Recurrent pregnancy loss: Evaluation and treatment options

Recurrent Pregnancy Loss and the stress of several miscarriages

Patients with recurrent pregnancy loss (RPL) are usually able to conceive naturally, but then they miscarry.  Typically, by the time we see the patient in our office, she has already had several miscarriages, which is extremely stressful psychologically as well as physically. If you have patients who’ve had multiple miscarriages, let tell you more about when you should refer a patient to a fertility specialist, factors contributing to RPL, how RPL is evaluated, and what treatment options are available.

When your patient should be evaluated

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 refer your patient to a fertility specialist or start an evaluation when a patient had two first trimester pregnancy losses.

Current testing and treatment options

Here are some factors associated with RPL and the current testing and treatment options for each:

• Chromosomal anomalies: The majority of early pregnancy losses are associated with sporadic chromosomal abnormalities in the fetus. Patients with RPL should 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 3D 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  TSH levels 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. We can address these factors with our patients during their consultation and help them make lifestyle changes if necessary.

Unexplained RCL

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.

By Dr. Sarajari

References:

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.