Recurrent Miscarriage Treatment (multiple miscarriages)
Pregnancy loss can be one of the most difficult experiences of a woman’s life. Fortunately for most women, a single miscarriage does not increase the chance of having another pregnancy loss in the future. Some women however, suffer multiple miscarriages; this scenario is termed recurrent pregnancy loss (RPL).
By strict definition, recurrent pregnancy loss is 3 consecutive miscarriages which occur before 20 weeks gestation. In reality, many women with 2 consecutive losses or those with 2-3 non-consecutive losses often seek evaluation and treatment. The good news is that women with multiple miscarriages can have a healthy pregnancy, they may just need a little help from a fertility specialist
The causes of recurrent pregnancy loss can be divided into 4 main categories and each category requires its own specific tests and treatment. Depending on a patient’s specific history and physical, some tests and treatments may be more pertinent than others.
Anatomic
Anatomic causes for RPL include congenital abnormalities of the uterus such as uterine septum as well as acquired uterine abnormalities such as scarring or fibroids. Anatomic causes may be evaluated by a variety of imaging tests such as HSG, ultrasound, MRI and more. Ultimately, surgery may be able to correct the anatomic abnormality and prevent future losses.
Diminished Ovarian Reserve (low egg supply)
If less eggs are left in your ovaries, there will be more genetically abnormal eggs, and a greater chance of miscarriage. Age is a primary factor for egg quality. But diminished ovarian reserve can occur in young women as well. Risk factors for diminished ovarian reserve include smoking, ovarian surgery, STDs such as Chlamydia or Pelvic Inflammatory Disease, fallopian tube problems, endometriosis, or a family history of early menopause.
Problems with the Uterus
Some women are born with a congenital uterine abnormality like a septate uterus, a dividing wall of tissue inside the uterus. Other problems with the uterus are acquired such as polyps of the lining of the uterus, and/or fibroid tumors (leiomyoma). Up to 25-50% of women have fibroids, but not all of them cause fertility issues or miscarriages – the number, size and location of the fibroids all matter. Scar tissue, especially from previous D & C procedures, can also be a problem. These uterine issues can generally be surgically corrected in a relatively quick outpatient procedure we can do inhouse.
Thyroid:
Thyroid problems or too much prolactin hormone may increase the risk of miscarriage, and untreated thyroid problems can increase the chance of OB complications. A prescription, which is a small pill taken before breakfast, is sometimes all that’s needed to carry a healthy baby to term.
Genetic
Chromosomal Abnormalities in Either Parent’s Genetic Makeup
Genetic causes of RPL can originate in the mother’s DNA, the father’s DNA or both. Highly specialized and advanced tests may be used to evaluate that DNA through a simple blood sample. Ultimately, if the DNA is implicated in the RPL, IVF can be employed to create embryos which are then evaluated for the abnormality prior to placement in the uterus. The embryo evaluation is performed using PGT-M (PGD).
Translocations, where part of one chromosome is swapped or joined with part of another, are rare. This occurs in approximately 3-5% of women with multiple miscarriages. But chromosomal abnormalities are common and the cause of many early miscarriages.
Male Factor: Men that exhibit abnormal sperm quality (low counts, or poor morphology) tend to have more genetically abnormal sperm, increasing the chance for genetic abnormalities in the embryo. 50% of couples having difficulty conceiving are due to the male factor. That is why we recommend a semen analysis as one of the first steps in diagnostic treatment. People do not often realize that early miscarriages may be caused by genetic factors on the male side. These issues can be overcome through IUI sometimes or with IVF and PGT screening of embryos.
Immune/ Hormonal/ Clotting
The hormonal and immune and thrombotic environment during gestation is critically important to successful a pregnancy. While some factors associated with immunity or blood clots are clearly associated with RPL (antiphospholipid antibodies for example), other factors (natural killer cells) have considerably weaker scientifically based connections. With that being said, our doctors at PSFC are skilled at choosing which tests to order and not order to best evaluate for this type of pregnancy loss. Once the cause is established, a variety of treatments are available.
Antiphospholipid antibodies and lupus anticoagulant are autoimmune conditions where a woman can make proteins that attack normal tissue in the body, including the baby’s placental tissue when pregnant. These increase the chances of miscarriage and, in some rare cases, can cause serious blood clots in the mother. We have treatments to prevent miscarriage in women with these antibodies.
Immune system-related thyroid problems are common in women with miscarriages and may just require thyroid medication to correct the issue. Serious autoimmune diseases like lupus also increase the risk of miscarriage but are not common.
Most, but not all of these are genetically based. You may be born with genes that can increase your risk of both miscarriage and blood clots (like blood clots in the leg veins, deep vein thrombosis or DVT, which can spread to the lungs and be dangerous, especially in pregnancy). The most common blood clotting disorders don’t usually cause blood clots in the mom, but they do increase the risk of miscarriage. More serious blood clotting disorders exist, with a much higher chance of miscarriage or blood clots, but these are rare.
Read on FAQ’s on Recurrent pregnancy loss / multiple miscarriage
Treatments to stay pregnant after multiple miscarriages?
The treatments available to reduce your chance of another miscarriage will vary, depending on diagnosis.
Diminished ovarian reserve may respond well to fertility treatments using your own eggs, or you may need to go the route of egg donation, using a semen bank, or adopting an embryo. These options may not be ideal if, like most couples you desire a genetically related baby, but they are good options and during diagnosis we may determine to cross those bridges when we get there, meaning we will usually try a number of things first.
Treatment for autoimmune conditions or blood clotting disorders can lower your chance of another miscarriage by a large amount, but we can never get you down to a zero chance of miscarriage. For example, if you have a blood clotting disorder and we treat you with a ‘baby aspirin’ a day (81 mg low-dose aspirin) combined with blood thinner shots (such as Heparin or Low Molecular Weight Heparin), your next pregnancy could still be genetically abnormal and end up as a miscarriage. The shots can’t fix the genetic abnormality. But blood thinners, given as small shots under the skin in the stomach area that can be administered at home, can improve your chance of success.
Problems in the uterus may need surgery, which perform inhouse in an outpatient procedure. Patients will be home, recuperating in a few hours and sometimes this is all that is needed to carry the next pregnancy to term.
If one partner has a genetic rearrangement, we can do IVF (In Vitro Fertilization) with Preimplantation Genetic Testing (PGT) to select healthy embryos with the correct number of chromosomes. IVF with PGT testing gives coupes the best chance of success and we are experts at this procedure. We now perform genetic testing on all IVF embryos as our standard of care. When we know what to look for, we can avoid a number of genetic diseases and remove them from the family bloodline going forward.
Another option for a couple with a translocation is to use donor eggs or donor sperm instead of the partner’s eggs/sperm who is carrying the genetic abnormality. Adopting an embryo may also be a good option.
Should I do anything different next time I’m pregnant?
Yes, please come see Fertility specialist at PSFC to receive extra care. We can check your progesterone levels and thyroid function early in pregnancy, with progesterone supplements or thyroid medication given if needed. Your pregnancy should be watched more closely with ultrasounds to check for normal growth and to find baby’s heartbeat in the first weeks of pregnancy.
If unfortunately, you do have another miscarriage, we can offer genetic testing to see if the pregnancy was genetically abnormal or not – e.g. if the baby had an extra chromosome (Down’s syndrome results in 47 instead of 46 chromosomes). We can tell if the genetic problem came from the egg or the sperm. Our hope is the sooner we see you, the faster we can get you to your healthy pregnancy and delivery.
Diminished ovarian reserve (low egg supply) is just as common in women with multiple miscarriages as it is in women who are having trouble getting pregnant (infertility), and we perform a specialized ultrasound to look at the number of small follicles in your ovaries (antral follicle count or AFC) and the size of your ovaries, and blood tests including FSH, Anti Mullerian Hormone (AMH), and possibly a Clomid Challenge Test (CCT).
Miscarriages are a terrible thing to go through, so please reach out and get the help you deserve sooner than later. At PSFC, we do a thorough set of tests for miscarriage to find a cause in most couples who can get pregnant but keep miscarrying. Once properly diagnosed, appropriate treatments to fix and/or work around the issues will be implemented. And for couples not getting pregnant at all, we can usually overcome that too.