Methotrexate dilemma

I have just had my 2nd miscarriage in 12mths. The first time, I started bleeding at 9wks and the baby's HB stopped at 12wks. I had 3 d & c's because after each one i still had 'retained product'. Finally 6wks after the 3rd one, the last of it passed on it's own (3mths of bleeding all up).

This time, i started bleeding at 6wks and the baby's HB stopped just after 7wks. I didn't want any more procedures so soon so decided to try medication management at home, with my OB's approval. I used misoprostal with some effect but still had 'retained product'. Tried two more lots of doses of misoprostal. Still have a little bit left and 2wks after i started the treatment my HCG is still 140. My Dr thinks it should be close to '0' by now so he has recommended I consider methotrexate. I'm scared of taking it because I'm worried about side effects. Like how long would I have to wait before i can TTC again? Are there risks of birth defects if I don't. My OB seemed to think i could try again in one cycle (but he seemed a bit unsure and is sending me to an oncologist for an opinion and to do the treatment, he's not doing it himself).

I think i'll also ask for one more blood HCG test in a week so they can see if my levels have dropped a bit and if so maybe continue the 'wait and see' approach.

Has anyone else had this dilemma or had methotrexate treatment for pg loss? Any advice?

Sorry to hear you are going thru this.

I have known of methotrexate use for ectopic pregnancy's due to fact that it dissolves products of conception and has less chance of tube damage or loss. Its given on a gynea ward and you need to double flush after going to toilet for 48 hrs after each dose.

this is my experience with methotextrate

I had it for a ectopic m/c in oct 02 we were told to wait 3 cycles and to start TTC then we fell pg 5th cycle after the injection @ 20 weeks we found out our little girl suffered from anencepahly which is one of the worst and totally incompatable with like neural tube defects... I was induced at 21 weeks and my katy wwas born silently into this world

what I wasn't told about mehtotextrate is it basically destroys you folic acid stores and to get them back to a level that will help prevent NTD is to wait at least 12mths before TTC again and on the day of injection start 5mgs of folic acid daily

now there is no way to 100% prove Katy's condition was cause from me having the injection and conceiving so closely but for anyone choosing to use methotextrtae to resolve a m/c or ectopic I plead them to think carefully and if going ahead wait 12mths take the folic acid and pray hard you dont have to make the same heart breaking decison I did

hi i had an etopic pregnancy when my DD2 was 6 months old july 09 and had the methatrexate injection which worked i had my HCG levels monitered and they eventually went to 0 i didnt suffer any side affects from it.
i was advised not to fall pregnant until 3 months after we werent TTC but i fell pregnant while taking the pill in the middle of october so not quite 3 months after having the methatrexate i had to take a strong dose f folic acid early on in the pregnancy but i had a normal pregnancy our DD3 is now 9wks old and appears to be healthy and normal.

I would have to agree with what Rach75 has said. I won't go into any more details but its a risk I wouldn't want to take if there are other options unless given to maintain fertility (in the case of ectopic pregnancy) or in someone not wanting to have children in the near future.

THank you ladies for your replies. I really appreciate it.
Rach75: so sorry for your heartbreaking loss. I can understand why you would want others to think carefully about this treatment choice.
Caplaylomay: COngratulations on the arrival of your DD3. Delighted that you were able to have a successful pg after your ectopic. Thanks for your feedback.
Mildez: I've 'met' you in the other threads and imagine you've had some experience with this as midwife? Thanks for your advice.
I will give it some serious thought and try to avoid it if possible i think. Waiting a few extra weeks for HCG to go back to zero without Methotrexate might make as much sense for me as taking Methotrexate and then having to wait months to TTC. (I really want to try again ASAP). And as i don't have the dangers of an ectopic i can probably have more freedom of choice. I don't completely understand why my OB prefers this over a wait and see approach. Need more information. Maybe he's concerned about the causes of my persisting higher HCG levels?

Possum what was your last HCG reading? Was it in the hundreds or thousands? Perhaps how high it is might help decide treatment if that makes sense. Its a horrible wait isn't it?

I hope nobody minds me jumping in, but this seems to be where the people who know about mtx are.

My situation is very different, however. I have been using mtx to treat severe rheumatoid arthritis for 18 months before my rheumatologist finally turned around and said my liver isn't coping so I must stop. During this time I was taking 5mg folate tablets daily. A couple of months back my GP checked my folate levels and found them to be "very high".

Anyway, my rheumy had always insisted on a 3-6 month break between taking mtx and going back to IVF again. When he finally takes me off the drug he turns around and says that the 3-6 months won't apply to me as I have frozen embryos. I just need to wait three and a half half-lives of mtx before I go back. Turns out that's ridiculously short and I'd be more than fine three days after my last dose - if you believe a word of it which at this point in time I personally do not!

Any thoughts? Comments? Ideas on where to go for more information on this?

Once again, hope people don't mind me butting in.

BW

The experience I have with methotrexate is limited as a midwife (only in treatment for EP) I am also on a site for people who have had EPs. So basically anything I know about it is related to that. Butterfly warrior I would imagine you would be on a very low regular dose in comparision to the once or twice dose given to treat ectopic pregnancies. Perhaps the difference in strength makes all the difference.

I have actually heard a few opinions (all professional) on the longterm effects of methotrexate for the treatment of ectopic pregnancy on childbearing women. One is that methotrexate will cause a decreased level of folate permanently and folic acid suppliments are then needed for many years afterwards. The other is no this does not occur and the effects on folate is short term and as soon as the HCG level hits less then 5 folic acid suppliments should commence until a desired level is achieved and then problem solved.

Butterfly warrior I'd be asking for another opinion. Your eggs themselves are not going to be affected by methotrexate its going to be the embryo once it implants. Not that one would but I would imagine no harm would become of your eggs if you were having a stimulated cycle whilst taking methotrexate. As Methotrexate works on rapidly dividing cells in thing such as the growing embryo I would imagine the risks would not commence until the embie implanted. So if anyone was crazy enough to collect eggs from a woman on methotrexate I would think you could still expect healthy eggs and a normal fertilization rate. If it was to cause harm to your eggs then it wouldn't be an option for childbearing women to ever take as seeing as we have our eggs for life any damage caused to them is not able to be reversed unlike a man and his sperm. That been said I can't imagine your lovely frozen embies would be protected anymore then a batch of now eggs seeing as they were obviously collected before you were on methotrexate.

In saying all this perhaps if your on a low weekly dose the effects are not the same as the dose given to induce m/c or treat EP. Also its the folate level that is the concern as limited folate in the body is what causes the effects on the embryo and by the sounds of it you have no problems there with low levels in your body of folate. But I'd be getting another opinion from an embryologist or someone that specilizes in embryo development not arthritis. Best of luck with your next cycle of OVF when you commence. I'll have my FX for a straight forward cycle this time resulting in another lovely bub first go.

Mildez: my last (and only!) HCG reading was 140 (2wks after first use of misoprostal to help complete missed miscarriage). THat's why i have decided to ask for another BT. They have nothing to compare to. So the Dr doesn't know if my level is dropping, stable or rising. I would have thought that's important information. Am feeling pretty freaked out (stupid me using google!) Actually i'm worried because i've still had a bit of spotting and am still feeling crampy on and off so things don't feel back to normal.

BUtterfly warrior: good luck. Sounds like a complex situation. happy for you to 'jump in' : )

Possum hopefully the spotting and cramping is the last of the products and your HCG is gone now or very close to it. Have you done any HPTs? I did one after my m/c early last year to confirm when no HCG was left in the system and I could see by the lines on the HPT that it was decreasing due to the line getting fainter and fainter before it was negative. Silly way I guess but it reasured me that it was going then gone when I knew for sure the pregnancy had no hope.

I was on 17.5mg of MTX weekly. I have two frozen embryos - and will be having them transferred if they survive the thawing process but I have decided that I will not do any more stim cycles. I've done three and ended up with OHSS each time - one cycle put me in hospital for a week and off work for over a month - can't be doing that with a child to care for! I'd have done it over and over again if that's what was needed, but if these last two embryos don't work then I'm with Sam being an only child.

Thanks for your thoughts, Mildez. I have pretty much come to the conclusion that I will consult with an FS about it. Remains to be decided whether I go with the one I used before or go with the one that is 2 hours away but is more focussed on the area of immunology. I'm also very much inclined to consult with another rheumatologist as well!

BW

Thanks Mildez, I like the HPT idea too!
will get BT on Wednesday then decide what to do next. I have everything crossed that the cramping is still due to a bit of retained product and nothing bad. (I know that there can't be much there bc OB did an ultrasound a few days ago. But maybe it's still enough to explain the cramping?)