it.  Some clinics will also want you to have regular ultrasound scans to check it itsn't giving you cysts which can also be a problem. It needs to be taken for at least three months prior to IVF to take effect.  Some clinics may be very much against you taking it.

    20.6.9   Echinacea
    This has been shown to increase immune response which is exactly what you want to fight a cold but not desirable if you are trying to reduce an overactive immune system, so I would avoid taking this whilst cycling and in pregnancy if you have, for example, elevated NKa.

    20.6.10   Evening primrose oil
    This may be beneficial when you are TTC naturally if taken up until ovulation, as it is estrogenic so, for example, may improve the quality of cervical mucus but as it is a phytoestrogen so it is not appropriate to take it after ovulation and very few fertility clinics would approve of its use during fertility treatment as it may interfere with hormone levels.

    20.6.11   Fish liver oil (cod liver oil, halibut liver oil)
    This should not be taken when TTC or pregnant because it contains excessive vitamin A. Animal liver or liver pate is not recommended for consumption during pregnancy for the same reason.

    20.6.12   Flaxseed oils (and other vegetable omega 3 oils)
    These are marketed mainly as an alternative to omega 3 fish oils.  They may be therefore be beneficial to vegetarian ladies.  However, they are likely to have some phytoestrogen content which may be unhelpful for fertility and they are not chemically the same as fish oils (mainly ALA rather than EPA or DHA) so whether or not they have the same benefits as fish oils is doubtful.

    20.6.13   Folic acid (and B6, and B12)
    All ladies who are trying to conceive should aim to take at least 400mcg of folic acid for at least three months before conception to prevent birth defects like spina bifida. (This level is included in all pre-natal vitamins together with additional B6 and B12 to balance B vitamin levels.)   Some consultants recommend higher intakes for ladies on steroids or with the heterozygous MTHFR mutation e.g., 800-2500mcg.  Most consultants recommend at least 5mg (5000mcg) of folic acid per day (balanced with about 20-50mg B6 and 0.05-1mg B12 if possible because the MTHFR mutation tends to reduce absorption/availability of B6 and B12 as well - also bear in mind that B12 deficiency is more common if you are vegetarian - and luteal phase deficit can also be exacerbated by B12 deficiency) for ladies with the homozygous MTHFR mutation whilst trying to conceive.  When you are no longer trying to conceive you should ask your GP (or ask your GP to ask a hematologist) about the appropriate dose of folic acid for homozygous MTHFR as you need to balance the additional stroke/clotting risk of not taking folic acid versus the small additional cancer risk of taking folic acid. Natural folate found in, for example, leafy green veg gives the same protection without any additional cancer risk.  The heterozygous form is unlikely to need long term folic acid supplementation but it would be sensible to eat a good diet with plenty of natural folate.  400mcg folic acid tablets are available from pharmacies and supermarkets very cheaply, but in the UK, the 5mg dose is only available on prescription and you would need just over 12 of the 400mcg (or 6 x 800mcg) tablets to equal 5mg (1g = 1000mg.   1mg = 1000mcg).  Methyl folate is easier to absorb (particularly for ladies with MTHFR) but it is more expensive e.g., solgar methyl folate or femibion. 

    20.6.14   L-arginine, L-carnitine and other amino acids
    These are marketed as improving fertility for both men and women e.g., improving egg and sperm quality.   They should be fairly abundant in a healthy diet which includes plenty of animal proteins (eggs, meat, poultry etc), but supplementation may help some ladies, and is unlikely to do any harm.   Ladies who are vulnerable to cold sores, shingles or recurrent mouth ulcers may find L-arginine triggers more attacks and may need to avoid arginine supplements or take with L-lysine.  Some men’s vitamin formulas contain arginine which can trigger the same problems and necessitate taking (a very low dose of) L-lysine.

    L'arginine (16 g per day) has been suggested to improve IVF ovarian response in poor responder patients but the published clinical trial used an extremely small sample size.

    20.6.15   Lycopene/tomato extract
    This is an antioxidant derived from tomatoes.  It is present in all tomato products but is more bio-available in cooked/pulped tomatoes than in raw tomatoes.  I see it as a cheaper (and probably safer, but possibly less effective) alternative to resveratrol and pycnogenol.   It may be cheaper to add extra tomato puree to your cooking each day or try it spread on crackers than buying a lycopene supplement.  Some ladies drink tomato juice for the same reason, but it may be more convenient to consume tomato puree because it is more concentrated and can be added to many dishes with the oil/fat in other foods helping to absorb the lycopene (lycopene is fat soluble). The optimal time to use it would be up until egg collection (to help with egg quality), but given tomatoes are a very common food, it seems reasonable to assume that lycopene supplements are safe to continue during pregnancy and the two week wait if you want to.

    20.6.16   Milk thistle extract (silymarin)
    Herbalists say that this cleanses the body by helping the liver be more efficient at removing toxins.   It is not known to be unsafe for pregnancy or trying to conceive but there is no formal safety data.

    20.6.17   Nettle leaf tea/capsules
    Nettle leaf has been shown in some small studies to have anti-inflammatory (anti TNFa) properties.  Many herbalists say that it is safe for conception and pregnancy however there is no official safety data on its consumption in pregnancy.

    20.6.18   Omega 3 fish body oil (not fish liver oil)
    Various studies have shown that EPA in fish oil has NK and TNFa-lowering properties, at least when taken in the short term. (Some studies suggest that the benefit is no longer present when it is taken for longer periods e.g., 1 year.)  DHA in fish oil has shown benefits for the development of baby’s brain.   Different brands differ a lot in content of EPA and DHA (Zita West brand for example is mainly DHA, whereas Eskimo and Nutrasea (Ascenta) contain a lot more EPA).  Cheaper brands are often more fishy tasting and are less likely to come with information proving their purity (in particular, contaminants like PCBs or mercury which are very dangerous for conception/in pregnancy).   Nutrasea seems good value for money (for a high purity product) compared to Eskimo.  It can be much cheaper if shopped around for on the net than from Holland & Barrett for example.

    The optimum dose to take is highly debatable.  One doctor in the US (who markets his own brand of fish oils) recommends 5g of fish oil per day.  Personally, I would stick to the recommendations on the bottle that you buy (Nutrasea and Eskimo recommend 1.5g of omega 3 (1500mg) per day - be careful to compare like with like e.g., 4.5g of nutrasea fish oil = 1.5g of pure omega 3) and I would be particularly cautious if taking clexane or aspirin at the same time as fish oil has blood thinning properties.  Its effects are individual and there is no recommended safe dose for use alongside clexane so, personally, I would drop the dose down initially to, say, ¼ of the recommended dose and be vigilant for any signs of excessive blood thinning (e.g., nosebleeds, unexplained bruising), then if you are ok on the reduced dose you can take a decision on whether you want to try gradually increasing the dose.  I have seen advice from Dr Sher on the SIRM board suggesting that it was safe to take 2.25g (2250mg) of fish oil with 40 mg clexane.

    http://forums.haveababy.com/index.php?showtopic=46329

    Vegetarian omega 3 capsules are also available, but these contain mainly ALA and very little EPA and DHA.  They do not therefore provide the same benefit (for either immune balancing or fetal brain development) as fish oils.

    Ladies with endometriosis may especially want to consider ensuring they have a good omega 3 intake (and a low saturated fat/low red meat intake) because studies have shown that a low omega 3 intake and a high red meat/saturated fat intake is associated with increased risk of endometriosis.

    http://humrep.oxfordjournals.org/content/19/8/1755.abstractijkey=87cadd8a5fcee3fcf73184a3b358cc3e39e89a98&keytype2=tf_ipsecsha

    http://humrep.oxfordjournals.org/content/25/6/1528

    20.6.19   Prenatal multivitamin/mineral (e.g., Pregnacare, Tommys, Tesco, Boots etc)
    Personally, I think every TTC lady should take one of these daily as the doses of vitamins and minerals are tailored to be appropriate to pregnancy and TTC. For example, they limit the amount of vitamin E and include vitamin A only as beta carotene (which is safe for pregnancy).  In my opinion, these supplements are so similar it is not worth paying over the odds for brands with fancy labels.  They are often for sale on three-for-two at the supermarkets or in Boots.

    20.6.20   Probiotics
    Many ladies think these are very helpful for overall and immune health, and are likely to be particularly helpful after/during courses of antibiotics.  The evidence for them is growing and overall, I would expect them to be helpful for most ladies and have very little chance of doing any harm.  Capsules of lactobacillae from health food shops that need to be refrigerated are likely to be better value for money (and contain less sugar) than probiotic drinks from the supermarket as you get higher levels of bacteria than in the drinks.  It is worth reading the label because the quantities of bacillae in different brands vary from less than 1 billion per pill to 30 billion per pill.   Apparently, you can preserve the levels of bacteria by storing the capsules in the freezer.  Only take them with cold water rather than with, say, a hot drink otherwise you risk killing off the heat sensitive bacteria before they've even got to your stomach.

    20.6.21   Protein powders (e.g., whey protein, pea protein, egg white protein, soy protein, hemp protein)
    It is important to get sufficient protein during stimulation and in early pregnancy for egg quality and to reduce the risk of OHSS.  Some ladies may find protein powders convenient and gentle on the stomach (particularly when you are feeling bloated and off-colour during IVF and early pregnancy).  There are many different brands based on whey (from milk), eggs, soya and peas, for example.  Personally I would avoid soya-based products whilst cycling because of their possible phytoestrogen content, but it might be a compromise you have to make if you need extra protein and are, say, allergic to dairy and eggs.   Different brands contain different levels of saturated fat, sugar, colourings and artificial sweeteners, and are available in different flavours.  Personally I would look for something low in saturated fat, sugar, colourings and without artificial sweeteners.  Solgar Whey to Go vanilla flavour seems to be low in saturated fat and does not contain sugar or sweeteners but there are other flavours which are sweetened e.g., with honey.  The powders can be made up into a shake with (skimmed) milk or water or added to cereal or to recipes like low fat/low sugar muffins, cookies, pancakes etc.

    20.6.22   Pycnogenol
    This is an antioxidant extracted from maritime pine bark.  Dr Sher at SIRM recommends taking it up until egg collection to improve egg quality in ladies whose egg quality has been shown to be poor in previous cycles, but he does not seem to specify a particular dose - although Dr Braverman (previously at SIRM) seems to have suggested 100mg (which is quite a high dose, and therefore expensive as pycnogenol is expensive to extract).  Dr Greene at SIRM recommends 30mg pycnogenol (all the time) for ladies with endometriosis to reduce its severity and symptoms.

    http://thegreeneguide.wordpress.com/2010/05/02/pine-bark-extract-and-endometriosis/

    Personally I wouldn’t take it during the 2ww or pregnancy because of a lack of safety data, but I would be happy to take it during stimulation/preparation for IVF.

    20.6.23   Resveratrol/grape/grapeseed extract
    This is an antioxidant derived sometimes from red grape but more commonly from Japanese knotweed.  Dr Sher at SIRM recommends taking it up until egg collection to improve egg quality in ladies whose egg quality has been shown to be poor in previous cycles.  As far as I am aware, he doesn’t specify a particular dose.- although Dr Braverman (previously of SIRM) has recommended 500mg (but that makes it quite expensive, because its an expensive supplement).  Personally I wouldn’t take it during 2ww or pregnancy because of a lack of safety data - in particular because of studies on animal suggesting it affects bloodflow to the placenta so much in pregnancy that it can damage the baby's pancreas.  http://www.fasebj.org/content/28/6/2466.abstract.  Some doctors (particularly Dr Nodares in Greece) seem to be recommending it for ladies with high TNFalpha ratios but personally, I haven't found any scientific studies that prove it would definitely have that effect.    I understand Dr Nodares has been using the Nature's plus 125mg extended release product (3 times per day). 

    20.6.24   Quercetin (green tea extract)
    This is an antioxidant which seems to have anti-inflammatory (anti TNFa, anti NKa) properties.   Some practitioners also think it helps improve egg quality.  Personally, I would stop any green tea supplement at ET, and limit tea consumption during the 2ww and pregnancy to two cups per day because of the caffeine.    Apples are a caffeine free source of quercetin.

    20.6.25   Selenium
    Prenatal vitamins usually include sufficient selenium for TTC.  Selenium is vital for fertility but toxic in excess so personally, if you are considering taking multiple products containing selenium, I would suggest checking that you are not far exceeding the RDA (60mcg) in total, unless you have a condition for which you doctor recommends additional selenium e.g., Hashimoto's where the recommended dose tends to be around 200-400mcg per day.  Some ladies eat brazil nuts as these are high in selenium, although according to the US NIH, the actual selenium content of brazil nuts varies a lot.  Patients with hashimoto's who are planning to take selenium long term, might want to think about getting their blood levels after a couple of months on the supplement.  Levels 130-150 mcg/l in blood are ideal  but very high levels are supposed to be associated with an increased risk of diabetes.  if you have Hashimoto's issues it is very important not to be deficient in selenium before you start necessary iodine supplements.

    20.6.26   Spirulina
    Spirulina is an algae and its dried extract contains a number of minerals, vitamins and amino acids.  Some ladies believe that it improves egg quality.  So long as it is a reputable brand that is free from contaminants e.g., mercury, I can’t see any harm in taking it.   There is some scanty data that suggests it might increase NK killing power but no independent studies, so far as I can see, on patients whose NK killing power is elevated to begin with.  Ladies with thyroid issues should speak to their endocrinologist before taking it or any other supplement that contains a lot of iodine.

    20.6.27   Tumeric (curcumin)
    Curcumin is derived from tumeric (the yellow curry spice).  It has been shown to have anti inflammatory (anti-TNFa) properties.  As it is a common foodstuff, I think it is fairly likely to be safe in pregnancy and for TTC but there is no official safety data.   Personally, I would take only a low-moderate dose during fertility Tx (e.g., ½ - 1/3rd of the maximum recommendation on the label - e.g., 500mg of extract e.g., Lamberts (bear in mind that it is difficult to compare different brands because some are turmeric and some are purified extract)) for safety reasons and because very high doses can irritate the stomach.   I would probably stop it either at embryo transfer or maybe at test date.

    20.6.28   Vitamin A and beta carotene
    Vitamin A should not be taken by ladies who are pregnant or TTC.   Beta Carotene is precursor of vitamin A which is safe for ladies to consume, as the excess can be excreted, unlike Vitamin A itself.  Beta carotene has antioxidant properties so some nutritionists suggest it might have antiinflammatory (e.g., anti-TNFa properties).  Red coloured vegetables like carrots and tomatoes are high in beta carotene, so some nutritionists have suggested drinking carrot and tomato juice to increase both beta-carotene and lycopene intake (see lycopene).

    20.6.29   Vitamin E
    Vitamin E supplements have been linked to birth defects in babies and can overthin the blood.  Personally I would avoid any vitamin E supplement higher than the amount already included in a prenatal vitamin, ideally for 3 months before TTC.  For the same reason I would avoid supplements high in vitamin E like wheatgerm.  Bear in mind that vitamin E is used as a preservative in foods and other supplements (normally listed as tocopherols), so you may be getting a higher dietary intake than you realise especially if you are also eating foods rich in wheatgerm, so deficiency may be unlikely.

    20.6.30   Vitamin D
    Most studies show that pregnant and breastfeeding women benefit from taking vitamin D (unless they get a lot of exposure to the sun).  Additionally, vitamin D is important for regulating the immune system (including NKa and TNFa).  Personally (as someone who doesn't get outside much), I would consider taking 25-50 mcg (1000- 2000 IU) of vitamin D3 per day during trying to conceive, pregnancy and breastfeeding, particularly during winter in the UK - unless blood tests show that my vitamin D3 level was sufficient - and ideally you would ask your GP for a blood test to check your vitamin D level before deciding to take a high dose vitamin D supplement.  Vitamin D3 is more effective to take than other forms of vitamin D. Blood levels of vitamin D tend to correlate with skin tone so darker skinned ladies in the UK are more likely to need a higher dose of vitamin D than redheaded ladies.  Some docs including the Scottish NHS are advising all pregnant and breastfeeding women to take a supplement of 12.5mcg (500 IU) vitamin D because they believe it may help to reduce the risk of multiple sclerosis, bone disorders like rickets and cancers like melanoma for baby later in life - bear in mind that Vitamin D deficiency is now so common than 1 in 5 children in some areas of the UK are apparently now being diagnosed with rickets.  If you have been diagnosed with a hypercalcaemia related disorder (e.g., calcium kidney stones, sarcoidosis) you will need to check with your GP.  Vitamin D3 will often cost a little more than Vitamin D2 but it is more effective.   

    Vitamin D is often included in calcium supplements but only in very small doses - to help calcium absorption - not enough to support the body's need for Vitamin D.    Vitamin D is also included in many pregnancy multivitamins but at variable doses, e.g., 5 mcg in Lamberts Strong Start, 15mcg in Pregnacare Conception, 12 mcg in Tommys pre-natal.

    Dr Braverman's clinic in the US appear to be currently recommending 50-100mcg (2000-4000 IU) of vitamin D3 per day to to reduce elevated TNFa ratios but only for ladies whose vitamin D level is low on blood test.  US studies suggest that if there is a deficiency of vitamin D shown on a blood test, it may take a dose of 75-100mcg (3000-4000IU) to get levels up to the normal range, before moving on to a maintenance dose of 25mcg/1000IU.

    25mcg = 1000 iu of Vitamin D3.  According to the US National Institute of Health, healthy adults can take up to 100mcg (4000 iu) of vitamin D supplements per day, but should not take more than that but some sources recommend that no-one should take more than 50 mcg/2000 IU without medical supervision (blood tests to check whether the dose is resulting in optimum blood levels). 

    There are two standard vitamin D tests: 25 OH and 1.25OH.   25 OH is the test you need to check your vitamin D level (1.25OH is mainly a diagnostic test for parathyroid disease - so not useful for fertility purposes unless you have reason to suspect parathyroid disease etc). Minimum blood levels of 25 OH vitamin D from different laboratories vary, partly because there are 2 different units of measurement, nmol/l and ng/ml, because there are different laboratory methods for measuring 25 OH vitamin D and also because there is no international scientific agreement on how high a vitamin D level to aim for yet.    UK authorities tend to suggest blood levels which are based on studies into the minimum levels required to avoid bone fractures due to vitamin D deficiency, but are about half that which has been suggested by several researchers is optimal.   Immunologists seem to favour the higher ranges, particularly for pregnant women or for patients who have signs of immune dysregulation e.g., autoimmune diseases.

    This article about vitamin D and doses etc:  http://www.medscape.com/viewarticle/731722 includes the following:

    "A normal range of vitamin D is 30 to 74 ng/mL(ug/L) (75-185 nmol/l), but this can vary among laboratories. Most experts agree that a concentration between 35 and 40 ng/mL (ug/L) (88-100 nmol/L) is reasonable for preventive health. Some suggest that the optimal concentration for protecting against cancer and heart disease is between 50 and 70 ng/mL (ug/L)(125-175 nmol/l) and up to 100 ng/mL (ug/L)(250 nmol/L). Side effects or toxicity can occur when blood concentrations reach 88 ng/mL ug/L (220 nmol/L) or greater. Symptoms include nausea, vomiting, constipation, headache, sleepiness, and weakness.  Too much vitamin D can raise blood calcium concentrations, and acute toxicity causes hypercalcemia and hypercalciuria."

    My understanding therefore is that those of us with autoimmune problems should be aiming for blood levels of 50-70ng/ml (125-175nmol/l)

    However, ladies with endometriosis may especially want to ask to have their 25 OH vitamin D levels checked from time to time as they may want to make sure their levels are optimal but avoid having very high blood levels of vitamin D.   This is because there has been at least 1 study which showed that ladies with endometriosis were more likely to have higher than average levels of 1 form of vitamin D in the body - although, the authors of the study suggested that dietary intake of vitamin D was probably less important than, for example, sun exposure and skin colour (with redheads tending to have the highest vitamin D blood levels and african origin ladies tending to have the lowest vitamin D blood levels) - they suggested that elevated levels of 25-hydroxyvitamin-D3 might be a marker for the risk of endometriosis but did not establish whether the high levels caused/exacerbated endometriosis or whether they were the result of other factors.

    http://humrep.oxfordjournals.org/content/22/8/2273.full

    One study also suggested that vitamin D deficiency might be a contributing factor to the growth of uterine fibroids, so fibroid-prone ladies might want to check their vitamin D levels and aim for high-normal levels.

    http://www.bellaonline.com/articles/art29992.asp/zzz

    Another study suggests that patients with low vit D have a reduced chance of pregnancy following IVF:

    http://www.ncbi.nlm.nih.gov/pubmed/19589516

    You can get a reasonably priced reliable vit D test privately run at an NHS lab by post here:

    http://www.vitamindtest.org.uk/

    20.6.31   Wheatgrass and Barleygrass
    Some ladies take this on the grounds that it may help reduce FSH or help improve egg quality.  Studies have shown that it does seem to raise NKa and TNFa (which could be an issue for immune treatment ladies), although these studies have generally focused on immunosuppressed patient groups like the elderly or cancer sufferers.   It is therefore not clear whether it is beneficial or disadvantageous for immune Tx ladies to take wheatgrass.  It is also not clear if using it to reduce FSH will actually give any benefit in terms of egg quality or ovarian response as its possible that any FSH suppression may come from increasing estrogen levels.

    20.6.32   Wobenzyme-N
    This is manufactured from protein-digesting enzymes extracted from cow and pig offal, pineapple and other sources.   This may be helpful, particularly for ladies who have gut issues leading to high TNFa, as it may improve digestibility particularly of proteins, but the manufacturers claim that its benefits go further than that and have a systemic (whole body) effect on the immune system.   I’m sceptical about some of the claims made but a lot of ladies with immune issues try it.

    20.6.33   Zinc
    This is normally included in prenatal vitamins.   It is essential for male and female fertility.  Ladies with autoimmune issues may be more likely to have gut conditions (e.g., IBS, Crohn’s, Coeliac, UC) or other conditions (e.g., diabetes) that reduce zinc absorption and vegetarian ladies may also be deficient.  Pregnancy is another cause of zinc depletion.  Many couples will therefore want to consider additional zinc supplementation, but levels greater than 40mg per day should only be taken on medical advice (according to the US NIH).


    20.6.34   Supplements for men
    I think most/all men would benefit from a good men’s multivitamin e.g., Wellman (preferably Wellman Conception) or one of the supermarket versions as that should ensure they have adequate zinc and selenium etc.  For men who have motility and morphology issues or whose sperm count is borderline, supplements including antioxidants (e.g., pycnogenol, lycopene, N-acetyl cysteine, vitamin E, vitamin C, maca, resveratrol), zinc, selenium, and amino acids e.g., L-carnitine may help to improve sperm quality. 

    The key supplements that have been proven in studies to have a positive effect on sperm parameters include:
    pycnogenol/maritime pine bark extract - e.g., 200mg - this is a lot higher than the doses included in branded supplements like Wellman (http://www.chiroonline.net/_fileCabinet/pycnog_pub.pdf).  Pycnogenol supplements are available for around £0.35 per 30mg to £0.42 for 150mg capsule from healthfood stores.
    lycopene (tomato extract) - e.g., 4mg - about the same as 1 tablespoon of tomato paste.  Lycopene capsules are available from healthfood stores for about £0.22 for 10mg. (http://www.springerlink.com/content/v267846648jq2782/)
    vitamin E and vitamin C - e.g., 1000mg of each - (http://www.andrologyjournal.org/cgi/content/abstract/26/3/349) these are higher than the doses included in branded supplements like wellman - but they are cheap to buy as individual supplements.   SERUM in particular favour high doses of vitamin E.  Vitamin E 170mg/400 IU capsule are available from supermarkets like Tesco and ASDA for £0.05 each and 500mg Vitamin C tablets for about £0.03 each.  However, a few recent studies have suggested that for some dna fragmentation problems, very high dose vitamin C can have a pro-oxidant effect so they suggest using a mixture of several different lower dose antioxidants (e.g, bilberry, lycopene etc) plus B vitamins rather than a high dose of vit C.
    zinc - e.g., 60mg (http://www.fertstert.org/article/S0015-0282(01)03229-0/abstract) - but the US NIH says you should avoid taking more than 40mg without medical advice. 15mg zinc tablets are available from supermarkets like tesco and asda for approximately £0.04 each.
    folic acid - e.g., 400-5000 mg (http://www.fertstert.org/article/S0015-0282(01)03229-0/abstract) - 400mcg tablets are available from supermarkets like tesco and asda for approximately £0.01 each.
    Selenium - e.g., 225mcg (http://informahealthcare.com/doi/abs/10.1080/01485010390129269) - 50mcg Selenium tablets are available from some supermarkets and health stores for about £0.03 each.
    L-carnitine - e.g., 2000mg (more likely to benefit men who don't eat a lot of red meat - red meat contains a lot of carnitine) (http://www.fertstert.org/article/S0015-0282(02)04679-4/abstract) - L-carnitine tablets are available from health food stores for about £0.17 per 500mg tablet.
    Omega 3 fish oil (DHA/EPA) - e.g., 1840mg (http://www.ncbi.nlm.nih.gov/pubmed/21219381)  1000mg omega 3 fish oil capsules are available from supermarkets like Asda and tesco for approximately £0.05 per capsule.

    A number of supplements claim to be 'complete' formulae for sperm e.g., Menevit (Australian), Proceptin (US), Proxeed (US), Wellman conception (UK), Fertilaid (US), Zita West vitamen & vitamen boost combination (UK) - but comparing them is very difficult, partly because the supplements made in the US do not disclose exactly what they contain (they describe using 'blends' of plant extracts but do not explain the exact compositions of these blends).   Additionally, none of them seem to include the high doses of individual nutrients that have been used in studies, and none of them that I have seen include any significant amounts of omega 3 oils.  As far as I can see, it would be better and cheaper to start with a supermarket men's multivitamin and then buy the individual high dose supplements separately (most of them are now available very cheaply at supermarkets e.g., Vitamin C, Vitamin E, Omega 3, folic acid, zinc with pycnogenol, selenium and L carnitine being available from many online stores and health food shops.  However, that would mean taking 8-10 pills per day - although some of the branded formulae require you to take 6 pills a day (e.g., Zita West combination).

    I have tried to compare some of the branded vitamins here:

    https://spreadsheets1.google.com/pub?hl=en_GB&hl=en_GB&key=0Ah3l-_AvvCXydGI4STZ6Rm1mU1hBSEEzNjRxS3d3ZXc&output=html

    Lifestyle changes like stopping smoking, cutting drinking, losing excess abdominal fat, avoiding tight pants, giving up arduous bicycling and avoiding medications like antidepressants can also make a big difference.   Motility and morphology (which are related to DNA fragmentation) may also be improved by frequent ejaculation (but this is less beneficial for men with very low counts).

    My understanding of studies on supplements is that they will probably not improve sperm count in men whose counts are very low (e.g., less than 1 million/ml) as those problems are more likely to be due to something permanent e.g., anatomical or other issues that have been present since birth.  That is not to say that men with very low counts cannot achieve a healthy pregnancy e.g., with ICSI - but they are more likely to have problems with excessive DNA fragmentation so, after trialling an antioxidant supplement regime (and stopping alcohol and smoking) for at least 3 months, it may be worth having a sperm DNA fragmentation test.  If DNA fragmentation is greater than 30%, the chances of a live, healthy baby are low (perhaps only 30% of normal).  If fragmentation is between 15-30% the chances are lower than normal.  Any one-off abnormal counts should be repeated as they could be due to a one-off problem like fever/infection in the last 3 months. 

    Personally, I also tried to discourage my partner from eating tuna fish (in case of elevated mercury), to reduce exposure to house paints (painters and decorators statistically have more male fertility problems due to the chemicals they are exposed to) and to cut his consumption of peas/beans/lentils/soya as they contain phytoestrogens that are thought to sometimes reduce sperm count.  BPA, a chemical found in canned foods, polycarbonate plastic bottles and till receipts printed on thermal paper is associated with poor sperm (as well as poor egg quality).  A diet high in antioxidants (plenty of fresh red/orange/green fruit and veg) and omega 3 (e.g., oily fish) and low in saturated fats should also help sperm parameters.   Some studies have suggested that laptops on the knees, or keeping mobile phones in trouser pockets might be enough to raise the scrotal temperature leading to poor sperm.

    20.6.35   Melatonin

    One study seems to be suggesting taking low dose melatonin (3mg at bedtime) for ladies starting their second IVF who were shown to have poor egg quality as shown by their first IVF.  Melatonin is a natural hormone which is related to regulation of the sleep cycle.  Some studies have promoted it as an alternative to sleeping pills but there have been some suggestions that it may increase the risk of some cancers (but possibly only at higher doses) - other studies have suggested that it can be used to treat other cancers.  At the moment there is only 1 study which suggests an improvement in egg quality with it.  Melatonin is not available for purchase in the UK but is available for sale over the counter in many other countries including the US and is easy to buy over the internet from reputable suppliers like Natrol and Biovea.

    http://www.bionews.org.uk/page_70654.asp

    20.6.35   Inositol

    Inositol is related to the B vitamins.  Studies on mice have shown that inositol or myo-inositol may improve egg quality.  There has been 1 human study which looked at egg quality in ladies with PCO (ladies with PCO often have a 'brittle' response to stimms - its easy to be on too low a dose and get very few mature eggs, but on a slightly higher dose to get many eggs (or even OHSS) that may be poor quality).   PCO is generally taken to be more than 10 antral follicles per ovary.  In the PCO study, ladies were given 2g of myo-inositol (and 200mcg folic acid) from day 1 of IVF stimulation.  They showed a higher number of mature eggs recovered and a lower rate of OHSS.  D-chiro inositol has been suggested to help with insulin resistance and PCOS but its effect on egg quality does not appear to have been tested.   Foods made with buckwheat e.g., soba noodles are supposed to have a high inositol content.

    20.6.37   Supplements for ladies (and men) with Crohn's disease, Ulcerative Colitis, Coeliac and other bowel diseases and diarrhoea

    Patients with Crohn's disease and other conditions involving inflammation of the bowel and frequent diarrhoea may suffer from poor absorption of nutrients and blood tests may show deficiencies of A, C, D, K , E, B1, B2, B6, B12, biotin, folic acid, calcium, zinc, protein, selenium, magnesium and glutathione, all of which are important for male and female fertility and for the health of the fetus.  Deficiencies of the B vitamins, particularly folic acid may result in elevated homocysteine levels which are associated with increased risk of blood clots and birth defects for baby (see MTHFR, below under Thrombophilia).    Studies have shown that simply taking tablets e.g., folic acid may not improve deficiencies in patients with severe bowel disease, particularly tablets which are generally poorly absorbed.    Patients with bowel disease may need to experiment with liquid vitamin/mineral supplements like floradix or sublingual supplements (supplements that are absorbed under the tongue) and have their blood levels remeasured to make sure they are rectifying deficiencies rather than the nutrients just going straight through the gut.   

    Some antibiotic therapies in the run up to and during fertility treatment may result in ongoing diarrhoea.  Both partners may want to think about taking probiotic capsules during this period and for several weeks afterwards to try to reduce diarrhoea and, potentially, liquid vitamin/mineral supplements particularly for iron, zinc and the B vitamins including folate.

    20.6.38   Beta carotene

    See vitamin A (above).