ERA/EMMA/ALICE Testing Thread 3

[Janefx40]

Hello all,

This is a continuation of the ERA/EMMA/ALICE Testing thread.

New posters are welcome. On here you will find a group of women who are either doing these tests or have done them already and are further on the journey

This is the friendliest and most supportive group so feel free to join and post

Xxx

I think you should repeat the imaging based on what you’ve said. If there are adhesions then they really should be removed by an expert in a hysteroscopy as more damage can be done when removing them. The first step would be to arrange a HSG or saline scan though to see if this is even something that needs to be considered.

In the UK the vaginal acid tablet I use is balance activ, there are a few brands here so I’m sure you will find something where you are. It’s a common treatment for people that have recurrent bacterial vaginosis (and that is a very common infection).

I seem to be an expert in vaginal probiotics! l.crispus is the strain that is used in a lot of the trials that are currently being undertaken, the product they use is not on the market as yet but I found 2 vaginal probiotics with l.crispus in:

• physioflor vaginal probiotics (I imagine this is the one you got as I got mine from France as well)
• vagibiom vaginal probiotics (from USA)

There are some oral probiotics that have l.crispus in as well e.g:

• bio.m femme v oral probiotics

My strategy is to mix and match different vaginal probiotics that have different strains in them and see what my body does with them!

You should be able to do Receptiva at the same time as your repeat EMMA, people get them done at the same time a lot in the USA. Receptiva isn't done often in the UK, I think there is only one place that can do it here.

Meant to @ you @Violette22

Thanks again @Gardenlady543 all of this information is really useful :). You really seem to be the number one expert on this matter!

Yes it is physioflor that I have ordered from France. Is it so that physioflor itself doesnt effect to the ph level like those acid tablets do?

Receptiva DX is very new here, I think I might even be the first patient who does it in Finland if we choose to have it done. Also here the sample would be sent to USA. All of these tests are done at a private clinique so they cost quite a bit...

@Violette22

This is what I wrote about the 3 pronged approach elsewhere:

You need an acidic environment for lactobacillus to adhere to the vagina walls, it is lactobacillus that produces that acidic environment under normal circumstances, so while you are replenishing it you may benefit from artificially creating that environment with a product specifically made for this purpose (in the UK one such product is called Balance activ).

Treatment for an abnormal microbiome should have a three pronged attack:

1. Get rid of the bad bacteria with antibiotics.
2. Ensure the vagina pH is acidic and if not use a course of vaginal acid tablets.
3. Replenish the good bacteria, you do this with vagina probiotics.

This article discusses the rationale for the 3 pronged approach (dx.doi.org/10.1136/sti.2002.002733)

@Gardenlady543 thanks again!

This seems very clear. It looks like my protocol has numbers 1 and 3 in place but not number 2. I cant find anything here in Finland with "vaginal acid" or by translating it but I think eg this product might be the same thing:

www.hyvinvoinnin.fi/products/vitabalans-gynolacta?variant=20161013973065&gclid=EAIaIQobChMI2eGLrdmB9gIVYgWiAx2aXQPTEAQYASABEgKL9_D_BwE

The description says that it is ment for balancing the vagina ph and used to cure and prohibit BV.

I can see from your earlier message that you started these after the antibiotics, so not during them?

And how can you monitor the vagina PH levels like you said you do regularly? :)

@Violette22

Yes take these with the probiotics, you can then look at maybe using 1-2 a week alongside a vaginal probiotic to try and prevent the microbiome becoming bad again. The rates of recurrence with bacterial vaginosis are very high.

Yep that product you found is a vaginal acid tablet. There's a few on the market in the UK the thing I like about balance activ is that it also has glycogen in it.

Glycogen is a prebiotic. Prebiotics are substrates that promote growth of healthy vaginal microbiota. Lactobacillus are unique amongst species of the vaginal microbiota in using glycogen as a carbon source and it is recognised that glycogen derived from vaginal cells is reduced in bacterial vaginosis.

So if you can find a product similar to that one that also has glycogen then I'd say that would be perfect. Essentially you're putting in a good bacteria and the vaginal acid product is giving the good bacteria the food it needs and the environment it needs. If you can't find one with glycogen then just go for there one you found.

To measure the pH you'll need some pH sticks that are designed to do that, these are the ones I get from Amazon in the UK, you'll have to have a look and see if you can find an equivalent where you are:

These ones are cheap, but tend to slightly overestimate the pH, you use a cotton bud, rub it on the wall of the vagina and then onto the pH paper https://www.amazon.co.uk/dp/B096TP2KD2/ref=cmswwrcppapiglttiJGGCG9PJQ02J7RRNW049

These work out more expensive but can be put straight into the vagina.
https://www.amazon.co.uk/dp/B07ZJ5LJGF/ref=cmswwrcppapigltti7B65NKGDWYF4EJEJT9XN

It's good to use them after you've finished the course of treatment (antibiotics, probiotics and vagina acid tablet course). You want the pH to stay under 4.5, if it's going up then you are likely to be developing an abnormal microbiome again. Menstrual fluid and semen increase the pH by the way.

I am a bit confused now since I noticed that the vaginal acid products sold here have a mention about not using them if you wish to become pregnant. There's a mention that the decrease in ph levels is not good for semen....hmm, what to think about this? My final aim is definitely to get pregnant and hope to start trying again if the emma retesting shows green light...

You have a lot of wisdom about these things @Gardenlady543 may I ask are you a doctor or some how in the field? :)

I tried to look for one that has glycogen....I am not sure if it is the same as "alfa glukaanioligosakkarideja (α-GOS)"....this product sold here has it and promotes itself as a new kind of product:

naistenalakerta.fi/tuotteemme/gynevia/gynevia-bakteerivaginoosiin/

Here translated in English what they say about the product:

"Gynevia works in three ways. It is a one of a kind of combination of new kinds of alfa-glukans, glyserol and lactic acids. Alpha-glucan oligosaccharides are nutrients that promote the growth of selected lactobacilli. Good lactobacilli helpS prevent vaginal inflammation. Lactic acid, in turn, naturally lowers vaginal pH. Together, these properties control inflammation."

Is it the same thing you talk about?

@Violette22 I'm a consultant physician, nothing to do with fertility medicine but very good at reading research papers and coming up with plans!

The product you've found looks perfect.

You are right to be concerned about a low pH and getting pregnant.

This is an extract from a review where it's perfectly explained:

pH strips measure acidity/basicity. The pH scale goes from 0 to 14, where 0-6.9 is acidic, 7.0 is neutral, and 7.1 - 14 is basic. Lemon juice (pH of ~2) and coffee (pH ~5) are acids. Water (pH 7) is neutral. Stomach tablets like Tums (pH of ~10) and soapy water (pH ~9) are basic. (If you’ve never seen it, “~” means approximately.)

These strips only measure pH between 3.0 and 5.5. Per Dr. Google, a healthy vagina will have a pH of 3.8 - 4.5 (although your pH may be higher than 4.5 before menstruation and menopause). A pH over 4.5 creates the right conditions for unhealthy bacteria and yeast to grow, leading to BV or other infections.

In case you’re wondering, Dr. Google says a pH that is too low could create and environment where sperm are unable to thrive. Apparently sperm like a pH of 7.0 -8.5, which is annoying because we’ve already established that is prime caging all infection/bacterial overgrowth conditions. Ugh, men. Amiright?! (Ha, just kidding. I think?)

So basically the healthy vagina is acidic, it's acidic because the good bacteria are producing acid. Seminal fluid is alkali, under normal healthy conditions the vagina can cope with that, because it has a mechanism to reduce the pH (you don't currently have this as you don't have any lactobacillus). You don't want to put an acid tablet in there right when you're about to introduce sperm when you're about to ovulate. But you also need to get the environment right to allow the lactobacillius to colonize to get the normal mechanism working.

I hope that makes sense. My advice is, get the microbiome right before trying to conceive again. Keep an eye on your vagina pH, be mindful of where you are in your cycle if using the acid tablets.

Hi @Violette22 welcome. I'm so sorry for your losses. At what point do you start progesterone? A friend of mine had 7 miscarriages and when she did IVF they found her progesterone crashed just after transfer (ie 5 days after ovulation). She also did Immunes but had a birth that next pregnancy. Too many doctors only give progesterone post pregnancy test in my opinion.

I have Dr Shehata tomorrow. He has all my history and results but is there anything else I should prepare? Any particular questions? Anything I should know? Is he nice? Chatty or do I need to be organised and to the point?

Best wishes for tomorrow @Janefx40 🤞 I like Dr S. He is to the point and the first meeting is to go through your history so it does feel quite structured and led by him. But he's OK with you asking questions. I feel now I've been under him a while, he's a bit more human and he's been very kind following our losses, but he's not touchy feely. I do remember feeling overwhelmed at the first meeting but the follow up where you get your results is the one, so I wouldn't worry about having to ask questions, unless you have something pressing. I asked him if he thought we had a chance of having a bsby and he said absolutely and it did help me as I was pretty broken after my 4th loss. I still believe he can help me. I hope you get some answers. Xx

@Violette22 I'm so sorry for your losses ❤️ I've had 6 now and 2 were tested as chromosomally normal babies. I do have an overactive immune system but am also trying a new drug to help build my stem cells in my uterus. @Gardenlady543 has given you loads of advice, I hope that is your answer.

Hope you're well @Gardenlady543 and @StillTrying10000

Thanks @VenusStarr what sort of tests might be do tomorrow? Should I be prepared for bloods or internal exams? I realise of course our cases are different!

Yes to blood tests @Janefx40 - if you go for all the tests he recommends it will be about 20 vials of blood! I didn't have a scan but I know some have. At ours he told us what bloods he wanted for me but we went back to the waiting room to chat about it. X

Thanks @VenusStarr sounds like I need to transfer some serious cash to the bank account!

Good luck @Janefx40 let us know how it goes!

Just saw Mr Shehata. He's lovely. Waiting for blood tests.

Now I have a genuine dilemma. I usually take IVF decisions based on "if this cycle fails, will I regret doing/not doing x".

BUT if I don't do Mr S's tests and treatment and the cycle fails I will think I should have followed his advice.

But I have this weird superstition thing about the months when my babies can be born. I've always believed that this would be a November baby (or March, April, May, June or September). So if I delay and it doesn't work then I will regret missing my November window! I know that sounds nuts!!! But genuinely not sure what to do

You'll all think I'm nuts!

@Janefx40 do you mean for transferring an embryo in IVF or trying naturally, if trying naturally then I think that's an easier decision. Am I right in thinking you have 1 x PGTA embryo left? If so, wait for Dr S opinion I'd say.

@Janefx40 as in wait for Dr S before transferring your last embryo in IVF.

Thanks @Gardenlady543 I needed some sense talking to me. Yes this is about FET with our final euploid. We can't get pregnant naturally and we don't try.

I've asked my consultant if I can take noresthisterone to delay this cycle. Mr Shehata says if my cytokines aren't elevated we can start straight away anyway. I will try to delay my cycle until the results then we can start immediately unless I need humira

Xxx

@Janefx40 definitely don't transfer your last euploid embryo until you know what's happening. Me and my husband always wanted a September born, but we really don't mind now.

What tests has he sent off?

@Gardenlady543 to be honest I am quite confused now with the ph levels, I mean the fact that high is bad for the microbiome but then good for semen :D But let's say if I would stop the acid tablets a week before ovulation, do you think I could trust that the level is fine for semen then? How long do they "effect"?

I also thought about those stripes. I suppose those are used to check that the level is below 4.5..right? So what if you are about to ovulate and you get a good level from then, do you then have poor chance with getting pregnant?

Thanks for your support @Janefx40

@Janefx40 that all sounds very complicated. I totally hear you about the due date, I was desperate for a September baby too. One thing to consider is I've been told as someone whose had previous MC I'm more prone to early births so you may find even trying next month might surprise you and be your November baby! xx

@Janefx40 I just saw this. I bet your head is whirring. But your results will be back in 2 weeks and on the basis of that you'll get a plan straight away. I know it's so hard when you've had some many waits and delays already, but going into your last FET with a solid plan and with a specialist behind you feels like a really strong position to be in. Yes, it does mean you might not get a November baby but hopefully the treatment will result in a healthy baby ❤️

Hi @Violette22 thank you. My recent pregnancy I was on aspirin, clexane, cyclogest, lubion, intralipids, hydroxychloroquine and prednisolone. So immune modulators and suppressants, we saw a heartbeat but it stopped at 6+2. So the stem cell theory / sitagliptin makes sense to me as 3 of my other losses have been in week 6 (although we didn't see a heartbeat). Our recurrent miscarriage specialist / immune Doctor thought the cause was my overactive nk cells but I think with all the meds I was on, they were well controlled. I had no issues flagged up in my emma and alice tests, so the stem cell theory is the only thing I've not tried. They want me to take it for 3 cycles to regenerate the stem cells and then try an embryo transfer. I'm sorry it didn't work for you x

@Violette22 the acid tablets are just setting your vagina to the pH that it should be anyway. You should do the course of acid tablets while taking the vagina probiotics. Then if you should keep an eye on your pH and consider doing one or two a week but space it around your fertile time.

The pH staying over 6.5 will lead to bad bacteria flourishing, so while it may transiently go high around menstruation and when semen is around it should come back down.

@Janefx40 I hope you don't mind me sounding all bossy but you've arranged to see Mr S for a reason, so it really does make sense for you to wait until you've had your follow up before ploughing on with your precious embryo. I think sometimes we need these irrational moments (I had one recently about the appointment bookings ) as a release and then can re-group an be level headed again. Get it out of your system.