Recurrent Pregnancy Loss (part 3 - treatment) To briefly recap my previous blogs – recurrent pregnancy loss (RPL) is a frustrating disorder. It may be due to chance/ age related changes alone, and all too often there is not a good answer as to why it has occurred. If a diagnosis is made, then the treatments follow from the diagnosis; following my outline from the previous blog: 1. If there are anatomic abnormalities, those can usually be corrected. Uterine septums, intrauterine polys/fibroids, and intrauterine adhesions (sometimes called synechiae or Asherman’s syndrome) can be treated with hysteroscopy. Hysteroscopy is a minor surgery that involves putting a “scope” through the cervix and into the uterus. The allows the inside of the uterus to be directly visualized and the problem can be corrected. Some uterine anomalies, most notably a bicornuate uterus, are not readily correctable. Sometimes the damage from scarring or fibroids can be so severe that the uterus cannot be completely restored. 2. Genetic causes. If it turns out that one partner is a carrier of a genetic translocation, IVF with genetic diagnosis before embryo transfer can be done to ensure that the embryo that is transferred is genetically normal. Or, the couple may elect to use donor sperm or donor egg. 3. Antiphospholipid syndrome. This is usually treated with bood thinners, often a daily injection and low dose aspirin. What about other diagnoses? There are many other evaluations that are touted for recurrent pregnancy loss. For example, until recently, an extensive panel of blood tests evaluating for blood clotting problems (thrombophilias) was widely performed. However, recent studies have shown that the treatments for these disorders are not decreasing pregnancy loss rates, so this testing, although occasionally useful, is no longer routine, and not recommended by the American College of OB/GYN. There are other more esoteric tests and treatments that are touted by some, including immunologic evaluations, “natural killer” cell testing, treatment with IVIG (intravenous immunoglobulin). These are not widely accepted and have not been proven to be helpful. In the absence of good data, I do not recommend them as they carry risk and expense with likely no benefit. But what if there is no clear diagnosis? Often the evaluation for recurrent pregnancy loss ends with no definitive explanation. The good new is, that many of these patients go on to have a normal pregnancy, likely their prior losses were due to bad luck. One relatively easy and harmless intervention that I do for my patients, and has been proven to be of benefit is the “TLC protocol”. This involves early follow up with weekly ultrasounds until the pregnancy has progressed beyond the point where prior pregnancies miscarried. Most likely the regular reassurance serves to decrease anxiety/stress which may be affecting the pregnancy. I was a skeptic at first but several good studies have shown evidence of efficacy, therefore as a relatively painless and risk free intervention, it makes a lot of sense. What about patients that continue to have losses despite normal testing and close follow up? This is rare, but always a tough situation. At times we will consider empiric treatment with a blood thinner, but this is not risk free so the risks/benefits have to be carefully weighed. It may make sense to do IVF and evaluate the chromosomes of the embryos to see if this is the problem. In some cases patients turn to gestational carriers to try to improve success. In conclusion, if you have suffered through RPL, you are not alone! It is much more common than most people appreciate. Fortunately the vast majority of patients do go on to have a healthy baby. There are good tests and treatments that can be done; but not all patients need elaborate or expensive treatments. There is always hope and there are many ways to reach a healthy child, it is just important to take it step by step and make sure that both the testing and interventions are rational. Good luck! Dr. Payson
Posted on: Tue, 29 Apr 2014 02:25:40 +0000
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