RECURRENT PREGNANCY LOSS (RPL)– Patient Information

1. What is recurrent pregnancy loss? 

• A pregnancy loss is the spontaneous loss of a pregnancy before 24 weeks of pregnancy. If it occurs two or more times it is called recurrent pregnancy loss (RPL)
• Primary RPL is that which occurs in women who do not have previous childbirth while secondary RPL occurs in a woman who has had one or more babies before.
• Almost 15% percent of all pregnancies end in a miscarriage. RPL occurs in 1-2% of women.

2. What tests are to be done for RPL and treatments? 

• Tests will be advised to determine the cause of RPL. Not all causes have treatment though. In the majority of couples with RPL, there is no identifiable cause and this is called unexplained RPL. 
• It is important to inform the doctor if you have blood clotting disorders, diabetes, thyroid disorders, PCOS, or birth defects/genetic diseases in family members. 

Antiphospholipid antibody syndrome 

• This is a condition where there is an increased tendency for the blood to clot. Women with this condition have antibodies called – lupus anticoagulant or anticardiolipin antibodies in their blood. This predisposes to RPL as it interferes with the blood supply to the growing baby during pregnancy. 
• If this condition is diagnosed, we will start the woman on low dose aspirin prior to conception and also a blood thinner called heparin with a positive pregnancy test. 

Thyroid tests and thyroid antibodies

• Abnormal thyroid function is associated with RPL and if present, we administer levothyroxine as treatment.

An ultrasound scan of the uterus 

• This is to ensure that the cavity of the uterus is smooth and normal. Usually, a 3D
• The scan is advised. Some abnormalities like a septum (division by a fibrous band) within the uterine cavity may need correction. Other abnormalities that may be present are submucosal fibroids (fibroids which project into the uterine cavity) and polyps (benign small growths inside the uterine cavity) and may need correction. 

Genetic testing 

• Some couples facing RPL have an abnormal chromosome number. These are usually balanced translocations- which do not cause a problem in the parent but may cause an abnormal number and structure of chromosomes in the baby leading to RPL. The chance of this being a cause is small (3-5%). Both partners may be advised karyotyping especially if there is a suggestive family history. 
• If there is an abnormality, genetic counseling will be advised. 
• It is possible to perform IVF and test the embryos by a process called pre-implantation genetic testing (embryo biopsy) such that chromosomally normal embryos can be identified for transfer. Your doctor will discuss this with you in detail if it is applicable. 

ANA/ Beta 2 Glycoprotein 1 – IgG and IgM

• These are tests to check if you have certain autoimmune diseases. 

Sperm DNA fragmentation

• Sperm which has broken or fragmented DNA are more likely to cause RPL. This test is not advised routinely. 
• If the sperm have a high DNA fragmentation index- you will be advised lifestyle modification and antioxidants.

PCOS 

• If you have PCOS and RPL, you will be advised lifestyle modification and weight loss if you are overweight. You may be advised a tablet called metformin increases your chance of having a live birth. 

Ovarian reserve tests

• These tests help us determine the number of follicles remaining in your ovaries. 
• The tests we use are a transvaginal scan which can tell us the number of follicles present in both ovaries and also a blood test to estimate the level of AMH (antimullerian hormone). 
• There is evidence to say that unexplained RPL may be associated with diminished egg numbers. 

3. What are the general measures advisable to decrease RPL?

• Smoking and excessive alcohol have a negative effect on a successful pregnancy. 
• Weight – it is important to lose or gain weight to maintain an ideal BMI 
• If you are vitamin D deficient, you will be advised vitamin D supplements 
• Stress is associated with RPL but there is no evidence to say that it causes it. 
• Ensure that you are taking folic acid 

4. What is unexplained RPL?

• When all tests are normal, it is called unexplained RPL. Here, there is no targeted treatment available. More than 50% of couples with RPL have no detectable reason. 
• Depending on the duration of trying, the woman’s age, and the number of prior pregnancy losses – your doctor will discuss your chance of having a successful pregnancy outcome. 
• Based on this a management plan will be suggested.