Infertility & Recurrent Pregnancy Loss

FIRST VISIT LABS: 

CYCLE DAY 3- FASTING: 

Health Labs: 

• CBC: Complete blood count
• CMP: Comprehensive Metabolic Panel - to look at baseline kidney and liver function
• Vitamin D level 
• glucose, 3 specimen & insulin, 3 specimen

*note glucose and insulin handout below

Reproductive Labs: 

• FSH/LH and estradiol 
• Prolactin: no nipple stim, sex or rigorous exercise 48 hrs prior to draw. 
• 17OH progesterone: drawn prior to 8AM. 

Comprehensive Thyroid Panel: 

• TSH/FT4
• Total T3/Free T3
• anti-TPO and anti-Thyroglobulin antibodies
• Thyroid Stimulating Immunoglobulins 
• Iodine levels 

Androgen Panel: 

• Testosterone, Total
• Testosterone, bioavailable
• SHBG (Sex Hormone Binding Globulin)
• DHEAs
• androstenedione

SECOND VISIT LABS: 

Hormone Panels: 

• Peri ovulatory estradiol panel: start on CD8, go to the lab EOD for an estradiol draw, until you have one draw post-peak. 
• post-Peak estradiol and progesterone panel: P+3, 5, 7, 9, and 11. See Handout #3 on the the Patient Handout webpage 
• Hormone panels require 2 mos of CrMS charting AND the patient must be able to confidently identify her Peak day.  

Semen Analysis: 

• I will recommend your husband has a semen analysis done. NaPro has the man collect the semen in a moral ethical way, during the natural act of intercourse. 
• Natural Women's Health sells a special collection kit through the office for $215, which is not covered by insurance. 
• ReproSource is an online lab who will accept insurance payment, if the order is submitted by a licensed medical provider. 
• For more information on NaPro Protocols for Semen Analysis click here. 

HYPERCOAGULABLE WORK UP: 

Anti-phospholipid Syndrome (APS) *always recommended for RPL

• anti-Cardiolipin Igg
• beta-2 Glycoprotein Igg
• Lupus anticoagulant (LA) 

Factor V Leiden (FVL)

Oftentimes, we will have a discussion about adding the FVL lab along with the APS labs recommended above. FVL mutation is the most common genetic Inherited Thrombophilia, occurring in approx 2-5% of the general Caucasian population and found in approx 12-18 % of persons who have been diagnosed with a deep venous thrombosis (a blood clot in a vein). 

FVL is a mutation in the Factor V protein, a protein involved in your normal healthy coagulation cascade (your ability to make clots and then dissolve those clots in a timely fashion). FVL causes problems with other proteins involved in the coagulation cascade, specifically a clotting factor called Protein C. Protein C along with Protein S are your body's  natural anticoagulants, which help you naturally dissolve clots. 

We will discuss adding the FVL lab and if this is found to be positive, I would recommend adding labs to look for Protein C deficiency and  Protein S deficiency. If you have two of three abnormal results, I do believe you would likely benefit from being treated with Lovenox (enoxaparin) 40 mg once daily, which may increase your chances of achieving and maintaining a healthy pregnancy. 

A little more about Inherited Thrombophilias.... 

There are five recognized "Inherited Thrombophilias", which are genetic conditions that pose a higher risk of forming blood clots: 

1. Factor V Leiden mutation
2. Prothrombin G20210A mutation
3. Protein S deficiency
4. Protein C deficiency
5. Antithrombin deficiency

Many providers routinely ordered  laboratory tests for all of the thrombophilias, along with another test called "MTHFR mutation". However, research indicates this testing may cause unnecessary treatments that may sometimes be risky and there is no data to indicate treatment improves pregnancy outcomes. For this reason, the expert opinion is to forgo testing for the Inherited Thrombophilias and MTHFR mutation. Click here to read why you don't need to test for MTHFR gene variants. Click here to read the American College of Medical Genetics and Genomics (ACMG) guidelines about MTHFR testing. Click here to read an open access article published by experts from the International Society on Thrombosis and Haemostasis.

IMPORTANT: If we do choose to add on the FVL, Protein S and Protein C labs, I would recommend you call your insurance carrier to inquire about the cost. Some insurances will not reimburse you for these labs because they are no longer recommended by the experts.