Most patients in a fertility expert’s office are there because they have problems getting pregnant. For some, the problem isn’t so much getting pregnant as staying pregnant. Embryologists and reproductive specialists are well-versed in diagnosing and treating the causes of recurrent miscarriage.
“Depending on your criteria for recurrent miscarriage,” says Dr. Jeff McKeeby of Shady Grove Fertility’s Annapolis, MD office, “I would estimate that at least 3 percent of couples are going through this experience. Because we’re following our patients from such an early point in their pregnancy, it’s likely that we see a greater percentage of miscarriage than in the general population.”
Until recently, miscarriage was referred to as “recurrent” if a woman experienced pregnancy loss three times or more. Now, partly due to advanced knowledge among reproductive medicine practitioners, women are typically advised to be seen for recurrent miscarriage (also called recurrent pregnancy loss, or RPL) after only two such events.
The term “miscarriage” is generally used to describe loss of a pregnancy up to 20 weeks gestation, most often in the initial 12 weeks or first trimester. Such spontaneous losses usually occur either because the embryo or fetus is not developing normally and/or other processes, such as failure of implantation of the pregnancy within the wall of the uterus.
“About half the time, recurrent pregnancy loss is unexplained,” McKeeby says regarding the diagnosis of miscarriage causes.
Finding the cause of recurrent miscarriage
Dr. McKeeby says that the causes with which his patients present initially are somewhat dependent on the referring practice. “There are some causes that are generally accepted, and there are some that are believed may be causes but are hard to prove,” he explains. The most agreed-upon causes of recurrent loss are:
- chromosomal abnormalities in the parents
- autoimmune conditions, such as having anti-phospholipid antibodies
- anatomic abnormalities such as uterine malformations, for example, uterine septum
- cervical incompetence (a factor in miscarriages occurring in second trimester or later)
More debatable causes include:
- endocrine disorders, like polycystic ovary syndrome (PCOS) or luteal phase deficiency
- autoimmune problems besides anti-phospholipid antibodies
- sperm quality problems
- infections
- stress and environmental factors
Maternal age should be considered in the list of potential causes simply because statistically, women in their 40s and older are documented as a group that experiences miscarriages more often.
“Most miscarriages, regardless of whether they recur or not, are due to chromosomal abnormalities, and the vast majority of those are due to either random chance (in the embryonic development process) or advancing maternal age,” McKeeby states.
Watch: SGF’s New On-Demand Webinar, Getting Pregnant with Endometriosis
Treating recurrent miscarriage
The cause of any individual miscarriage may be hard to determine in many cases, but women who’ve experienced such loss can do more than simply shrug their shoulders and hope for the best the next time.
“Many of these problems can indeed be treated either prior to or very early in subsequent pregnancies,” assures Dr. McKeeby.
For example, if testing on the woman has indicated an antiphospholipid antibody syndrome, injections of a drug called Lovenox (a low molecular-weight heparin, or blood thinner) could be started at the first signs of pregnancy. If an anatomical condition existed, surgical correction could be performed prior to getting pregnant again.
McKeeby says, that while miscarriage is common, it’s still recommended for a patient or her OB to wait until a second loss before seeking possible causes. It’s appropriate to avoid over-testing and possibly rendering false test results, which can lead to unnecessary treatment.
“We recommend a fertility evaluation after a second miscarriage,” he says, “because after two losses, your chances of another miscarriage are about 25 percent. After three losses, the chance is 30 percent. So since we’re not talking about a significant difference between those numbers, it makes sense to start looking for things that may be correctable before a subsequent conception.”
Prepregnancy Genetic Screening (PGS)
One situation that requires a higher-tech approach to answering the needs of women with recurrent pregnancy loss is in the case of what is called “balanced translocation,” a term referring to parents in which their chromosomes have missing or incorrectly located pieces. Men and women with such genetic occurrences almost never have any resulting conditions or symptoms that would clue them in on their chromosomal structure. Usually, they learn about it after having a simple blood test called a karyotype — a picture of how one’s chromosomes are arranged.
“In these cases, the risk of recurrence is somewhere between 2 and 10 percent, depending on random chance and on the gender of the parent who has the balanced translocation.” Dr. McKeeby explains that prepregnancy genetic testing, can provide the solution that these patients need to have a healthy pregnancy and baby. A more advanced option is genetic testing of embryos known as preimplantation genetic diagnosis (PGD). PGD is a cellular biopsy and DNA analysis of an embryo created through in vitro fertilization, or IVF. In fact, the two main reasons for utilizing PGD is recurrent pregnancy loss and recurrent IVF failure.
“The most important thing in genetic testing is to perform a karyotype on the pregnancy that is lost,” McKeeby says, “not only on the parents.”
Diagnosing recurrent miscarriage
As disheartening as it is to experience even one miscarriage, and certainly more than that, the best news is that most patients are able to achieve a successful pregnancy. Chance of success is almost greater than risk of failure.
“If you find something that’s significant and you treat it,” explains McKeeby, “or you don’t find anything wrong, you have about a 70 to 75 percent chance of a successful pregnancy after that. Even if you’ve had four or five miscarriages, your odds with either a treated condition or no cause found are still over 65 percent for successful subsequent pregnancies.”
Another role of a reproductive endocrinologist is reassuring patients—referred to as a “tender loving care” approach—that their chances for having a healthy baby are very good. Recurrent miscarriage patients in the Shady Grove Fertility practice receive the attention from staff and access to treatment and technology to feel confident that they will go on to have a healthy pregnancy.
Getting pregnant after miscarriage
Dr. McKeeby stresses that women who read about the details of miscarriage, and its diagnosis and treatment, should not be concerned about a specific cause until the evaluation is complete. While women in their 40s do have higher chances of miscarriage, even they should not approach conception feeling initially worried. Younger women, in particular, have less statistical cause for concern. All women who are hoping to conceive should focus on important lifestyle factors— nutrition, folic acid intake, weight control and maintaining optimal health—that can have a greater impact on their pregnancy chances.
“Patients should feel reassured overall that it’s far more likely they’ll have a successful pregnancy and healthy baby.”
Medical Contribution by: Jeffrey McKeeby, M.D., of Shady Grove Fertility’s Annapolis, MD office
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Editors Note: This post was originally published in October 2014 and has been updated for accuracy and comprehensiveness as of June 2017.
