Recurrent Pregnancy Loss and the stress of several miscarriages.
Hi, this is Dr. Kay Waud at Dominion Fertility. In my practice, I treat quite a lot of patients with recurrent pregnancy loss (RPL), who were able to conceive naturally but then were not able to keep the pregnancy and had a miscarriage. Typically, by the time the patient presents to me, she already has had several miscarriages, which is extremely stressful psychologically as well as physically. I just wanted to give you an overview of how RPL is evaluated and potentially treated.
RPL is a disease distinct from infertility, but can be treated.
The American Society of Reproductive Medicine (ASRM) defines RPL as a disease distinct from infertility, defined by two or more failed pregnancies. Pregnancy is usually defined by a clinical pregnancy meaning that a pregnancy was confirmed by ultrasound or histopathological examination of the products of conception after a miscarriage. It is reasonable to start an evaluation when a patient had two first trimester pregnancy losses.
I have listed here some factors associated with RPL and the current testing and treatment options:
- Chromosomal anomalies: The majority of early pregnancy losses are associated with sporadic chromosomal abnormalities in the fetus. However, patients with RPL should also undergo chromosomal testing (karyotyping) to evaluate them for any chromosomal abnormalities. This is done by a simple blood test. To make sure embryos are chromosomally normal before embryo transfer, preimplantation genetic testing (PGD/PGS) can be used to evaluate the embryos for chromosomal abnormalities and then a chromosomally normal embryo can be transferred. Transferring a chromosomally normal embryo improves conception rates significantly.
- Uterine abnormalities (such as a uterine septum): Assessment of the uterus is recommended and can be done with a hysterosalpingogram (HSG) and more fully with an MRI or 3-D ultrasound. The uterine cavity can also be evaluated with a saline sonohysterogram. Uterine abnormalities can often be surgically treated.
- Antiphospholipid syndrome: Certain antibodies (lupus anticoagulant, anticardiolipin antibody and anti-beta2 glycoprotein I) have been associated with RPL. A blood test can tell if these antibodies are present and if present the patient can be treated with low-dose aspirin in addition to a blood thinner.
- Inherited thrombophilias (an abnormality in blood coagulation that increases the risk of blood clots in blood vessels): The ASRM currently recommends obtaining blood tests for certain factors involved in blood clotting if a patient has a history of a blood clot or if a first-degree relative has a blood clotting disorder. Frequently patients will need to be treated with a blood thinner.
- Hormonal/Metabolic factors: Endocrine disorders such as uncontrolled diabetes, thyroid disease or elevated prolactin levels can be contributing factors to RPL. Blood sugar levels, prolactin levels and a TSH should be obtained and the appropriate medical therapy initiated if levels are abnormal.
- Other factors: Smoking, obesity, drug use, alcohol consumption and increased caffeine consumption have all been associated with RPL. These factors should definitely be addressed with your doctor during your fertility consultation and lifestyle changes made if needed.
Despite the above factors being associated with RPL, in more than 50% of patients a clearly defined cause can not be elucidated and the pregnancy loss remains unexplained. In these situations, preimplantation genetic screening of embryos and transferring a chromosomally normal embryo can improve pregnancy rates significantly.
Evaluation and treatment of recurrent pregnancy loss: a committee opinion. Fertility and Sterility. Vol. 98, No. 5. November 2012.
Definitions of infertility and recurrent pregnancy loss: a committee opinion.
Fertility and Sterility. Vol.99, No.1. January 2013