diagnosis guide
If you’ve just received a medical diagnosis, or you’re concerned that something in your present or past health history might be jeopardizing your fertility, check here for quick info on common medical conditions and how they can affect conception and pregnancy.
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Miscarriage, Recurrent (Recurrant Pregnancy Loss)
What It Is
Recurrent pregnancy loss is defined as two or more failed pregnancies. Although approximately 25 percent of all recognized pregnancies result in miscarriage, fewer than 5 percent of women will experience two consecutive miscarriages, and only 1 percent will suffer three or more. If the cause for the pregnancy loss is unknown, a medical evaluation may be warranted. After three or more miscarriages, experts recommend a thorough evaluation.
Causes
There are many possible causes of recurring pregnancy loss, including:
(1) Genetic/chromosomal causes. So-called translocation (when part of one chromosome is attached to another chromosome) is the most common inherited chromosome abnormality. A miscarriage occurs when the embryo receives too much or too little genetic material. While inherited genetic causes are rare, many early miscarriages (60 percent or more) are the result of a random chromosomal abnormality in the embryo, such as a missing or duplicate chromosome.
(2) Metabolic abnormalities. Women with diabetes improve their chances of motherhood if blood sugar levels are brought under control even before conception. Women who have insulin resistance, such as obese women and those who suffer from polycystic ovarian syndrome (PCOS), also have higher rates of miscarriage (see entries on PCOS and diabetes).
(3) Maternal age. After age 40 more than one-third of all pregnancies end in miscarriage; in most cases these embryos had abnormal chromosomes.
(4) Hormonal Abnormalities. Progesterone, a hormone produced by the ovary after ovulation, is necessary for a healthy pregnancy. Controversy still rages over whether low progesterone levels, often called luteal phase defect, may cause repeated miscarriages.
(5) Structural (uterine) abnormalities. Ten to 15 percent of women with recurring pregnancy loss have distorted uterine cavities, which can be diagnosed with a hysterosalpingogram, a sonohysterography, an ultrasound, or a hysteroscopy. Congenital uterine abnormalities include a double uterus, uterine septum, and a uterus in which only one side has formed. Asherman’s syndrome (scar tissue in the uterine cavity), uterine fibroids, and possibly uterine polyps are acquired abnormalities that may also cause recurrent miscarriages.
(6) Antiphospholipid Syndrome. Three to 15 percent of miscarriages are caused by so-called antiphospholipid syndrome, which is identified via blood tests (of the woman) for anticardiolipin antibodies and lupus anticoagulant. Women with high levels of antiphospholipid antibodies can improve their odds of a healthy pregnancy by taking aspirin and heparin.
(7) Thrombophilias. These inherited disorders raise a woman's risk of serious blood clots (thrombosis) and may also increase the risk of fetal death in the second half of pregnancy. However, there is no proven benefit for testing or treatment of women with thrombophilias and recurrent miscarriage in the first half of pregnancy.
(8) Male factor. Increasing evidence suggests that abnormal sperm DNA may affect embryo development and possibly increase the risk of miscarriage. However, these data are still preliminary, and it’s not known how often sperm defects contribute to recurrent miscarriage.
(9) Unexplained. In the vast majority of cases (half to 75 percent of couples) no explanation is found for the recurrent pregnancy losses.
Treatment
The treatment of multiple miscarriages obviously depends on the causes. For instance, if the cause of recurrent pregnancy loss is structural uterine abnormalities, these can sometimes be correctly surgically to allow proper implantation and a healthy pregnancy.
Metabolic abnormalities such as diabetes and PCOS should be controlled (as much as possible) before conception. Low progesterone levels (also called luteal phase defect) may be treated with ovulation induction, progesterone supplementation, or injections of human chorionic gonadotropin (hCG, but according to the American Society of Reproductive Medicine evidence is lacking to support the effectiveness of these treatments).
According to the ASRM, the following tests and treatments have NO proven benefit for recurrent miscarriage: cultures for bacteria or viruses; tests for insulin resistance, antinuclear antibodies, antithyroid antibodies, maternal antipaternal antibodies, antibodies to infectious agents, and embryotoxic factors; leukocyte (white blood cell) immunization; and intravenous immunoglobulin (IVIG) therapy.
Pregnancy Prognosis
Couples with genetic translocations may benefit from pre-implantation genetic diagnosis (PGD) of the fertilized egg, which is only possible as part of an in vitro fertilization (IVF) procedure.
The good news is that 60 to 70 percent of pregnancies following recurrent pregnancy loss are successful. Of course, a healthy lifestyle and taking folic acid before attempting another pregnancy can never hurt. Smoking cessation, reduced alcohol and caffeine consumption, moderate exercise, and weight control are all beneficial. Counseling may provide comfort and help couples cope with feelings of the grief, anger, and helplessness.
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