Episode 30: Do Biochemical Pregnancies "Count"?

Dr. Klimczak and Dr. Reed discuss biochemical pregnancies. Do they "count"? Are they important? What can they tell us? Should you have additional testing? What kind of testing can be done?

Transcript

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Hi, I am Dr. Beverly Reed. And I'm Dr. Amber Klinczak. And we are Two Peaks and a Pod. Hi, everybody. Welcome back. How are you doing today, Dr. K? I am having a great day. Good. You've been busy lately. I miss you. I feel like we don't get to hang out as much because you're always seeing patients all the time. Well, I, it was funny all because I had a hilarious story to tell Dr. Reed and I was like dying to tell her, but I haven't seen her in so long I didn't get to tell her. But I'll share with our audience, but you are listening to a celebrity because I was at a meeting yesterday with a group of OBGYNs and I mentioned that my partner was Dr. Beverly Reed and I had a girl, completely fangirl, over Dr. Reed, she grabbed my arm and was like, wait, your partner is Dr. Reed, I follow her, she's so great, I love that practice, and it just made me die laughing. Because it caught me really off guard and, and obviously she is very famous, um, but I was so proud to be. Well, that was very nice of her. I know I was afraid when you were telling me, she said, Dr. Reed, that she had something bad to say. I'm like, Oh no, what'd I do? Um, but it is really cute now. This happens to both of us now where sometimes I'll see a patient, they'll see you walking through the hallway and they'll be like, that's Dr. Pei from your Instagram. So, um, I do love that. Yeah. but I think you know what's so important is that patients are getting to know us. They're getting to connect with us and I think it's great because they're seeing we're just like y'all. We're just women out there trying to sort through our own issues and just all trying to collaborate and help each other. So I love it. Okay. I have a question for you. Um, this comes up quite a bit in my consultations where I'll have somebody who says, you know, I've been trying to get pregnant, and I'm not getting pregnant, except I had a positive pregnancy test at home, but then it went away, it turned negative, um, or sometimes it even went to get blood drawn, but then the levels didn't increase, it never got to the point where they could see a baby on ultrasound. And they always say, I don't know if I should count that. As a pregnancy. And so I just wanted to kind of see, have you, have the patient say this to you and what is your answer to that? Yes. I say it's like reading tea leaves. We used to joke that they're in a residency and you would look at pregnancy tests. It's kind of like reading tea leaves. I mean, if you are out there and you've ever struggled with getting pregnant, you will probably taken a pregnancy test, held it under different lights, had your partner or your mom look at it. Can you see the line? I can see the line. It's there. Yeah. That was true. Yeah, I've definitely been there myself and you know, there's this just faint line and it maybe just hangs around for a couple days and so, yes, I frequently encounter this. I have patients that bring me photos of their pregnancy test from, you know, several days in a row where you can see the test kind of get positive and then go away. Yeah. Um, so certainly, of a frustrating situation. And yeah, you know, there's a name for this. This is what we call a biochemical pregnancy. Um, basically a pregnancy that got like really started, but didn't quite get going. Um, and then ultimately resolves in a loss. Yeah. Yeah. Well, I've definitely, um, scrutinized those pregnancy tests too. And I have to say one thing I noticed with myself is those early pregnancy tests did not work for me. for me. Um, you know how somebody will do, for example, a first response. And I've read this package a thousand times. It says you should be able to get a positive up to 60 for your missed period. And so I remember when I was trying to get pregnant here, I'm testing six days, five days for a negative, negative, negative, negative. And then. I was like, okay, well, I'm not pregnant. And it wasn't until the day after I missed my period that it ended up turning positive. And so I, they do not work for everybody. I have to say, but number two, I think the hard part is you do have to follow the directions because it tells you, you have to read the test within a certain period of time. If you try to read it later, very often you can get, I think they call it an evaporation line, where it looks like there's a line there, um, but you read it outside the window, so that's not a true positive. So I think that's probably one point to bring up with them of like, hey, you know, was it, did it actually turn positive? in that window in which you're reading it. Um, but if so, was it truly a pregnancy? And, and I do think in most cases it probably is a pregnancy and could be important. It definitely can tell us a lot of things about what could be potentially going right. If somebody gets a positive pregnancy test, it seems that the sperm found the egg. And it made an embryo. It doesn't really tell us did it end up in the right spot or anything like that, but I think that tells us that definitely some of the steps, um, that are on your way to having a baby are, are capable of being done. So I think it can be a positive experience even if the overall, um, outcome is negative, right? Right. Absolutely. I mean, you've talked about this so many times. But often when we meet with you, we're trying to figure out, are you ovulating? You know, we often do this from your history. You may have regular cycles, but hey, if you've got a biochemical pregnancy in the past, fairly good chance that you're ovulating. So we know that you're releasing an egg. It's at least making it hopefully to the fallopian tube where the sperm is finding it. Right. You're not having a pregnancy out in the abdomen, but usually making it into the fallopian tube. to meet with the sperm and fertilization is occurring. Um, and we're getting to that really embryo stage, but then it's not quite making it past that. So a lot of things are going in the right direction. When I see this, when I'm treating my patients, I'm really encouraged. I usually feel really positive and it's usually stuff in the right direction. I have a lot of patients that get pregnant the very next month with an ongoing pregnancy after a biochemical pregnancy. Um, so I feel really positive about it. Yeah. Yeah. Um, Well, so here's kind of a bit of a controversial topic I'm going to ask you about. So I think we've done another podcast before where we talked about women who may have undergone multiple miscarriages. Um, but our traditional definition of somebody who has recurrent miscarriage means that they've lost two or more clinical pregnancies. And what we mean by clinical pregnancy is that you can see. see the pregnancy on an ultrasound, not just on the blood test. Um, and so what I wanted to know is that how, what is your take on that? What is your experience been? Of course, we're going to evaluate and work at those patients, but could it, or should it be reasonable to maybe consider doing an evaluation on somebody who has been getting these positive tests at home or positive blood tests? Um, but never got to the part where you could see anything on an ultrasound. Yeah, I think it's definitely debatable. For my patients, it really depends on the type of testing that we're considering doing, okay? Um, so probably something is going on, but whether or not biochemical pregnancies really warrant this diagnosis of recurrent pregnancy loss, I think that's really the part that's controversial, because when you put your patient into that, category of recurrent pregnancy loss. You're really leaning towards testing for a bunch of etiologies that are very specific and have been researched in that patient population to be potential causes of a clinical pregnancy loss. For example, one of the tests that we do, and we've talked about this before is antiphospholipid antibody syndrome. It's just not something that we can even diagnose if the only type of loss you have had is a biochemical loss. So it puts us in a bit of a clinical predicament when we have tested you for a disorder that you don't really meet criteria for, right? So I don't want to lead my patients down this really confusing path. So that sort of testing I wouldn't do on a biochemical Just someone who's had only biochemical pregnancy losses But there are some other things that I think are warranted in this population. For example, I think It's important to check someone's thyroid. A thyroid dysfunction can certainly alter certain phases of your menstrual cycle and maybe lead to an early disruption in pregnancy. So I think that that's an important consideration. I think looking at other endocrine disorders like pre diabetes or diabetes, you never want to miss that causing something like that. Um, prolactin is a hormone that can come from your brain and kind of, turn on on its own. And it's something that can also disrupt and maybe lead to a biochemical pregnancy. So I think there are certain things that I, I do think of when I'm thinking of recurrent biochemical, but I don't necessarily put those patients into a category of, yes, you have recurrent pregnancy loss. Right? Absolutely. Um, I think another one that I feel like I've seen, and you'll have to tell me if you have the same experience that may be associated with recurrent biochemical pregnancy loss is. some type of problem that's going on within the uterus itself. Um, so of course, when a pregnancy goes to implant, it wants a nice, fluffy, calm environment to implant on. But sometimes the uterus can have polyps. It can have inflammation. That's called cramps. chronic endometritis. And I think you can imagine that if your pregnancy is kind of on its way to implanting and then it just isn't really able to thrive in that environment, that that might be one that's a little bit more associated, um, with biochemical pregnancies too. And I can't say that's backed up by any studies that I know of, but I think logically, um, that could definitely make sense and could be something that's pretty easy to check for. Um, On a patient, have you, have you seen any association with that? Yeah, I think certainly, um, so the test for that would be like a saline infusion sonogram. A saline infusion sonogram really is very low risk to do. It's, it's a minimal type of procedure, so I think that there's not a lot of harm. And if we do find something like a polyp or, you know, maybe even a fibroid that's a pushing into the cavity. We then have something to really work with. And I think that that often is relieving to a patient. Patients really want answers to why these things are going on. So if we can find something, absolutely. Yeah. Well, you know how I always say SIS is my favorite test and I did have one the other day, which it just gave us all the answers. So I had a patient where she'd had kids before. She was trying to have another kid and they were having just so much trouble trying to get pregnant again. They'd been trying for a very long time and she'd even had some testing done elsewhere where everything looked like it was fine. And so she said, I'm ready for IVF. So we're going to do IVF. And as part of IVF, we do routinely do a saline infusion sonogram. And the reason I like this test is because it's really getting a good view of the inside. So I would say you have your two layers of lining. Um, but when you put the sal those layers open. And wh there's a giant public si I said, well, that's why pregnant. Cancel your IV need it anymore. Um, and and the public this week that that she's going to such a, just a simple procedure. It really was just a few appointments for her, her saline infusion sonogram, and then her procedure to get the polyp taken out. And it really can make just a world of difference to just have a nice, um, favorable place for the embryo to. What a good feeling. Yeah. I'm sure she's been wondering for years. Yeah, exactly. And it all made sense. And I think too, that's really what happens to us every single time. We're like detectives. We've got the case. The case is, you're either not getting pregnant or you're having recurrent miscarriages. We need to help you figure out what is going on in that case. And a history like that definitely tells you you need to be kind of, um, looking for things that, um, that would make sense. And in her case, it definitely made sense. I actually have, um, something interesting when it comes to biochemical pregnancies. I had gone to a conference where the speaker, um, kind of explained to me why the recommendation is to only count clinical pregnancies for recurrent miscarriage, and, you know, I think we've talked about this before too, but it made a lot of sense to me, and that is that in certain states, there is mandated. Coverage for infertility treatment. But to qualify for infertility treatment, you must be infertile, meaning you've never been pregnant. And so what happens is if you count a biochemical pregnancy as having gotten pregnant, then they tell you, well, you're not infertile. So no, you can't get covered treatment. And so that was a lot of the discussion that went behind that recommendation when they were trying to decide whether Who gets this diagnosis of recurrent miscarriage versus, um, infertility. And, um, and so the speaker I thought was really interesting because he said, Look, do these biochemical pregnancies matter? And he said, Absolutely. But some of the causes are the same causes that we see with somebody who has a more advanced miscarriage. So probably number one cause. of biochemical pregnancies is that the embryo is not normal. So we all have 46 chromosomes. Sometimes when the egg and the sperm come together, nature makes a mistake. It gives the embryo too many chromosomes or not enough chromosomes. And oftentimes those are pregnancies that either won't implant. Or if they do can end in early or sometimes even late miscarriage as well. Yeah, this is a question that I get a lot from my patients. So they may have come to me with a clinical loss where they knew they were able to get testing on the products of conception. They had a pregnancy that had an abnormal amount of chromosomes or maybe they have biochemical pregnancies. Unfortunately, there's not a lot of treatment options that we can offer the patients. And this is, I think, another place that is a little bit controversial in what we do. Um, but one thing that I actually, um, looked at a lot of data on where I trained is whether or not IVF with pre implantation genetic testing for aneuploidy or testing the embryos genetics before we put it in and knowing ahead of time, is this a normal set of genetics? whether it can improve success rates in that patient population. We looked at over 6, 000 cases and yeah, and it did show an improvement using pre implantation, um, genetic testing for any blade. Is that something that you offer your patients in this setting? I do, but it's hard because I sometimes get a mixed reaction because, um, Especially in patients, so if they have been multiple times able to easily conceive on their own, it is really hard for them to make the leap in their mind that they would need such invasive treatment like IVF. And although they understand the logic behind it, um, and how it could or would work, I do notice a lot of hesitation because it's a lot of people. It's a lot of expense and they keep asking themselves, is this really necessary? But I think it could be potentially based on the diagnosis, why it's happening. And so I do think that's why sometimes it's helpful to offer them as much testing as we feel comfortable with offering them, because if you're kind of ruling out some of those other issues. And everything else is normal. Then we kind of go back to, okay, the most likely cause, the most likely scenario is that maybe these embryos that are implanting are abnormal. And do you want to consider IVF not only to be able to put a normal embryo in, but also to help us troubleshoot deeper? Let's say we do IVF and we're putting normal embryos in. And they're still miscarrying. There you go. That gives us more information of, okay, there's more going on. What else do we need to be looking for? What else do we need to be digging for as well? And it gets things a little bit further along, you know, we may be bypassing other because a lot of the studies on biochemical pregnancies have been kind of like From the very beginning, how quickly can you determine whether this is going to result in a loss? There's a lot of other markers other than just hcg levels that they're doing research on, you know, right after fertilization Right after implantation are things already abnormal at that point and when we do IVF Remember, we're helping things along until the point that that embryo is about a week old So we may be overcoming these early processes that were already going awry You Right. And correcting things so that by the time we put the embryo into uterus, it may not end in a biochemical. Yeah. Well, I do think it's interesting too, because there's really not that much research on biochemical pregnancies. And probably a large reason why is that pregnancy tests, are relatively new. I mean, I know probably most of our audience has grown up around them, but if you think back to, you know, let's say 40 years ago or so, it's not like pregnancy tests were just readily and easily available for the average person. Now, these days, my patients will get a huge bag from Amazon and they'll just be on a stick every day, you know? And, and so honestly, it seems like we're getting more data than women of the past have had before. And I do think that could be a really interesting area of research for us to kind of. You know, look and see, um, if a patient's doing a home test, when is it turning positive? How long does it stay positive for? And, and, you know, I have people that, you know, we'll look at the lines and lines getting darker, but what if they don't get darker? Could it still be okay? And, um, I think that that's a whole area that really needs to be explored further now that, um, so many women have much better access to just doing home pregnancy tests and they have interest in it, right? And you're in that situation where you took a pregnancy test and it was lighter than yesterday You're Googling, you're looking, you're trying to find stories of hope. Could it be okay? Am I just more hydrated today than I was yesterday? You know, there's so many different things that kind of go on in your head and go on in your head. And I think it would be, um, maybe interesting to, um, to be able to study that further too. Yeah. Um, one of my, um, co fellows and Dr. early. Dr Nola early. He did a really nice study where she looked at a different form of H C G called hyperglycosylated H C G. And so when we do an embryo transfer, we typically don't get a pregnancy test until, you know, about 9 10 days later. But she was actually looking at just two days after transfer. Can you already start to detect this hyperglycemic? Clostylated form of HCG, um, and whether or not that predicts the outcome of the pregnancy. So really interesting studies like that that we can kind of look at with like, early, early testing and whether or not something is already, you know, how quickly is their test going to be positive? Because I do have patients that I swear they take their pregnancy tests. positive. I'm like, how are you getting a positive? And they're right. Yeah. Levels look great. Yeah. And other people will be negative just a couple of days leading up and then the rise. It just depends on what your absolute value is going to be. Yeah. And I was actually even just sharing, um, with the girls, um, I, Remember, I had a patient who came in for her blood draw and she was so looking very sad. You know, what's wrong? Oh, I've been testing at home. It's negative. I'm like, Hey, I'm sorry. I get that. I'm so sorry. But let's see what the blood test was. And blood test comes back and she was pregnant and ultimately was even pregnant with twins, but had never gotten a popped at home pregnancy test. And I was just so glad that she trusted us. Enough to still come in for the blood test. Um, because sometimes I've had patients who get really discouraged. They go looking online and they'll be saying, you know, my test is negative seven days past transfer, or things like that. And they get discouraged. They think it means it doesn't work. And although those home tests are very good. They are not 100 percent as again, I told you guys personally in the beginning and so really if in doubt or even if you're feeling anxious to you can probably always check with your doctor and say, Look, I can I do my blood test early? I'm stressing out. I'm nervous. But the main thing is you definitely don't want to stop taking your medications before you've actually gotten your final blood test result. Yes, the other thing I will caution people about, especially if you're prone to miscarriage, if you've had a miscarriage in the past, a lot of my patients really do get fixated on taking pregnancy tests. And so maybe you're not seeing a fertility doctor where you can't do early pregnancy monitoring, so what do they do? They take pregnancy tests every day for weeks, you know, until they're even able to be seen by their doctor at 10 weeks. Well, something interesting can happen with the urine pregnancy test, where you have your pregnancy hormone level in your blood, it's called HCG, it's circulating, and it does rise. Eventually, it can get so high, So high that it actually saturates the test that you're trying to do through the urine and it will result in a negative test. It's actually finding both sides of the assay, um, and interfering with it. And so one way that you can kind of get over that is if you're seeing this happen, you can dilute the urine and then test it, but also. probably unnecessary to continue testing that long. If you're not having any bleeding or other signs of a miscarriage after you get those initial tests, I probably wouldn't keep testing because it's going to add a lot of anxiety to your life. Right, right, right. And then rarely, sometimes you can get a positive when you're not pregnant. So this used to be. quite a bit back when, so before I was a fertility doctor, I was an OBGYN and oftentimes I would be covering call for the ER. And in a very common situation is I would get a call and they'd say, this patient is 50 years old and she has a positive pregnancy test. It happened all the time. We used to get this call. Um, but what happens, especially Especially when we are perimenopausal or postmenopausal, right around that time, our pituitary gland actually makes very small, um, amounts of pregnancy hormone and it can turn a home pregnancy test positive and that can feel very confusing as well. Um, and so it is still important to be able to tell your doctor if, so if you have a home pregnancy test, you should definitely let your doctor know and they'll need to check your blood test and everything. And it will show up positive in a blood test as well. But then they have to look at the overall clinical situation, meaning if you had multiple blood tests, they're not really rising, they're staying about the same, then they might need to evaluate you to see if you have that. And a quick and easy way to do that is if you put a patient like this on birth control pills for about two weeks, and you recheck the pregnancy hormone test, it will go down to zero because it actually suppresses the pituitary gland whenever you're doing um, birth control pills. Um, so it's a little bit more rare probably for our average, um, patient audience, but important to know that there are other reasons or other things that can happen that can make you have recurrent positive tests too that seem like they just aren't turning into a full term. All right, should we wrap it up? Yeah, great discussion. Okay, good. All right. Thank you guys. Have a great weekend. If you have a chance, give us a good review. All right. Have a good one. Bye