Recurrent Pregnancy Loss
Recurrent pregnancy loss is a difficult problem that 3-5% of all couples face when trying to start a family. While miscarriage is a very natural part of reproduction, a pattern of 2 or more miscarriages deserves proper investigation and management. A miscarriage is a loss of a pregnancy of less than 5 months or 20 months.
Recurrent Pregnancy Loss is defined as two or more losses at any stage of pregnancy.
Having a single miscarriage is believed to be a mechanism of quality control, and often the result of a pregnancy starting off with an abnormal number of chromosomes. An abnormal number of chromosomes can lead to missing or duplicated genetic information, which may not be compatible with life.
This type of miscarriage, or random genetic error usually occurs very early in the pregnancy. Almost half of all losses of early pregnancies (less than 6 weeks in gestational age) are caused by this type of error.
Seeing a specialist for miscarriages is important when:
- Pregnancy tissue from the miscarriage was tested and found to have had a normal number of chromosomes
- you are over 35 years of age
- You are having difficulty conceiving again, and or
- One or more of the pregnancy losses took place after 10 weeks gestational age
- Genetic
- Hormonal (Endocrine)
- Infections
- Structural (Anatomical)
- Clotting issues which may affect the placenta, specifically Inherited thrombophilias (or clotting disorder); or Acquired thrombophilias (Antiphospholipid syndrome)
Genetic Testing
In approximately 3% of couples with recurrent pregnancy loss, one partner is carrying a structural abnormality in their chromosomes (genetic material) which then can be passed on to a pregnancy. We can examine your chromosomes by taking a blood sample from you and your partner. If an abnormality is found, we will arrange a consultation with a genetics specialist who can provide you and your partner with further information on how this may affect future pregnancies In Ontario, this result can take up to 6 weeks to return. We can expedite this by sending the sample to Buffalo for a result in 48 hours. Your doctor will discuss this with you if you are interested.Endocrine Profile
This refers to measuring the levels of several hormones that we know to play a role with fertilization and pregnancy. We will screen for thyroid problems, prolactin (milk producing hormones) as well as male and female hormones that may give us information on how your menstrual cycle is functioning.Approximately 20% of couples with recurrent miscarrieage are found to have a problem with development of the lining of the uterus (endometrium). This is called a luteal phase deficiency (LPD). This development is controlled by the hormones estrogen and progesterone.
The optimal way to find out if the hormones are working together correctly is to take a sample of the lining called an endometrial biopsy (EB). It is very important that you use some form of birth control or abstain from intercourse during the cycle in which the EB is done. This test is scheduled during the latter half of your cycle, between day 21 – 23.
To do an EB test, the doctor will insert a speculum into the vagina and then a small flexible, hollow tube with be placed in the cervix into the uterus. A small amount of suction will be applied to obtain the sample. The test takes about 5 minutes to complete. You may feel some mild cramping during and after the procedure which may last from a few minutes to an hour after the procedure is finished. You may choose to take some ibuprofen (Advil or Motrin) about 30 minutes before the procedure to help with this. Results from this test take about 2 weeks to return.
Anatomical testing
This screening is done to determine the shape of your uterine cavity. An abnormality in the shape of the uterine cavity is found in approximately 16% of women with recurrent miscarriage.
Types of uterine abnormalities seen in recurrent pregnancy loss:
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Uterine septum
This is the most common type of anatomical abnormality.It is a fold of tissue that bulges into the uterine cavity. It has poor blood flow and interferes with the development of a normal endometrial lining.
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Adhesions
These are made of scar tissue inside the uterine cavity. -
Fibroids
These are abnormal growths of smooth muscle tissue in the wall of the uterus, or in the lining. They are benign, but may interfere with a pregnancy implanting.
Types of procedures we may order to assess the uterine cavity:
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Pelvic ultrasound (abdominally and vaginally)
This is often the first step, and will be done at the time of your initial clinic visit. Please arrive to the appointment with a partially full bladder, at the end of your consultation, you will have the ultrasound.
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Hysterosalpingogram (HSG)
This is often referred to as the “dye tests”. A small amount of dye is inserted into the uterus through a cannula and an x-ray is taken. The x-ray shows the shape of inside of the uterua as well as the fallopian tubes. This test is done between day 6-10 of your menstrual cycle.
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Hysteroscopy
A small telescope is placed into the cervix into the uterus. This is hooked up to a TV monitor so that you and your doctor can see the inside of your uterus. This can be done at any time in your menstrual cycle as long as you are not bleeding or pregnant.
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Sonohysterogram
This test is similar to the HSG but an ultrasound is used instead of x-rays. Saline is inserted into the uterine cavity through a small plastic tube and a 3D ultrasound details the uterine cavity, and if needed, the patency of the tubes.The ultrasound probe is placed in the vagina to visualize the uterus on a TV monitor.
All tests can be done at First Steps Fertility, 36 York Mills Road, Toronto. The doctor will recommend the type of procedure based on your history.
Some women may experience cramps during the test which may last for a few minutes to a few hours after the procedure. You may find it helpful to take ibuprofen 600-800 mg approximately 30 minutes before the test.
Autoimmune Testing
What are antibodies and autoantibodies?
When you become ill, your body makes antibodies against the germs. These antibodies help your immune system fight off the infection. Sometimes your body starts making antibodies against itself. These are called autoantibodies. Some common diseases caused by autoantibodies include hypothyroidism, and diabetes.
In pregnancy, we believe there are certain autoantibodies that can cause blood clots in the placenta or interfere with its development.
Types of autoantibodies:
Antiphospholipid antibodies are autoantibodies that are associated with recurrent pregnancy loss. Antinuclear antibodies (ANA) are often measured as well but the connection between ANA and recurrent pregnancy loss is not as strong as with antiphospholipid antibodies.These autoantibodies can be measured through blood testing.
In Ontario, these tests are not covered under OHIP. Therefore there is a charge for these blood tests, the doctor will go over this with you if they are ordered.
What is Antiphospholipid Antibody (APA) Syndrome?
The APA Syndrome is a medical problem that can affect pregnancy outcome. If you have a history of recurrent pregnancy loss, late loss or a history of blood clot, and you test positive repeatedly for antiphospholipid antibodies, you may have the APA Syndrome. If so, you must be followed carefully in pregnancy because there are associated complications in pregnancy, both for the baby and the mother.
Women with the APA Syndrome are at increased risk of developing a blood clot even outside of pregnancy. It is important to avoid other factors that increase you chance of developing a blood clot such as smoking, being overweight, inactive, and using estrogen-containing medication such as birth control pills.
What kind of treatment is there for women with the APA Syndrome?
Although standard treatment cannot prevent your body from making these autoantibodies, treatment can protect you and your pregnancy by making your blood less likely to clot. Treatment can be as simple as taking low dose aspirin daily. This has been shown to e safe in pregnancy and has proven helpful to many women with the APA Syndrome. In cases where autoantibody levels are very high, or where aspirin alone may not be enough, a second medication called heparin or fragmin may be added.
Heparin and fragmin are given by injection only. Instruction on administering heparin would be arranged with a clinic nurse.
What is empiric therapy?
Empiric therapy is sometimes used when the medication is known to be safe and when your past obstetrical history suggests that it could be of benefit.
We often use low dose aspirin and/or progesterone vaginal suppositories as empiric therapy. This type of treatment is not appropriate for everyone.
Is there any issues related to sperm quality that should be tested?
So far, science has not linked sperm count or motility to a history of recurrent pregnancy loss. However, there is some value to looking at sperm function (ie. Level of motility, DNA fragmentation) which may be linked to repeated miscarriages. Specifically these problems are caused by heat or toxin exposure. We always recommend a healthy lifestyle when trying to conceive that includes avoiding excess heat exposure, not smoking, no binge drinking (less that 5 drinks/week), and limiting caffeine intake to 2-3 cups/day. There may also be some value to vitamin therapy with antioxidants such as zinc, vitamin C and vitamin E. Your doctor will discuss this further with you if needed.
What happens if all my tests are normal?
Approximately 40% of couples with recurrent miscarriage do not have a genetic, endocrine, anatomical, or autoimmune factor. If all of the standard tests are normal, the couple is classified as having unexplained recurrent miscarriage. You and your doctor together will decide what course of treatment is indicated here.
A large part of our recurrent pregnancy loss program involves very close and early pregnancy monitoring. Studies have shown this management does significantly improve your chances to take home a baby.
The Recurrent Pregnancy Loss program at First Steps Fertility is currently involved in several research studies including unexplained recurrent miscarriage, the endometrium and RPL, and Polycystic Ovarian Syndrome and RPL. Our overall goal is to improve the evaluation and management of women and their partners who suffer from recurrent pregnancy loss.
