With homo. MTHFR is Hep. or Lovenox Always given?

[mvan]

Hi,

I just received the news that I tested + for homo. MTHFR. I just did a fasting Homocysteine test this morning and won't know the results for a while. I am gearing up for a FET and as far as I know, my Dr. is planning on only giving me Folgard for the MTHFR, but has not mentioned anything about Lovonex or Heparin. I am going to be on BA as well. I am confused as to what meds. are necessary for homo. MTHFR and what difference it will make if my homocystein levels are high or normal as far as meds. and pregnancy/getting preg. goes.

Any answers will be appreciated.

Thanks

[Josie1021]

My haematologist believes that is the high homocysteine levels that cause the problem. If they are normal or controlled with extra folic acid and Vit B6 and B12 supplementation, she thinks heparin/Lovenox is unnecessary.

A lot of doctors do seem to prescribe the Lovenox as well as low dose aspirin. My attitude (after 4 losses) is that Lovenox is a reasonable precaution if the potential benefits outweigh any risks to you.

Good luck

Josie

[mvan]

Thanks Josie--that helps a lot. I think I need to just wait and see what my dr. decides and go from there. She is always more cautious than not, so she might end up putting me on Lovenox, but hasn't said anything yet. I just need to be patient.

I'm sorry to hear of your losses. That is so devastating. I've lost 2 (six years apart), but I'm not convinced both were due to MTHFR. It's really hard to say.


Thanks again and good luck!

[Josie1021]

I'm not good at being patient, possibly due to my age, 39. My losses were possibly due to Factor V Leiden, another thrombophilia due to a common gene mutation.

I hope Lovenox and aspirin will help next time. I only wish they had tested me for it at the same time as all the other tests they ran. It took another m/c, this time at 12 weeks, for them to run the test. I am still waiting for the results on the MTHFR sequence but am taking the extra folic acid and B vitamins anyway.

Good luck to you too

Josie

[raytw]

you should be tested by a hemotologist - a person thats speciality is blood disorders - a hemotologist will do much more extensive testing than any other dr.

you may have read my other posts,but i will post it again just in case. i can't say enough about this

my hemotolgist is having me start lovenox at the very start of my next FET as there is a risk of blood clotting even from the estrogen and progesterone. according to her the dosage of lovenox is based on body weight and is therefore much safer and easier than the heperin. seeing a hemotologist is important.

GOOD LUCK TO YOU! i am very sorry for your losses and will be praying God Blesses you!

here is my previous post on this:

hi girls, i have been meaning to posts this for a while

hopefully, it will help some of you

for those of you that know my situation you know that i had a m/c at 6 weeks on our first ivf attempt- after this i insisted that the RE test me for anything that may have caused the m/c. it was found that i am prone to blood clots. i now see a hemotoligist and will be put on heparin or a similar drug to prevent clotting when we do our fet. i know three girls at my work that have miscarried for the same reason.

i wrote a letter to my RE and actually sat down with he and read the letter to him in which i expressed my GREAT belief that it should be STANDARD PROCEDURE to do this basic testing work up BEFORE going ahead with IVF. With all that is a stake - it is the least that can be done.

I cannot get back what we lost, but maybe, can prevent some one else from going through the same heartbreak

So, If possible, I would advise everyone to DEMAND testing on anything that could cause a m/c before going forward with IVF

[krampuszi]

Hi, I'm also homo MTHFR. From 4. IVF/ICSI I was pregnent, but only for 11 weeks . After we missed, I was allowed to go to a Haematologist, end we get this info. If anyone is here I would pleased to talk about the problem. I'll get Heparine (Clexane) during my pregnany (from transfer) end Folid as well.

[Lauren2005]

Oh, dear. The above posts have me very concerned. Prescribing Lovenox based on homocysteine levels is very OLD thinking. Please, all of you, research this topic and challenge your doctors. You will see two things:

1) less proven accuracy about homocysteine levels as medical predictors for WOMEN than men
2) research showing that homocysteine elevation in women is a RESULT and NOT A CAUSE of the reproductive problems that MTHFR is associated with. For example, your homocysteine levels would be normal, then you would have a m/c and THEN your homocysteine levels would go up in response.

Please look into this. The research is out there; this isn't uncharted territory. Don't just go along with these particular doctors. I worry for you. Yes, there are women doing the same non-Lovenox regimens you have described, and yes, some are succeeding. Like my real-world friend who is now 17 weeks pg after FIVE m/c's. So 1/6 is working. That's about statistically predictable without the added Lovenox! But her doctor says homocysteine levels are what matters, so her babies just kept dying. He convinced her that this was just bad luck, five times over. I am crossing my fingers (and everything else) for the survival of this baby and no clotting-related complications for her. I'm not being flip about this. Please research the topic.

Please read this article http://circ.ahajournals.org/cgi/con...ull/111/19/e289 about MTHFR, and notice in particular the sentence I have typed in bold below (the article is much longer than this paragraph). THIS is what your doctor needs to understand (remember, the article itself is about MTHFR):

There are certain implications of having elevated homocysteine that are specifically relevant for women. Elevated homocysteine levels have been observed more frequently among women with certain pregnancy complications, including preeclampsia (elevated blood pressure that can lead to dangerous consequences), placental abruption (where the placenta detaches from the uterus), recurrent pregnancy loss, and giving birth to a small, low-birth-weight baby (called intrauterine growth restriction). HOWEVER, MEDICAL RESEARCH SUGGESTS THAT ELEVATED HOMOCYSTEINE LEVELS MAY BE A CONSEQUENCE OF THESE COMPLICATIONS RATHER THAN THE CAUSE.

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In addition, please review the following:

[Treatment with enoxaparin (“Lovenox”) adapted to the fertility programs in women with recurrent abortion and thrombophilia]
Sarto A, Rocha M, Geller M, Capmany C, Martinez M, Quintans C, Donaldson M, Pasqualini RS.

Acquired and inherited thrombophilia are associated with recurrent pregnancy loss (RPL). Antithrombotic therapy could restore hemostatic balance and improve early placentation and gestational outcome. We evaluated the efficacy of enoxaparin adapted to the fertility program for prevention of pregnancy loss in 35 women (W) with early RPL and thrombophilia. Previous to the diagnosis of thrombophilia, they had had a total of 105 gestations of which 89 (85%) ended in early pregnancy loss. After diagnosis of thrombophilia, 35 subsequent pregnancies were treated with enoxaparin. In 5 cases assisted reproductive techniques were necessary to achieve pregnancy due to couple infertility. In 17 W who had had at least one preclinical pregnancy loss, enoxaparin (20 mg/d/s.c.) was started previous to conception and adapted to the fertility program. All the women continued with the gestational regime. Eighteen W with only clinical pregnancy loss started enoxaparin (20 mg twice per day s.c.) after biochemical pregnancy diagnosis. During gestations heparin dose was adjusted with anti Xa test, maintaining a range between 0.3 at 0.6 u/ml. With antithrombotic therapy, 30/35 (85%) of the pregnancies ended in live birth versus 16/105 (15%) of the pregnancies without treatment (p < 0.001).

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American Journal Of Reproductive Immunology
Volume 49 Issue 2 Page 90 - February 2003

Successful Pregnancy with Low Molecular Weight Heparin in Two Women with Recurrent Miscarriage of Unknown Etiology

Yoshihiro Miya****a, Masako Waguri, Isao Nakanishi, Noriyuki Suehara, and Tomio Fujita

We report here two cases of recurrent miscarriages that were successfully treated with continuous intravenous administration of low molecular weight heparin (LMWH). One patient experienced 11 spontaneous abortions, and the other eight abortions. Previous treatments including prednisone, aspirin and mononuclear-cell immunization were all unsuccessful. They were negative for anticardiolipin antibodies and lupus anticoagulant, and had no inherited thrombophilic disorder. Intravenous administration of LMWH, 4800 units of dalteparin, was started as soon as the conception was confirmed, and was continued until 34 weeks of gestation. They were delivered of live born infants.

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Clin Appl Thromb Hemost. 2005 Jan;11(1):1-13.
Recurrent miscarriage syndrome and infertility due to blood coagulation protein/platelet defects: a review and update.

Bick RL, Hoppensteadt D.

University of Texas Southwestern Medical Center, Dallas, Texas 75231, USA. rbick@thrombosis.com

Three-hundred fifty-one women were referred for thrombosis and hemostasis evaluation after suffering recurrent miscarriages. All patients were referred by a high-risk obstetrician or reproductive medicine specialist after anatomic, hormonal or chromosomal defects had been ruled out. These patients were assessed over a three year period. The mean patient age at referral was 34 years and the mean number of miscarriages was 2.9 (2-9). All patients underwent a thorough evaluation for thrombophilia and, when indicated, a hemorrhagic disorder. Of the 351 patients, 29 (8%) had no defect. Of the remaining 322 patients, 7 (2%) had a bleeding disorder: 3 with platelet dysfunction, 1 with Factor XIII deficiency, 3 with von Willebrand's and 3 with Osler-Weber-Rendu. The remainder of the patients had a thrombophilia as follows: 195 (60%) had antiphospholipid syndrome, 64 (20%) had Sticky Platelet Syndrome, 38 (12%) had MTHFR mutation, 23 (7.1%) had PAI-1 polymorphism, 12 (3.7%) had Protein S deficiency, 12 (3.7%) had Factor V Leiden, 3 (1%), had AT deficiency, 3 (1%) had Heparin-Cofactor II deficiency, 3 (1%) had TPA deficiency, and 6 (2%) had Protein C deficiency. There were a total of 364 defects found in the 312 patients harboring thrombophilia; thus, several harbored two and a few harbored three separate defects. All patients with thrombophilia were treated with preconception ASA at 81 mg/day with the immediate post-conception addition of heparin or LMW heparin (Dalteparin). Both ASA and heparin/LMW heparin were used to term. The first 120 patients were treated with unfractionated heparin at 5,000 U every 24 hours, subcutaneously and the last 192 have been treated with Dalteparin at 5,000 U/day subcutaneously. The patients with MTHFR were also treated with folate at 5 mg/day + pyridoxine at 50 mg/day. All patients were carefully monitored with CBC and platelet counts, anti-Xa levels, frequent ultrasounds and physical exams. Only 2 of the thrombophilia patients suffered another miscarriage; all others had a normal term delivery. There were no pregnancy-related thromboses, no delivery complications and no episodes of post-partum thrombosis. The only bleeding consisted of 1-4 cm bruises at injection sites. No episodes of thrombocytopenia (HIT) were noted. In our experience, thrombophilia is a common cause of recurrent miscarriage and all patients with no anatomical, hormonal or chromosomal defect should be evaluated for thrombophilia or a bleeding disorder. The success rate of normal term delivery in these 312 patients was 94% using ASA + heparin or Dalteparin. In addition, side effects of therapy were minimal.

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Acta Obstet Gynecol Scand. 2000 Aug;79(8):655-9.
Birth outcomes in pregnant women treated with low-molecular-weight heparin.

Sorensen HT, Johnson SP, Larsen H, Pederson L, Nielsen GL, Moller M

The Danish Epidemiology Science Center at the Department of Medicine V, Aarhus University Hospital.

BACKGROUND: Pregnancy and puerperium are associated with an increased risk of venous thromboembolism. Low-molecular-weight heparin is the anticoagulant of choice in pregnant women because, unlike warfarin, it does not cross the placenta. However, there are limited data on the risk of adverse birth outcomes following use of low-molecular-weight heparin in pregnancy. PATIENTS AND METHODS: We performed a population-based cohort study to examine the safety of low-molecular-weight heparin use in pregnancy using data from the Pharmacoepidemiological Prescription Database, The Danish Medical Birth Registry and the Regional Hospital Discharge Registry in North Jutland County, Denmark. The birth outcomes in a cohort of 66 pregnant women treated with low-molecular-weight heparin between 1991-98 were compared with the birth outcomes of 17,259 pregnant women who did not receive any prescriptive drugs during pregnancy. RESULTS: No increased risk of malformations, low birth weight or stillbirth was found. However, an increased risk of pre-term delivery was found (odds ratio: 2.11, 95%, confidence interval: 0.96-4.65), which could reflect inherited thrombophilia as an indication of low-molecular-weight heparin. CONCLUSION: We have provided additional evidence of the safety of low-molecular-weight heparin use in pregnancy.

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Fertil Steril. 2005 Sep;84(3):770-3.
Effects of enoxaparin on late pregnancy complications and neonatal outcome in women with recurrent pregnancy loss and thrombophilia: results from the Live-Enox study.
Brenner B, Ellis M, Yarom I, Yohai D, Samueloff A, Live-Enox Investigators

Rambam Medical Center, Haifa, Israel. b_brenner@rambam.health.gov.il

Women with thrombophilia and a history of recurrent pregnancy loss have poor pregnancy outcomes. Prophylaxis with enoxaparin 40 mg/day or 80 mg/day resulted in favorable gestational and neonatal outcomes.

PMID: 16169422 [PubMed - in process]

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Those and other such studies can be found in the files of the Yahoo immunology group, which I highly recommend joining. Many of the women there have "inherited thombophilia" (MTHFR, Factor V Leiden, Factor II Prothrombin) as well. http://health.groups.yahoo.com/group/immunologysupport/

I'm only a patient, so please consider what I've said to be just that -- words of a patient. It is entirely up to you to be your own advocate and to trust whom you decide to trust. I have given you all the information I can about this topic and hope that you find it empowering and helpful rather than annoying and confusing.

Hope that's a good start. All the best to you.

Lauren

[krampuszi]

Oh my God. It is a wery hard question. I red so many things about our typ (becouse it is not an illness as a know, in Hungary 10 persent are homosigot MTHFR). Is far as a know, the main problem is the small "mass" in the blod(sorry, a don't know the correct words even in hungarian) which blockades the blod supply of the placent/baby.

Thank for the new informations I will read them!

[Lauren2005]

Glad to help! In addition to possible large clots during pg, and neural tube defects without the use of high-dose folic acid, the other problem (some consider it the main problem) is little tiny clots that form in the teeny, tiny blood vessels of the uterus, cutting off the blood supply to the embryo/fetus. This can result in implantation problems, early m/c, late m/c, or worse. Remember with MTHFR patients, many doctors put them back on Lovenox for six weeks post-delivery, because the postpartum period is a dangerously hypercoagulant time. The Lovenox is used to prevent stroke, heart attack, or DVT. Hope that's helpful information. It's great that you're researching. We immune gals absolutely owe it to our future children to do as much research as possible, so that we know we are seeing the right doctors and getting the best possible care. Lauren