First Visit with Dr. Braverman

So, yesterday was our big consultation with Dr. Braverman, the Reproductive Immunologist (RI) in Manhattan. I found his information online after we learned that our third pregnancy was not going to continue. He is one of only a handful of RIs in the country, a type of doctor who has expertise in both immune and reproductive issues -- and one of few doctors who can look at what has happened to us and know what to do about it. We have been looking forward to this appointment for about four weeks, which was the quickest they could get us in when I first called and consulted with him on the phone (he is a popular guy!).

We spent about an hour and 15 minutes with Dr. Braverman and he went through all of the blood tests that he had ordered ahead of time, which was great because our time was very productive (as opposed to his having ordered the tests yesterday and having to now wait for a bunch of results to come back). As he suspected, the ANA (Anti-Nuclear Antibodies) is an issue, but there are some others, too. Here is how it all breaks down:

1. ANA: My body produces these antibodies when they shouldn't, and they act by attacking the developing trophoblast cells when I get pregnant and the embryo implants into the uterine lining. Normal ANA titers are 1:40 or lower, and my most recent ANA titer was 1:640 (they double every level, so 1:640 is 4 dilutions higher than 1:40). Luckily, the treatment for this is relatively straightforward -- I'll be on Lovenox injections starting in the next couple of weeks and continuing probably through the first trimester of a viable pregnancy. Lovenox is a blood thinner, but it also acts by binding to the ANA and basically escorting it out of my body. J will have to give me a nice little shot in the bootie, which I don't think he is much looking forward to -- but I think it will be manageable.
2. HLA matches: HLA is a protein on the outside of all cells in the human body. It operates by a lock and key mechanism to help the immune system identify cells that are part of the self vs. from an invader. One of the ways that nature has ensured that the human species stays diverse is to resist allowing pregnancies when maternal and paternal HLA are too similar. There is nothing wrong with my HLA or with J's HLA, but it does look like our HLA are a little bit too similar. There are different ways of counting "matches," and the universally-accepted cutoff for HLA being a problem is at 5 matches. The way most doctors would count, we have 4 matches -- but Dr. Braverman counts a little differently and he sees 7 matches for us. It's still unclear whether this is actually causing a problem, and another test that can indicate HLA-matching issues came back looking very good, suggesting that maybe the HLA stuff wasn't a problem, at least with pregnancy #3 (my blood was drawn during the pregnancy). The treatment for HLA-matching issues is a very expensive injectable drug called Neupogen, which often isn't covered by insurance -- so we are going to hold off on treating this one and only do it if I have another loss. Dr. Braverman is confident that this is a smart course of action given all of the other factors at play.
3. Natural Killer (NK) cells: NK cells are immune cells that everyone has in their bodies and all women have in their uterine lining. Mine are a little more active then they are supposed to be (hey, I've always been something of an overachiever), but the numbers are borderline. NK cells that are "too active" disrupt the implantation process. Because it's fairly straightforward and to be conservative, we are going to treat this -- and the treatment is a blood transfusion, which will take place likely within the next few weeks. I will probably need to have several more transfusions during the first trimester once I get pregnant. The transfusion is a washed blood product that comes from a blend of blood from approximately 1,000 people. Dr. Braverman said that a nurse will come to our house to administer the transfusion, though I have heard from others who get this done in hospitals or other medical centers. Each transfusion takes about 6 hours.
4. Uterine Blood Flow: Dr. Braverman did a vaginal sonogram to check the blood flow to my uterus and take a look at my ovaries. With my uterus, it looks like the blood flow coming IN to the uterus is good, but the blood flow going back OUT (what happens between heartbeats when the blood vessels relax) is not quite what it should be. This is treated by taking Vitamin E, which acts as a vasodilator.
5. Finally, Dr. Braverman's tour of my ovaries revealed something called a "string of pearls" appearance, meaning that small, painless cysts may be present on the outside of my ovaries. This can be a sign of insulin resistance and polycystic ovarian syndrome, but more tests are needed to confirm this. I'll be having some more blood tests in the next week or so to get more insight on this. I'm not sure what the treatment is for this, we didn't really get into it with Dr. Braverman since it's not clear yet whether this is really an issue. However, when I talked to my regular OB about all of this, she said that the standard treatment is to be on Metformin (which is consistent with what I have read). 

So, where do we go from here? Well, more blood tests for me, a semen analysis for J (to check for DNA fragmentation, which will rule out genetic abnormalities in the embryo as the cause of the miscarriages), and a day 3 ovarian reserve test to make sure that I am still producing healthy eggs.

We are feeling optimistic, if not a little bit overwhelmed at the number of issues we're dealing with. Dr. Braverman feels pretty confident that he can help us, and he has a really great track record with getting women with repeated pregnancy loss to get and stay pregnant. We sincerely appreciate all of your support and promise to keep you posted.