Recurrent Pregnancy Loss
Miscarriage is very common and can be devastating for couples trying to conceive. Dr. Shah answers questions about why they happen, how to know what happened, and where to find support.
How common is pregnancy loss?
Pregnancy loss is unfortunately very common. One in four women will experience a pregnancy loss in their lifetime. Many early pregnancy losses occur too early for women to even recognize, and the true incidence of miscarriage may be much higher because early losses may occur before a missed menstrual cycle.
What is recurrent pregnancy loss (RPL)?
Recurrent pregnancy loss, as defined by the American Society of Reproductive Medicine, is two or more clinical pregnancy losses. A clinical pregnancy loss is a pregnancy documented by ultrasonography (for example, the presence of a gestational sac, yolk sac, or fetal pole), which is in contrast to a biochemical pregnancy, which is a very early pregnancy loss confirmed by a positive blood pregnancy hormone test (bhcg), but lost too early to be seen on ultrasound.
What should I do if I’ve had two or more miscarriages?
If you have had two or more miscarriages, it’s time to see your OBGYN or a fertility specialist. Your OBGYN will be able to order basic blood work and discuss the common causes of pregnancy loss. If you are 35 or older, or your pregnancies took more than six months to conceive, it may be advisable to go straight to a fertility specialist to discuss a broader range of treatment options.
The most common cause of miscarriage is genetic abnormalities. This accounts for at least 70% of all pregnancy losses.
How do you test for it?
The most common cause of miscarriage is genetic abnormalities. This accounts for at least 70% of all pregnancy losses. Genetic abnormalities arise from abnormal eggs or sperm which then give rise to abnormal embryos. Each egg or sperm contain 23 chromosomes. With aging, eggs and sperm are more prone to errors in the stages of cell division, leaving the eggs or sperm with missing or extra genetic material. This process is much more accelerated in female reproductive biology, hence why most miscarriages are due to genetically abnormal eggs.
After a diagnosed pregnancy loss, patients will be presented with several options for management. One of these include undergoing a D&C (dilation and curettage), which allows the tissue to be gently removed from the uterus in a quick and safe procedure. The tissue can then be sent for genetic analysis to identify a potential genetic cause.
What is the evaluation for recurrent pregnancy loss?
The evaluation consists of testing the following:
- Parental karyotypes: This is a blood test taken from the male and female partner, to identify any rearrangements in the genetic material which could cause an increased risk of genetically abnormal eggs or sperm. This typically takes about four to six weeks for results.
- Uterine cavity evaluation: Abnormalities in the shape or structure of the uterus may increase the risk of miscarriage. This includes the presence of uterine fibroids or a uterine anomaly (a congenital malformation of the uterus), for example a uterine septum. An evaluation can be done either by a saline infusion ultrasound, a hysterosalpingogram, or a hysteroscopy.
- Autoimmune testing: A condition known as anti-phospholipid antibody syndrome has been associated with an increased risk of miscarriage. This can be tested for in the blood by checking the following markers: Lupus anticoagulant, Beta-2 glycoprotein, and anti-cardiolipin antibodies.
- Endocrine tests: It is also important to check the status of the thyroid gland, as well as markers for pre-diabetes, as these conditions can increase a woman’s risk of miscarriage.
- Other risk factors: Obesity, smoking, alcohol, and other recreational drug use has also been linked to miscarriage risk.
Are there any treatments?
Treatments depend on an identified cause. Sometimes your doctor might recommend weight loss, lifestyle modifications, or initiation of medications, such as thyroid supplements, to improve your chance for success.
If a genetic abnormality is identified in the parental karyotype, IVF with preimplantation genetic testing (PGT) may be indicated.
For anatomical abnormalities, surgery may be needed to restore the uterine cavity to normal.
For antiphospholipid antibody syndrome, blood thinners are initiated at the time of a positive pregnancy test.
In about 50% of couples with recurrent pregnancy loss, the evaluation is completely normal. This can be very frustrating. I will often offer progesterone vaginal supplements, which has been demonstrated in a few well designed studies to improve live birth rates in the next pregnancy. It is important that this therapy is discussed with your fertility specialist, as the timing of initiating therapy is critical for its efficacy.
I also counsel couples that even with a history of recurrent pregnancy loss, most women will have a subsequent successful live birth. For example, a 35 year old woman with a history of RPL has a 70-75% chance of a successful live birth in her next pregnancy!
Where can I get support? I feel so alone.
Women grieve from a pregnancy loss in different ways. It is important for women to reduce any self-blame and hear the words from their provider that “This was NOT your fault.” For some, reaching out to close friends or family to share the painful news can often lead to an outpouring of support. For those who prefer to keep this more private, that is okay too. Sometimes a small vacation, self-care excursion, exercise, or a new hobby can help rejuvenate the soul from the grief of a pregnancy loss. I highly recommend the book “Not Broken,” written by a dear colleague of mine, Dr. Lora Shahine, a recurrent pregnancy loss specialist practicing in Seattle, Washington. In her book, she breaks down the stigma of miscarriage, explains the causes and treatments in a very digestible way, and provides hope for those seeking their rainbow baby.
Read more about Grief and Coping After Miscarriage.