Q. I am 28 years old. I have been married for the past 3 years. I was diagnosed with PCOS (polycystic ovaries) 6 years ago. I also have a history of diabetes and I suffer from insulin resistance. My gynaecologist advised me to lose some weight. Presently my weight is 66 kg and I am 5 feet 3 inches tall. Since I was not ovulating, my doctor put me on Metformin (1000 mg) and Folic Acid (5 mg). Six months ago my husband and I wanted to have a baby, so she prescribed Siphene and put me on follicular imaging. In the fourth cycle when I had Siphene (100 mg) from D2 and D7, I conceived. But since I could not go for follicular imaging in that cycle, my date of conception was not clear. I went for all the hormonal tests and everything was normal. In the first scan after the conception, only the egg yolk could be seen. In the second scan, the fetal pole was very fine and the cardiac activity was 47 BPM. The doctor asked me to go for a scan after 20 days. In the third scan the cardiac activity was not there at all. The doctor said it is a case of missed abortion. She advised DNC, which was done earlier this year. Why did this happen since my hormonal tests were normal and my husbands semen analysis was also perfect? When can I try for a baby again? How much gap do I need? The doctor says that this is common in PCOS and is not recurrent. She has asked me to have Metformin and Folic acid. She says I can try after 2 months. Is she giving me the right treatment? Another doctor asked me to discontinue Metformin. Do I need to undergo some more tests? Did Siphene have any effect on the fetus? Please advise.
I think your doctor has told you all the right things and is giving you the right treatment. She has so far done all the right things and I think you should follow her advice even now and in future, as she must have explained these early abortions are common and mostly of no consequence. They are a random event and on the day of conception it is the wrong sperm mating the wrong egg (both of which are selected by nature at random), which were faulty and the fetus formed was not good enough to grow into a healthy individual. Recent research has shown that almost 60 percent of all fetuses conceived are less than perfect and therefore only about 40% result in the birth of a healthy baby. To your question what went wrong, the answer is we do not know and we shall never know but basically it is just a random event in nature. In fact, with so many things that can possibly go wrong in conception, one wonders how nature ever eventually makes a normal baby. Even when all of us were born our mothers have the same chance of having a normal/abnormal baby. Any fetus, which is not good enough to live 70 years on this earth, is excluded by nature by natural selection (basic Darwinism) - this is across all species. Reproductive loss is universal in all plant and animal species. Most of these abortions occur very early and pass off as delayed periods and those that are noticed late (after the pregnancy is documented by urine/blood tests or ultrasounds) are seen clinically as abortions. About 22 percent of all pregnancies, which are clinically diagnosed, end in an early abortion (like in your case). The percentage is marginally higher in PCOS (about 2-4% higher only).
To answer your questions point wise -
1. The hormones and the sperm test would be normal and they do not prove or disprove anything. You still have to take your chances and you have the same 22-24% chances of losing next pregnancy (same as any other woman who is pregnant)
2. About how long you should wait? The answer has been given by your doctor; you do not have to wait at all. You can conceive, as soon as you want. As soon as you are mentally prepared, you are lucky to conceive soon after starting the treatment with clomiphene and you should conceive again without much problem. Hopefully and once you are pregnant again, please do not get paranoid and get too many ultrasounds and tests and treatments just folvite is to be taken and a scan at 7 weeks to see the fetal heart and one at 11-14 weeks to see that the baby is normal. There is nothing worse than meddlesome pregnancy and the loss of this pregnancy should not be a reason to mismanage your next pregnancy. Please read about antenatal care and follow evidence based guidelines for a healthy management of pregnancy. You can download these guidelines from the site of royal college of obs and gynaecology at www.rcog.org.uk - go to the site and download the guidelines for patients.
3. You don't need any tests. You may be asked to do a lot of tests, which have no role like TORCH but please do nothing and go ahead and plan for the next pregnancy.
Most women in your position would be prescribed Metformin and your doctor is the best judge to know whether you need it or not. Metformin is fairly safe in pregnancy and not much is documented against it. It is a relatively new drug in pregnancy and not everything is known yet, but enough is known to give it without much problem. But you will have to leave it to your doctor to decide and you can read more on the FDA site if you want.