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The Miscarriage Manual: Coping with the Emotional Aspects of Pregnancy Loss by Elizabeth Carney

Miracles and Memories Family-Building Pins

Miracles and Memories Family-Building PinsFourteen years ago I gave birth to a baby girl. Four hours later she died because of an internal malformation that was undetectable during my pregnancy. During my short hospital stay, nurses and doctors seemed to avoid me and my questions. What they did say was about the same as what my friends and family were saying. "You're young. You'll have other babies. Try to forget." 

I didn't want any other baby; I wanted that one! Forget? How could I forget? Instead I was overwhelmed with crushing, breathtaking grief. I remember how empty I felt the day I left the empty womb and empty arms. I never really knew her but I missed her and ached for her so desperately. 

Soon after I returned home, everyone acted as if they had already forgotten her, as if they expected me to also. Someone had removed all the baby items I had acquired before coming home, hoping to spare me the pain. Instead, it felt like a further denial of her existence. When I tried to talk about her everyone became very quiet, or changed the subject, or left the room. Friends were very careful not to say anything that might remind me of my experience. Baby shower invitations didn't come in the mail. Birth announcements didn't come in the mail. Many stayed away because they simply did not know what to say. My husband had three days to "get over it" before he was expected back at work. The world kept on spinning as if nothing had happened. I remember thinking that I must have lost my mind. I thought that if my baby had lived for a while, if people had gotten to know and love her, maybe then I would have been given the affirmation to grieve the way I needed to. But I was the only one with any memory of her, the only one who had the chance to love her. I had no one to share that with, not even my husband. Most of his grief was for me and for the dreams we had shared for this child. I felt all alone as I began my mourning. 

Over the years, after much healing, I have had the opportunity to speak with other parents who have had experiences which were similar to mine. As a result of that, and also as a result of my search for answers to all those unanswered questions, I have compiled a list of several "truths and non-truths" concerning the grieving process as it relates to perinatal bereavement. 

This is not intended to be the absolute word on the subject, but rather a gauge for the unexpected emotions felt by parents who have suffered this type of loss. Most of the parents I have spoken to agreed that the uncertainty of their grief was frightening and may have been alleviated had they known what to expect. 

Friends and family may also benefit from reading this over so they might understand the special kinds of pain and emotions involved in this type of loss and allow them to be expressed. 

The Truth Is...

1. The truth ISN'T that you will feel "all better" in a couple of days, or weeks, or even months. 

The truth IS that the days will be filled with an unending ache and the nights will feel one million sad years long for a while. Healing is attained only after the slow necessary progression through the stages of grief and mourning. 

2. The truth isn't that a new pregnancy will help you forget. 

The truth is that, while thoughts of a new pregnancy soon may provide hope, a lost infant deserves to be mourned just as you would have with anyone you loved. Grieving takes a lot of energy and can be both emotionally and physically draining. This could have an impact upon your health during another pregnancy. While the decision to try again is a very individualized one, being pregnant while still actively grieving is very difficult. 

3. The truth isn't that pills or alcohol will dull the pain. 

The truth is that they will merely postpone the reality you must eventually face in order to begin healing. However, if your doctor feels that medication is necessary to help maintain your health, use it intelligently and according to his/her instructions. 

4. The truth isn't that once this is over your life will be the same. 

The truth is that your upside-down world will slowly settle down, hopefully leaving you a more sensitive, compassionate person, better prepared to handle the hard times that everyone must deal with sooner or later. When you consider that you have just experienced one of the worst things that can happen to a family, as you heal you will become aware of how strong you are. 

5. The truth isn't that grieving is morbid, or a sign of weakness or mental instability. 

The truth is that grieving is work that must be done. Now is the appropriate time. Allow yourself the time. Feel it, flow with it. Try not to fight it too often. It will get easier if you expect that it is variable, that some days are better than others. Be patient with yourself. There are no short cuts to healing. The active grieving will be over when all the work is done. 

6. The truth isn't that grief is all-consuming. 

The truth is that in the midst of the most agonizing time of your life, there will be laughter. Don't feel guilty. Laugh if you want to. Just as you must allow yourself the time to grieve, you must also allow yourself the time to laugh. Viewing laughter as part of the healing process, just as overwhelming sadness is now, will make the pain more bearable. 

7. The truth isn't that one person can bear this alone. 

The truth is that while only you can make the choices necessary to return to the mainstream of life a healed person, others in your life are also grieving and are feeling very helpless. As unfair as it may seem, the burden of remaining in contact with family and friends often falls on you. They are afraid to "butt in," or they may be fearful of saying or doing the wrong thing. This makes them feel even more helpless. They need to be told honestly what they can do to help. They don't need to be told, "I'm doing fine" when you're really NOT doing fine. By allowing others to share in your pain and assist you with your needs, you will be comforted and they will feel less helpless. 


8. The truth isn't that God must be punishing you for something. 

The truth is that sometimes these things just happen. They have happened to many people before you, and they will happen to many people after you. This was not an act of any God; it was an act of Nature. It isn't fair to blame God, or yourself, or anyone else. Try to understand that it is human nature to look for a place to put the blame, especially when there are so few answers to the question, "Why?" Sometimes there are answers. Most times there are not. Believing that you are being punished will only get in the way of your healing. 

9. The truth isn't that you will be unable to make any choices or decisions during this time. 

The truth is that while major decisions, such as moving or changing jobs, are better off being postponed for now, life goes on. It will be difficult, but decisions dealing with the death of your baby (seeing and naming the baby, arranging and/or attending a religious ritual, taking care of the nursery items you have acquired) are all choices you can make for yourself. Well-meaning people will try to shelter you from the pain of this. However, many of us who have suffered similar losses agree that these first decisions are very important. They help to make the loss real. Our brains filter out much of the pain early on as a way to protect us. Very soon after that, we find ourselves reliving the events over and over, trying to remember everything. This is another way that we acknowledge the loss. Until the loss is real, grieving cannot begin. Being involved at this early time will be a painful experience, but it will help you deal with your grief better as you progress by providing comforting memories of having performed loving, caring acts for your baby. 

10. The truth isn't that you will be delighted to hear that a friend or other loved one has just given birth to a healthy baby. 

The truth is that you may find it very difficult to be around mothers with young babies. You may be hurt, or angry, or jealous. You may wonder why you couldn't have had that joy. You may be resentful, or refuse to see friends with new babies. You may even secretly wish that the same thing would happen to someone else. You want someone to understand how it feels. You may also feel very ashamed that you could wish such things on people you love or care about, or think that you must be a dreadful person. You aren't. You're human, and even the most loving people can react this way when they are actively grieving. If the situations were reversed, your friends would be feeling and thinking the same things you are. Forgive yourself. It's OK. These feelings will eventually go away. 

11. The truth isn't that all marriages survive this difficult time. 

The truth is that sometimes you might blame one another, resent one another, or dislike being with one another. If you find this happening, get help. There are self-help groups available or grief counselors who can help. Don't ignore it or tuck it away assuming it will get better. It won't. Actively grieving people cannot help one another. It is unrealistic, like having two people who were blinded at the same time teach each other Braille. Talking it out with others may help. It might even save your marriage. 


12. The truth isn't that eventually you will accept the loss of your baby and forget all about this awful time. 

The truth is that acceptance is a word reserved for the understanding you come to when you've successfully grieved the loss of a parent, or a grandparent, or a beloved older relative. When you lose a child, your whole future has been affected, not your past. No one can really accept that. But there is resolution in the form of healing and learning how to cope. You will survive. Many of us who have gone through this type of grief are afraid we might forget about our babies once we begin to heal. This won't happen. You will always remember your precious baby because successful grieving carves a place in your heart where he or she will live forever.


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How to Become a Fertility Nurse

A close up of the face of a masked fertility nurse

How to Become a Fertility Nurse

Fertility nurses play a very important role when it comes to reproductive health. These nurses, also referred to as reproductive nurses, are there to provide help and support to women dealing with fertility issues. They might be asked to work with couples who have difficulty conceiving, menopausal women, and women going through infertility.

This is a great career choice and a good option for those who want to help women and couples deal with reproductive issues. Let's take a look at what you should do to become a fertility nurse. We'll also touch on what the job entails and some of the outlooks for the position.

What do Fertility Nurses Do Exactly?

Fertility nurses have a lot of responsibilities. One of your primary jobs will be to educate patients on different fertility treatments including the benefits and disadvantages of different options. Fertility nurses are also there to give patients and the ones close to them support and counseling. All of this will need to be done in a non-judgmental way. Also, these nurses might teach patients how to administer fertility treatments.

The responsibilities go way beyond working with patients. Fertility nurses have to be up-to-date on all the latest procedures in the field. They may also assist in cloning or stem cell research as well as facilitate the egg donation process. They will often act as bridges between the donor and the receiving parent.

On a typical day, nurses will have to interact with patients a lot. This makes it a great job if you love the public and want to help. This is also a great option for those who want a fulfilling nursing job and directly see the effects of their work. Parents often form a very special bond with their reproductive nurse and some have relationships that last a lifetime.

You will spend a lot of your day speaking with patients and conducting interviews. You might also be teaching medication administration, making follow-up appointments, and speaking about different treatment options with families. Besides, you might be asked to perform blood tests and scans, help with embryo transfers, and perform physical examinations, among other things.

How Can I Become One?

If you want to become a fertility nurse, you will first need to at least have an associate’s degree in nursing or a bachelor’s degree. The good news is that anyone can get their bachelor’s through accelerated BSN online programs even if they are not coming from a nursing background. Schools like Elmhurst have accredited accelerated BSN online programs that allow students coming from other fields to get their bachelor’s in as little as 16 months.

Once you have your degree, you will need to pass your National Licensure Exam (NCLEX-RN) so you can become a registered nurse. Only once you've gotten your RN license can you enter reproductive nursing. Know that you can also get additional certification through the National Certification Corporation. While it's not mandatory, it could increase your prospects and your salary. The exam is taken by computer and consists of multiple-choice questions related to reproductive health and nursing.

What are the Skills Needed to be a Good Fertility Nurse?

First of all, you need to have a real desire to learn and teach about reproductive health. Your true goal should be to help patients first and foremost. Reproductive nurses have to be patient and be great at simplifying complex concepts. Patience will be important as some patients may grow desperate and impatient themselves or disagree with what you have to say. Also, you will have to be compassionate. Couples who are going through infertility require support and you will need to learn how to support them while still being realistic. You have to be there to hear their concerns and help them throughout the process.

Reproductive nurses also have to be open to continuing education. This is one of the most dynamic fields in healthcare and changes to procedures and sometimes philosophies can be introduced overnight. So, know that you will need to dedicate your whole life to the field.

Another skill you will need to have as a fertility nurse is investigative skills. It is during interviews that you will get to know a lot about someone’s reproductive health. You might be able to get more information out of them if you know how to ask the right questions. Just doing this will make you much better at your job and will help you find better solutions for patients.

Last, but not least, fertility nurses need to be physically fit. Working in this position means that you'll be spending a lot of time on your feet looking after patients and you’ll need to have a basic level of fitness to be able to get through the day.

What Are the Prospects for Fertility Nurses?

The Bureau of Labor Statistics groups fertility nurses with registered nurses and the prospects for those is really good. Jobs for registered nurses are expected to grow by 7% leading into 2029, which is higher than the average for all professions. They can earn anywhere from $60,000 to $80,000 or more per year depending on their expertise and level of certification.

Another great thing about working as a fertility nurse is the specialization opportunities. This is a great way to transition into fields such as family nursing or become a NICU nurse. Some decide to become OB/GYNs or move into research. Fertility nurses are at the forefront of innovation in the field. They know practically better than anyone else what is going on the ground and the effects of different methods and treatments, which makes them a great fit for research. All of these positions are in very high demand and are some of the best paying in the nursing field.

Working as a fertility nurse is your chance to make a real difference in the life of someone else. It's a great career option with promising prospects, so, if you think you’re cut out for it, we suggest you look into it in more detail.

Dealing with the Stress of the Holidays




The stress of the holidays is a topic that has appeared with regularity in articles and newsletters since 1979 when I began working as a psychotherapist with infertility patients.  Rightfully so.  Infertility is demanding and stressful.  The Holidays are demanding and stressful.  And in this case, one plus one equals way more than 2.

It is no longer in dispute that both the mental and physical experiences of stress land in the body.  That’s about the last thing that an infertility patient needs.  Your body is the stage upon which the treatment gets played out.  Being poked and prodded physically evolves very naturally into a mental ordeal for everyone.

This article addresses a big opportunity to turn down the level of stress that comes with the holidays.  That opportunity exists in the marital relationship.

In the best of families, tensions abound at holiday time.  The backdrop for get-togethers may have to do with who expects what, who can’t stand whom, whose house is center stage, whose traditions “win”, who’s impossible to buy presents for and who’s jealous of what.  And of course, a separate and very long thorn is who’ll be there who has babies.  The whos, whose and whats go on ad nauseum.

This does not mean that all families are looney toons.  It does mean that in the most serene of families, things can’t ever be perfect – AND – you are not likely to be in the mood for anyone’s imperfections.  It is a known fact that often, well-meaning people do not know what to say and invariably say the wrong thing, presuming that they even know about your struggle.  And if they don’t know, the secret may be the lesser of two evils, but it still creates additional stress.

The opportunity for any couple lies in the fact that it is critically important to be on the same page when it comes to making decisions about how to handle the holidays.  Infertility may be the first crisis of major proportions that has hit you in the time that you’ve been together.  Any crisis will demand that a person locate his or her coping methods.  It might even put you in a spin if you need better coping mechanisms than you have.  But it is only the rare couple whose coping mechanisms are congruent when a crisis hits.  This does not mean that you aren’t supportive of one another.  Most couples are.  But there is a difference between the support that flows out of compassion for someone you love and working to achieve a united front, which works best, at holiday time especially.

The Chinese character for crisis is a combination of the characters for danger and opportunity.  It may feel dangerous to set a limit to one or both families.  But it is very important for any couple to define their “coupleness.”  As married adults, it is your job and your right to let both families know what boundaries you need for your mutual satisfaction.   It is highly recommended that if you cannot get past the pull back to the whos and whats of your respective families, that you seek the guidance of a therapist with skills in both infertility counseling and family counseling.

Whether on your own or with professional help, if you successfully decide and declare your decisions about the holidays, you set yourselves up to minimize the impact of family/holiday stress on your bodies.  And beyond the logistics of who and what, there exists a further opportunity to nurture the marriage.  Now is the time to explore techniques of mind/body relaxation that you can enjoy together.  Besides being on the same page, feeling loved and understood is palliative and has a positive impact as a stress reducer.

As hectic as the holiday time can be, it would make a difference if you could locate a yoga class designed specifically for couples or a massage class for couples.  Or, this could be a really good time to go to a spa together for a weekend.  By focusing on gaining physical relief from tension, you can break the grip of the aspects of the infertility challenge that land in your bodies.

Furthermore, couples can learn methods of breathing, muscle relaxation, mindfulness meditation and self-hypnosis that go a long way toward breaking the grip of the infertility challenge from the inside out.  These techniques are extremely empowering, at a time when couples tend to feel powerless.

In this society most of us live in a state of red alert, tolerating high levels of stress.  The incidence of stress-induced illness and anxiety has risen dramatically.  As a culture, we need to take better tender-loving care of ourselves, but we tend not to.  So, while there are many who need to learn stress reduction techniques as much as you do, few need to learn them more than you.

Infertility is nasty.  But the silver lining in the clouds is that as a couple, you can and should put your needs front and center.  You need to keep your love alive, for each other and for yourselves.  The best way to do this is to acknowledge the enormous stress involved and take the opportunity to learn to communicate so you can land on the same page.  And then, you can pursue the myriad of techniques available these days which reduce stress on the body and the mind.








Mental Health and Starting a Family: A Guide

Happy couple looking at a pregnancy test

Mental Health and Starting a Family: A Guide

Starting a family is a life-changing experience which many people aspire to at some point in their life. Having a child truly is a miraculous experience which has the power to change everything, both regarding your life and regarding you as a person.

As with any life-changing event, your mental health may be impacted by the change, as well as being severely compromised if you have trouble starting a family or if you run into problems conceiving the way you had hoped. You may then feel as though you need further tailored support, such as from someone with a masters in mental health counseling.

Perhaps you have always thought that you would like to start a family and are wondering whether now the right time for you is. When making this decision, you may want to ask yourself the following questions:

  • Are you financially able to support a growing family?
  • Is your home equipped for a new baby, such as having the right amount of space and room?
  • How will your career be affected by having a baby? Are you ready to take a career break, or have your job take a back seat for a while?
  • Are you with the right person, or are you mentally ready to raise a child alone if you are considering family options as a single person?

This guide discusses the issues you may face where mental health is concerned, and important steps to consider when starting a family.

Mental Health and Trying for a Baby

Deciding to try for a baby and start a family is a significant step. No matter whether you've always planned for it or whether you've recently decided, it would be natural to feel overwhelmed by such a momentous decision. It's possible that your mental health can therefore be compromised if you feel the pressures, as well as the desperate desire, to start a family.

Although starting a family and trying for a baby is a wonderful thing, it can take a lot of planning, crucial steps and lifestyle changes. It may also take a very long time to conceive. This can easily affect your mindset and mental health if the routine becomes too draining or if you develop anxiety over not being able to conceive as quickly as you would have hoped.

It's important to be as positive and healthy as you can be while trying for a baby. Undue stress on the mind and body may only make it more difficult to naturally conceive or make it difficult to enjoy the process. To make everything easier, consider:

  • Seeking advice regarding how to improve your chances of conceiving
  • Try to avoid treating intimacy as a strict routine and instead try to conceive when you naturally feel ready to try
  • Speak to others about how you're feeling, including your partner if the situation is becoming overwhelming

Trouble with Conceiving: Which Steps to Take

It may be that, after trying to conceive for a significant period, it simply isn't working. This, naturally, can have a detrimental effect on your mental health, as not only are you not achieving the beginning of your new family, but you may also begin to worry why it is not working for you and whether there is any cause for concern health-wise for you and your partner.

In the first instance, it is crucial to speak to a medical professional regarding your trouble conceiving so that you can discuss the possibilities. Tests may need to be carried out, and your next options may need to be explored. This can be a difficult and worrying time which can take a toll on your mental health. Still, it's important to understand that difficulty conceiving in the first instance doesn't mean that you will never be able to start the family that you've been dreaming of. Alongside health and physical attention, you should also seek mental health support if necessary, from those with a masters in mental health counseling.

If you cannot conceive naturally, there are other steps you can take, such as:

  • Adoption
  • IVF treatment
  • Treatment options for infertility
  • Sperm or egg donation
  • Surrogacy

When considering which option may be right for you, be sure to do as much research as possible and gain the relevant medical advice. Taking one of these options, even if it means you can achieve the family you had hoped, can still be overwhelming and upsetting, therefore affecting your mental health.

Support is crucial during this key decision-making, so be sure to check your options from those with a masters in mental health counseling.

Mental Health and Helping Others

If you are a parent who has experienced mental health issues relating to starting a family, or perhaps an individual who has suffered from their mental health following infertility issues and not being able to start a family, maybe you're eager to help others struggling through the same — whether those with general mental health issues or specifically parents who are suffering through mental health concerning conception or raising a child.

There are various avenues to explore if you would like to help others, including seeking a career in counseling and a masters in mental health counseling so that you can support others going through the same journey or any related issues with mental health.

Wanting to start a family and either wanting to be a parent or becoming a parent, naturally means you're a compassionate and caring person who wants to help and care for others (your own child or family), so these are virtues which can be applied to counseling and helping others, too.

Mental Health and Adoption

Adoption can introduce a variety of mental health issues, both for you as a parent, and for an adopted child. For a parent choosing to adopt, it can be a difficult path if you always wanted to conceive naturally. It is a big step in deciding to seek an alternative to raising a family and helping a child who needs to have a home and a family.

Furthermore, it's important to be in a healthy and good mental state when preparing yourself to adopt a child. If your mental health has become compromised due to difficult circumstances around trying to conceive (such as being told that you're infertile), it may be a good idea to take a break and concentrate on your own recovery before adopting. That way, you can be in the healthiest condition to care for a new child. It's, therefore, imperative to seek out support options, such as sessions from a licensed individual with a masters in mental health counseling.

Regarding an adopted child, if they are at an older age when they are adopted, or if you choose to tell your child the truth about their adoption when they reach a certain age, this knowledge can affect their mental health. They may struggle emotionally trying to understand about their birth parents, or why they had to be put up for adoption. Or perhaps the truth may simply be something they struggle with mentally. It may even be the case that an adopted child suffered through difficult circumstance or even trauma, leading to the need for them to be adopted, and this could result in issues later in life.

Your child always has the option of receiving counseling at any age from someone with a masters in mental health counseling.

Mental Health and IVF Treatment

If you've chosen the IVF route, then firstly, it can be expensive, depending on how many attempts of the treatment you need. Therefore, you may experience stress and anxiety relating to your finances when trying to get pregnant through IVF. It's essential to manage your finances properly and plan for the cost of IVF treatment in advance, to have a better understanding and avoid any unwarranted stress.

Furthermore, IVF treatment is never guaranteed to work successfully. This can be extremely traumatic for those parents who had hoped the treatment would work for them. There are other options you can consider as an alternative if IVF treatment is not a success for you, or you can try again with the same treatment. Alongside this, support your mental health during this journey by seeking out services from someone with a masters in mental health counseling.

Mental Health and Your Growing Family

Mental health issues can arise at any time, at any age, in anyone. This means both for you as a parent, and for your growing child. You can never plan for how your child is going to behave, whether in their childhood years or as they develop. You can easily run into difficulty and negativity as a parent if you are worried about your child's behavior or if they are difficult.

Additionally, your child may develop mental health issues of their own as they age. It's important as a parent to know what to look out for in others regarding signs and symptoms of mental health issues such as depression.

In growing children, this could include:

  • Persistent low mood
  • Withdrawing from social situations
  • Disruptive or out-of-control behaviour
  • Speaking of negative or troublesome thoughts
  • Issues with behaviour and mood in other situations, such as school or out in public

There is always support available for parents struggling with their own mental health issues, such as from those with a masters in mental health counseling, or for parents with children who have mental health problems.

Mental Health and Suffering with a Miscarriage

While it is possible to heal and gain support from loved ones and professionals who can help through the process of miscarriage recovery, your own mental health and how you choose to handle the situation is what is most important. Nobody can tell a parent how to act when they have lost a child, and it's important for you to never keep it inside about what you are experiencing.

You may want to speak to other parents who have suffered through the same experience so that you can gain a better understanding and the support you need. Naturally, those who have never experienced the loss of a child will not be able to understand or support you fully — even if those people love you and care about your grief — so it can be very helpful to speak to other parents who know directly how it feels.

Physical, mental and emotional health can be severely impacted following the loss of a child, perhaps even for the rest of your life. The emotional distress and grief experienced by those who suffer from a miscarriage will undoubtedly mean that their mental health is compromised, and they may benefit from the services of a professional with a masters in mental health counseling.

It's important to understand that suffering a miscarriage does not mean that you can never try again for a family or that you will never be able to have a child. Still, it's also important to allow yourself enough time to understand, grieve and heal.

Understanding Postnatal Depression

You can never plan for postnatal depression, and you may think that it would never happen to you, but the truth is, it can arise in any parent following giving birth to their child. What's important to remember if suffering through postnatal depression that is — just with any mental health illness — it is not your fault, and it does not mean that you are any less of a loving parent. After all, having a baby is completely life-changing, which means it can trigger new and overwhelming responses in your mind and body when raising a new child.

The signs of postnatal depression include:

  • Feeling anxious and tearful. While this is natural after giving birth, if these symptoms persist for a long period, such as a month or longer after giving birth, it could be a sign of a large problem
  • Lack of energy and feeling tired
  • Loss of interest in anything
  • Withdrawing from other people, or different situations
  • Worrying thoughts involving your baby, including negative thoughts towards them

Strategies to cope with postnatal depression include:

  • Seeking professional help and support, such as from those with a masters in mental health counseling
  • Being prescribed medication, such as anti-depressants
  • Speaking with loved ones
  • Trying to keep up with a healthy routine, such as exercise and your diet choices
  • Trying to partake in activities which will help you to feel more positive, such as pastimes you've always enjoyed
  • All of the above

Take Away

While the experience of trying for, and raising, a family is rewarding and positive, it's undoubtedly one where many problems can be faced. These problems don't mean that raising a family isn't everything you'd hoped for or that it can't be a success, it simply means that better care and planning may be needed for problems which can arise.

Most importantly, it is your own emotional and mental wellbeing as a parent — as well as that of your child — which needs to be taken into consideration during this important time, and you can always seek support from those with masters in mental health counseling.

Clomid Use and Abuse

Photo of the medication clomid

Some women can't get pregnant because they don't secrete enough LH and FSH at the right time during the cycle and, as a result, they don't ovulate. For these women, the first drug doctors often prescribe is clomiphene citrate (Clomid, Serophene). This synthetic drug stimulates the hypothalamus to release more GnRH, which then prompts the pituitary to release more LH and FSH, and thus increases the stimulation of the ovary to begin to produce a mature egg.

Clomiphene is a good first choice drug when a woman's ovaries are capable of functioning normally and when her hypothalamus and pituitary are also capable of producing their hormones. In short, the woman's reproductive engine is in working order but needs some revving up.

Structurally like estrogen, clomiphene binds to the sites in the brain where estrogen normally attaches, called estrogen receptors. Once these receptor sites are filled up with clomiphene, they can't bind with natural estrogen circulating in the blood and they are fooled into thinking that the amount of estrogen in the blood is too low. In response, the hypothalamus releases more GnRH, causing the pituitary to pump out more FSH, which then causes a follicle to grow to produce more estrogen and start maturing an egg to prepare for ovulation. Typically, a woman taking clomiphene produces double or triple the amount of estrogen in that cycle compared to pretreatment cycles

If a woman is menstruating, even if irregularly, clomiphene is usually effective, particularly if she develops follicles that aren't reaching normal size. Usually, a mature follicle is about 20 millimeters in diameter, or about the size of a small grape, just before it ruptures and releases its egg. Clomiphene may help small, immature follicles grow to maturity.

A low estradiol level in a woman's blood correlates with an inadequately stimulated, small follicle. A woman having a spontaneous ovulation cycle (that is, ovulating without the aid of fertility drugs) generally has peak estradiol levels ranging from 100 to 300 picograms (one trillionth of a gram)/ml. A woman may have enough hormones to produce an egg, but if her estradiol production by the follicles is low (less than 100 pg/ml), she may not adequately stimulate her cervix to produce fertile mucus or stimulate her endometrium to get ready to accept a fertilized egg for implantation. Clomiphene could boost the weak signals from the hypothalamus to the pituitary to the ovaries.

"A woman who ovulates infrequently, say at six-week intervals or less often, is also a good candidate for clomiphene therapy, since clomiphene will induce ovulation more frequently. The more a woman ovulates, the more opportunities her mature eggs have to be exposed to her husband's sperm and, therefore, the greater her chance to become pregnant.

Clomiphene is also often effective for a woman with a luteal phase defect (LPD). A woman with LPD may begin the ovulation process properly, but her ovarian function becomes disrupted, resulting in low production of the hormone progesterone in the luteal phase of the menstrual cycle. Following ovulation, the ovary produces progesterone, the hormone needed to prepare the uterine lining for implantation of the fertilized egg, which has divided and entered the uterine cavity. A fall in progesterone levels in the blood during this critical time can interfere with early embryo implantation or, even if a fertilized egg has already implanted, cause a woman to menstruate too early and end a pregnancy within a few days after implantation.

Using an LH-urine detector kit or keeping a basal body temperature (BBT) chart can help a woman taking clomiphene determine whether the luteal phase of her cycle is shorter than the normal fourteen days. The luteal phase of the cycle, the length of time from ovulation until she menstruates, has a normal range of thirteen to fifteen days. Clomiphene can often "tune up" the hypothalamus and pituitary so they keep producing the hormones the ovary needs to manufacture progesterone throughout the luteal phase.

"Of women whose only fertility problem is irregular or no ovulation at all, about 80 percent will ovulate and about 50 percent will become pregnant within six months of clomiphene treatments. About three percent of women on clomiphene have multiple pregnancies, usually twins, compared with about one percent in the general population.

If a woman responds to clomiphene and develops a mature follicle (determined by adequate estrogen production and ultrasound examination), but has no LH surge by cycle day 15, then injection of the hormone human chorionic gonadotropin (HCG), which acts like LH, can be given to stimulate final egg maturation and follicle rupture, releasing the egg. The woman tends to ovulate about 36 hours after the LH surge or HCG injection, which can be confirmed by further ultrasound scans.

"Clomiphene is a relatively inexpensive drug, and is taken orally for only five days each month. The doctor attempts to initiate clomiphene therapy so that the woman ovulates on or around day 14 of a regular 28-day cycle. The simplest, most widely used dose starts with one daily 50 mg. tablet for five days starting on cycle day three or five. If a woman ovulates at this dose, there is no advantage to her increasing the dosage. In other words, more of the drug isn't necessarily better. In fact, more may be worse, producing multiple ovulation, causing side effects such as an ovarian cyst or hot flashes, and most commonly, interfering with her fertile mucus production.

If a woman doesn't ovulate after taking one clomiphene tablet for five days, then her doctor will usually double the daily dose to two tablets (100 mg) in her next cycle, and if she still doesn't respond, then triple the daily dose to 150 mg, or add another fertility medication such as human menopausal gonadotropin (Pergonal) in the next cycle. Some doctors increase the dose up to 250 mg. a day, but this is NOT recommended by either of the drug's two manufacturers. Women tend to have side effects much more frequently at higher doses.

If the dose of clomiphene is too high, the uterine lining may not respond completely to estrogen and progesterone stimulation, and may not develop properly. As a result, a woman's fertilized egg may not be able to implant in her uterus.

Side Effects

Because Clomiphene binds to estrogen receptors, including the estrogen receptors in the cervix, it can interfere with the ability of the cervical mucus glands to be stimulated by estrogen to produce fertile mucus. Only "hostile" or dry cervical mucus may develop in the days preceding ovulation. If this occurs, adding a small amount of estrogen beginning on cycle day 10 and continuing until the LH surge may enhance cervical mucus production.

Some women taking clomiphene experience hot flashes and premenstrual-type symptoms, such as migraines and breast discomfort (particularly if they have fibrocystic disease of the breasts). Visual symptoms such as spots, flashes or blurry vision are less common and indicate that treatment should stop.

Clomiphene is a very safe medication with relatively few contraindications. Preexisting liver disease is one contraindication since clomiphene is metabolized by the liver. Enlarged ovaries are also a contraindication since clomiphene may occasionally produce hyperstimulation of the ovaries.

The hot flashes are just like the hot flashes women experience at menopause when the level of estrogen circulating in the blood is low. The clomiphene fools the brain into thinking that blood estrogen levels are low.

Clomiphene Abuse

Too often, doctors give clomiphene to women with unexplained infertility before the couple has a fertility workup, or even after they have a workup, but there is no evidence of an ovulation disorder. This empiric therapy may create new problems, such as interfering with fertile mucus production and often delays further evaluation that can lead to a specific diagnosis and proper treatment.

For a woman who has normal, spontaneous ovulation, driving the pituitary harder with clomiphene won't make ovulation any more normal. If a woman has taken clomiphene for several cycles without becoming pregnant, then she and her fertility specialist should investigate other conditions that may be preventing her pregnancy.

After noting a good postcoital test (PCT) during a fertility workup, some doctors fail to repeat the test after placing a woman on clomiphene. A PCT needs to be repeated to check the quality of the woman's cervical mucus while she is on clomiphene, since 25 percent or more of women who take the drug develop cervical mucus problems. It's important for a woman to monitor her cervical mucus production during every cycle while trying to become pregnant, including her cycles while taking clomiphene.


Webinar: East Meets West (Reproductive Endocrinology and Acupuncture)

Dr. Mark Perloe and Acupuncturist, Mike Berkley, L.Ac. (Acupuncture & Board Certified Herbalist) both practice in "hot spots"around the country. Dr. Perloe is a reproductive endocrinologist in Atlanta and Mike Berkley is an acupuncturist practicing in Manhattan (NYC). The video is long approximately 40 minutes but you can skim through the topics; everything from practicing in a pandemic to donor eggs and epigenetics.



Immunology May Be Key To Pregnancy Loss by Carolyn Coulam and Nancy Hemenway

African American couple listening to news on the telephone


Until the last decade, there was little a couple could do if they suffered from recurrent pregnancy losses. Miscarriages that couldn't be attributed to chromosomal defects, hormonal problems or abnormalities of the uterus were labeled "unexplained," and couples would continue to get pregnant, only to suffer time and again as they lost their babies. New research, however, has provided information on the causes of the heretofore unexplained pregnancy losses allowing more effective treatment enabling women to carry their babies to term.
About 15-20% of all pregnancies result in miscarriage, and the risk of pregnancy loss increases with each successive pregnancy loss. For example, in a first pregnancy the risk of miscarriage is 11-13 %. In a pregnancy immediately following that loss, the risk of miscarriage is 13-17 %. But the risk to a third pregnancy after two successive losses nearly triples to 38 %.
Many doctors do not begin testing for the cause of pregnancy loss until after three successive miscarriages. However, because the risk of a third pregnancy loss after two successive miscarriages is so high, the American College of Obstetrics and Gynecologists (ACOG) now recommends testing after a second loss-especially for women over the age of 35.
There are two major reasons for recurrent spontaneous abortion (RSA), or miscarriage. One is that there is something wrong with the pregnancy itself, such as a chromosomal abnormality that curtails embryonic development.  A fertilized ovum is an embryo until 10 weeks gestation and a fetus thereafter. Most miscarriages, though not all, occur between six and eight weeks, with expulsion taking place four weeks later, between 10 and 12 weeks.
The best way to find out if the pregnancy itself is the problem is to test the chromosomes of the aborted embryo. While in many cases this information is not available, requesting genetic testing after a dilation and curettage (D&C) for a missed abortion can often give couples some definitive answers about what went wrong. An alternative to obtaining genetic testing of the pregnancy is to test the chromosomes of the couple. This test is called a karyotype and involves a blood test for each partner so that both sets of chromosomes can be evaluated for abnormalities which may cause RSA, or which may be passed on to children. In addition to chromosomal problems, the pregnancies can have either abnormal genes or abnormal DNA contributing to their losses.  Gene abnormalities associated with recurrent pregnancy loss include mutations in HLAG genes contributed by either the father or the mother as well as gene deletions on the Y chromosome contributed by the father.  Fragmented DNA from the sperm has also been associated with early pregnancy loss.
The other major category of causes of RSA is a problem within the uterine environment that does not allow the pregnancy to grow properly. The most frequent environmental causes of pregnancy loss are attributable to immunologic factors followed by thrombophilic or blood clotting factors.  Other possible environmental causes of pregnancy loss are hormonal (not enough of necessary hormones to sustain the pregnancy) and anatomic (such as structural abnormalities of the uterus).  Anatomic problems may be detected with a hysterosalpinogram, hysteroscopy or hysterosonogram. Assessment of the hormonal environment looks at hormone levels and uterine response at the expected time of ovulation and implantation, usually through an endometrial biopsy or high level ultrasound examination.
The final way to determine an environmental cause of multiple miscarriages is through immunologic and thrombophilic testing.   To better understand the rationale for immunologic and thrombophilic testing, the roles of the immune and blood clotting systems in nature and reproduction will be reviewed.
Immune System

The immune system functions as the first line of defense against disease and is one of the most intricate and complex systems in the body. It works by generating cells and molecules that are capable of identifying and eliminating potentially harmful “foreign” invaders.   The key to the function of the immune system is its ability to distinguish between the body’s own cells (self) and foreign cells (nonself). The body’s immune defenses normally coexist peacefully with cells that carry distinctive “self” marker molecules.  But when immune defenders encounter cells or organisms carrying markers that say “foreign”, they quickly launch an attack.  Cell markers, as well as any other substance triggering an immune response, are called antigens.  Functionally, an immune response can be divided into two activities:  an innate immune response and an adaptive (or acquired) immune response. 
The innate immune system is an ancient mechanism of host defense found in essentially every multicellular organism from plants to humans.  It is the quick-to-respond, wired-in-the-genes immune system that serves as the body’s first line of defense that comes into play immediately or within hours of an antigen’s appearance in the body.  These actions are activated by chemical properties of the antigen and provide rapid, nonspecific and generalized defense mechanisms against a wide range of organisms.  The cells involved in innate immune responses include natural killer (NK) cells.
NK cells are a type of immune cells that are called lymphocytes.  NK cells secrete different proteins or cytokines depending on the signal they receive.  They also contain granules filled with potent chemicals that can destroy other cells NK cells recognize other cells that lack the so-called self molecules or antigens so they have the potential to attack many types of foreign cells.  If this first line of defense is not successful in neutralizing the potential harmful invader, the adaptive immune system is signaled. 
The adaptive immune system is slower and more complex than the innate immune response.  The antigen must first be processed and recognized.  Once an antigen has been recognized, the adaptive system activates immune cells specifically designed to attack that antigen.  Adaptive immunity also includes a “memory” that makes future responses against that specific antigen faster.  The cells involved in the adaptive immune response include both T and B lymphocytes.
T cells are a subset of lymphocytes that play a large role in immune responses.  The abbreviation “T” stands for thymus, the organ in which T cells develop.  Most of the T cells in the body belong to three subsets:

  • Cytotoxic T cells express on their surface an antigen called CD8.  The role of cytotoxic T cell is to monitor all cells in the body, ready to destroy those express foreign antigens.  Destruction is mediated by molecules secreted. CD8+ cells secrete molecules that destroy the cell to which they have bound.
  • Helper T cells express on their surface CD 4 antigens and function as “middlemen” in immune responses.  When activated, helper T cells proliferate and secrete proteins called cytokines that regulate or “help” other lymphocyte function.  There are two kinds of cytokines secreted by T helper cells:  pro-inflammatory cytokines that are largely involved in cell-mediated immunity (called Th1 responses) and anti-inflammatory cytokines that are involved in promoting B cells to secrete antibodies (called Th2 responses).
  • Regulatory T cells (also known as suppressor T cells) suppress activation of the immune system. Regulatory T cells express the cell surface antigens of CD8 and CD25.  Failure of regulatory T cells to function properly may result in autoimmune disease in which the immune cells attack healthy cells in the body.


B cells when activated secrete proteins called antibodies Antibodies belong to a family of large proteins known as immunoglobulins. Antibodies inactivate antigens by several mechanisms: 
1.      Complement fixation (proteins attach to antigen surface and cause holes to form, i.e. cell lysis)
2.      Neutralization (binding to specific sites to prevent attachment)
3.      Agglutination (clumping)
4.      Precipitation (forcing insolubility and settling out of solution). 
Thus B cells and antibody activity have been referred to as humoral immunity whereas T cells activity has been called cellular immunity.

Role of the Immune System in Pregnancy

Since the pregnancy contains antigens contributed by the father they will be foreign to the mother.  Thus the mother must adapt her immune response so as not to reject or destroy the pregnancy.  At the same time the maternal immune system has to tolerate the contribution of paternal antigens, it must also maintain anti-infectious immune responsiveness to protect both the mother and the pregnancy.  Pregnancy has therefore been thought to be a state of immunologic tolerance.   This tolerance is thought to result from signals given by the pregnancy to the mother’s immune cells.  Such signals include secretion of a protein called soluble HLA G.  HLA G turns off the innate immune response by inactivating NK cells. After the innate immune response has been suppressed, the adaptive immune response directed toward the foreign antigens of the pregnancy must be curtailed. 
Recent research suggests that regulatory T cells are increased during normal pregnancy and decreased in pregnancies complicated by loss.  Regulatory T cells are known to suppress T cell activation and provide tolerance.  In addition, T cells during normal pregnancy predominantly secrete anti-inflammatory cytokines (Th2 response) compared with increase pro-inflammatory cytokines (Th1 response) observed in patients with recurrent miscarriage.   Pro-inflammatory (Th1 type) cytokines can induce blood clotting.  Clotting off of placental vessels leads to pregnancy complications and failures.    
Immune Causes of Recurrent Pregnancy Loss
Incomplete tolerance results in pregnancy loss.  Thus, immunologic causes for pregnancy loss include a problem within the embryo such that the signals to the maternal immune cells are inappropriate or a problem within the maternal immune cells such that they don’t respond properly to normal embryo signals.
Problems with embryo signaling

Antigens on the surface of the invading embryo or secreted by the embryo must signal the maternal immune cells that it is “self” rather than “nonself” or foreign so that the mother will not mount an immune response to reject the embryo.  Soluble HLA G is an antigen secreted by the embryo that signals the mother’s immune cells that it is “self” and should not be rejected.  Abnormalities in HLA G signaling as a cause of recurrent pregnancy loss can be detected by looking at HLA G gene in the mother and the father or by measuring soluble HLA G protein in culture media of in vitro fertilized embryos.  The most frequent HLA G gene mutation found in couples experiencing recurrent miscarriage is HLA G-725C/G.

Problems with Maternal Immune Response

When the mother’s immune system cannot or does not respond appropriately to embryonic signals, pregnancy loss can occur.  How can we tell if the maternal immune cells cannot respond appropriately?  There are blood tests that can identify inappropriately functioning immune cells:

  • NK cells can be tested with the Reproductive Immunophenotype (RIP) and the NK activation (NKa) assays.
  • T cells can be assessed by measuring the activated RIP and regulatory T cells (CD4+25+).  In addition T cell function has been associated with the presence of Anti-thyroid Antibodies as well as the presence of circulating embryotoxins in the Embryotoxicity Assay (ETA).
  • B cells function is evaluated by their production of autoantibodies including antiphospholipid antibodies, antinuclear antibodies, antithyroid antibodies and lupus-like anticoagulant.

Thrombophilic Causes of Recurrent Pregnancy Loss                                          

Once tolerance has been established and implantation completed, the mechanism of other immunologic causes of pregnancy loss involve blood clotting or thrombophilia.  Vessels of the placenta that take blood and nutrients to the fetus clot off and the pregnancy “withers on the vine.”  Cytokines, especially Th1 cytokines can cause the placental vessels to clot.  Th1 type of cytokines can be secreted by either activated NK or T cells.  Other reasons for clotting of the placental vessels include both acquired and inherited thrombophilia.  The most common cause of acquired thrombophilia is antiphospholipid antibodies.  Inherited thrombophilias can result from gene mutations involved in coagulation (Factor V von Leiden, Factor II Prothrombin, Fibrinogen, Factor XIII), fibrinolysis (PAI-1) and thrombosis (Human Platelet Antigen-1, Methylenetetrahydrofolate reductase).
Tests Available to Diagnose Immunologic Causes of Pregnancy Loss
There are a number of tests mentioned in the above description of immunologic of pregnancy loss available to diagnose immunologic causes of pregnancy failure.  These are listed below in alphabetical order.

Activated Reproductive Immunophenotype

Identification of the type of relative concentrations of various white blood cell populations in blood is valuable in determining risk factors for pregnancy loss. The Reproductive Immunophenotype has been shown to be useful in identifying individuals at risk for not implanting embryos and for loosing karyotypically normal pregnancies due to elevated circulating Natural Killer (CD56+) cells. The Activated Reproductive Immunophenotype measures not only the percentage of circulating lymphocytes as the Reproductive Immunophenotype does, but also activated NK and T cells. Women experiencing implantation failure after IVF/ET have significantly higher expression of NK cell activation marker of CD69+ and of T cell activation marker of HLA-DR.

Antinuclear Antibodies

Antinuclear antibodies react against normal components of the cell nucleus. They can be present in a number of immunologic diseases, including: systemic lupus erythematosus (SLE or Lupus), progressive systemic sclerosis, Sjorgen's syndrome, scleroderma polymyositis, dermatomyositis and in persons taking hydralazine and procainamide or isoniazid. In addition, ANA is present in some normal individuals or those who have collagen vascular diseases. The presence of ANA indicates there may be an underlying autoimmune process that affects the development of the placenta and can lead to early pregnancy loss.
Histones are proteins that combine with the DNA of the cell nucleus to govern the development of tissues. Histones are the smallest building blocks of DNA. Antibodies to these histones mean the mother is developing immunity to histone components of DNA. The mechanism by which ANA cause pregnancy loss is not known.

Antiphospholipid Antibodies

In pregnancy, phospholipids act like a sort of glue that holds the dividing cells together and is necessary for the growth of the placenta into the wall of the uterus. Phospholipids also filter nourishment from the mother's blood to the baby, and in turn, filter the baby's waste back through the placenta.
If a woman tests positive for any one of variety of antiphospholipid antibodies (APA), it indicates the presence of an underlying process that can cause recurrent pregnancy loss. The antibodies themselves do not cause miscarriage, but their presence indicates that an abnormal autoimmune process will likely interrupt the ability of the phospholipids to do their job, putting the woman at risk for miscarriage, second-trimester loss, intrauterine growth retardation (IUGR) and pre-eclampsia.
While testing for anticardiolipins (cardiolipins are a kind of phospholipid) is standard in some infertility clinics, this test alone cannot identify the presence of all underlying autoimmune processes that cause RSA. A panel of tests for antibodies to six additional phospholipids is recommended to determine the presence of APA. Testing positive for one or more kinds of antiphospholipid antibodies indicates the woman has the immune response that can cause RSA. 
Because some circumstances can cause false positives for these tests, it is important to determine persistent positive levels by repeating the tests in six to eight weeks.
The live birth rate for a patient with untreated APA ranges from 11-20%. Individuals with recurrent pregnancy loss and/or implantation failure, venous or arterial, thrombosis, thrombocytopenia, elevated APTT, or a circulating lupus-like anticoagulant are among those at risk for development of APA. Also at risk may be women experiencing infertility associated with endometriosis, premature ovarian failure, multiple failed in-vitro fertilization, and unexplained infertility. With treatment, the live birth rate for women with APA increases to 70-80%.

Antithyroid Antibodies

Women with thyroid antibodies face doubling the risk of miscarriage as women without them. Increased levels of thyroglobulin and thyroid microsomal (thyroid peroxidase) autoantibodies show a relationship in an increased miscarriage rate, and as many as 31% of women experiencing RSA are positive for one or both antibodies. Chances of a loss in the first trimester of pregnancy increase to 20%, and there is also an increased risk of postpartum thyroid dysfunction. Therefore, antithyroid antibody testing should be routine in women with a history of two or more losses or thyroid irregularities.
It is important to note that when only the hemagglutination blood test is used, one out of five women with thyroid antibodies will not be correctly screened. More sensitive tests, enzyme-linked immunosorbant assays (ELISAs), or gel agglutination tests, have become the standard for thyroid antibodies associated with recurrent pregnancy loss.

Embryotoxicity Assay

Cells make proteins called cytokines. Different cytokines do different things; some stimulate growth of cells while others inhibit growth. The pro-inflammatory cytokines stimulate an inflammatory response, while others inhibit the inflammatory response of cells. The embryotoxicity assay (ETA) is looking for cytokines that kill embryos.  Embryotoxic factors have been identified in as many as 60 percent of women with recurrent, unexplained miscarriage, and also reported among women endometriosis-associated infertility.  For the ETA, blood serum from the woman is incubated with mouse embryos. If the embryos die, a toxin (to the embryo) cytokine is present. IVIg therapy controls these cytokines and allows a pregnancy to progress.

HLA G Testing

The major histocompatability complex (MHC), well known for its role in the regulation of cell-cell interaction in the immune response, also influences reproductive success. The MHC affects a variety of reproductive parameters including spontaneous abortion, protection of fetus from attack by the maternal immune system and regulation of preimplantation embryo growth and survival.  One gene in the MHC has that has had special attention with respect to reproduction is the class I gene HLA-G because it is important in establishing immunotolerance of the pregnancy.   Mutations in the HLA gene could interfere with this vital process, resulting in pregnancy loss.

Immunoglobulin Panel

Patients with autoimmune diseases characteristically exhibit significant abnormalities in total immunoglobulin isotypes. A very high incidence of such gammopathies is also seen in women experiencing endometriosis, recurrent pregnancy loss, infertility and failure of implantation after in vitro fertilization. The occurrence of hypergammaglobulinemias has been reported to decrease the clinical pregnancy rate with IVF. Hypogammaglobulinemia of IgA needs to be further evaluated to rule out IgA antibodies before treatment with intravenous immunoglobulin is considered.

Inhibin B

Inhibin-B serum concentration provides a new measure of ovarian reserve.  Ovarian reserve describes the ovary's capacity to respond to gonadotropin stimulation by producing a sufficient number of good quality eggs capable of generating normal embryos. Granulosa cells of the ovarian follicle secrete Inhibin-B. Most of the serum Inhibin-B concentration originates from large or dominant follicles since these follicles secrete ten-fold higher concentrations follicles measuring 4mm. Inhibin-B controls FSH secretion from the pituitary gland. Thus, Inhibin-B is a more direct measurement of assessing ovarian function than FSH. Inhibin-B serum concentrations drawn on cycle day 3 have been shown to predict the response of ovaries to gonadotropin stimulation in vitro fertilization (IVF) cycles. Women who had less than 45pg/ml Inhibin-B on cycle day 3, required 50% more ampoules of the day of hCG, 33% reduction in the number of oocytes retrieved, less embryos transferred per cycle and 70% reduction in pregnancy rate, than women with day 3 Inhibin levels greater than 45pg/ml. The women with day 3 Inhibin levels less than 45pg/ ml that did get pregnant had an 11 fold increase in spontaneous abortions compared with greater than 45pg/ml.

Lupus-like Anticoagulant

About 4% of women with recurrent miscarriage test positive for lupus-like anticoagulant and 9% of individuals diagnosed with SLE have a positive lupus anticoagulant test, or activated partial thromboplastin time (APTT). APTT is an adequate screening test for lupus-like anticoagulant antibodies, but there is a high incidence of false positives. Women who have a positive APTT should also have more specific tests, such as Kaolin clotting time, Russel viper venom assay, and the platelet neutralization assay a to confirm the presence of lupus anticoagulant antibody activity. And, since some women do not test positive until they are pregnant or have suffered a pregnancy loss, repeat testing during early pregnancy is highly recommended when there is a history of RSA.

Natural Killer Activity

Natural Killer cell activity or activation assay (NKa) measures the killing activity (cytotoxicity) within each cell.  Increased killing activity is associated with implantation failure and pregnancy loss.  A value of greater than 105 killing with a target to effector ratio of 1:50 is considered abnormal.  The NKa also measures the ability of IVIg to suppress the killing activity.  Patients with high NK cell activity that suppress with IVIg in the NKa will respond very well to intravenous immunoglobulin (IVIg) therapy. In fact, the live birth rate with preconception IVIg is more than 80%, compared to 20% without treatment.

Reproductive Immunophenotype

White blood cells that belong to the innate or primitive immune system kill anything perceived as foreign.  Some types of NK cells produce a substance called tumor necrosis factor (TNF), which might be described as your body's version of chemotherapy, and is toxic to a developing fetus. Patients who have high levels of these cells are at risk for implantation failure and miscarriage.  The proportion of NK cells is determined by a reproductive immunophenotype (RIP) test, which looks for cells that have the CD56+ marker. An NK (CD56+) cell range above 12% is abnormal.

Sperm DNA Integrity assay

Results of recent research indicate that sperm influences not only rates of fertilization of eggs but also subsequent embryo development.  The markers of sperm quality used to predict pregnancy outcomes are not the parameters included in the standard semen analysis (sperm concentration, motility or morphology) but rather the results of the Sperm DNA Integrity assay, which measures the amount of sperm DNA that is fragmented.  A sperm DNA fragmentation index of greater than 30% is associated with poor fertility potential.

Thrombophilia Panel

Thrombophilia is defined as a predisposition for thrombosis. Increased thrombosis can result from defects in coagulation, fibrinolysis, platelet aggregation, and endothelial damage. About 40% of patients with thrombosis are inherited.  Inherited thrombophilias have been associated with early and late recurrent pregnancy loss as a result of uteroplacental microvascular thrombosis and hypoperfusion. Obstetrical complications such as intrauterine growth retardation, placental abruption as well as preeclampsia have also been related to abnormal placental vasculature. Genetic thrombophilia are suspected to account for about 30% of these obstetrical complications. Poor pregnancy outcomes are associated with maternal thrombophilia but may also be associated with fetal thrombophilia by inheritance of maternal and paternal thrombophilic genes.

A successful pregnancy requires fibrin polymerization to stabilize the placental basal plate as well as to prevent excess fibrin deposition in placental vessels and intervillous spaces. Thus, a balance between coagulation and fibrinolysis is mandatory to ensure a successful pregnancy outcome as early as implantation.  The following bullets breakdown the complicated relations involved.

  • Coagulation factors linked to reproductive disorders include mutations of Factor V, Factor II, and Factor XIII. Factor V mutations associated with reproductive problems have included G1691A (von Leiden), H1299R (R2), and Y1702C.
  • Factor V von Leiden and Factor II prothrombin mutation G20210A are twice as common among women experiencing recurrent first-trimester pregnancy loss and are suspected of tripling the risk of late fetal loss. The mechanism of loss is through the generation of thrombin.
  • Thrombin converts fibrinogen to fibrin. Fibrinogen is a protein with three polypeptide chains. A mutation in the b chain (-455G1A) has been associated with thrombosis.
  • Fibrin is stabilized by cross-linking polymers under the influence of Factor XIII. One of the variations in the Factor XIII A gene, the Val34Leu polymorphism, has been correlated with thrombosis. Women who are homozygous for Factor XIII mutations also have a high risk for recurrent spontaneous abortion.
  • Increased thrombosis can result from a defect in fibrinolysis as well as coagulation.
  • The main cause of defective fibrinolysis is an increase in plasmin activator inhibitor (PAI 1) concentrations. PAI 1 is induced by insulin and is increased in patients with polycystic ovary syndrome (PCOS) associated with insulin resistance.  Clotting problems associated with increased PAI 1 may cause abnormal uterine artery blood flow, thus contributing to miscarriage associated with PCOS. 
  •  Thrombosis can also result from increased platelet aggregation and endothelial cell damage. Human platelet activator 1 (HPA-1) is part of the thrombosis system involved in platelet aggregation. It is a member of the integrin family. The integrin b3 gene encodes glycoprotein IIIa (GP IIIa) which is part of GP IIb/IIIa complex when activated interacts with fibrinogen to cross-link platelets to one another and causes platelet aggregation. Two allelic forms of GPIIIa have been identified (PLA1 and PLA2). The A2 form has been associated with increased thrombosis. 
  • Endothelial damage leading to thrombosis can be caused by hyperhomocysteinemia or antiphospholipid antibodies. Methylenetetrahydrofolate reductase (MTHFR) catalyzes the remethylation of homocysteine to methionine.  Several mutations in the MTHFR gene, C677T and A1298C, leads to hyperhomocysteinemia via decreased enzyme activity. Hyperhomocysteinemia is a major risk factor for both arterial and venous thrombolic disease. Individuals homozygous for the MTHFR gene are at increased risk for thrombosis and pregnancy-related disorders. The risk of embryonic and fetal loss is increased if the MTHFR gene mutation is combined with additional thrombophilic factors.  Disturbance of maternal and fetal homocysteine metabolism has also been implicated in a decrease in the incidence of dizygotic twinning and an increase in fetal neural tube defects.


The Thrombophilia Panel of tests includes testing for the following gene mutations:

  • Factor V Y1702C mutation
  • Factor V G1691A (Leiden)
  • Factor V H1299R (R2)
  • Factor II Prothrombin G20210A
  • b-Fibrinogen –455 G>A
  • Factor XIII V34L
  • PAI 1 4G/5G
  • HPA1 a/b Human Platelet Glycoprotein (PLA1/PLA2)
  • MTHFR C677T
  • MTHFR A1298C

Results are reported as normal, heterozygous, or homozygous.

Y Chromosome Microdeletion Assay Related to Recurrent Pregnancy Loss (MYC/RPL)

While Y chromosome deletions were initially reported to be associated with infertility due to oligo-azospermia, more recently sequence-tagged sites in the proximal AZFc region of the Y chromosome have been shown to be microdeletion among men whose partners experienced recurrent pregnancy loss.  The four sites analyzed for deletions are

  • DYS262
  • DYS220
  • DYF85S1
  • DYF86F1

Treatment for Immunologic Causes of Recurrent Pregnancy Loss
Effective treatment depends on the cause of pregnancy loss.  If the cause of the pregnancy loss is a problem within the embryo itself, elimination of the problem involves treatments including donor egg, donor sperm, or IVF with preimplantation genetic diagnosis (PGD).  If, however, the cause is related to activated immune cells and their cytokines, treatments include Intravenous Immunoglobulin (IVIg), Intralipid, and Phosphodiesterase Inhibitors.  If either acquired or inherited thrombophilia is causing clotting of the placental vessel and subsequent pregnancy loss, then heparin and aspirin is the treatment of choice.  If the blood clotting is the result of an immune process, then steroids and/or IVIg can be used. Further information on each of the treatment options is presented below.

Intravenous Immunoglobulin (IVIg)

IVIg has been used to treat both pre-implantation and post-implantation recurrent pregnancy loss associated with elevated levels of antiphospholipid antibodies, antithyroid antibodies, circulating NK cells, and NK cell killing activity and embryotoxins.  It has also been used for treatment of unexplained recurrent implantation failure and pregnancy loss.   The mechanisms by which IVIg works include:

  • IVIg provides antibodies to antibodies (anti-idiotypic antibodies)
  • IVIg suppresses B cells production of autoantibodies
  • IVIg enhances regulatory T cell activity
  • IVIg suppresses NK cell killing activity

Originally, IVIg therapy was used to treat women who had not been successful in pregnancies previously treated with aspirin and prednisone or heparin. The rationale for the use of IVIG in the original studies was the suppression of the lupus anticoagulant in a woman being treated for severe thrombocytopenia. IVIg was often given with prednisone or heparin plus aspirin. The estimated success rate of 71% for women at very high risk for failure with a history of previous treatment failures suggested IVIg treatment was effective.  More recently, IVIg therapy alone has been used to successfully treat women with antiphospholipid antibodies as well as women who become refractory to conventional autoimmune treatment with heparin or prednisone and aspirin.
Proinflammatory cytokines at the maternal-fetal surface can cause clotting of the placental vessels and subsequent pregnancy loss. One source of these cytokines is the NK cell. Biopsies of the lining of the uterus from women experiencing repeat pregnancy loss reveal an increase in activated NK cells. Peripheral blood NK cells are also elevated in women with repeat pregnancy loss compared with women without a history of pregnancy loss. Measurement of NK cells in peripheral blood of women with a history of recurrent miscarriage and a repeated failing pregnancy has shown a significant elevation associated with loss of a normal karyotypic pregnancy and a normal level associated with loss of embryos that are karyotypically abnormal. Furthermore, increased NK activity in the blood of nonpregnant women is predictive of recurrence of pregnancy loss. Suppressor T cells are required for protection against NK cytokine-dependent pregnancy loss.
IVIg has been shown to decrease NK killing activity and enhance Suppressor T cell activity. Both of these events are necessary for pregnancy to be successful. IVIg has been used to successfully treat women with elevated circulating levels of NK cells, NK cell killing activity and embryotoxins with live birth rates between 70% and 80%.
IVIg has also been used to treat women with unexplained repeat pregnancy loss. Four randomized, controlled trials of IVIg for treatment of repeat pregnancy loss have been published.

  • A European-based study showed a positive trend but did not achieve statistical significance due to too few patients for adequate statistical power given the magnitude of the effect.
  • A US-based trial did show a significant benefit, the difference in live birth rates being 62% among women receiving IVIg and 33% among women receiving placebo. The greater magnitude of effect in the US-based study than the European-based trial could have arisen from the use of a different study design. Patients began IVIg treatment before conception in the US-based trial, but after implantation in the European-based trial. By waiting until 5-8 weeks of pregnancy to begin treatment, women with NK cell-related pathology occurring earlier would have been excluded and those pregnancies destined to succeed would be included, providing an opportunity for selection bias. Indeed, a negative correlation with delay in treatment was significant in this study.
  • A third trial treated only women who had a previous live birth, a group that showed no significant benefit of treatment using leukocyte immunization, but significant benefit from IVIg.
  • The fourth Canadian-based trial had too few patients for adequate statistical power to give significant results but did show a trend toward benefit in women with a history of previous live birth followed by recurrent miscarriage.

When the results of all of these trials were combined in a meta-analysis the conclusion showed IVIg to be an effective treatment for repeat pregnancy loss. None of the studies took into account the pregnancies lost as a result of chromosomal abnormalities except the US-based trial. Approximately 60% of the pregnancies lost in the clinical trial would be expected to have chromosomal abnormalities that would not be corrected by IVIg.
The usual dosage of IVIg for treatment of repeat implantation failure is 40 gm and repeat post-implantation pregnancy loss is 25 grams but successful pregnancies have been reported using dosages from 20 to 60 grams. The half-life in circulation is 28 days so infusions are usually given every 28days. Depending on the obstetric history, IVIg is continued every 28 days until the end of the first trimester (women with a history of first-trimester pregnancy losses) or until 28-32 weeks gestation (women with a history of late pregnancy losses). Pregnancies are monitored with immunologic blood tests and treatment can be modified based on the results of the blood tests.
Side effects of treatment with IVIg include nausea, vomiting, headaches, chills, chest pain, difficulty breathing;  all side effects which usually occur during the infusion of IVIg and are related to the rate of infusion. If these side effects occur, the rate of the infusion of IVIg is slowed. Other side effects that have been reported much less frequently are migraine-type headaches and sore or stiff neck occurring from one to four days after the infusion.
Last, but not least, while IVIg is a purified protein particulate that is reconstituted in fluid and infused in veins, the protein is extracted from human plasma. Therefore, it runs the same theoretic risks for transmittable disease as other blood products. However, IVIg has been available on the American market under FDA and CDC surveillance since 1981, with no reported instance of HIV transmission. There were reports of cases of hepatitis C after IVIg treatment reported in 1992 and the first part of 1993 for which some manufactures changed the method of extraction and added a detergent solubilization step. Thus the theoretic risk at this time is an unknown risk of transmission of presently unidentified infectious particles. Because of the rigorous screening, it must undergo, the cost of IVIg is high. The high cost of IVIg therapy can be a deterrent to treatment for some individuals.


Evidence from both animal and human studies suggests that intralipid administered intravenously may enhance implantation and maintenance of pregnancy. Intralipid is a 20% intravenous fat emulsion used routinely as a source of fat and calories for patients requiring parental nutrition. It is composed of 10% soybean oil, 1.2% egg yolk phospholipids, 2.25% glycerine, and water. Intralipid stimulated the immune system to remove “danger signals” that can lead to pregnancy loss.  The appeal of Intralipid lies in the fact that it is relatively inexpensive and is not a blood product. Its likely benefit to IVF patients with immunologic dysfunction is under evaluation.

Phosphodiesterase Inhibitors

The phosphodiesterases are responsible for enzymatic degradation of molecules within the cells involved in generating energy for the cell to function.  They have anti-inflammatory effects.  Two phosphodiesterase inhibitors—Sildenfil (Viagra) and Pentoxiphylline (Trental) have been shown to increase blood flow to the uterus.  Viagra in the form of vaginal suppositories given in the dosage of 25 mg four times a day has been shown to increase uterine blood flow as well as the thickness of the uterine lining. Significant improvement of the thickness of the uterine lining in about 70% of women treated. Successful pregnancy resulted in 42% of women who had previously experienced repeated IVF failures and who responded to the Viagra. Similar results were obtained when Trental was used in 400mg twice a day dose alone with vitamin E to treat women experiencing implantation failure associated with thin endometrium and elevated uterine NK cells.   Animal studies have demonstrated that pentoxifylline prevents miscarriages in abortion-prone mice.  The efficacy of pentoxifylline for treatment of recurrent pregnancy loss in human beings remains to be established.


Low-dose aspirin (80mg or 1 baby aspirin) alone has used for the treatment of both repeat implantation failures and post-implantation pregnancy losses.  Aspirin therapy has been reported to enhance implantation rates in women undergoing IVF/ET.  In these studies the numbers of eggs retrieved and numbers of embryos generated were higher in the aspirin-treated group than in the non-treated group making it unclear whether the enhancement in implantation rate was the result of better embryo selection or a direct effect on the lining of the uterus.  Among women with increased resistance of blood flow through their uterine arteries who were treated with aspirin for a minimum of two weeks, the pregnancy rate was increased from 17% to 47% and the miscarriage rate decreased from 60% to 15%.  As a prostaglandin inhibitor, aspirin would be expected to increase blood flow to the ovary prior to implantation, to the endometrium during implantation and to prevent clotting of the placental vessels following implantation.  However, in studies of women experiencing recurrent post-implantation pregnancy loss/miscarriage associated with antiphospholipid antibodies, results of clinical trials have shown aspirin alone to be half as effective as other treatments including heparin and steroids. In two studies women receiving aspirin alone or heparin plus aspirin for treatment of repeat pregnancy loss associated with antiphospholipid antibodies, heparin plus aspirin provided a significantly better outcome than aspirin alone (live birth rate of 80% vs 44%).
A rationale for the use of low-dose aspirin therapy during pregnancy for women with antiphospholipid antibodies is to decrease blood clots from forming in the placental vessels. The mechanisms by which aspirin prevents blood clots are through its anti prostaglandin and antiprostacyclin effects and inhibition of platelet adhesiveness and aggregation.


Heparin has also been used in conjunction with aspirin to prevent blood clotting.  The rationale for using heparin is that it is a blood thinner and inhibits clot formation by a different pathway than the aspirin.  While the effectiveness of heparin and aspirin for treatment of women with elevated circulating antiphospholipid antibodies and a history of recurrent miscarriage is well accepted, the use of heparin with or without aspirin to enhance implantation rates has been controversial. Most clinical trials of women with elevated antiphospholipid antibodies and a history of implantation failure undergoing IVF/ET show no enhancement of implantation rates with heparin and aspirin compared with no treatment.  This observation is not surprising since the action of heparin is on the cells lining the blood vessels and pre- and peri-implantation pregnancy loss occurs before placental blood vessels appear. The combination of both heparin and aspirin given to women experiencing repeat pregnancy loss who had antiphospholipid antibodies are associated with a live birth rate of 80% compared with a live birth rate of 44% in women receiving aspirin alone. Live birth rates with heparin, aspirin and a steroid called prednisone are 74%. Thus no enhancement of live birth rates is noticed when prednisone is added to heparin and aspirin therapy for the treatment of recurrent miscarriage.
Heparin is usually administered at a dose of 5,000-10,000 units subcutaneous twice a day along with aspirin 80mg each day. In women with a circulating lupus-like anticoagulant, more heparin may be required. The side effects of heparin therapy include bleeding, decreased platelet count, and osteoporosis or thinning of the bones. Calcium supplementation (two tablets of Tums a day) is recommended while taking heparin.  Low molecular weight heparins such as Lovenox and Fragmin have also been used to treat recurrent pregnancy loss associated with thrombophilias, either acquired or inherited.


Steroid therapy in the forms of prednisone, prednisolone, and dexamethasone has been used to prevent both pre-implantation pregnancy failure and post-implantation pregnancy loss.  Steroids are routinely administered in many IVF programs.  These medications are started prior to initiating ovarian stimulation with gonadotropins and continued until the diagnosis of pregnancy.  If the pregnancy test is negative, the dosage is tapered off over the next week and then discontinued.  If the pregnancy test is positive, treatment is continued until 8 to 12 weeks of gestation.  Steroids are believed to act by inhibiting the cellular immune response.  The exact mechanism and the degree to which implantation is enhanced by the use of steroids are not known.  Dosages of steroids for treatment of pre-implantation failure vary depending on the preparation.  A typical regimen is dexamethasone 0.5mg a day. 
Historically, repeat pregnancy loss associated with antiphospholipid antibodies was treated with combinations of prednisone and aspirin. The rationale for prednisone therapy is the suppression of autoantibodies such as antiphospholipid and antinuclear antibodies. A study comparing live birth rates in women treated with heparin and aspirin with prednisone and aspirin showed 75% live births in both groups. However, both maternal complications and preterm delivery with premature rupture of membranes and toxemia of pregnancy were significantly higher in pregnant women treated with prednisone and aspirin compared with heparin and aspirin. Other side effects of steroid medication include fluid retention, weight gain, and mood changes. Therefore, the current recommendation for the “first attempt” treatment for repeat pregnancy loss associated with antiphospholipid antibodies is heparin and aspirin.


As much as 40 percent of unexplained infertility may be the result of immune problems, as are as many as 80 percent of "unexplained" pregnancy losses. Unfortunately for couples with immunological problems, their chances of recurrent loss increase with each successive pregnancy.
Certainly, couples with RSA (two or more) would benefit from the full range of available immunological testing, especially if a woman is older than 35 years. And, because immune problems are often the cause of implantation failure, couples with good embryos that fail to implant during IVF procedures are also good candidates for immunological screening.
Medical researchers have begun to pay attention to the problems of recurrent pregnancy loss, and ongoing genetic and immunologic research will continue to improve the diagnosis and treatment of this heartbreaking problem.

Carolyn B. Coulam, M.D. is Director of Millenova Immunology Laboratories and a physician at the Rinehart/Coulam Center for Reproductive Medicine in Chicago, IL.  She has served as a member of INCIID's Advisory Board since the organization's inception. Nancy P. Hemenway is an INCIID co-founder and serves as the INCIID Executive Director



Fertility Treatment with Acupuncture

Acupuncture module

An E-Learning Module and educational project in conjunction with the Berkley Wellness Center.

Maryland: A Friendly State for Surrogacy


Maryland is a great state for surrogacy. In Maryland, both gestational (a surrogate who is not biologically related to the child) and traditional surrogacy (a surrogate who agrees to be artificially inseminated with the intended father’s sperm and to carry the pregnancy to term), is possible for married, unmarried, and gay individuals.

There are no statutes or administrative regulations governing surrogacy arrangements in Maryland.  However, there have been two significant cases, both involving traditional surrogacy.

In both cases, the surrogate relinquished custody of the child when it was born and consented to the second-parent adoption by the intended mother.  In one of the cases, the court ruled that despite the fact that the second-parent adoption should be granted, surrogacy arrangements should be considered void and against public policy. In the second case, the court again ruled that the second-parent adoption should be granted and that surrogacy is not against public policy and does not violate Maryland law.  The judge in the latter case stated that the legislature should determine the legality of surrogacy agreements, not the courts.

The Maryland legislature tried to pass bills in 1992 and 1994 that would have made surrogacy agreements void against public policy.  However, the Governor vetoed these bills.  

In 2000, the Maryland Attorney General’s Office issued an opinion on surrogacy as well.  It’s a statement said that surrogacy agreements that pay fees to a birth mother are illegal and unenforceable. 

There has also been one appellate decision regarding surrogacy. In this case, the court ruled that if a single father is pursuing surrogacy, a surrogate mother, who has no genetic connection to the baby, does not have to be listed as the child’s mother on the birth certificate. The court also noted in this case that the payment of money for a child in a surrogacy agreement is illegal.

From the above cases and opinions, it can be deduced that it is important to have a surrogacy agreement that clearly states the intent of the parties, their rights, and responsibilities and that payments to the surrogate are not compensation for payment of a child.

In Maryland, intended parents can also get a pre-birth order, so that their names go directly on the birth certificate. In traditional surrogacy cases, the biological father’s name can go directly on the birth certificate. However, the biological father’s partner or wife would have to file for second-parent adoption in order to become the second legal parent.

Because Maryland is one of the friendlier surrogacy states, many couples wish to pursue surrogacy in Maryland.  However, in order to have Maryland laws apply, either the intended parents or the surrogate needs to reside in Maryland.



Legal Representation During Surrogacy Process: Don't Cut Corners

Legal Representation During Your Surrogacy Process: Don’t Cut Corners

The cost for undergoing a surrogacy process is significant, over  $100,000 for gestational surrogacy (using the intended mother’s ovum or donor ovum). Often times, to try to reduce costs, parents will cut corners. One avenue where parents have tried to reduce their fees is to try and do the legal aspects of the surrogacy process themselves. While this method might work for some, in general, it’s a better idea to have legal representation throughout your surrogacy process, both for your own protection and the surrogate’s protection.

A carefully and properly drafted contract is necessary, both so that all parties understand their rights and responsibilities, and also for any parental rights/adoption proceedings. A surrogacy contract should detail each parties’ duties, and all the critical issues involved in the surrogacy process, such as confidentiality, abortion/selective reduction issues, medical/psychological screening, parental rights, contact, compensation, and expectations. Both the parents and the surrogate need to feel comfortable with the contract before moving ahead.

Sometimes, parents will attempt to draft their own contract or use a contract they found on the internet. These contracts are often incomplete and leave out important elements. Further, they do not ensure that all the necessary safeguards have been met. This can be extremely detrimental to the parties if any issues arise. For example, in Munoz v. Haro, intended parents and their traditional surrogate, who was non-English speaking, entered into a surrogacy contract. (1) However, the surrogate did not have her own attorney and did not understand the contract. In fact, the surrogate thought she would be able to keep the child upon its birth. The court ruled that although surrogacy contracts are lawful, and the contract would have been valid had there been proper safeguards (such as legal counsel), in this case, those protections were not met and the contract was therefore unenforceable.


Finally, courts often want to see certain language in the contract in order to grant parental rights to the parents. This is necessary if the parents want to obtain a pre-birth order or their names on the birth certificate. It is also necessary to protect the intended parents if they separate or divorce during the surrogacy process. In Buzzanca v. Buzzanca, the intended parents used both donor ovum and donor sperm. (2) The parents filed for divorce before the child was born. The intended father claimed that he was not the father of the child, since it was not his sperm, and should not have to pay child support. The court ruled that the intended father had to pay child support since he was responsible for bringing the child into the world. The consent that the intended father gave in his surrogacy agreement, gave him the legal responsibilities of fatherhood, which include child support. Had there not been a carefully drafted surrogacy agreement, the court might not have held that the intended father had parental rights and responsibilities.

While there haven’t been very many court cases involving third party reproduction, in those cases that are contested, courts turn to the surrogacy contract to determine rights. It is therefore important that parties take proper legal measures to protect themselves during their surrogacy process, and have an appropriate contract written by an attorney with experience in surrogacy.




1. Munoz v. Haro No. 572834 (San Diego Super. Ct. 1983)

2. Buzzanca v. Buzzanca 61 Cal. App. 4th 1410