Overcoming Consecutive Miscarriages
One miscarriage can happen to any woman. But after two or three miscarriages in a row we start to wonder ‘Why’ this is happening and what can be done to prevent it from happening again. There is a long list of possible tests to do, as we investigate consecutive miscarriages. Which tests are indicated is based on the circumstances of the miscarriages, the age of the mother, as well as her total pregnancy history. We must also consider the health and reproductive history of her partner. The best thing to find is that everything is normal. This can be frustrating because there is no answer but it is optimal because the available treatments are still not as good as everything being normal.
The investigative testing is divided into different categories:
Ultrasound, saline ultrasound, hysterosalpingogram, or MRI can detect fibroids or abnormalities of the Inside shape of the uterus. Certain irregularities can get in the way of placental attachment and blood flow and cause miscarriage. We can also do surgery to look inside the uterus, and “fix” or remove things that don’t belong there.
There are RARE instances in which a piece of one chromosome is moved onto another chromosome. This translocation of information has no effect on the parent but it can be a predictable cause of consecutive miscarriages. Chromosome testing is done on a regular blood sample. Abnormal chromosomes can not be treated. But knowing the chance of miscarriage can be helpful in understanding ‘Why’, and knowing the chance of miscarriage: average chance, 25%, 50% or 100%.
Thrombophilias (abnormality of blood coagulation) and Antiphospholipid (when your immune system mistakenly attacks some of the normal proteins in your blood) Antibodies can cause abnormal blood clotting, which can lead to miscarriage. These abnormalities are more commonly found in late miscarriage (after 14 weeks), but we can test for them after multiple early miscarriages. Maternal physiology can affect some of the results, so these tests should be ordered between pregnancies.
- ACA: anticardiolipin antibody (IgG and IgM which are immunoglobulins) – More Common
- PTT and DRVVT – More Common
- Some will test for lupus anticoagulant or LAC.
- A normal PTT (partial thromboplastin time) and dRVVT (dilute Russell viper venom test) excludes LAC.
- Factor V Leiden: A gene test PCR (polymerase chain reaction) is used to determine whether you have Factor V Leiden, which is a mutation of one of the clotting factors in the blood called factor V (V stands for five) – LESS Common
- Prothrombin gene mutation (20210) – A gene test PCR is used to determine whether you have Prothrombin gene mutation, which is a genetic variant that approximately doubles or triples the risk of forming blood clots in the veins – LESS Common
- AntiThrombin III deficiency – ELISA (laboratory technique) study for enzyme activity, Antithrombin III is a protein in the blood that naturally blocks abnormal blood clots from forming– LESS Common
- Protein S activity – should not be measured until 6 weeks after miscarriage – LESS Common
- Protein C activity – should not be measured until 6 weeks after miscarriage – LESS Common
- Hyperhomocysteinemia – a medical condition characterized by an abnormally high level of homocysteine in the blood – LESS Common
- Some will test for the gene mutation called MTHFR (a gene that provides instructions for making an enzyme called methylenetetrahydrofolate reductase; enzyme that plays a role in processing amino acids).
- A normal homocysteine level excludes a problem with the MTHFR gene
Once the testing has been completed we can determine which alternative treatment options are best for you. There are a number of interventions we use to make it more likely you will have a become and stay pregnant. It will be important to discuss whether these treatment options are right for you, and why.
A better egg
Clomid and Letrozole are an available option with estrogen and/or progesterone and/or intrauterine insemination. Clomiphene and Letrozole help the body make a “better” egg. Women who do not ovulate Need Clomiphene (a non-steroidal fertility medicine that causes the pituitary gland to release hormones needed to stimulate ovulation). These medications can be used in women who do ovulate too, if we believe that the egg preparation needs help. There is a 10% chance of having twins with Clomiphene. [Twin pregnancy is “high risk” and can be much more complicated that a singleton pregnancy.] Clomiphene and Letrozole do however have side effects. We have not found an association between these medications and birth defects and/or ovarian cancer.
Progesterone is the “energy” needed by an early pregnancy to survive. The progesterone usually comes from the corpus luteum, which is the cells left over from the cyst which makes the egg. It has been postulated, but not proven, that sometimes a corpus luteum does not make enough progesterone to keep the early pregnancy going. This is called a luteal phase defect. We have not been able to prove that this luteal phase defect really exists, and we have not proven that progesterone use makes a difference. One solution to the luteal phase defect, or this potential problem, is medication. Clomiphene and letrozole help make a better egg, including a better “cyst” that prepares the egg. As a result, clomiphene should also make a better corpus luteum AND more progesterone. There is also progesterone medicine. A woman can take the progesterone, beginning when she has a positive urine pregnancy test, and continue taking the progesterone for 8 weeks. There does not appear to be any serious side effects from the progesterone.
Baby Aspirin (81 mg each day) is a mild blood thinner. The blood tests we get to evaluate miscarriage look mostly for blood clotting problems. Blood that clots too easily can cause miscarriages. A traditional approach to treating miscarriage has been the use of blood thinners to help overcome a blood clotting problem. Sometimes the aspirin is used even if the lab tests are normal. There is very little risk in using 81 mg of aspirin each day. Unfortunately, we have not been able to prove that aspirin actually makes a difference. However, because it has been used so much in the past, and because it does not seem to do much harm, some patients decide to take the aspirin anyway.
Heparin shots for blood thinning
This is usually limited to women with laboratory abnormalities. If aspirin is a mild blood thinner, than heparin is “the real thing.” The risks and complications associated with heparin shots for blood thinning can be serious. If we find abnormalities of blood clotting in the miscarriage blood tests we may have to discuss in more detail the risks and benefits of thinning your blood during pregnancy.
Blood thinning medication can prevent blood clots. Blood thinning medicines include aspirin, heparin shots, and warfarin pills. There are levels of blood thinning, too: enough to prevent a clot OR enough to dissolve a clot. There are significant risks with blood thinning, so it must be carefully considered and carefully monitored.
Advanced infertility treatments
If, after trying any of the above mentioned treatments, you are still having trouble maintaining a pregnancy then the next level of treatment may include in vitro fertilization (IVF), donor egg or donor sperm, and lastly, some couples may consider adoption…[read more]