Evaluating Recurrent Pregnancy Loss
Recurrent pregnancy loss is one of the most difficult and emotionally draining problems any couple can face. Couples often wonder what they did to cause it or what they could have done to prevent it. While this is a very normal response, it has no foundation. There are exceedingly rare circumstances in which a loss is due to something a couple did or did not do. Do not blame yourselves. It may be bad luck or there may be some identifiable cause, but it's not your fault!
The toll that the loss of a pregnancy takes can be enormous, let alone repeated losses of pregnancies. It is perfectly normal to hurt after a loss, and the couples who do the best in the long run are those who go ahead and let it hurt, learn to deal with that hurt (this can take time), and then become stronger because of it. One of the biggest mistakes couples can make is to jump right back in to trying again before they completely deal with the hurt from the prior loss.
So when do we start to do some evaluation and initiate some treatment, and what treatment is reasonable? It is hard to justify doing much evaluation after only one loss unless the history of that loss suggests some particular cause. Beyond that, the answer is "it depends." In some couples, particularly older couples, at least some evaluation should be undertaken after two losses. Any couple who has three consecutive losses deserves some evaluation. They should be very cautious about conceiving until that evaluation is complete.
This evaluation should include:
- Blood tests from both partners for chromosome analysis;
- A hysterosalpingogram to evaluate the uterus;
- Blood tests from the female for prolactin, TSH, lupus anticoagulant, and anticardiolipin antibodies; and
- Evaluation of ovulatory function and the luteal phase, including progesterone levels.
This evaluation may include:
- The sophisticated testing to check for the possibility of an alloimmune problem.
The treatment should include:
- Genetic counseling for any chromosomal abnormality discovered;
- Consideration of correction of any abnormality of the uterine cavity;
- Correction of any other medical problems such as thyroid disease;
- Initiation of low-dose aspirin and heparin if there is any evidence of an autoimmune problem; and
- Ovulation induction or progesterone suppositories to correct any evidence of inadequate luteal phase function. Progesterone supplementation is often initiated even in the absence of any specific indication. It is safe, cheap, non-invasive and may be of some benefit until the placenta takes over producing the progesterone at about 10 weeks into the pregnancy.
The treatment may include:
- Treatment of both partners with tetracycline to eliminate any concerns over a possible infectious etiology;
- Initiation of alloimmune treatment protocols, e.g., paternal lymphocyte injections. (This is very controversial. Be sure to discuss it carefully with your physician.); and
- Cervical cerclage if there is evidence of an incompetent cervix. Cervical cerclage is a surgical procedure in which the cervix is "sewn shut," thus allowing it to hold the pregnancy in place. This can be performed as early as nine to 10 weeks if the ultrasounds appear normal up until that time.
Once conception does occur, the pregnancy should be carefully monitored. An ultrasound done as early as possible will provide a lot of reassurance if it appears normal. In some couples frequent (even weekly) visits, ultrasounds, and reassurance are well worthwhile.