A little bit pregnant?
August 15, 2018 10:14 AM   Subscribe

I just got a positive home pregnancy test. What tests do high-octane fertility clinics do upon a positive pregnancy test to ensure the pregnancy is proceeding? What sort of support do they provide? (TW: mild mention of MC)

Hi all. I had a "chemical pregnancy" (aka, positive pregnancy test followed within days by not being pregnant any more) last year.

When I had my first child a few years ago, I was in a fertility program at Kaiser (no issues ever diagnosed, just took forever to get pregnant apparently). Upon getting a positive result, they ordered a series of tests -- like three HCG tests a few days apart, but I think other things as well. Maybe progesterone?

During this past chemical pregnancy, the doctors were very hands off about it, but they said that they'd be more assertive about monitoring next / this time. But then I moved and have established myself with a primary care person but no OB yet. So I'm either going to be asking my non-OB (most likely) or cold-calling an OB in town to ask for tests. (The old place has said that they can't order them remotely.)

Given that I'm kind of between doctors at the moment and have seen the medical establishment kinda not care once already, I'd like to be able to be specific about what I want them to do. What tests do I ask for to get the same standard of care I got at Kaiser that first time around? And is there anything that can be done to either provide support if the numbers aren't doubling, or at least gather data to tell us what to do next time? Thanks!
posted by ruff to Health & Fitness (19 answers total) 5 users marked this as a favorite
I’ve had 2 chem MC in the past 4 months. They told me that early there’s nothing to do. If the HCG numbers don’t double 2 days later then you will get a period within a week or so. Try again next month.

For the future: After my second chem MC given my “advanced maternal age” I started with a reproductive endocrinologist and they’re putting me through a battery of tests - blood, biopsy and radiology. So far it’s all unexplained which is frustrating.

My RE said progesterone levels or supplements doesn’t do anything at this point, it’s either viable or it isn’t. Good luck!!
posted by St. Peepsburg at 10:28 AM on August 15, 2018 [7 favorites]

From my experience dealing with a fertility clinic (approx 7 years ago), it was basically the 2 or 3 HCG tests to make sure it was doubling and then I came back in like 6 weeks for an ultrasound to confirm the embryo was there with a heartbeat. There weren't additional tests until well after that.

I'll cross my fingers for you!
posted by machine at 10:32 AM on August 15, 2018 [2 favorites]

Oh and my RE said once I get a positive they will just monitor development through ultrasound - sac present, heart beat etc. He didn’t indicate any major tests or interventions. If you don’t have a diagnosis there’s not much to treat.
posted by St. Peepsburg at 10:33 AM on August 15, 2018 [1 favorite]

IANAD (but I'm a woman who had a baby...). What you likely need to ask for today is a series of requisitions for quantitative Beta HCG. This is the chemical which 'shows' you are pregnant. The levels can be tracked to show the pregnancy is progressing (or sadly, isn't progressing). The numbers should basically double on a pretty specific timeline. A PCP can order this labwork. In the face of multiple miscarriages, you probably do want to get hooked up with an reproductive endocrinologist and/or and OB sooner rather than later. They can order additional labwork and possibly progresterone (although that seems to be a hit/miss thing as to if folks feel it makes any difference). Good luck with everything!
posted by Northbysomewhatcrazy at 10:33 AM on August 15, 2018 [1 favorite]

Response by poster: Thanks for the responses so far. While waiting for replies, I read here that they monitor HCG, progesterone, and estrogen. But it sounds from what you're saying that that might not be common practice?
posted by ruff at 10:45 AM on August 15, 2018

HCG is the common one, and I've gotten it from a PCP just by asking. My RE had said they could try to help with hormones to keep an otherwise-viable pregnancy going, but if HCG wasn't doubling on schedule, there wasn't a whole lot of point. After that, yes, ultrasounds to make sure it's an actual embryo actually implanted in the uterus, making good progress toward fetuship.
posted by teremala at 12:02 PM on August 15, 2018 [2 favorites]

For me, after an ectopic pregnancy, they started doing every other day HCG and progesterone monitoring for my subsequent pregnancies (1 MC, 1 successful). I don't think they measured for estrogen in my case, or the numbers were irrelevant so they didn't mention it. I believe they did the HCG numbers until they fell (for the MC) or until they rose to a certain level (for the successful pregnancy), maybe 3 times?

As it turns out, they actually also measured HCG numbers for my first, ectopic pregnancy, and those numbers were low, though they rose barely enough, but it ended up being a sign of the ectopic. I think they initially ordered that test by mistake (the NP was new to the practice, she may have thought it standard for my advanced maternal age - I happened to ask and she said "oh, it's a bit low, yeah, let's do another").

So in my experience, the first pregnancy they won't report the HCG numbers, but if you've had trouble maintaining a pregnancy in the past, they will or should. This assists with diagnostics for the individual pregnancy as well as helps ID pattern problems.

Note that some people also see unusually high HCG numbers and that can indicate twins or molar pregnancy (or for a person I knew, a chromosomal issue they later uncovered); if I had abnormal numbers on a viable pregnancy, I would push for the cell-free DNA testing at 10-12 weeks. Actually I would do it either way especially with fertility issues.

As for the progesterone levels, I think sometimes they discover that people need some progesterone support for early pregnancy. I know of people who believe that this helped them stay pregnant, though my OB was a dubious that it actually makes a difference - "doesn't hurt" she said.

GOOD LUCK. Fertility issues are a shitty row to hoe, but it's so great when it all works out.
posted by vunder at 12:05 PM on August 15, 2018 [3 favorites]

I should add that the last MC that you had, it sounds like they probably reverted back to low monitoring because you had a successful pregnancy. I would expect them to treat your new, post-MC pregnancy as worthy of closer monitoring, but you are right to be self-educated because non-OBs don't necessarily know the protocol and it could be a missed opportunity.
posted by vunder at 12:11 PM on August 15, 2018 [1 favorite]

Quantitative HCG at 2 weeks post-conception and then again shortly after that. Ultrasound at 6 weeks (i.e. 4 weeks post-conception) and 8 weeks (6 weeks post-conception).
posted by If only I had a penguin... at 1:15 PM on August 15, 2018 [1 favorite]

Just a random data point to throw out there, but I called up the OB right away when I had a positive pregnancy test 6 months after having a MC at 10 weeks. They didn't even have me come in to the office, just signed me up for the 6-week ultrasound. It might be because I had had a previous successful pregnancy, I don't know, but I remember thinking "all these internet ladies are getting all these blood tests why didn't they do that for me?"
posted by cabingirl at 1:25 PM on August 15, 2018 [1 favorite]

Response by poster: These answers are all really helpful! I tried to mark best answers, but it's been so helpful to get a sense of what various REs have said and various people's experiences that I pretty much want to mark them all as a best answer.

I called the doctor and asked if they'd order HCG and progesterone, so we'll see what they actually do when the doctor reviews my request.
posted by ruff at 4:43 PM on August 15, 2018

Because us internet ladies are Old with Loud Mouths and Good Insurance.
(I, too, had a previously successful pregnancy.)
posted by St. Peepsburg at 5:01 PM on August 15, 2018 [3 favorites]

I became pregnant via IVF and the day they did the transfer, they started me on progesterone supplements. They said to continue them until either a negative pregnancy test administered by them, or if pregnant, the whole of the first trimester.
posted by ficbot at 5:18 PM on August 15, 2018 [1 favorite]

Oh right, I also did progesterone vaginal suppositories for 6 weeks.
posted by If only I had a penguin... at 6:48 PM on August 15, 2018 [1 favorite]

And is there anything that can be done to either provide support if the numbers aren't doubling, or at least gather data to tell us what to do next time?

Most early miscarriages are caused by chromosomal defects and those dice are rolled at conception. While slow-rising hCG or low progesterone can indicate a problem, they aren’t themselves the problem, and the problem itself usually isn’t fixable. (There was a big study on progesterone supplementation a few years ago that found it doesn’t prevent miscarriage. But it’s not harmful so some doctors may still want to prescribe it anyway, on the grounds that it might possibly help some women in some circumstances and doesn’t hurt.)

However: just being on the radar of your medical provider at this stage can be helpful in terms of collecting data. If you were to miscarry this pregnancy after 5/6 weeks, they could carry out testing for chromosomal issues which would give you useful information one way or the other. And if you are flagged as having recurrent miscarriages they can carry out tests on you/partner to see if there’s a detectable reason for it - sometimes there’s a cause that can be managed before/during future pregnancies.

Fertility clinics would also do early ultrasounds, which can give a good indication of whether a pregnancy is developing properly or not. If you see normal development and a heartbeat at 8 weeks there’s something like a 95% chance of the pregnancy continuing to term.

But: I would caution that most of what can be done in early pregnancy, even with the world’s most advanced medicine, still can’t actually change the outcome for most pregnancies. So I’d recommend seeing the hCG etc. testing as something that could give you useful information and pursuing it on those grounds, but not seeing it as itself a necessary treatment and standard of care you need to pursue in order to assist your pregnancy to continue, just for your own peace of mind.

(as a datapoint, I’ve had three miscarriages and one live birth. I had hCG testing and early scans in my last pregnancy, which I wanted; I’ve opted out for my current pregnancy, because for me personally this time the cost/benefit of the stress and time involved isn’t worth it.)
posted by Catseye at 3:54 AM on August 16, 2018 [3 favorites]

As with all research reporting, it's important to be precise: This: "There was a big study on progesterone supplementation a few years ago that found it doesn’t prevent miscarriage." is not what the linked article says.

The project described in the linked article is about one class of women: those who conceived naturally and had previous unexplained recurrent miscarriages. That's not all woman. Progesterone is needed in women who do IVF because their own progesterone production is disrupted. It may also be needed by some women with miscarriages due to known causes, and possibly for women with threatened miscarriage (i.e. early bleeding). This study doesn't speak to any of those situations and it's important not to overgeneralize.
posted by If only I had a penguin... at 8:02 AM on August 16, 2018 [2 favorites]

No, this is also the case for IVF patients. We do not have evidence that progesterone supplementation prevents miscarriages for anybody. There are theories and anecdotal evidence that it may prevent miscarriages for some women in some situations, and perhaps some future study will identify a specific subset of women who do benefit from the intervention, but as yet we do not have that evidence. Whether it’s still worth trying as a low-cost, non-harmful intervention is between doctor & patient of course.

As with so much about miscarriage, there’s a lot about the mechanics we don’t yet have a decent understanding of, and a lot of theories and beliefs about potential causes (stress, exercise, even the link to coffee consumption) that don’t really hold up. Sadly there is just not a lot we can do a lot of the time.
posted by Catseye at 8:55 AM on August 16, 2018

"We do not have evidence that progesterone supplementation prevents miscarriages for anybody. There are theories and anecdotal evidence that it may prevent miscarriages for some women in some situations, and perhaps some future study will identify a specific subset of women who do benefit from the intervention, but as yet we do not have that evidence."

Which is different from saying "We do have evidence that it doesn't work (period)." No?

And btw the linked study is on prolongation of progesterone, not on using progesterone versus not. In the first para it reads "An earlier meta-analysis (Soliman et al., 1994) indicated that after IVF, it is of value to give luteal support, using either HCG or progesterone, during the luteal phase itself. The luteal phase has been defined as the time span from the day of transfer of embryos until measurement of HCG 2 weeks later. Using the long protocol and down-regulation with GnRH agonists, LH secretion may not have completely recovered during the luteal phase. Therefore, progesterone supplementation could be of benefit in order to `cover the gap' between the disappearance of exogenous HCG and the rise of endogenous HCG during early implantation." which does seem to imply that for women doing IVF at least the first two weeks of progesterone are important.

My reproductive endocrinologist was by all accounts a research superstar. The non-medical staff at the clinic didn't like her much because she wasn't very friendly, but the other docs (especially junior) were in awe of her. She'd leave the room and they would talk about how smart she was and how well she knew the field. I would come in saying I found some study that said X, Y, Z and she would know the study and be able to off the top of her head give me a lit review of context (this other study with a different population, that study with a larger sample, this metanalysis etc. etc.). If she put me on progesterone it was because she thought there would be a benefit in my specific circumstance and she thought that based on knowing every study out there (yes, I realize that's not technically possible, but you get my point).

I think to some extent we need to assume that our doctors are better at reading the literature than we are. They have the proper context to interpret the results and know when we can generalize from one population to another and when we can't. I read the literature in my field better than a lay person would. Assuming you get a doctor you trust to keep up with the field it often makes more sense to assume they're doing what they're doing for an evidence-based reason than to find one study on google scholar that says the opposite and assume they're wrong.
posted by If only I had a penguin... at 12:33 PM on August 16, 2018 [1 favorite]

Mod note: Final update from the OP:
A final update and thanks. I'm mainly just writing to let everyone know that I'm typing this next to my six-month-old baby. The blastocyst I was asking about went ahead and miraculously transformed herself into a person who can now sit up.

In terms of testing in those early days, the doctors measured HCG three times, which doubled pretty much on schedule. (Even at the first test, it was beyond the double-digit levels where it had stalled out in my previous pregnancy.) Then as the pregnancy progressed, the OB did a 6-week ultrasound and all the screenings that they do for everyone of similarly "advanced" maternal age. They didn't do anything particularly special related to the previous CP other than keep a tighter eye on the HCG.

Best wishes to anyone in a similar situation, and thanks to everyone who provided information.
posted by taz (staff) at 4:14 AM on October 28, 2019 [2 favorites]

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