Diagnosis and management of recurrent pregnancy loss: Fellowship in Reproductive Medicine

 

Any sign of pregnancy rings bells for couples who are keen to start or expand their family. While the couple themselves are celebrating their joy of exploring parenthood, the other family members join the couple in their journey of becoming new parents by providing them with all the needed guidance, emotional and moral support. They ensure that the couple is not alone for the next 9 months and the whole family is involved with making space for the new child to come into this world.

However, unfortunately sometimes, this excitement turns into disappointment when there is a sudden loss of pregnancy due to unknown reasons and this affects the family as a whole, and not just the woman or the man. But naturally, a woman tends to be more emotionally attached to the unborn child, since she has borne the pregnancy right from the day of conception.

This commonly occurs in 15-20% of all pregnancies, usually within 13 weeks of gestation. For some couples, there is always good news and a fairly full-term pregnancy, followed by an unexplained miscarriage. But when a woman has repeated miscarriages consecutively in 3 or more pregnancies, it is termed as Recurrent Pregnancy Loss (RPL) and is a serious condition that needs immediate attention.  Although it is a natural process, it is very crucial to understand the causes in order to:

ü  Develop effective management strategies,  

ü  Improve pregnancy outcomes,

ü  Ensure that the woman completes a full-term successful pregnancy.

Causes of Recurrent Pregnancy Loss

RPL can be attributed to a variety of factors, often multifactorial in nature.

The main causes include:

1.     Genetic Factors

o   Chromosomal abnormalities in either the mother or the father can lead to miscarriages. However, it has been estimated that approximately 2-5% of couples with RPL have a balanced chromosomal translocation.

2.     Anatomical Factors

o   Problems related to the uterus, such as septate uterus, uterine fibroids, or intrauterine adhesions can interfere with implantation and can hinder the chances of having a successful pregnancy.

3.     Endocrine Factors

o   Hormonal imbalances, including thyroid dysfunction, polycystic ovary syndrome (PCOS), and uncontrolled diabetes may not be directly linked to this condition but can contribute to RPL, if they are not diagnosed and managed on time.

4.     Immunological Factors

o   Autoimmune conditions, such as antiphospholipid syndrome (APS), can cause blood clots, impairing the functioning of the placenta, thereby leading to a miscarriage.

5.     Infectious Factors

o   Chronic infections of the reproductive tract are not commonly identified as one of the main causes but may be associated with RPL.

6.     Lifestyle Factors

o   Smoking, excessive alcohol consumption, and obesity have been directly linked to increase the risk of miscarriage.

Diagnostic Approach

Diagnosing RPL involves a comprehensive evaluation to identify underlying causes. The diagnostic workup typically includes:

1.     Medical History and Physical Examination

o   Detailed history of previous pregnancies, menstrual cycle, and overall health.

o   Physical examination to detect anatomical abnormalities.

2.     Genetic Testing

o   Karyotyping of both partners.

o   Testing of fetal tissue from miscarriages for chromosomal abnormalities.

3.     Imaging Studies

o   Ultrasound, hysterosalpingography, or MRI to identify uterine anomalies.

4.     Hormonal Assessment

o   Blood tests to evaluate thyroid function, glucose levels, and reproductive hormones.

5.     Immunological Testing

o   Screening for antiphospholipid antibodies and other autoimmune markers.

6.     Infection Screening

o   Testing for chronic infections that could impact pregnancy

Management Strategies

Management of RPL is tailored to the identified causes and often involves a multidisciplinary approach that involves intervention by obstetricians, geneticists, endocrinologists, and reproductive specialists. Key management strategies include:

1.     Genetic Counselling and Interventions

o   Genetic counselling for couples with chromosomal abnormalities.

o   Preimplantation genetic diagnosis (PGD) with IVF to select embryos without genetic defects.

2.     Surgical Interventions

o   Surgical correction of uterine anomalies such as septate uterus or removal of fibroids.

3.     Hormonal Treatments

o   Thyroid hormone replacement or treatment of other endocrine disorders.

o   Progesterone supplementation in the first trimester to support early pregnancy.

4.     Immunological Therapies

o   Anticoagulation therapy (e.g., aspirin, heparin) for women with APS.

o   Immunotherapy in cases of other immune-mediated conditions.

5.     Lifestyle Modifications

o   Smoking cessation, reducing alcohol intake, and achieving a healthy weight.

o   Stress management and psychological support.

6.     Infection Management

o   Antibiotic treatment for identified infections.

Supportive Care and Follow-Up

Providing emotional support and counselling is essential for couples experiencing RPL. Ongoing follow-up care includes:

• Regular prenatal visits and monitoring in subsequent pregnancies.
• Psychological support or counselling to address the emotional impact of RPL.
• Educating couples about lifestyle modifications and healthy pregnancy practices.

Recurrent miscarriage is a complex, multifaceted condition which required a thorough diagnostic evaluation and individualized approach to manage the condition, based on the causes ruled out through diagnosis. In today’s age, we are equipped with the latest advances in genetic testing, surgical techniques, and immunological therapies to improve outcomes for many couples facing RPL. Comprehensive care, including emotional support and follow-up, will always remain the most essential aspect of treatment, to help couples navigate this challenging condition and achieve successful pregnancies. If you are interested to learn more about the topic, enrol for our next batch of Fellowship in Reproductive Medicine.

Under the guidance of Padma Shri Dr. Kamini Rao, we now have hundreds and thousands of IVF consultants who have not only established their own IVF centres after completing their IVF Fellowship in India, and have followed her legacy in terms of following ethical treatment protocols and conducting effective patient counselling with an empathetic approach, and thereby improving the chances of a successful pregnancy for thousands of couples worldwide. As clinicians in the field of reproductive medicine and IVF fellowship in India, there is no student who has never read her books or articles or attended her seminars/webinars till date. Being a Chairperson of Medline Academics, she has immensely contributed to the success of Medline Academics, right from conception to implementation. Her ideas and her approach towards her students will continue to inspire all her students. If you’re dreaming to make it big, Dr. Kamini Rao’s Medline Academics is indeed the right place to lay the foundation for your future goals of setting up your own IVF center.