Your options for dealing with recurrent pregnancy loss
Posted on 31 January 2018
Are you or your partner facing the heartbreak of recurrent miscarriages? Dr Abri de Bruin, a gynaecologist and reproductive medicine specialist based at Genesis Reproductive Centre at Mediclinic Kloof, offers his invaluable support and treatment advice for couples struggling with recurrent pregnancy loss.
It can be a devastating cycle of loss, grief, a semblance of acceptance, trying to conceive again, hope, worry, waiting interminably – only to deal with the trauma of another miscarriage. ‘Couples who face pregnancy loss require empathy and understanding because early loss, especially when recurrent, can be an emotionally traumatic experience, similar to that associated with stillbirth or neonatal death,’ explains Dr Abri de Bruin, a gynaecologist and reproductive medicine specialist at Genesis Reproductive Centre in Mediclinic Kloof in Pretoria (www.genesisart.co.za; www.drabridebruin.co.za ).
Spontaneous pregnancy loss, or miscarriage, in a first pregnancy is a surprisingly common occurrence, with approximately 15% of all clinically recognised pregnancies resulting in miscarriage. ‘Keep in mind though, that many more pregnancies fail prior to being clinically recognised,’ adds Dr De Bruin.
However, recurrent pregnancy loss (RPL) – which is defined by some reproductive medicine experts as two consecutive losses, and by others as three consecutive losses prior to 20 weeks from the last menstrual period – is less common, explains Dr De Bruin. ‘Fewer than 5% of women will experience two consecutive miscarriages, while epidemiologic studies have revealed that only 1 to 2% of women experience RPL,’ he says. ‘According to a Swedish study published in 2017 there’s been a significant increase in the incidence of RPL in the last decade.’
What are the causes of recurrent pregnancy loss?
Couples struggling with RPL are often desperate to know the exact cause of their repeated miscarriages, but approximately 50% of these cases will remain unexplained even after evaluation by a fertility expert. ‘Recurrent pregnancy loss is one of the most frustrating and difficult areas in reproductive medicine because the aetiology (cause) is often unknown,’ explains Dr De Bruin. ‘Additionally, there are few evidence-based diagnostic and treatment strategies.’
The good news though, is that most women with RPL have a good prognosis for eventually having a successful pregnancy, even when a definitive diagnosis is not made and no treatment initiated, he says. ‘In one study, the overall live birth rates after normal and abnormal diagnostic evaluations for RPL were 77% and 71%, respectively.’
The known causes of RPL include the following:
- Parental chromosomal abnormalities. The abnormality may come from the egg, sperm or the early embryo. For example, increased maternal age is associated with miscarriage due to embryonic aneuploidy, explains Dr De Bruin, that is, a woman aged 35 years or older is more likely to have poor egg quality than a younger woman, resulting in chromosomal abnormalities and pregnancy loss.
- Untreated hypothyroidism. If the problem of an underactive thyroid remains untreated, it can lead to miscarriage and infertility.
- Uncontrolled diabetes mellitus. ‘Women who control their diabetes well won’t experience an increased risk of miscarriage (related to their diabetes),’ says Dr De Bruin.
- Anatomic and uterine abnormalities. Anatomic abnormalities include adhesions (scarring) in the uterus, fibroids and polyps. ‘A uterine septum – a congenital malformation where the uterine cavity is wholly or partially divided by a wall of tissue – is most closely linked to RPL, with a 76% risk of spontaneous pregnancy loss,’ says Dr De Bruin.
- Antiphospholipid syndrome (APS). This autoimmune disorder sees the immune system mistakenly making antibodies to certain substances involved in normal blood clotting, leading to pregnancy complications.
- Thrombophilias: Both inherited and acquired thrombophilias – a group of conditions that increases the risk of blood clots, leading to deep vein thrombosis and pulmonary embolism – could cause miscarriage. ‘They’re common with more than 15% of the white population carrying an inherited mutation,’ says Dr De Bruin.
- Endocrine disorders: This could include luteal phase defect (LPD is when your ovaries don’t release enough progesterone, or if the lining of your uterus doesn’t respond to this hormone), hyperprolactinaemia (abnormally high levels of the hormone prolactin), and polycystic ovarian syndrome (PCOS). ‘Studies have found evidence of PCOS in at least 40% of women with RPL. The miscarriage rate may be as high as 20 to 40%,’ says Dr De Bruin.
Other causes include immunologic abnormalities (here the foetus isn’t genetically identical to the mother, and can lead to its rejection where the normal “protecting” systems doesn’t protect the foetus, explains Dr De Bruin), and infections from, for example, measles.
‘Environmental factors such as smoking, high alcohol intake (three to five drinks per week), obesity and too much caffeine (more than three cups a day) could also contribute to RPL. If these lifestyle factors have been identified as a likely cause, the good news is that the couple can work towards controlling them,’ says Dr De Bruin.
What are the treatment options for RPL?
There is unfortunately no ‘magic pill’ treatment option that fertility specialists are able to offer RPL couples. The basis of treatment is management of the underlying cause, so your specialist will first need to investigate a possible cause through various tests such as, for example, a 3-D ultrasound, a hysteroscopy (a camera is inserted into the uterus via the vagina and cervix), hormone function tests and ovarian reserve tests, amongst others.
‘However, in 50% of cases no underlying cause will be found, hence these patients need to be treated in a multidisciplinary unit specifically dealing with RPL patients,’ advises Dr De Bruin. ‘Close monitoring and support of RPL couples at a dedicated clinic has been shown to markedly improve subsequent pregnancy outcome.’
Some treatment options include the following:
- For parental chromosomal abnormalities, genetic counselling will be advised. ‘Treatment options may include in vitro fertilisation (IVF) with pre-implantation genetic diagnosis to ensure that a transferred embryo doesn’t have the genetic abnormality, or the use of donor oocytes (a mature egg cell from a donor),’ says Dr De Bruin.
- Anatomical abnormalities like adhesions, fibroids and septae can be corrected with surgery.
- Medical management of diabetes, hypothyroidism and hyperprolactinaemia.
- Treatment of APS with anticoagulation therapy.
‘Treatment for unexplained RPL may include lifestyle modification, oocyte donation and surrogacy,’ adds Dr De Bruin.
The positive news is the majority of RPL patients will ultimately, given available treatments and persistence, be able to carry and deliver a healthy child, says Dr De Bruin. ‘Additionally, patients who finally succeed in having a child will enjoy a reduced risk of a miscarriage in the subsequent pregnancy,’ he adds.
How important is emotional and psychological support for RPL patients?
Pregnancy loss can have an immense adverse psychological impact on affected couples. ‘RPL patients are prone to heightened anger, depression, anxiety and feelings of grief and guilt. Social, emotional and psychological support in the form of medical treatment, group support systems, psychologists and psychiatrists can’t be underestimated, and may even enhance their therapeutic success, ’ says Dr De Bruin.
When to stop trying to conceive is advice that can only be given on an individual case-by-case evaluation, says Dr De Bruin. ‘The emotional impact of RPL will differ between couples – where one couple will continue trying, other couples are just not able to cope with the emotional impact. Couples usually set themselves a limit of number of tries or miscarriages and then stop.’
However, if a woman reaches 42 years of age a specialist will usually advise her to stop due to the high incidence of embryonic aneuploidy. ‘Adoption or egg donation is a definite option for these patients,’ says Dr De Bruin.
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