Thursday, October 3, 2013

Reproductive Immunology Consult

In my never ending quest to figure out why we haven't been able to get pregnant easily, nor keep a pregnancy once it happens, I've done some personal research on RI (reproductive immunology) here and there. RI is a somewhat limited scope of practice within reproductive endocrinology, and to say that it's controversial would be an understatement. There are very few physicians who focus on treating the immune system as a cause of infertility. The ones who do believe strongly in it's importance and are quick to defend the protocols they prescribe to their patients, many of them claiming to help the women no one else can help.

Most RE's who DO NOT look at immunology on an in-depth level as part of the infertility patient's treatment plan are likely to point out that "there's not enough large scale double blind peer reviewed research." I get this. Even as a lay person, I am extremely selective with which studies I think are worthwhile, and it's not hard to recognize which studies simply show correlation vs. true causation. The infertility field is FILLED with studies showing causal relationships between various lifestyle factors and IVF success/failure rates. For instance, as you probably know, just because someone drinks less than 3 glasses of red wine per week, it doesn't mean that is THE THING that caused them to become pregnant through IVF. It just so happens people who drink less than 3 glasses of wine might also tend to eat healthier, sleep more, and engage in a host of other healthier lifestyle practices, which could ultimately affect IVF outcomes...You see my point.

Still, I do think there is something to be said about treatment options that might not have the huge body of double blind research backing it up quite yet. It's very commonplace to treat cancer patients with drugs that "show promise" through clinical trials. Some of the most effective cancer treatments available today were once only available through clinical trials and that is HOW they were discovered to be so effective in the first place. That is how I kind of view the field of RI right now.

There may not be a sufficient amount of well-designed RI studies that would garner complete acceptance for many of our RE's at this point in time. However, even my RE admits, "We think there's something to it (autoimmunity as a factor in infertility & pregnancy loss)." He is also quick to follow that up with, "We just don't agree with many of the treatments being used on patients, not until there is more research showing sufficient proof."

So, here I am as a patient who has now transferred 5 seemingly normal blastocysts with no success beyond a chemical pregnancy. Was my lining just not optimal? Were our blasts genetically or chromosomally abnormal is some way? Was it just a bad batch of eggs altogether? OR is there some sort of autoimmune issue causing my body to see each embryo as a "foreign invader" and attack it?

There are quite a few doctors who believe some women have heightened levels of activated natural killer cells in their uterus, which basically attack embryos looking to implant. It's even theorized that because activated natural killer cells only live in the uterus and not the fallopian tubes, ectopic pregnancies occur in some cases. I have personally had 3 early losses now, one of which being a suspected ectopic. So yeah, it does interest me and make me scratch my head a little, wondering if there's any chance this could be part of our issue? I also have a family member with lupus and have tested positive for APA's (blood antibodies) myself. Both factors are autoimmune in nature and could be seen as "smoke" which might lead to fire in my case.

I already blogged about the book Is Your Body Baby Friendly before, but if you haven't read it and want a Cliff's Notes version of the principles I'm talking about, feel free to check out these videos...

Failed IVF, Chemical Pregnancy, or Miscarriage
Implantation Dysfunction
...More Videos on Infertility, IVF & Pregnancy Loss

There are definitely two sides to the story for women who do seek immunological treatment to become pregnant. There are those who experience years of infertility, including multiple pregnancy losses, failed IVF attempts, and even donor eggs before seeking treatment for the "underlying immunological cause" which seemingly was the answer the whole time. They found THE THING that worked for them, and with some very individualized tweaks to basically "turn off" their overactive immune system, went on to have their own biological children.

Then, there are other women who regret opening the giant can of worms that is RI; Expensive tests done by very few labs in the country, somewhat untested treatment plans (by the larger medical field's standards), some traveling to Mexico for non-FDA approved treatments, and thousands upon thousands of dollars spent and more time wasted,  only to end up with no baby. Some of these same women have even gone back to their original RE after no success with RI, and THEN became pregnant without any immune protocol whatsoever. So obviously, even if specific immune testing revealed abnormalities in these women, they didn't have success with immune treatment but ultimately DID without this special treatment? How do the RI's explain these cases then?

My own RE still contends that our losses and failed IVF's have most likely been due to genetic abnormalities in the embryos (and more specifically those coming from the egg). There is a plethora of research out there to back up his viewpoint that this is the most feasible argument. However, what if I am yet again one of the very few % of women who doesn't just have "flawed eggs" and it's something else?

I have been extremely hesitant to even toy with the idea that there could be something autoimmune related going on with us, because of the mixed outcomes I've seen out there. So far, I've been continuing to put my trust into my own RE's extensive expertise of more than 30 years, while also reading about all the other cutting edge stuff going on and bombarding him and any other doctors who will listen to & answer my questions. Ha!

Hubby and I have been discussing seeking a 2nd opinion for a while now. I guess a forced break following surgery and knowing we only have two embryos left in the freezer lit the fire under my ass. We had a Skype consult with Dr. Geoffrey Sher (in the videos above...one of the more well-known RE's who practices RI) on Monday morning. I read his book IVF: The ART of Making Babies before we ever did IVF, and I am familiar with how he practices from watching his videos. There are other popular physicians like Braverman (NYC), Kwak-Kim (Chicago) and Beer's Clinic (CA) who delve pretty deeply into the autoimmune stuff. To be clear, I'm not jumping ship on my current RE at this point in time. I've asked Dr. V first how he felt about us seeking outside opinions out of respect, and he is all for it. Dr. Sher gives FREE consults to anyone who wants one so why not, right?

Just as I suspected, Dr. Sher would like me to do a blood test for activated natural killer cells; Specifically the K562 Target Cell Test. I have been curious this whole time if I have activated natural killer cells, so I am fine with doing it. I appreciate Dr. Sher ordering the test for me pro bono. I have not paid him a dime. The test is done through Reprosource in Boston, as they are one of the few labs in the country who run this test. They will refer me somewhere to have my blood drawn here, and I will just Fed Ex my sample to them. If it's found to be negative, nothing further will be needed as far as immune testing. If it is positive, then further testing can be performed.

I am doing this K562 test with extremely OPEN eyes; Knowing that while Dr. Sher might truly believe in the importance of it and I'm more than curious to find out the result myself, a good deal of his business is built upon finding a "reason" the patient would need to seek help from him...because most RE's out there do not specifically treat for these underlying immune issues. He has gone so far as to give me his cell phone number, send a follow-up email, the works. I am ultra sensitive to feeling like I'm being sold something, and I really have zero buy-in to that approach.  I kind of feel like a guy just sent me a drink from across the bar, and now I'm half obligated to talk to him or something. I would like to think he really cares that much to help someone for nothing, but I know better.

Plus, I was already annoyed that he was 15 minutes late to our Skype call, even if he was doing it pro bono (It was so early, I had to be his first patient of the day, so no excuse really). He also got a couple of the facts wrong concerning our previous timeline of treatment in his follow-up summary email. Most troubling is that he does not report his success rates through SART because he's a staunch opponent to the entire reporting system. He's created a reputation for himself by being somewhat "rogue" or what he'd probably call a "pioneer", but personally I feel like the non-reporting of success rates through SART is a total cop-out. I see no evidence of his own success reports in a format of his own choosing either on his own website.

I don't care how much you don't agree with the establishment. If your success rates are that great (80% as dictated by his nurse), you will find a way to shout them from the rooftops to every other doctor, government agency, and prospective patient out there! This is a major red flag to me. I have extremely high expectations with the medical care I choose, and so far he's falling short in the "this feels like a fit" department.  So, I will let him do this test because I'm curious and it's supposedly covered by my insurance anyways,  but my bullshit detector is on standby, and it will go off loudly at a moment's notice!


I know there are quite a few women out there who have looked into RI, or those who've at least done research on it and are curious. What did you learn? What are your hesitations? Any feedback on Dr. Sher or other RI's specifically? Would love to hear your thoughts!

30 comments:

  1. Good for you, you are literally taking the bull by the horns and leading the way! I don't know anything about RI's but now I know what to pray for you.

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  2. Emily, I am always so very impressed with how thorough you are with all of your research. I have no idea about RI, I am starting to wonder if I should look into it more...All I know is, whatever info and options out there, you're going to find it. Love that you're getting the blood test. Why not, right?! One more thing to say yep...checked. :)

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  3. I agree with you on the not reporting part, that would bring up a red flag for me as well. I don't know anything about RI but you always amaze me with all of the research you do and how knowledgable you are. I am continuing to keep you in my prayers Emily :)

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  4. Wow. Thank you for sharing this! I am still on edge as to what I want to do regarding seeing an RI. I called, and spoke to, Dr. Braverman recently. He told me that my HSG, hysteroscopy and BETA 3 tests were all BS and that they really don't tell you anything. It's just odd because CCRM says the complete opposite. I'll be so curious to see how this test goes for you!!

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    1. See, now that is what irks me...the fact that Braverman would make a blanket statement about ALL those tests. My RE happens to agree with him on the Beta integrin test not being very valid, but c'mon....HSG and hysteroscopy having no benefit? I don't buy that one bit. So, are you doing any testing at all then for curiosity sake, or no?

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  5. This is really well thought out and interesting. Thanks for sharing.

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  6. I'm really enjoying learning more about RI through your experience. I hope this test leads to more answers rather than more questions. Looking forward to hearing more!

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  7. I always wondered if my body rejects pregnancy because all of our ducks are supposedly in a row. I will request a full work up again when we are starting IVF. I can't wait to hear how it goes for you.

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  8. Great job, Emily! I know a lot of people are really interested in this, and you always explain it all so well! Hopeful that the test will give you an answer and that you will feel confident moving forward after the results!

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  9. You are so wise! So impressed with all your research! I look forward to hearing how the results come back and what else you find out from the doctor! So glad you got to speak with him!!

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  10. Well, this post pissed me off!

    Not you, of course, but Dr. Sher! So after my 2 unexplained losses AFTER hearing a heartbeat both times... and chromosomal testing for my twins (first pregnancy) and everything coming back NORMAL... my RE insisted I see Dr. Braverman. I called. $900 for a consult. No, thank you.

    Then, I found out that Dr. Sher did free Skype consults, so I called them. The receptionist claimed that he stopped doing them, and now a Skype consult was $450! And this was legit two months ago. So WTF??

    Right now I'm PUPO after my third IVF, taking a whole lotta things recommended in the book Is Your Body Baby Friendly (PIO shots, baby aspirin, Prednisone, Lovenox). I loved the book, but it also made me freak out more than necessary, I'm sure. Plus, I can't really afford to do IVIg (up to $5,000 per session?) and that seems to be what they recommend for the killer cells. The whole thing is so overwhelming.

    I'm also doing a hardcore elimination diet, cut out everything but the bare basics. No gluten. That seems to be the one thing that's linked to miscarriage. In my case it seems like diet/allergic reactions are linked somehow. I truly wish there was more established research in this field.

    I really hope you find your answers. I don't know if I've ever commented on your blog before, but I've been following you for a while. The next time you talk to Sher, tell him I'm so pissed! I want a free consult and pro bono testing! No fair! Haha.

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    1. Well that's some crap you didn't get your free consult! What gives? It seems that most of the RI's are replacing IVIg therapy with Intralipid therapy these days, although some still recommend IVIg. I am really hoping for no activated natural killer cells so I will never have to even be given the recommendation for either of these. We shall see.

      Like you, I am pretty hardcore with a healthy diet while cycling, eliminating anything that can remotely cause an inflammatory response; gluten, dairy, alcohol, etc. Just so happens the last two times I've at least gotten a short lived pregnancy, I've been totally gluten free. Last time I was also on Lovenox. My RE is totally against using prednisone, even though I've asked about adding it numerous times. He has finally relented to give me dexamethasone for this "last chance" FET which I'll add to the estrogen, Lovenox, baby aspirin, and progesterone. Who knows, maybe I should just suck it up and use PIO instead of Crinone just to try something different? It's such a crap shoot isn't it?

      I REALLY hope that you have success this time around. I would love to see you get pregnant despite not using either of those RI's!

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    2. Oh, and P.S. I went through Sher's St. Louis clinic when calling for the consult. Not sure if you called Las Vegas, but I wonder if that makes a difference? He practices in both, but his last round of IVF in St. Louis will be in Nov. so he's still taking consults through their practice right now.

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  11. Are we living the same life?? I have been thinking about looking further into the immunology and actually spoke to an immunologist today. I still need to discuss it with my husband (there's too much going on), but it makes sense to at least test. What I choose to do with the results potentially could be another whole issue, but as I explained to the immunologist some of the drugs and protocols the doctor has tried on me, she described it as just trial and error rather than really knowing if I need it or if it will help me (and whatever all my issues are).
    I will be contacting reprosource probably tomorrow to see if my insurance will cover the blood tests...

    Thank you for this post. Lots to think about... I hate having to decide what to do or what not to do, and I hate even more wondering if someone is just trying to make money off of you or truly has your best interest at heart!

    I will be interested to hear more of what you learn!

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    1. Yeah, not sure what we'll do with our results either. Guess we'll cross that bridge when we come to it, depending on what the first test says. I'm definitely treading lightly into the immunology waters, but I do think there is something to it that's worth exploring with my history.

      I hope your insurance will cover some things for you! I am still waiting on the call to set up my blood draw. It's been 2 days since Sher's office said Reprosource would be contacting me. I'm not going to hunt them down, so we'll see how long it takes them to call me.

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  12. Hmmm something else to think about. Thank you for sharing this, Emily. It's always so hard to know whether or not to "open another can of worms." Personally, I'm pretty confident my issue is my eggs ... At this point, I almost want that to be my issue in a way so I don't have to do more digging. :/ Something else to ask my doctor about today!

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  13. Although I do believe that immunological factors can play a huge role in fertility (my husband has an autoimmune disease and I often wonder if that is what is also causing his infertility) like you said, it would be hard to jump into any form of treatment if it has not been thoroughly tested and proven to work. I think you are doing the right thing by trusting your RE while also doing everything you can do naturally through your diet to decrease the risk of an immune response.

    I am wishing you all the best! xo

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  14. Hi Emily:
    I have been checking in on your blog for quite some time. I can't remember, when you had your initial retrieval, did you have your embryos biopsied and tested before transfer? I only ask because that could be a really simple (maybe too simple) answer to your issues so far with IVF not working. We recently went through IVF, and THANKFULLY it worked. I really account our success to our doctor! We were only able to retrieve 10 eggs, 7 mature and all 7 fertilized using ISCI (did I get that acronym correct...???) Out of the 7, 6 made it to biopsy. From all accounts they looked like strong healthy embryos, however only 2 were "normal! My hubby and I are both early 30's (32 and 33), and in general in good health. We had NO REASON to suspect that we would have any abnormal embryos. But to our surprise more than half were! I can't imagine now NOT testing. We could have been trying and trying to transfer and could have been potentially transferring the abnormal ones! If you ever want to think about coming out to Southern California for a second opinion, I HIGHLY recommend my doctor's clinic, HRC Fertility. They have one of the highest success rates in CA (so I was told, I didn't really research it). We came into contact with them because my husband's cousin used them. They have 3 beautiful boys (a singleton and twins) all from IVF and HRC! I am wishing you all the best in your endeavors to become pregnant and ultimately a mother! I will keep you and your hubby in my thoughts and prayers!
    Best!
    Lindsey

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    1. Congrats Lindsey! We discussed doing PGS testing of our embryos but ultimately decided against it. First reason, we were told we didn't really need it with our first try, would be like $5000-$7000 extra and that it's not 100% accurate ultimately. Of course we kind of wish we'd done it now, even if it cost extra $. We thought for sure IVF would just work for us. I guess we have one more try to find out if any of our 7 will work!

      Another reason we decided against doing PGS was that I've struggled with the idea of discarding aneuploid embryos. Reason being, we actually did chromosome testing on both hubby and I and were shocked to find out he himself has an abnormal karyotype (aneuploidy). You would never even know looking at him, and he's perfect in every way! Out of 50 of his cells tested, most had XY, but some of them were missing Y's. So aneuploidies do occur without anything actually being wrong with the person/embryo. What if my hubby's mom had done IVF w/PGS? They could have considered him "aneuploidy" and just discarded him! I would hate to do that with any potential children.

      However, I know we'd ultimately have the decision on what to do with each embryo, even after the PGS testing is done. It's my understanding that if you do the testing on Day 5 blasts, they test quite a few more cells from each embryo, and so the testing is more accurate, and less chance to discard an embryo based on abnormal testing from just one single cell (as is done with Day 3 PGS testing). For this reason, it's not completely out of the question if we do end up needing another retrieval. Guess we'll cross that bridge IF we have to go there.

      Thank you for the wonderful info. on HRC as well! I really appreciate you passing that along and will def check it out!

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  15. I think it is smart to look into all possibilities and I'm a huge proponent of getting second opinions. One question I was wondering...you said that you had 5 seemlingly normal embryos transferred. Did you have PGD done to ensure that they are normal (euploid) embryos?

    If not, is is possible that you are just transferring genetically abnormal embryos and that is resulting in the failure to implant or miscarry? Just a thought.

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    1. It's quite possible that is the case Jessah, and that is what my RE's hypothesis is. We did not have a need to do PGD (looking for a specific genetic disease) but we definitely could have done PGS (complete chromosomal screening) and just chose not to. When we did our fresh IVF, my RE said, "Not necessary to do PGS" but now that we've had a few transfers fail, he recommends doing it if/when another retrieval is needed. Kind of annoys me, because we would probably would have done it to begin with had he encouraged us strongly to do so right out of the gate. Yet again, an instance of his more conservative approach where he sees so many people get pregnant just fine WITHOUT the PGS, so why recommend it for every single IVF patient? I get it, but at the same time I am getting tired of trying and need to make sure we're checking all the boxes, even if it costs more and requires more effort and $. I did have a bit of a moral dilemma doing the PGS as well. You can read about that in my reply to Lindsey Lu above ^^

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  16. Using this couch time to catch up in blogs. While my mind is too spent to wrap my head around this, I'm going to pick your brain about recurrent loss and testing/questions to ask for. As soon as I get the strength. You should be an advocate. I've said it before but you having an amazing depth of infertility knowledge.

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  17. I'm wondering if you've read about Neupogen. I've mentioned it briefly on my blog, and we'll begin using it soon if the next cycle or two doesn't work. Because all of my issues were "small" and are now resolved, the only thing my doctor feels is left to suspect is egg quality (which she's treating me for with Femara and supplements) or an immune issue. She said she can have me tested for immune issues, but that they don't always give a full picture, and with my insurance, it's likely, I'd end up paying a ton to have certain tests done. So, she recommended Neupogen. It's an injection, but there are some studies that show it's ability to create a very healthy lining (which I know is something you have mentioned struggling with) and helps with implantation that would otherwise be prevented by immune issues. I know Braverman uses it, but it's fairly new, so I haven't heard of many others using it yet. Just wanted to give you the info in case that is something you'd want to discuss with an RI.

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    1. I have read about Neupogen, although I don't know a lot about it. I had no idea it also assisted with a healthier lining either. I do know it's used on a very limited basis....was actually surprised to read about your docs using it, since I'd only heard it mentioned with Braverman's name in the past. Supposedly, Sher's office will code any of the tests I take as "immune testing" so it's covered? We shall see what the outcome on coverage is.

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  18. Um, I saw Dr. Sher and another associate from one of his clinics. They immediately started running these expensive, obscure tests to (IMHO) "stampede" me into IVF by building on my fear that my autoimmune disease was a factor (even though I have been preggo unassisted & at the time only had one miscarriage). He had me do DQ Alpha matching too--beware, his associate left the practice & informed me Dr. Sher nearly always uses DQ Alpha + HLA matches to insinuate you need IVIG, etc. And here's my biggest qualm--I think he's getting a back-end from Reprosource. Yep. They are a middle-man & OUTSOURCE most of these tests to other (often cheaper) labs. I believe in RI and since you're already doing IVF, SIRM may be a good place for you. But they were shady to me and wasted my money on reprosource for both NK cells/ATA's and DQ Alpha matching...without ever doing so much as an ultrasound or HSG...because he knew if he could convince me I'd never get pregnant or carry to term without IVF, then he'd get his $$$. So yeah, free consult but watch out for those reprosource bills.

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    1. Thank you so much for your feedback. So far I haven't gotten a warm fuzzy "good" feeling from Sher. I do not doubt anything you've said about your experience.

      I am giving blood on Monday for the initial testing. I notice that Reprosource does outsource the NK testing to a lab in CA but that they'll perform the expanded APA panel themselves. Thought that was interesting. So far, they're telling me the tests will be coded as "immune disorder" and not infertility so that everything's covered under insurance. We shall see. I will not be surprised one bit if our NK cell testing comes back as elevated and "further testing is required." It's at that point that I'll either decide to take my NK cell testing somewhere else and at least use the results as justification to at just add prednisone or dexa into my protocol (since my current RE doesn't typically use them). If Sher recommends DQ Alpha and all that other jazz, I'm not sure I will pursue it whatsoever.

      Thank you so much for your feedback! I've added you to my blog list and will be following your journey as well. :)

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  19. Thanks lady! So, even though Sher coded my tests as "immune issues", reprosource called me up and said they're offering me a "deal". The tests would cost something like $6000, and my insurance would (supposedly) require me to pay $1000, BUT reprosource would only charge me $650, regardless of how much my insurance paid/didn't pay! Sher's office f*ing knew that reprosource was going to call me 3-5 days after both my blood tests & request upwards of $600, and said nothing about it either time. Rude? Weird? Sketchy. Wait for the phone call...XO

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    1. Oh, very interesting indeed. I did make Reprosource email me in writing with the "self pay" price of the tests I'm doing ahead of time just in case insurance doesn't cover them. Mine will be $453 if my insurance covers nothing and I paid an additional $50 for someone to come draw my blood at my house.

      Of course, I asked a bunch of questions about all of this ahead of time because I didn't want some "surprise" in the thousands of dollars range ya know! In my Skype consult Sher flat out said, "The tests will be covered by insurance." Even then, I was thinking "Um, how do you know? Are you familiar with my insurance plan?" Sher's office also told me when they called me later, "Your insurance is in-network with Reprosource and we do not code anything for infertility." I am not stupid though...I know the tests they are running are not standard, so I anticipate the possibility of insurance covering nothing. It will be verrrry interesting to see if it plays out like you said...with insurance covering nothing and a "self pay" bill to me in the end anyway.

      If that's the case, it will be one more red flag against pursuing anything he suggests...esp. because of the way they try to scoot you through the hoops in their "process." If that happens, it will definitely prove to me they are shady! We shall see.

      To be honest, I don't have any strong intentions of using Sher anyways. I was just really curious what my NK cell testing would show, and my RE doesn't look at anything immune related. In a way, I guess I was just using him to get the test done out of curiosity. I do think there is something to RI, but I don't trust Sher based on my first impression & intuition alone.

      I really appreciate your input on your experience. I will wait for the phone call! haha!

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  20. Be wary of Reprosource. That is all I am going to say.

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    1. Yeah, definitely not impressed with their customer service or methods. I got my bill VERY late in relation to the actual testing. I knew full well it may not be covered, even though the ordering doc and the lab all try to tell you "We run this with immunology coding so as it get it covered." Well, I knew that wouldn't happen and knew it would end up being $450 for the tests so not a huge deal since I expected it. What I really do NOT like is the crap they write on the bills once you receive them about how they are a superior infertility lab, even when testing regular stuff like AMH or whatever. Um no, not buying that. They put such a big push on using them over another lab, and it's just a red flag to me...like they are constantly trying to sell you on the need for their services.

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