What is Recurrent Pregnancy Loss?
A pregnancy loss is the spontaneous loss of a pregnancy before 24 weeks of gestation. A diagnosis of Recurrent Pregnancy Loss or RPL could be considered after the loss of two or more pregnancies. This includes pregnancies after spontaneous conception and after assisted reproduction (e.g. IUI and IVF/ICSI). It is estimated that up to 15% of pregnancies result in pregnancy loss. RPL affects 1 to 2% of couples.
Which tests should my doctor perform?
Several investigations have been suggested for couples with RPL. The aim of doing such tests could be to:
- identify the cause, or likely cause, of the previous pregnancy loss(es)
- recommend or suggest appropriate treatment, if that is an option
- help the doctor to estimate the chance of having a baby in the future
Even if a cause is found, there may not be a treatment.For example, you may have antibodies which are believed to be a contributing factor in RPL, but there are currently no treatments available to increase your chances of a successful pregnancy.
In the majority of RPL couples, no cause is found. This is called unexplained RPL.
What are investigations for RPLWe discuss investigations that are recommended for all couples with RPL, and tests that might be considered for some couples depending on their medical and family history.
Screening for antiphospholipid syndrome (APS)When you cut your finger, the blood will clot to stop you losing too much blood. Thrombophilia is a condition that makes the blood clot more than it should. Thrombophilia can be inherited (passed down genetically) or it can be acquired (not inherited). When it is acquired, and there is also a history of pregnancy loss, it is called antiphospholipid syndrome or APS. Testing for antiphospholipid syndrome (APS) is done by a blood test for lupus anticoagulant and anticardiolipin and maybe also aß2GPI antibodies. It is unclear whether inherited thrombophilia could also be a cause of RPL.
UltrasoundIf there is a problem with the shape of the uterus (womb), a fetus may not be able to develop and this increases the chance of a pregnancy loss. Saline infusion sonography is more helpful than routine USG to detect abnormal uterine shape.
Genetic analysisWhen the genes are combined during conception (when egg and sperm meet), errors can occur. Some of these errors or abnormalities can be significant and result in a fetus that cannot survive. As such, genetic errors in the fetus could be the cause of a pregnancy loss, and are more frequent in older women. If the testing shows that there was a genetic error or abnormality in the fetus, this means that it might be the cause of this pregnancy loss. This may be important information for you, even though it doesn’t tell you if you’re other loss/es happened for the same reason. It is also important to know that there are no treatments to improve the chances of a healthy baby in the next pregnancy.
Genetic testing on both parents (called parental karyotyping) can show a genetic abnormality that does not cause a problem in the parent, but may cause a genetic defect in the fetus. The chances of finding a genetic abnormality in the parents is small, and even if an abnormality is found, the chances of a healthy baby are still good.
Antinuclear antibodiesANA are antibodies in your blood that are directed against your cells. These antibodies are often detected in patients with autoimmune diseases. Studies have shown that ANA can also be detected in some patients with RPL, and therefore testing can be considered to explain a possible cause of the pregnancy loss.
Sperm DNA FragmentationDoctors have recently started to look at male causes of RPL and there is now some evidence that damaged sperm could increase the risk of pregnancy loss. We still need much more research, but assessing sperm DNA damage could be considered in couples with RPL in order to provide some information on the role of the father in the pregnancy loss.
What are the options for treatment?Most couples with RPL have a higher chance of a live birth in their next pregnancy than of having another pregnancy loss, but that does vary depending on maternal age and the number of pregnancy losses and on whether a likely cause has been found.
What are the options for treatment of explained RPL?
You have Antiphospholipid syndrome (APS) - Treatment with heparin and low-dose aspirin
You have a problem with the shape and/or inside of your uterus (uterine malformation) If you have a septate uterus (e.g. where the uterus is divided by a band of tissue [a septum]), you may be offered septum resection.There is no evidence that surgery increases the chances of a healthy pregnancy in the future.
Tests showed a genetic abnormality
Genetic counselling is recommend. Genetic counselling includes a discussion of what the test results mean for you and your family, the implications for your baby, and your treatment options. Treatment options include preimplantation genetic diagnosis (PGD, which would be done as part of an IVF procedure) but there is only limited evidence showing a benefit to reduce the risk of another pregnancy loss.
Your partner’s sperm showed sperm DNA damageCessation of smoking, a normal body weight, limited alcohol consumption and a normal exercise pattern is recommended.
You have Hyperhomocysteinemia (high levels of homocysteine in your blood)Folic acid and vitamin B6 supplements are recommended
What are the options for unexplained RPL?If none of the tests show a problem or likely cause of your pregnancy losses, you will be diagnosed as having unexplained RPL.
- There are no treatments available that are known to improve your chances of a having a baby.
- It is still advisable to try to live as healthy a lifestyle as possible, with a balanced diet, maintaining a healthy weight, stopping or reducing smoking, avoiding excessive alcohol and avoiding (hard and soft) drugs.
- Ask your doctor about taking vitamin D supplements.