Northeastern Reproductive Medicine

Vermont Fertility Services Including IVF, Egg Donation and Fertility Preservation

  • Patient Portal
  • Donor Portal
  • 1 (802) 655-8888

Schedule A Consultation
  • Home
  • About
    • About Us
    • Our Physicians
    • Meet Our Team
    • Our Facilities
      • Laboratory
      • Ultrasound
  • Services
    • Fertility Testing
    • Basic Fertility Treatment
    • Carrier Screening
    • In Vitro Fertilization (IVF)
      • Intra-Cytoplasmic Sperm Injection (ICSI)
    • Pre-Implantation Genetic Screening and Diagnosis
    • Gender Selection
    • Donor Egg IVF – Overview for Intended Parents
    • Gestational Surrogate
    • LGBTQAI+ Family Building
    • Fertility Preservation
  • Success Stories
  • Financial Info
    • Insurance Information
    • Payments
  • Patient Info
    • Unexplained Infertility
    • Fertility Preservation
    • Bloodwork Screening Protocol
    • Genetic Carrier Screening
    • Letrozole
    • Antidepressant Use in Pregnancy
    • Understanding Recurrent Pregnancy
    • Thyroid Function in Pregnancy
    • Embryo Grading and Development
    • Varicella and Immunity
    • Rubella and Immunity
    • Female Fertility Supplements
    • Male Fertility Supplements
    • Vitamin D
    • Third Party Reproduction
    • Egg Donor Options
    • Gestational Carriers FAQs
    • Cytomegalovirus FAQs
    • Traveling to Vermont
    • Canadian Patients
    • Join Our Fertiility Family
    • FAQs
  • Egg Donors
    • Overview for Intended Parents
    • Overview for Donors
    • Donor Submission Form
  • Blog
  • Contact

Reproductive Pearls: Recurrent Pregnancy Loss

Posted January 6, 2016 by Claire

Recurrent pregnancy loss (RPL) is distinct from infertility, and some confusion generally surrounds the appropriate work-up for these patients. Here, we try to provide a simple guide to help you evaluate your patients suffering from RPL.

Who to evaluate?

  • Couples who have experienced 2 or more first trimester pregnancy losses.
  • Classically, this excludes biochemical losses—evaluation is recommended for those with pregnancies reaching the 5-6th week gestation and/or recognized on ultrasound

What to evaluate?

The causes of RPL include anatomic, endocrine, autoimmune, genetic, and ovarian factors.
  1. Anatomic: 3D ultrasound and/or sonohysterogram are used to evaluate for a uterine septum, other congenital uterine anomaly, or acquired anomalies such as uterine fibroids or adhesions.
  2. Endocrine:
    1. Thyroid function should be tested with TSH and thyroid antibodies (TPO).
    2. Impaired glucose tolerance and diabetes should be ruled out with HgA1c testing in anyone who is overweight, has irregular cycles, has other risk factors, or has a strong family history of diabetes.
    3. Progesterone levels should be checked one week after ovulation to ensure adequate luteal function. (Day 21 if ovulation occurs on day 14; otherwise this should be timed one week after LH surge detected on ovulation predictor kit)
  3. Autoimmune: Anticardiolipin antibodies (ACA), lupus anticoagulant (LAC) and anti beta-2-glycoprotein (B2GP) antibodies can be detrimental to placental implantation and should be tested in all patients with RPL. The tests are repeated 6-8 weeks later if a low-level positive is detected on the first screen.
  4. Genetic: Karyotype abnormalities account for 5% of cases of RPL, and most commonly include reciprocal or Robertsonian translocations. Karyotype testing of both partners is recommended.
  5. Ovarian: The most common cause for an individual miscarriage is aneuploidy—chromosomal abnormalities caused by ovarian aging. This can be assessed with day 3 labs (FSH and estradiol), and anti-mullerian hormone (AMH) testing.

Are other tests indicated?

  • Karyotyping of the products of conception may provide useful information: if the fetus is identified as euploid (normal karyotype) this may indicate a maternal factor as listed above, whereas if it is aneuploidy (abnormal), then this is the presumed cause of the miscarriage.
    • Classic chromosome analysis requires cell culture and is limited by maternal contamination (an XX result may not represent the fetus but rather the mother).
    • Newer technologies, such as Anora Miscarriage testing are provided by Natera and involve DNA-based screening to prevent the need for cell culturing and cross-contamination.
  • Testing for thrombophilia is indicated when there is a personal or family history of thrombosis. These tests include: FVL, Protein C and Protein S deficiency, Antithrombin III deficiency and Prothrombin gene mutation testing.
  • Infectious testing has been explored (such as culturing cervical mucous for mycoplasma) but infection has not been identified as a cause of RPL.
  • Internet searches commonly emphasize other auto-immune tests and their effects on implantation; for example: natural killer cells, HLA typing, or testing for other autoantibodies or cytokines. These tests and their treatments remain investigational and are not routinely performed. Additionally, positive anti-nuclear antibodies (ANA) have not been associated with RPL.

How to counsel patients?

Patients experiencing pregnancy loss have experienced overwhelming heartbreak and anxiety. These patients need resources, reassurance, and TLC. While in many cases the reasons for RPL are not understood, overall the prognosis for success in these patients is high: 70% will experience a live birth. This includes those with an abnormality identified on evaluation and those with “unexplained” RPL.

Summary of Evaluation and Treatment

Cause Evaluation Abnormality Treatment
Anatomic 3D US, sonohysterogram Uterine septum Adhesions Fibroid/ polyp Hysteroscopic resection
Endocrine TSH, TPO TSH>2.5, +TPO Synthroid
HgA1c HgA1c>5.7% HgA1c>6.0% Metformin through first trimester Diabetes management
Luteal progesterone Progesterone <10 Progesterone 100-200mg q HS starting 3 days after ovulation Endometrin 100mg qd to BID Prometrium 200mg qHS
Auto-immune ACA, LAC, B2GP Moderate to high positive twice, 6-8 weeks apart Lovenox or Heparin Low dose ASA daily
Genetic Karyotype of both partners Translocation IVF with pre-implantation genetic diagnosis
Ovarian Day 3 FSH, Estradiol AMH FSH >10 E2 >50 AMH <1.0 IVF with pre-implantation genetic diagnosis

Filed Under: Reproductive Pearls

Recent Posts

  • NRM Partners with Ovation
  • Should you get the COVID Vaccine?
  • NRM Re-Opens May 4th
  • NRM doctors caring for patients via Telemedicine
  • Reproductive Medicine Update! NEFS Annual Meeting 2019

Categories

  • Egg Freezing
  • Fertility Clinic
  • Fertility Tips
  • Fertility Treatment Options
  • Gestational Surrogates
  • NRM News
  • Patient Education
    • Endocrine Disorders
    • Female Infertility
    • IVF and Other Advanced Reproductive Technologies
    • LGBT
    • Male Infertility
    • Natural Fertility
    • Other
    • PCOS
    • Recurrent Pregnancy Loss
  • Reproductive Pearls
  • Stories and Updates
  • Who are we?
    • Meet our doctors

Fertility Preservation Services

NRM offers freezing and storage of eggs, sperm, or embryos for individuals with a recent cancer diagnosis who desire future fertility, or those who elect to delay childbearing for other reasons.

  • Egg Freeze
  • Sperm Freeze

Referring Providers: Did you Know?

We want to work with you toward a common shared goal: maximizing reproductive health and increasing patients’ potential for successful pregnancies. We offer a set of referral services designed to help your patients take the first steps of fertility treatment Learn More.

Northeastern Reproductive Medicine

105 West View Road Suite 302
Colchester, Vermont 05446
1 (802) 655-8888

nrm-map

ASRM
Royal College
ABOG
ACOG
resolve
College of American Pathologists
Health First

  • Patient Portal
  • Donor Portal


Copyright © 2023 · Northeastern Reproductive Medicine — 105 West View Road Suite 302, Colchester, Vermont 05446