Miscarriage and Recurrent Pregnancy Loss
The American Society of Reproductive Medicine (ASRM) defines recurrent pregnancy loss (RPL) as two or more pregnancy losses documented by ultrasonography or histopathological examination. Apart from its physical effects, recurrent pregnancy loss has a profound and unique emotional impact. Identifying the reason why RPL is occurring becomes important in assisting couples in their journey to baby.
Daniela from Dreaming of Baby speaks with Dr. Mark Trolice, M.D., on classifying Recurrent Pregnancy Loss, its causes, and treatment.
Daniela: We have with us today Dr. Mark Trolice from The IVF Center and with whom we shall be discussing recurrent pregnancy loss (RPL). To better inform our readers, it would be great if you could introduce yourself as well as give us an overview of your experience working in this field.
Dr. Mark Trolice: Thank you, Daniela. Hello, everyone; it is my pleasure to be with you today and hopefully answer all your questions on fertility. For 20 years I have been caring for patients trying to conceive and it is a privilege that I hold dear. I see no greater purpose than to assist those struggling to have a child. My areas of expertise are in vitro fertilization, polycystic ovarian syndrome, and recurrent miscarriage.
Classifying Recurrent Pregnancy Loss
Daniela: Thank you for that. If I may, I would like to move on to discuss recurrent pregnancy loss. At which point are miscarriages classified as recurrent pregnancy loss?
Dr. Mark Trolice: Based on a woman’s age, the natural rate of miscarriage changes. In women less than age 30, the risk is approximately 10% but approach 50% in women above age 40. The most common reason for a miscarriage are chromosomal abnormalities of the embryo; this occurs in more than 2/3 of the time. Recurrent miscarriage is defined as two or more first trimester pregnancy losses. Two losses occur in approximately 5% of women whereas three or more losses occur in approximately 1% of women. After two losses, it is reasonable to pursue an evaluation because the risk of subsequent miscarriage is the same following 2 or 3 losses and the finding of a treatable cause is also the same. Unfortunately, approximately 50% of cases of recurrent miscarriage are unexplained.
What Causes Recurrent Pregnancy Loss and How Can it be Treated?
Daniela: Thank you for that overview. In the 50% of cases where the cause is explained, what is the process for reaching this explanation?
Dr. Mark Trolice: The known causes of recurrent miscarriage are genetic (5%), hormonal (15-20%), anatomic (10-15%), and antiphospholipid antibodies (3-5% of general population). So, the standard evaluation is a blood test on the couple to check their chromosomes in order to determine if there is an inherited genetic risk involving the balanced structure of the chromosomes. Hormone testing includes thyroid, prolactin, and blood sugar screen along with consideration of an endometrial biopsy to determine if there is chronic inflammation (endometritis) in the lining of the uterus. For the anatomic evaluation, we perform either a hysteroscopy or water ultrasound (saline infusion sonogram) to determine if there is a congenital malformation of the uterus versus acquired, namely polyps, fibroids, or adhesions. Anti-phospholipid antibodies are present in a small percentage of fertile women however there may be a higher percentage in certain patients with recurrent miscarriage. When these antibodies are elevated, they have a number of negative effects on the placental tissue and interaction with the uterus. Fortunately, when a cause is determined and treated, the subsequent pregnancy rate is high.
Dr. Mark Trolice: “Unfortunately, approximately 50% of cases of recurrent miscarriage are unexplained.”
Dr. Mark Trolice: If either one or both have a chromosomal abnormality, they can still potentially achieve a pregnancy naturally based on a random distribution of the chromosomes in the embryo, although there is a higher risk of loss. Another option for the couple is IVF with pre-implantation chromosome testing of the embryos. The overall live birth rate with either of these options is equivalent, though IVF may reduce the miscarriage rate. For hormonal abnormalities, we usually will address with medication. Uterine abnormalities are usually treated surgically. The most common congenital uterine abnormality is a septate uterus where the uterine cavity is formed but does not completely resorb [re-absorb] internally. The surgery for this condition is very straightforward as an outpatient procedure. Lastly, when anti-phospholipid antibodies are determined, the treatment is typically low dose aspirin and heparin twice daily. Unfortunately, each miscarriage does increase the risk of subsequent losses.
Dr. Mark Trolice: However, when a woman has a live birth, her risk of subsequent miscarriage does not continue to increase but is higher than the general population. When unexplained recurrent miscarriage occurs, weekly 17 hydroxyprogesterone caproate intramuscular injection has been shown to improve outcome.
Dr. Mark Trolice: “When a woman has a live birth, her risk of subsequent miscarriage does not continue to increase but is higher than the general population.”
If You’re Experiencing Recurrent Pregnancy Loss…
Daniela: Thank you for this very detailed overview about Recurrent Pregnancy Loss and its treatment. The insight provided will prove very helpful for women who have experienced this as well as in knowing that there is still hope for a positive outcome. On a final note, what would be that one piece of advice that you’d give to a woman who is experiencing RPL?
Dr. Mark Trolice: The overall prognosis is still favorable with an approximately >60% live birth rate within five years even in women with five prior losses. Her support system should be solid and she should seek out a compassionate physician who is well educated on the topic to provide medically evidence-based testing and treatment in order for her to avoid the risk of exploitation due to her desperation. Equally important, she can meet with a reproductive health psychologist to gain coping strategies and stress reduction. There is a role for stress being associated with losses. While there is no definitive evidence that stress causes miscarriages, we know miscarriages certainly cause stress and impair quality of life.
Dr. Mark Trolice: Recurrent miscarriages is one of the most difficult problems our patients have to face. My advice to all women is to be sensitive to those trying to conceive whether or not they already have a child. When a woman is trying to conceive and is having difficulty, the world looks pregnant to her and this can be overwhelming, especially when they are trying to conceive a sibling for their existing child.
Daniela: Thank you, Dr. Trolice, especially for also addressing the emotional and mental aspects surrounding RPL. It is indeed a challenging journey. I wish to thank you for your time today; what you’ve shared with us today will be helpful to many.
Dr. Mark Trolice: My pleasure Daniela and I hope I was able to empower your followers. I wish them the courage to endure this journey and the fulfillment they desire.
