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Recurrent Pregnancy Loss Analysis

Recurrent Pregnancy Loss also known as recurrent miscarriage, is defined as the loss of three or more consecutive pregnancies and it affects 1% of couples trying to conceive. Human reproduction is remarkably inefficient; nearly 70% of human conceptions do not survive to live birth. Spontaneous fetal aneuploidy is the most common cause of spontaneous loss, particularly in the first trimester of pregnancy. Although losses owing to de novo fetal aneuploidy occur at similar frequencies among women with sporadic and recurrent losses, some couples with recurrent pregnancy loss have additional associated genetic factors and some have nongenetic etiologies.
Recurrent Pregnancy Loss Analysis

What is Recurrent Pregnancy Loss?

Recurrent Pregnancy Loss (RPL), also known as recurrent miscarriage, is a heartbreaking reality for many couples trying to conceive. It is defined as the loss of two or more consecutive pregnancies before reaching the 20th week of gestation. While miscarriages are relatively common, occurring in about 10-20% of recognized pregnancies, RPL affects approximately 1-2% of couples attempting to conceive.

How Common is Recurrent Pregnancy Loss?

Although it can feel isolating, recurrent pregnancy loss is more prevalent than one might think. Around 1% to 2% of couples experience RPL, highlighting the importance of understanding the various reasons behind recurrent miscarriages. Determining the specific cause(s) often involves a thorough evaluation by healthcare professionals specializing in reproductive medicine.

Despite the challenges posed by RPL, advances in medical technology and reproductive treatments offer hope for many couples striving to overcome this condition and achieve a successful pregnancy. From genetic testing and hormonal therapies to surgical interventions and assisted reproductive techniques like in vitro fertilization (IVF), there are various avenues for addressing the underlying reasons and increasing the chances of a healthy pregnancy.

Moreover, emotional support and counselling are essential components of care for couples navigating the complexities of RPL. Seeking support from healthcare providers, support groups, or mental health professionals can provide much-needed guidance, validation, and comfort during this challenging journey.

What Can Cause Recurrent Miscarriages?

Several factors can contribute to recurrent miscarriages, ranging from genetic and chromosomal abnormalities to lifestyle factors and underlying health conditions. Some of the key reasons and causes of RPL include:
  1. Chromosomal Abnormalities: One of the most common causes of miscarriages is chromosomal abnormalities in the fetus, which often occur spontaneously during conception and can prevent typical embryo development.

  2. Advanced Maternal Age: As women age, the quality of their eggs tends to decline, increasing the risk of chromosomal abnormalities and miscarriages. Advanced maternal age, typically defined as 35 years and older, is associated with a higher incidence of RPL.

  3. Uterine Abnormalities: Structural abnormalities in the uterus, such as fibroids, polyps, or a septate uterus, can interfere with implantation or disrupt the normal development of the fetus.

  4. Hormonal Imbalances: Hormonal imbalances, including thyroid disorders and insulin resistance, can affect the stability of the uterine lining and interfere with embryo implantation.

  5. Blood Clotting Disorders: Certain blood clotting disorders, such as antiphospholipid syndrome (APS) and thrombophilia, can increase the risk of blood clots forming in the placenta, restricting blood flow to the fetus.

  6. Autoimmune Disorders: In some cases, the immune system may mistakenly identify the developing fetus as a foreign invader and mount an immune response, leading to miscarriage. Conditions such as lupus and rheumatoid arthritis are associated with an increased risk of RPL.

  7. Genetic Factors: Both maternal and paternal genetic factors, such as inherited genetic disorders like balanced translocations or other chromosomal abnormalities, can contribute to recurrent miscarriages.

  8. Environmental Factors: Exposure to certain environmental toxins, such as tobacco smoke, alcohol, and certain chemicals, can adversely affect fertility and increase the risk of RPL.

  9. Lifestyle Factors: Factors such as obesity, excessive alcohol consumption, smoking, and illicit drug use can all negatively impact fertility and increase the risk of recurrent pregnancy loss.

  10. Infections: Infections such as bacterial vaginosis, sexually transmitted infections (STIs), and certain viral infections can increase the risk of miscarriage if left untreated.

Recurrent pregnancy loss can have multifactorial causes and identifying the underlying reason(s) often requires a comprehensive evaluation by healthcare professionals. Treatment options may include lifestyle modifications, hormonal therapy, surgical intervention to correct uterine abnormalities, or assisted reproductive technologies such as IVF with preimplantation genetic testing. Additionally, emotional support and counselling play a crucial role in helping couples cope with the challenges of RPL and navigate their journey toward parenthood.

The most commonly identified causes include genetic abnormalities, uterine problems, immunologic factors, hormonal disorders, metabolic diseases, and infections. Recurrent early miscarriages (within the first trimester) are most commonly due to genetic or chromosomal problems of the embryo, with 50-80% of spontaneous losses having abnormal chromosomal numbers. Smoking and excessive alcohol can harm a developing baby and may increase the risk of miscarriage. Being overweight increases the risk of miscarriage. Men who have a higher BMI are likely to have poor quality ‘fragmented’ sperm, which causes an increased risk of miscarriage. Obesity and Diabetes in men and women can cause recurrent miscarriages. The risk for recurrent miscarriage increases with age, women 35 years and older. Studies suggest that a father’s age at the time of conception (paternal age) might pose health risks for a baby.

Blood tests for metabolic, hormonal, and immune causes of RPL

Diabetes and other diseases in men and women can cause recurrent miscarriages. At least 15% of recurrent miscarriages occur as a result of Antiphospholipid antibody syndrome, and it is now recognized as the most common, treatable cause. With correct diagnosis and treatment, the pregnancy success rate has risen from 20% before 1990 to around 70-80% today.

Tests for genetic abnormalities in the fetus or parents

Pedigree chart analysis can be done to know if there are any genetic predispositions in the family. Genetic testing of the products of conception from couples experiencing two or more losses may aid in defining the underlying etiology and in counselling patients about prognosis in a subsequent pregnancy. Parental karyotyping of couples who have experienced recurrent pregnancy loss (RPL) will detect some couples with an increased likelihood of recurrent fetal aneuploidy; this may direct interventions. The utility of preimplantation genetic analysis in couples with RPL is unproven, but new approaches to this testing show great promise.

Tests for abnormalities in the shape of your uterus

A 3D-4D pelvic ultrasound scan to detect any abnormalities in the shape of your uterus. If an abnormality is suspected, further investigations may include a hysteroscopy (a procedure to examine the uterus through a small telescope that is passed through the vagina and cervix) or a laparoscopy (a procedure in which a surgeon uses a fine telescope to look inside the abdomen and pelvis).

Tests for infection screening

Tests such as blood samples and vaginal swabs may be taken at the time to look for any source of infection. PCR (polymerase chain reaction) tests are a fast, highly accurate way to diagnose certain infectious diseases and genetic changes. The tests work by finding the DNA or RNA of a pathogen (disease-causing organism) or abnormal cells in a sample. Most viruses and other pathogens contain DNA or RNA. Unlike many other tests, PCR tests can find evidence of disease in the earliest stages of infection. Other tests may miss early signs of disease because there aren’t enough viruses, bacteria, or other pathogens in the sample, or your body hasn’t had enough time to develop an antibody response. Antibodies are proteins made by your immune system to attack foreign substances, such as viruses and bacteria. PCR tests can detect disease when there is only a very small amount of pathogens in your body.

STEP-WISE WORK UP at Krishna IVF Clinic :

Based on the detailed history and physical examination, a workup is done in a step-wise approach. It is important to know if nature is expelling an abnormal pregnancy or if the body is rejecting a normal pregnancy. Workup and treatment vary significantly in both these situations. Some may need a pedigree chart analysis before any further investigations. Advanced 3D-4D pelvic ultrasound of the lady is done to rule out uterine abnormalities. CASA and Sperm chromatin tests are done to diagnose malefactors. Genetic tests and infection screening tests will be done after ruling out metabolic, hormonal, or immunological causes. This sequential planning of investigations is beneficial for the couple. Treatment will depend on individual medical history, test results, and current circumstances. Time factor if any and fertility options will be discussed in detail after completing the step-wise workup.

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