Recurrent Pregnanacy Loss Evaluation
Recurrent pregnancy loss (RPL) is a complex and emotionally taxing diagnosis. A RPL work up requires more aggressive testing in an attempt to identify the underlying etiology. However, even with this testing a cause is only identified less than 50% of the time. The most common cause of pregnancy loss and recurrent pregnancy loss is fetal genetic abnormalities accounting for ~50-75% of cases. Other causes of RPL that are assessed as part of this work up are: paternal and maternal genetic abnormalities inherited and acquired thrombophillias (conditions that increase risk of blood clots), structural or anatomic abnormalities especially with the uterus, hormonal disturbances (such as with the thyroid, glucose control, prolactin or androgen levels, PCOS), or infectious causes. Additionally, the field of reproductive immunology is rapidly advancing and providing insight into other potential immunologic or autoimmune conditions which may play a role in RPL. At this time, there is very limited data to justify wide-spread screening for these conditions especially since treatment modalities are woefully understudied. However, more extensive testing on a patient to patient basis is reasonable if management options exist.
As mentioned far and above the most common cause of pregnancy loss and recurrent pregnancy loss is genetic abnormalities. While not the only cause, advanced maternal and paternal ages increase risk of pregnancy loss through chromosomal abnormalities. Chromosomal abnormalities can be determined by testing the fetal tissue or “products of conception” through a karyotype or microarray to identify if the chromosomal number was abnormal. Additionally, parents are also screen through a blood draw to make sure their chromosomes are normal in appearance through a karyotype.
To further evaluate thrombophilias a work up for antiphospholipid antibody syndrome (APLS) and inherited thrombophillias can be performed. Inherited thrombophilias are genetic changes and only ever need to be checked once in a person’s life. Acquired thrombophilias (like those looked for in the APLS work up) need to be positive on 2 results greater than 12 weeks apart to meet laboratory criteria for APLS.
Infectious and hormonal causes or RPL can also be assessed through simple tests such as cultures or blood draws. These can provide useful information, and if an abnormality is identified it can often be corrected.
RPL is a very troubling diagnosis which should be treated with a multimodal approach. The psychological impact this diagnosis has on patients cannot be over stated. Based on the results of a patient’s workup there are several treatment options available to help prevent future losses which you should discuss with your fertility provider.