September 14th, 2011 by Hasham

Miscarriage of Twins

I could not find any information about miscarriage of twins when I found out we had lost our second twin as well. The only story I heard was an email recieved from another MOMYS. She had miscarried twins and had passed tissue, thought that was it, then kept up some bleeding, and passed more tissue about a month later. She said she’d have done a D&C if she’d known it would be so prolonged.

A D&C was not an option for me – I have an incompentent cervix and I was afraid that forced dilation could make my cervix even worse, so I was determined to wait it out. If I’d known then what I know now, though, I’d have called my midwife friend to come to me as soon as I started bleeding heavily.

A few days after my miscarriage, in which I passed both babies about 30-40 minutes apart and bled extremely heavily needing medication to stop it, I had a talk with a different midwife. She said that she’d had a twin miscarriage as well. Her story was like my MOMYS friend – two episodes of tissue passage a few weeks apart. However, she said she’d had three cases of twin miscarriage in her practice. Coincidentally (?) those three mothers were the only cases of hemorraging in miscarriage she’d had in her practice as well.

This is all just observational, but if you are expecting multiples and miscarry, then you may want to call for help to stay with you immediately as soon as the heavier bleeding starts and make sure they have herbs or medicines to stop the bleeding if necessary.

BTW, I had no bleeding after the death of our first twin at 6 weeks. I had cramping the day before the ultrasound showing only one sac instead of the two we’d seen the week before. The cramping was not severe at all and stopped after a few hours. It did not affect my cervix. I understand from my midwife friends that you can have no bleeding/no cramping, bleeding/no cramping, cramping/no bleeding, passage of tissue or no passage of tissue if you miscarry one twin of a twin pregnancy.

When we miscarried finally, one of the babies (who died at 9-10 weeks) was in a complete sac and placenta, the other (who died at 5-6 weeks) had a broken sac and placenta. I am very glad we stayed at home and were able to see what our little ones had left behind when they went to heaven. It was so important to me to see clearly that there had been two of the precious little ones. We are planning to bury them at our family’s lake house and I’m going to plant two trees there.

BACKGROUND:

A series of monozygotic (MZ) twin pairs discordant for premature ovarian failure presented an unusual opportunity to study ovarian transplantation. METHODS: Ten MZ twin pairs requested ovarian transplantation and eight have undergone transplantation with cryopreservation of spare tissue. Seven had a fresh cortical tissue transplant, one of whom received a second frozen–thawed transplant after the first ceased functioning at three years. One had a fresh microvascular transplant. RESULTS: All recipients reinitiated ovulatory menstrual cycles and normal Day 3 serum FSH levels by 77–142 days. Six have already conceived naturally (one twice). Currently, two healthy babies have been delivered, and another three pregnancies are ongoing. The oldest transplant functioned for 36 months, resulting in one child and one miscarriage. She conceived again after a frozen–thawed secondary transplant. There was no apparent difference in return of ovarian function between the eight fresh ovarian grafts and the one frozen graft.

CONCLUSIONS:

Ovarian transplantation appears to restore ovulatory function robustly. Successful pregnancies, including one after cryopreservation, bode well for application to fertility preservation.

Materials and Methods:

Eight MZ twin pairs aged 24–40 years presented with discordant ovarian function, one sibling of each pair having undergone POF by 34 years of age (one had primary amenorrhoea). POF was diagnosed after at least 12 months of unexplained amenorrhoea accompanied by elevated serum levels of gonadotrophins (one case had undergone bone marrow transplantation, indicating her POF was iatrogenic). Their sisters, in contrast, still had normal menstrual cyclicity, and six of the eight had successful pregnancy histories, and only one miscarriage was reported (Donor for Case 2, i.e. 2D). None of the twin pairs was actively recruited. Each had enquired about treatment to restore normal reproductive endocrine function with fertile potential after hearing reports of the first successful ovarian transplant in a twin pair in 2005, as well as from researching an earlier testis transplant report for anorchia (Silber, 1978; Silber et al., 2005). The patients volunteered many reasons for preferring transplantation to conventional oocyte donation technology. Some of them had previous failures with donor oocyte cycles, or the twin had the opportunity to donate an ovary at the same time as having surgery for other gynaecologic problems (such as fibroids or cysts). All of them found the possibility of natural conception attractive. In some cases, the twins lived far apart (even in different countries) and the donors preferred to make a single visit for one-time donation, with the hope that frozen banked tissue could serve as a backup if the first transplant failed.

Clinical profile:

These studies were carried out with informed consent under a protocol approved by the Institutional Review Board and the Ethics Committee of St. Luke’s Hospital, St. Louis, MO. The donors were informed that they may reach menopause slightly earlier than normal based on theoretical models and experimental studies (Gosden et al., 1989; Faddy et al., 1992) and were aware of the relative risks associated with unilateral oophorectomy. Harvesting a large biopsy was judged to be no greater burden or risk but would have provided less tissue for fertility restoration.
The reproductive history of each twin pair was reviewed and ovarian function was investigated by standard gynaecological procedures. Serum from peripheral blood was prepared for immunoassay of FSH, LH and estradiol (E2) three days after the start of menses in women who were cycling naturally, but not on any specific day in those with POF. Some prospective donors had been taking birth control pills or were pregnant at the time of presentation, rendering hormone measurements meaningless. The antral follicle count (AFC) was recorded by transvaginal ultrasound scanning. Spare tissue becoming available during oophorectomy of the donor and resection of ovarian cortex in the recipient was prepared by fixation in Bouin’s fluid, embedding in paraffin wax, sectioning and staining with haematoxylin and eosin (Fig. 1a and b).

Genetic studies:

DNA fingerprinting confirmed the genetic identity of all eight twin pairs, who were also screened for common genetic causes of POF. Peripheral lymphocytes were prepared as DNA for testing genetic polymorphisms at 15 loci (Paternity Testing Corporation, Columbia, MO), and cultures (and in some cases spare ovarian medullary tissue) were karyotyped by the G-banding technique and fluorescent in-situ hybridization. DNA was also screened for the number of CGG repeats in the FMR1 gene using Southern blot analysis or the polymerase chain reaction for fragile X syndrome (Silber et al., 2005). In addition, genomic DNA and lymphoblastoid cell lines were prepared for future genetic studies of the twin pairs.

Results;
Patient profiles:

The clinical profiles of all eight twin pairs who have undergone ovarian transplantation between siblings are summarized in Table I. The recipients had become menopausal 2–26 years prior to case presentation, and at ages ranging from 13–34 years. All 16 women had normal 46, XX karyotypes and were free of FMR-1 premutations. Serum hormone profiles confirmed POF in the recipients, with FSH being .50 mIU/ml, with LH and E2 levels also in post-menopausal ranges. Moreover, sonographic inspection verified the complete absence of antral follicles in both ovaries, confirmed by histology of ovarian tissue which revealed a complete absence of primordial and growing follicles (Fig. 1a). Apart from case 3R, the reproductive tracts of the other seven recipients were unremarkable, apart from diminutive ovaries. Case 3R reported that she had adrenarche but never experienced menarche, nor any menstrual cycles. At surgery, she was found to have bilateral absence of ovaries, tubal ampullae and fimbriae, although the isthmus and uterus were normal. In contrast to the recipients, their sisters had normal ovarian morphology, AFCs and Day 3 FSH levels (Table I). Histology confirmed that primordial follicles were located ,1 mm below the ovarian surface. Four donors had previously undergone controlled ovarian stimulation for oocyte donation, and had demonstrated a normal ovarian reserve at that time. They strongly resisted suggestions to repeat this procedure. In cases 4D and 5D, the ovarian reserve of the donor was more marginal based on AFCs (n ¼ 11 and 10, respectively), though this had not prevented one of them becoming pregnant (Table II).