Fertility Forward
Fertility Forward
Ep 177: ‘Time to Undetectable HCG Following Early Pregnancy Loss in ART Pregnancies: A Comparison of Management Strategies’ with Dr. Erkan Buyuk
Welcome back to another sneak peek of the upcoming ASRM Conference. Today, we welcome Dr. Erkan Buyuk back to the show to hear about his abstract at the ASRM Conference titled, ‘Time to Undetectable HCG Following Early Pregnancy Loss in ART Pregnancies: A Comparison of Management Strategies.’ Tuning in, you’ll hear about this one-of-a-kind study, the delicate way doctors have to handle miscarriages, the three options patients have after finding out a pregnancy isn’t viable, and so much more! Our guest shares what inspired him to conduct this study before delving into some of its findings. We even discuss how this study has helped us have a better understanding of when HCG levels will reduce after miscarriage. Finally, our guest tells us what we can expect in the future from this study and shares what he is grateful for today. Thank you for listening!
Hi everyone, we are Rena and Dara and welcome to Fertility Ford. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Ford podcast brings together advice from medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate. I am so excited to welcome to Fertility Ford today a recurring guest, Dr. Erkin Biuk, who is a reproductive endocrinologist at Marn Minnie of New York. And he is here to share about an abstract he is going to present at the upcoming ASRM conference. So we are super excited to hear from him. And the title of this study is Time to Undetectable HCG Following Early Pregnancy Loss in Art Pregnancies, a comparison of management strategies. Thank you so much for being here today and for this research. I was reviewing it before, and I think this is going to be an amazing presentation for our listeners.
SPEAKER_02:Thank you very much, Rina, for having me. I agree with you. This is a gap in the literature. So one of the one of our hardest parts of our job is to tell a patient that they have a miscarriage. The pregnancy they work so hard to achieve is not going to end up with a live birth. So think of it. Some of our patients are trying to conceive for years, some five years, 10 years. Finally, we achieved the pregnancy with a treatment. It can be insemination, it can be just ovulation induction, or it can be IVF in vitro fertilization. They went through multiple steps. They got the great news that the pregnancy test is positive. And then the next step is on the ultrasound, we don't see a pregnancy sack. Or we see the pregnancy sack, we don't see the heartbeat. Or we already saw the heartbeat, but now the uh there is no heartbeat anymore. So there is a miscarriage. And then what is the next step? The way we counsel our patients is they can have an expectant management. That means do nothing, let nature take its course, you know, have a natural miscarriage. The advantage of this is there is no medication, there is no instrumentation. The disadvantage is you don't know when it's gonna happen. It may happen within a week, it may not happen for the next month or two months. A second option that we offer our patients is medications to start the miscarriage itself. So the advantage of this is you know when this is gonna happen. Once these medications are 80 to 90 percent of the time effective, so they know when the miscarriage is gonna happen, so they can arrange their day, it can be on a weekend, etc., so that it doesn't happen at work, for example. The disadvantages, you know, it is uh it's a miscarriage, it is maybe painful. One to two percent of the time, the bleeding may be so much that they may need to go to an emergency room. So the third option is surgical termination of pregnancy, with the advantage uh being, again, we know when it is gonna happen. There is no surprise. It is under often under anesthesia, so the patient sleeps, they don't feel any pain, anything, etc. The disadvantages, you know, it is a procedure. There are risks associated with procedure itself, like infection and bleeding. So these are the main, these are our main treatment modalities, and these are the main points for discussion with our patients. The most important question that comes after that is when can I try again? When we can we start the treatment again, when can we do an embryo transfer? When can we do an insemination, etc.? And the answer is when the HCG level pregnancy hormone becomes negative. Before that, we cannot do anything. Of course, the natural next question that follows when is it gonna be negative? So, you know, the answer is we don't know 100%.
SPEAKER_01:I want to interview you there just to clarify for our listeners. By negative you mean zero, correct?
SPEAKER_02:Zero, exactly. You know, HCG going down to zero. We don't know when this is gonna happen, you know, depending on the procedure or no, if it's expectant management, we have no idea. Like I said, it can take up to two months. Sometimes there may not be even a miscarriage within that time period, and we don't want to wait that long. Uh, with others, we say most likely it's a month, it can be a little bit shorter, longer, but we don't know. So then the question is which one is gonna be fastest? And then the answer is I don't know. And that's why we came up with this project. We compared the time to a negative pregnancy test, to a negative HCG, among comparison of that time among these three treatment modalities: expectant management, medical treatment, and surgical treatment. So, what we did in that study is we identified uh the time of loss when we saw that the pregnancy was not advancing. This can be, for example, we saw a pregnancy sack before, a week later, we see the same pregnancy sack. There is no uh progression in the pregnancy itself. So that's that's the time of the loss. Or you know, we saw a heartbeat. The next time the patient came in, there is no heartbeat. So that's uh that's the time of the loss. And then we follow the patients with expected management, or with the media once we give the medication, or once we do the surgery, on average we follow them weekly until the pregnancy test again uh becomes negative, so that by that time we can restart uh another cycle. So this time from the loss to the pregnancy uh test being negative is what we compared between all three treatment modalities. And then so at the end, one thing to mention, which is very important, is the disappearance of HCG, the pregnancy hormone level, is gonna be very much dependent on how much the pregnancy is advanced. So why? Because the hormone levels, HCG levels, are gonna be higher as the pregnancy is more advanced. Okay, and then because of that, the time to disappearance is gonna be longer in uh more advanced pregnancies. So these are the things that we controlled when we analyze our data. Okay, and you know, at the end of analysis, uh we found that again, it depends on the week uh of the uh pregnancy, but it looks like at around six and seven weeks of pregnancy, medical treatment seems to be most effective in for the HCG levels uh to come back to negative when compared to other modalities. Surgical treatment came in second, and expectant management uh was the last. Uh it took longest for the hormone levels to become negative in the expected management group after controlling for the confounding factors, the ones that we discussed mainly, the age of the pregnancy at which the pregnancy loss happened, and the initial beta-HCG, the pregnancy hormone levels. For eight weeks of pregnancy, we didn't see any difference between the groups. This may be due to a relatively lower number of patients in those groups. However, at the end of the study that we are gonna present uh at the uh American Society for Reproductive Medicine meeting, now we have another tool to counsel our patients, to say if they are at a certain gestational age when the pregnancy was happened, we can say this particular treatment method can help us to get you to faster to a negative HCG level. And if you want, you know, with that treatment, we can start your treatment a little bit earlier.
SPEAKER_01:Wow, this is uh so incredible to present because I can tell you one of the things that I deal with all the time is cases of patients who are just so miserable and upset. You know, how long is it gonna take my HCG to drop? And being in that space of both grieving almost and having to cope with that, and then also so desperately wanting to know when they can start again because that's what's gonna give them hope. And then when they're stuck in that limbo and the HDG, it's not dropping, or maybe it's dropping, you know, incrementally, it's so frustrating and such a difficult place to be in. And so I think this research and being able to give them this specific concrete data is going to be so helpful.
SPEAKER_02:I agree. Again, one of the main things that they ask, when can I start again? Now we have some counseling tools, you know, some concrete data that we can tell them it's gonna take that much time if you choose that particular treatment versus the other one.
SPEAKER_01:Well, I mean, I think this is incredible. Is this the first study of this kind to really be done?
SPEAKER_02:The way it is done, I believe it is the first one, yes. Because until now, you know, we we couldn't say exactly which one is gonna bring your HCG levels, you know, to negative first or more likely to be a shorter interval. Until that time, you know, we didn't have that information. One of the strengths of the study is we also subgrouped into weeks, you know, at six weeks, at seven weeks, at eight weeks. We were lucky to have enough samples to tell the difference for six and seven weeks. And unfortunately, you know, most of our miscarriages you know fall in that range. So for those weeks, we can confidently say that you know, if you get medical treatment, that seems uh to resolve the HCG uh faster.
SPEAKER_01:I don't want to throw you a hardball question, but you know, my patients are so data-driven. I don't and I don't know if this study can sort of flesh this out. But, you know, so say someone has an HCG of whatever it'd be in the in the thousands, you know, at six to seven weeks, and then they want to know, well, how much should I expect it to drop weekly? So then they can do the math on how much it should drop each week for them to get to zero.
SPEAKER_02:Depending on the treatment. If it is expected management until the preg uh miscarriage starts, it's not gonna drop, most likely. It may even go up. Uh, for uh medical and surgical treatments, because we know when it is happening, you know, from that day to the next time we are gonna check. For example, we check in seven days. The biggest drop is gonna be during that time. So if it is shares that HCG of 10,000, for example, the numbers that we are gonna see in uh within a week is gonna be in the low thousands or even you know high hundreds, maybe. So at first it's gonna drop very quickly, and then you know, uh the drop may be a little bit slower. At the end of the day, on average, you know, within a month or so, uh the HCG uh is gonna be negative.
SPEAKER_01:Okay, so based on this study and using the interventions that you presented, if you have a loss at six to seven weeks, you could hang on to hope that you could potentially start again within a month.
SPEAKER_02:Roughly, that's correct. Again, everybody's metabolism is different. That's why you know we cannot pinpoint a certain date. Uh, you know, everybody clears, you know, let's say the medications or the hormones from their body at a different rate. But you know, that seems to be you know the average duration. However, you know, that being said, like I said at the very beginning, every every modality has their pros and cons. Uh, for example, with medical treatment, it is very difficult, majority of the time impossible to get genetic testing from the aborted material. So you know, surgical treatment gives you that advantage. So at the end of the day, like I said, the advantage of this study is it gives you one more tool to counsel the patient depending on their preferences. But that doesn't mean that you know everybody should choose a medical treatment because uh HCG levels are gonna go down faster. Everybody's interests may be different. Uh so again, based on what we want to achieve, you know, from the results, is it very important to get the genetic testing? Majority of the time, it is very important. Maybe surgical treatment may fit better, you know, that particular situation.
SPEAKER_01:I think that's a that's a great point. And I think hopefully all physicians will be like you and present all of this data and options to their patients. I know sometimes I have patients get frustrated because they feel like, okay, well, the doctor told me I can choose between, you know, XYZ options and I I don't know what to do. I'm not the physician, and that leaves them feeling quite frustrated.
SPEAKER_02:Correct. So that this is where we guide them. You know, we give them all the information, you know, we ask them to choose, but like you said, you know, they cannot always choose. Ask, you know, what is the most important for you? Or also we we give them some guidance, you know. This is an, for example, untested embryo. I really want to know if that embryo was genetically normal or not. So that guides our treatment. And if the patient agrees with us, I say, okay, let's do surgical, let's send the sample because that will guide our management afterwards, also. So uh if it is an abnormal embryo, there is nothing else to do. Why? Because the miscarriage happened because the embryo was abnormal genetically, it was not tested before, it was from insemination cycle or just ovulation induction, then let's proceed with our treatments. If it is a genetically normal embryo, then there is more reason to look for other reasons why miscarriage happened. So that's how we guide the decision. You know, if it was an embryo that was tested before, we know it was genetically normal. Again, we we are still offering to test the embryo. However, those genetic tests are 98-99% accurate. So majority of the time, we are gonna get as a result what we got when we tested the embryo. So in those cases, going medical treatment route, uh, especially if the time is of essence, may be more beneficial for the patient.
SPEAKER_01:I think that's a great point. I think it's also really important for patients to remember there really is no one size fits all for this. And so, as much as people love going on Reddit and going down those rabbit holes, you know, it's so important to trust your physician and be able to speak to your doctor about these things so they really can guide you. And I think sometimes what's hard here is that sometimes there isn't a clear-cut answer, and it's kind of just everyone's best guess. Um, but as long as you work with a physician that you trust and can guide you in the right way, I think that makes all the difference.
SPEAKER_02:You know, you said it very well. You know, there is no you know, one size fits all approach, uh, especially in medicine. Uh, there are so many factors that are involved. So we gauge and, you know, we know the pros and cons and then come to a final decision accordingly.
SPEAKER_01:Yeah, it's super tough. You know, I always tell people that nothing's ever a waste in this process. And even if it's not the outcome that you wanted, that medicine is all about science and data and numbers. And so you've collected an amazing amount of knowledge about yourself, and in that you can take forward with you to the next step to get you to where you want to go.
SPEAKER_02:That's absolutely true. We always learn from the past experiences of the patients, past treatment cycles, and you know, adjust or fine-tune uh the next treatment accordingly.
SPEAKER_01:Yeah, so I think all data is so important. So I guess any future implications for this study or any next steps from here?
SPEAKER_02:From here, you know, like I said, we don't have enough power to find out, you know, at eight weeks loss, you know, what is the best treatment options. Our data didn't show any difference in between three modalities, but I don't know if that is because there is really no difference, or we don't have enough power, meaning with our sample size is not big enough to detect the difference. So, next in the two years, three years, you know, we are gonna recollect the data, see if we have enough power to detect whether there is a difference, you know, if between modalities at eight weeks loss. It is possible there may not be, you know, it all may be equal, or with enough power, we may see the difference, and then we can counsel our patients accordingly.
SPEAKER_01:Well, I think this is incredible. I'm so happy to be able to share this with my patients and so excited for you to present this at ASRM by the time this airs, you will have already presented it. And thank you so much for your amazing work, both with patients and with the research.
SPEAKER_02:Thank you very much, Rena. Thank you for the opportunity.
SPEAKER_01:Yes. So the way we like to end our podcast is by saying something we are grateful for. So a gratitude that you have today.
SPEAKER_02:So I'm grateful for my patients, you know, for them, you know, choosing me as their doctor. And I'm grateful, you know, for great outcomes that we gave them.
SPEAKER_01:That's beautiful, and I love that. I guess minimum throwback, I'm I'm really grateful to have amazing physicians to work with. You know, sometimes people come to me and I'm so disheartened by who they're with, and it makes such a difference. And I'm so happy to be able to have such wonderful professionals such as yourself to refer people to and know that there are physicians out there who really care and are so invested in this. And that's an amazing thing.
SPEAKER_02:Thank you very much, Lena.
SPEAKER_01:Thank you so much.
SPEAKER_00:Thank you so much for listening today. And always remember, practice gratitude, give a little love to someone else and yourself, and remember you are not alone. Find us on Instagram at fertility underscore forward. And if you're looking for more support, visit us at www.rmanny.com and tune in next week for more fertility forward.