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Recurrent Pregnancy Loss

Recurrent pregnancy loss is classically defined as the occurrence of three or more consecutive pregnancy losses; however, the American Society of Reproductive Medicine (ASRM) has redefined recurrent pregnancy loss as two or more pregnancy losses. A pregnancy loss is defined as a clinically-recognized pregnancy involuntarily ending before 20 weeks.

Recurrent Pregnancy Loss Causes

Most pregnancy losses result from chromosomal, or genetic, abnormalities, and are random events.

The abnormality may come from the egg, the sperm, or the early embryo. Approximately 15% of all clinically recognized pregnancies end in miscarriage; however, it is estimated that at least 40-50% of all conceptions will end within the first 12 weeks of gestation.

Advancing maternal age is associated with an increased risk of miscarriage, which is thought to be due to poor egg quality leading to chromosomal (genetic) abnormalities. Sometimes, the mother or father themselves may have a slight irregularity in their genes, but the offspring could be more severely affected and thus result in miscarriage.

Sometimes, there could be an abnormality in the uterus that leads to miscarriage. The miscarriage may be due to poor blood supply to the pregnancy or inflammation. Some women may be born with an irregularly shaped uterus, and some women may develop abnormalities with their uterus over time (i.e. fibroids).

A woman’s immune system may also play a role in recurrent pregnancy loss. Hormone abnormalities may also impact pregnancy loss, including thyroid disease and diabetes. Abnormalities in a mother’s blood clotting may also affect pregnancy loss.

Recurrent Pregnancy Loss Testing

  • First, a physician will take a detailed medical, surgical, family, and genetic history. Testing that may be done includes karyotype analysis of both partners. The karyotype is the chromosomal, or genetic, make-up of a person. The purpose is to find abnormalities in the parents that could be passed on to the offspring, resulting in miscarriage. Karyotype abnormalities are relatively rare.
  • The uterine cavity (inside of the womb) will be evaluated. There are several ways to accomplish this, including a sonohysterogram, a hysterosalpingogram (HSG), and hysteroscopy (to look inside the uterus). An ultrasound is often done as a first test. The ultrasound can give information about the shape of the uterus and the presence of fibroids (benign tumors). A hysteroscopy is a minor surgical procedure where a camera is placed through the cervix into the uterus so that the doctor can directly visualize the inside of the uterus. The doctor can also remove polyps and fibroids and can resect a septum or scar tissue, if present. A uterine septum is an abnormality of the shape of the uterus that a woman has since birth.
  • Antiphospholipid antibodies, particularly anticardiolipin antibody and lupus anticoagulant, will likely be checked. These antibodies are related to the antiphospholipid syndrome, which may be related to pregnancy loss. Any woman with a pregnancy loss at or beyond the 10th week of gestation (with a “normal” appearing fetus) or with 3 recurrent losses at any gestational age should be screened.
  • Tests of hormone function may also be done. Thyroid function tests may be checked, along with measurement of prolactin, the hormone responsible for breast milk production. Ovarian reserve tests may be performed, which indicate how well an ovary is functioning. Testing for diabetes may be done if a woman is at risk for diabetes.

Recurrent Pregnancy Loss Treatment

The treatment recommendations for patients with recurrent pregnancy loss are based on the underlying cause of recurrent pregnancy loss.

  • When a karyotypic (a chromosomal or genetic) abnormality is found in one of the parents, they are referred for genetic counseling. The genetic specialist can discuss what the genetic abnormality is and the likelihood of having a chromosomally normal or abnormal pregnancy in the future. Some affected couples may choose to undergo IVF with preimplantation genetic diagnosis (PGD). With this process, a genetic probe is created from the affected parent which allows us to screen the embryos created during an IVF cycle. This allows us to avoid the transfer of an affected embryo.
  • If a uterine abnormality is found, surgery may be performed depending on the defect. If antiphospolipid syndrome is diagnosed, certain medications that reduce blood clot formation may be given. If thyroid dysfunction or diabetes are diagnosed, specific medications can be prescribed.

Unexplained Recurrent Pregnancy Loss

Over one-half of patients with recurrent pregnancy loss will have unexplained recurrent pregnancy loss, which means that no specific cause could be identified in the work-up. There is no universal recommendation for treatment of these patients. Despite this, the overall chance of pregnancy is good, more than 50%, without any intervention at all.

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