Recurrent Pregnancy Loss

Recurrent pregnancy loss is defined by the American Society of Reproductive Medicine (ASRM) as two or more consecutive pregnancy losses.  A pregnancy loss is defined as a pregnancy which involuntarily ended before 20 weeks.

Most pregnancy losses, especially those in the early part of pregnancy, result from genetic abnormalities.  The abnormality may come from the eff, the sperm, or the embryo itself.  Approximately 30% of all clinically recognized pregnancies (one which was visualized on an ultrasound or pregnancy tissue identified at the time of the loss) end in a miscarriage.  However, it is estimated that at least 40-60% of all conceptions will end in miscarriage.  Most of the time, a woman does not even realize that she was ever pregnant, as the loss comes around the time a period was expected.  

Advanced maternal age, which is defined as maternal age at or greater than 35 years old, is associated with increased miscarriage rates which is thought to be due to poor egg quality which leads to genetic abnormalities.  Sometimes the mother or father has a slight alteration or irregularity in their genes which can severely affect a fetus and result in miscarriage.  Sometimes there is an abnormality in the uterus or cervix which leads to an inability to hold onto the pregnancy.  Problems with blood supply, hormone levels, or infection/inflammation can cause also cause miscarriages to occur.   A woman's immune system may also play a role in recurrent pregnancy loss if hormonal abnormalities are present from thyroid disease, diabetes, lupus, or other infections or autoimmune conditions.  Additionally some conditions which cause abnormalities in a mother's blood clotting system can affect pregnancy loss.  

In general, stress and occupational factors do not seem to be related to recurrent pregnancy loss.  

Dr. Worley and Dr. Silva are both extensively trained in performing complete work ups for recurrent pregnancy loss.  The initial step of evaluation is to review a detailed medical, surgical, family, and genetic history and perform a physical examination.  

Laboratory testing typically will include evaluation of thyroid function tests and thyroid antibodies, testing for diabetes, and checking for antiphospholipid antibodies which may be related to pregnancy loss.  Sometimes ovarian reserve testing may be performed to indicate how well the ovaries are functioning.  Blood testing may also include prokaryote (the chromosomal or genetic make up of a person) analysis of both partners to determine if there is an abnormality in the parents which could be passed to the offspring resulting in miscarriage.  

Imaging studies are often performed to evaluate the uterus both inside and out.  Typically an ultrasound is first performed to obtain a general overview and obtain information about the shape of the uterus and whether or not any polyps or fibroids are present.  A hysterosalpingogram, or an X-ray of the uterus and tubes, can help identify problems within the uterus and confirm that the tubes are patent (open).  A hysteroscopy is a procedure where a small camera is placed through the cervix and into the uterus so that your physician can directly visualize the inside of your womb.  If there is inflammation, a polyp, a fibroid, a septum, or scar tissue present, they can identify and sometimes treat the problem right then and there.  All of these  procedures are done routinely within the office setting and do not require hospitalization or sedation which minimizes both cost and recovery time.  

Treatment recommendations for couples with recurrent pregnancy loss are different for each couple and are based on the underlying cause identified for the losses.   If a hormonal problem such as thyroid dysfunction or diabetes is found, certain medications can be used to correct the problem and improve pregnancy outcomes.  Similarly, if antiphospholipid syndrome is diagnosed, medications which reduce blood clot formation may be given.  Uterine abnormalities which are found can typically be treated with procedures or surgeries, depending on the defect identified.  Individuals or couples in whom a karyotypic abnormality is found may be refereed for genetic counseling or may choose to undergo in vitro fertilization (IVF) with preimplantation genetic diagnosis (PGD) to identify an embryo that is not affected by the condition and chose to implant that one for best results.  No matter the diagnosis found, the chances of a successful pregnancy ranges from 70-80%.

Approximately 50% of patients will have unexplained recurrent pregnancy loss which means that no specific cause could be identified in the workup.  Empiric treatments may be offered to these patients but there are no universal recommendations.  Despite this, the overall chance of pregnancy is greater than 50%, even without any intervention.