I am going to copy and paste the results from Dr. Kim. Most of this you might not understand unless you have been through the testing.
I highlighted all of the tests that I came up positive for.
Assessment/Plan
Lab Results and Recommendations
Autoimmune abnormalities are often present in women with recurrent pregnancy
losses or implantation failures. Autoimmune screening tests determine the
presence of any aberrant reactivity to self-tissue components such as
phospholipids, nuclear components and thyroid antigens.
APA (286.53 Autoimmune disease, not elsewhere classified) Tested High Positive
Antiphospholipid antibody test was positive. Women with antiphospholipid
antibody have increased risk to develop fetal death, stillbirth, recurrent
pregnancy losses, severe pregnancy induced hypertension, intrauterine growth
restriction and placental insufficiency even during the latter half of
pregnancy.
ANA (710.9 Unspecified diffuse connective tissue disease) Tested High Positive
Antinuclear antibody and autoantibody to nuclear components (such as DNA,
nucleotide and histones) were tested. ANA screen was found to be positive with
a titer of 1:320 and Centromere pattern. Due to the potential risk of
miscarriage with a positive ANA, early re-screening for ANA is recommended with
a positive pregnancy test.
Antibodies to nuclear components
Autoantibodies to nuclear components were negative.
ATA
Anti-thyroid antibody tests including anti-thyroglobulin antibodies and
anti-peroxidase antibodies were negative.
Thyroid function testing was normal. TSH was 1.55.
NK Assay (288.8 Other specified disease of white blood cells) Positive
Natural killer cell levels and cytotoxicity have been reported to predict a
pregnancy outcome. The NK assay demonstrates normal CD56+ natural killer cell
levels with relatively elevated NK killing capacity by flow cytometric
analysis. The NK cell in vitro response to immunoglobulin G was adequate. B
lymphocytes were measured by flow cytometric immunophenotype study. The patient
has normal CD19+ B cell levels with normal CD5+ B-1 cells. These CD5+ B 1 cells
are capable of producing autoantibodies that damage the placenta and decrease
maternal to fetal blood flow.
TH1/TH2 Cytokine (279.10 Immunodeficiency with predominant T-cell defect,
unspecified)
T lymphocytes were investigated based on their cytokine producing capabilities.
The patient has increased T helper 1, inflammatory immune responses. T Helper
1/T Helper 2 cytokine producing cell ratio reflects the ratio between two
opposing T Helper immune responses. An elevated ratio reflects the dominance of
TH-1 cells (represented by secreting TNF-alpha and IFN-gamma), which are
cytotoxic and pro-inflammatory; as against the TH-2 cells (represented by
secreting IL-10) which are important for implantation and pregnancy.
Anti-inflammatory medication or immune modulators such as steroid and/or
intravenous immunoglobulin G infusion treatment is recommended.
Hormonal evaluation
DHEAS level is within normal limits.
DHEA level is within normal limits.
Testosterone Free and Total levels are within normal limits.
Fasting free insulin level was relatively elevated.
Thrombophilia (289.82)
Testing for inherited blood clotting tendencies or acquired thrombophilia was
performed.
Leiden factor V gene was normal.
Prothrombin gene was normal.
Factor XIII gene was heterozygous mutated.
B-Fibrinogen gene was normal.
HPA-1 gene was normal.
PAI-1 gene was heterozygous mutated.
MTHFR (C677T) gene was heterozygous mutated.
Anticoagulants, folic acid, vitamin B6 and B12 supplements are often considered
for MTHFR gene mutation.
Serum homocysteine level was normal.
Plasminogen Activator Inhibitor 1 level was normal.
Protein C Activity was normal.
Protein S Activity was normal.
Other evaluations
Vitamin D 25, hydroxy was normal.
The following are recommendations for treatment during conception cycle:
· Start Metanx once daily, vitamin E 400 i.u
once daily and prenatal vitamins once daily.
· Start Metformin ER 500 mg twice
daily orally as directed.
· Start coated or buffered aspirin 81 mg. (one
baby aspirin) orally, daily the cycle of planned conception and continued
throughout pregnancy.
· Start vitamin D3 1000 unit per day.
· Recommend to see a rheumatologist prior to
next pregnancy attempt.
· Start Prednisone 10 mg. once daily 48 hours
after ovulation. Increase Prednisone to 10 mg. twice daily at the time of a
positive pregnancy test. Since Prednisone can induce gestational diabetes, fasting
blood sugar should be monitored monthly at the referring physician’s office
with test results forwarded to us. If pregnancy is not achieved after 3
conception cycles on Prednisone, discontinue the medication and contact the
office for further recommendations.
· Start endometrin 100mg twice daily
intravaginally twice daily 48 hours after ovulation for 10 days then stop for
this cycle.
· Blood work one day between cycle days 1-3 of
conception cycle for NK Assay, TH1/TH2 cytokine, Chemistry panel TFT, ANA,
fasting free insulin and testosterone total and free.
· Start Lovenox 40 mg once daily, this must be
injected subcutaneously and initiated cycle day 6 of the cycle of planned
conception. It should be stopped if menses begins and pregnancy test is negative.
· Increase Lovenox 40 mg twice daily with a
positive pregnancy test and continue throughout pregnancy until instructed to
stop.
· Uterine Biophysical Profile 5-7 days post
initiation of Lovenox treatment.
· Start Endometrin 100mg intravaginally twice
daily and Prometrium 200 mg. orally, once daily the cycle of planned
conception, 48 hours after ovulation or within 48 hours of embryo transfer and
continue throughout pregnancy until instructed to stop. Discontinue the
Endometrin and Prometrium if the pregnancy test is negative.
· Start supplementary Calcium Caltrate 600 mg
with vitamin D 200-400 IU twice daily when taking Lovenox and/or Prednisone
therapy.
· Start Intravenous Immune Globulin (IVIg) as
follows: Immunoglobulin G 400mg/Kg/day for one day between days 6-14 of
conception cycle, at time of positive pregnancy test and repeated every 2 to 3
weeks as indicated by follow-up laboratory testing.
PLEASE NOTE FIRST DOSE NEEDS TO BE DONE AT RFUHS
· NK assay, cytokine ratio and ANA study
should be done 5-7 days after each IVIg infusion.
· Pregnancy test 10 days after ovulation (Blood
testing for b-hCG, serum E2 and P4 level).
The following are recommended as follow-up tests during pregnancy.
1. We recommend an APTT, Chemistry panel and a CBC with platelet count every
month while on Lovenox. These tests should be done at the referring physician’s
office with test results forwarded to us.
2. We recommend TSH, Free T-4 and Free T-3 weekly to monthly as needed. These
tests should be done at the referring physician's office with test results
forwarded to us.
3. Antiphospholipid antibody, anti-DNA/histone antibody, ANA, NK assay, PAI-1
and TH1/TH2 cytokine testing starting with positive pregnancy testing then as
needed. Patients must schedule this test with our office.
4. A β-hCG should be drawn every two days until a heartbeat is established per
ultrasound.
5. Progesterone and Estradiol levels should be performed at the time of a
positive pregnancy test and weekly during pregnancy until instructed to stop.
6. Blood pressure monitoring should be done monthly while patient is on
prednisone.
7. A Triple Test (AFP, ß-hCG, unconjugated estriol) is recommended at
approximately 16 weeks of gestation. The Triple Test screens for open neural
tube defects and aids in assessing the risk for fetal chromosome abnormalities.
Abnormal Triple Test results should be followed up by genetic counseling,
high-resolution ultrasound evaluation and amniocentesis, if necessary.
8. Ultrasounds using gray-scale and Doppler techniques to assess the pregnancy
development should be done every week beginning at 5-6 weeks of gestation
through the first trimester and then monthly.
9. At 28-30 weeks, weekly Non Stress Tests and biophysical profile exams should
be done.
1. POLYCYSTIC OVARIES (256.4)
·
METFORMIN ER 500 MG
TABLET,EXTENDED RELEASE 24 HR -
Take 2 tablet(s) every
day by oral route in the evening for 30 days. Qty: 60 tablet(s)
Refills: 3 Pharmacy: WALGREENS DRUG STORE 12027
Note to Pharmacy: Start one pill every other day for 3 times,
then one pill every day for 7 days, then 2 pills per day.
2. SECONDARY HYPERCOAGULABLE STATE (289.82)
·
METANX (ALGAL OIL) 3
MG-35 MG-2 MG-90.314 MG CAPSULE -
Take 1 capsule(s) every
day by oral route for 90 days. Qty: 90 capsule(s)
Refills: 3 Pharmacy: WALGREENS DRUG STORE 12027
3. RECURRENT PREGNANCY LOSS WITHOUT CURRENT PREGNANCY (629.81)
·
PROMETRIUM 200 MG
CAPSULE -
Take 1 capsule(s) every
day by oral route for 30 days. Qty: 30 capsule(s)
Refills: 1 Pharmacy: WALGREENS DRUG STORE 12027
4. LEIOMYOMA OF UTERUS, UNSPECIFIED (218.9)
5. UNSPECIFIED DIFFUSE CONNECTIVE TISSUE DISEASE (710.9)
·
PREDNISONE 10 MG TABLET
-
1 tab daily
Qty: 30 tablet(s) Refills: 3 Pharmacy:
WALGREENS DRUG STORE 12027
6. ANTIPHOSPHOLIPID ANTIBODY WITH HEMORRHAGIC DISORDER (286.53)
·
ENOXAPARIN 40 MG/0.4 ML
SUBCUTANEOUS SYRINGE -
Inject 0.4 mL every day
by subcutaneous route for 30 days. Qty: 12 mL
Refills: 0 Pharmacy: WALGREENS DRUG STORE 12027
Discussion: All test results were reviewed with the
patient and a treatment plan was established. Pros and cons of treatment and
possible side effects of medications were thoroughly reviewed. Patient was
recommended to read the educational booklet that was given for further
information regarding medications.
Patient was informed to check insurance for IVIg coverage.
Patient was instructed to contact her infertility specialist and establish a
plan for next conception cycle.
Patient is planning to have ART with/without IUI cycle as next cycle.
Any of you that have seen Dr. Kim or have any experiencing with this testing, I would love some feedback!
