Recurrent pregnancy losses (RPL) is defined as 3 consecutive miscarriages occurring at less than 20 weeks of gestation. Based on this definition, RPL affects 1-2% of all fertile couples.
For a definitive evaluation for the possible causes below, please make an appointment with an FCI physician by calling 1.877.FCI.4IVF or apply online.>
POSSIBLE CAUSES
Chromosomal abnormalities – This is an abnormality with the genetic material of a embryo and usually occurs when the chromosomes from the egg and the sperm fail to line up correctly. This can result from flawed genetic material (a translocation) from the mother or father that does not necessarily affect the mother or father’s health but can prevent an embryo from developing correctly. Because the baby only inherits half of each parent’s genes, there is still chance of creating a healthy baby if the defect gets bypasses or spontaneously corrects itself when the embryo is created.
Uterine abnormalities – If your uterus is anatomically “abnormal” or divided, such as a uterine septum (the most common uterine abnormality), the embryo either can’t implant or gets undernourished early in the pregnancy.
Hypo or Hyperthyroidism – A very common endocrine issue affecting many women. Symptoms can be very subtle and can present with recurrent miscarriages only.
Hyperprolactinemia – An important hormone produced by your brain that has multiple effects but has significant reproductive impact on the uterus if elevated.
Advanced maternal age >35 and egg quality - As all women realize, their fertility decreases as they age. This can affect their ability to get pregnant but also affect their ability to keep a pregnancy.
Uncontrolled diabetes – elevated insulin levels and glucose levels can result in increased risk of miscarriage.
Polycystic Ovarian Syndrome (PCOS) - Click for details.
Immunologic disorders – A very controversial field. All treatments are considered experimental but heparin and baby aspirin in certain medical situation may be indicated and proven beneficial. An evaluation to determine whether patients with RPL have antiphospholipid antibody syndrome or anticardiolipin antibodies are the only immune antibodies that have been clearly associated with RPL and have a therapy that has with certainty shown to improve retention rates for pregnancy.
Environmental – Smoking, alcohol and recreational drugs have all been associated with increased miscarriage rates. Cessation of such therapy is recommended.
Bacterial infection – controversial area in which two bacteria, in particular – mycoplasma hominis and ureaplasma urealyticum – can raise the risk of miscarriage. However, no studies have shown definitively that treatment or existence of these bacteria in the vaginal/cervical flora are associated with improving or associated, respectively, with recurrent miscarriages.
Thrombophilia – Miscarriages have been associated with a hypercoagulable state or an ability to clot blood more than normal. Such clotting is important is preventing bleeding but clots can also block valuable blood supply to a pregnancy. Various different tests have been developed to check for a propensity to clot. Because such deficiencies in clotting factors are so rare, it is controversial whether or not to check for such abnormalities in the general recurrent miscarriage population. Patient with a history of 2nd or 3rd trimester loss, leg thrombosis in their personal history or unexplained high order (>3) recurrent miscarriage should have a thrombophilia workup.
POTENTIAL THERAPIES
Regarding the necessity of any of these therapies below, please consult an FCI physician by calling 1.877.FCI.4IVF or apply online.
As we learn more about genetics, embryology, immunology and blood clotting, we have developed better diagnostic tests to tests for causes of miscarriage. The next large step for any particular diagnostic test is therapy. In other words, a abnormality may exist but is there reasonable therapy shown to be beneficial. RPL therapy is even less certain. There are very few definitive clear therapies known to decrease miscarriage rates.
Preimplantation genetic diagnosis (PGD)
Click for details.
Surgery
Depending on the type, uterine abnormalities can be corrected surgically. Surgical Correction of a uterine septum (where the uterine cavity is divided in half) has been shown to be extremely beneficial for RPL. Although overall very rare in the general population, uterine septi can affect 10-15% of those who suffer from repeated pregnancy losses.
Thyroid and prolactin medical therapies
Abnormalities with the thyroid and prolactin can be easily treated with simple medical therapy.
Immunotherapy
Immunology is the most hotly contested field of research for miscarriages. The basic theory is that an embryo consists of material from the mother and “foreign” material from the father. This foreign material is recognized by the mother’s hyper-immune system and is attacked. Research surrounds therapy to reduce the recognition of “foreign” material or inhibit the destruction of foreign material, in this case, the pregnancy.
Current immunotherapy, i.e. IV IgG, is considered very experimental and there is currently no studies that validate its usage outside of research protocols. Any immunotherapy available is considered “off-label” (FDA approved drug that is being used in an unapproved manner). FCI follows the American Society of Reproductive Medicine guidelines that warns that such therapy has no long-term data yet proving that it has any beneficial effect. Previous historical data on other “promising” therapy that made intuitive sense that other practices may offer but was later proven to be ineffective warrants a conservative approach until more definitive data and research is done.
Anticoagulant therapy
Those patient diagnosed with Antiphospholipid Syndrome (APL) may benefit from therapy. Antiphospholipid antibodies and anticardiolipin antibodies are antibodies found in the walls of blood vessels and can, simply put, cause blood vessels to constrict. This can cut of flow of blood containing nutrients and oxygen to a pregnancy.
Women with RPL have an increased risk of having APL and treatment with heparin and baby aspirin during early pregnancy can reduce a pregnancy loss by 50%.
Such therapy, although promising, has been cavalierly applied to other medical situations such as infertility without any definitive data regarding its benefit. Because heparin and aspirin are not completely risk-free and can have significant side effects, FCI believes that such therapy should be reserved for those with a definitive diagnosis of APL.
Anti-insulin therapy
Women with PCOS, a specific reproductive issue that can result in irregular cycles and elevated male hormone levels, can benefit from a diabetic drug called metformin during early pregnancy.
