The Infertility-->Fertility Team at
Also serving Cortez, Pagosa Springs, Telluride and Farmington, NM
Expert Diagnosis and Treatment Starts Here
MISCARRIAGE (RECURRENT PREGNANCY LOSS – RPL)
Losing a baby, no matter how early in pregnancy, can be a heartbreaking experience. When a pregnancy is planned and desired in particular, this unexpected event can be difficult to bear and hard to understand. Miscarriage is common, however, and most of the time it is due to random and completely unpreventable genetic/chromosomal abnormalities. Studies have shown that as many as one-third of all pregnancies are lost, usually early in the first trimester (initial 12 weeks). And many of these very early losses are not even detected or noticed as a miscarriage. When miscarriage is repetitive it is called Recurrent Pregnancy Loss or RPL, and testing and treatment to prevent a third or fourth miscarriage may be possible. Although 70 - 75% of all miscarriages are thought to be due to random genetic defects, the remaining miscarriages may be due to detectable and potentially treatable causes. Any woman who has had two or more consecutive miscarriages is more likely to have a preventable cause for the miscarriages.
About 5% or less of miscarriages may be caused by a detectable chromosomal abnormality in the cells of one or both of the parents. Although the parents are perfectly normal, a balanced translocation (displaced piece of a chromosome) may be detected on a blood test called a karyotype. This otherwise harmless defect can cause miscarriage in some pregnancies and not in others. Couples will usually report a combination of normal pregnancies and births along with miscarriages. Other than undergoing the expensive process of in Vitro fertilization (test-tube baby procedure) combined with pre-implantation genetic testing, there is no known way to attempt to prevent all miscarriages in parents that are known to have this abnormality. And even this treatment is not totally effective. The testing for this defect can cost $1000.00 to $1500.00 without any assurances that insurance will pay for the testing. Unless a couple would use this information to prevent further pregnancy or to undergo pre-implantation diagnosis, we are currently not recommending that this testing be performed.
Potentially Preventable Miscarriage:
About 20 to 25% of all miscarriages may result from causes that can be treated very early in subsequent pregnancies. These potentially preventable causes include abnormalities of the uterine cavity, hormone deficiencies, such as inadequate progesterone or androgen production inside the egg follicle, and harmful antibodies that can be detected in a woman’s serum (antiphospholipid antibodies). Very recent research is also showing that some miscarriages may be due to sperm defects (disruption of the DNA within sperm). It is too early to be certain about the validity of this last possible cause and there is no easy or proven treatment for this defect. In view of this recent finding, however, it may be possible to improve sperm quality naturally and prevent some miscarriages by making better nutrition and behavioral choices. The website, lifechoicesandfertility.com, provides suggestions for both men and women to help with fertility and possibly lower the likelihood of miscarriage.
Some early miscarriages may be caused by abnormalities inside of the uterine cavity near the area where the embryo (developing baby) needs to implant. These abnormalities can include polyps (small, usually non-cancerous, growths) inside of the cavity, scarring of the lining or small muscle tumors called fibroids that can interfere with implantation. A regular vaginal ultrasound or one performed after a small amount of fluid is injected into the uterus (saline sono-hysterogram) may be suggested to determine whether this is a likely problem. An additional surgery may be needed to correct these problems if they are detected. If a normal hysterosalpingogram (HSG) or hysteroscopy has been performed and reported, the saline hysterogram is usually not needed.
Progesterone is an essential hormone for normal pregnancy. It’s name comes from the knowledge that it Promotes Gestation or pregnancy and some miscarriages may be due to an inadequate amount of progesterone. This potential cause of miscarriage is still controversial, however, and there is some disagreement in the medical community about whether supplementation with additional progesterone is effective and, if it is, when the progesterone should be started and how it should be given. We believe that extra progesterone may be helpful but that if it is to work it should be started a few days after ovulation in the second half of a menstrual cycle when pregnancy is being attempted. This requires some monitoring of cycles in which pregnancy is wanted so that the hormone can be added shortly after ovulation. We further believe that progesterone is only reliably absorbed when it is given by needle injection or inserted into the vagina as a gel or suppository. Oral ingestion of micronized progesterone and topical (skin) application are not known to be consistently reliable. There is another way to improve progesterone level, however, and that is to use one of several medications that are known to promote healthier ovulation and the formation of the corpus luteum cyst, which naturally provides progesterone during the first 12 weeks of pregnancy. Ovulation induction has been shown to improve corpus luteum function and progesterone production.
Recently, particularly in women over 35, it has been shown that the follicular fluid that bathes the egg before ovulation, may be deficient in androgen (male hormone) and that this deficiency may result in less healthy eggs at the time of ovulation. Although there is currently no direct proof that this could affect the likelihood of subsequent miscarriage, we believe that using medication early in a cycle where pregnancy is desired is a reasonable treatment for women who have had at least two previous miscarriages.
Treatment of women with RPL for either or both of these possible hormonal causes of miscarriage requires very early monitoring with ultrasound in cycles where pregnancy is desired and will be attempted.
There are two types of antibodies that may be detected in a woman’s serum that could be a cause or causes of miscarriage. The two are known as anticardiolipin and lupus anticoagulant. The syndrome is known as antiphopholipid syndrome and it is thought to be the cause of 3 to 15% of early miscarriage. These antibodies can cause problems with coagulation (clotting) of blood and may result in early fetal death and miscarriage. It is recommended that these tests be repeated twice about 6 weeks apart and that full treatment (low dose aspirin and long-acting heparin) be initiated ONLY if both tests are positive. Treatment with low dose (81mg) aspirin can be initiated for RPL even if testing for antiphopholipid syndrome is negative and should be discontinued at about 34 weeks of pregnancy. Low dose aspirin has been shown to improve implantation in some pregnancies and it has less side effects and complications than heparin.
There is NO KNOWN benefit in terms of RPL from testing or treating for antinuclear antibodies, antithyroid antibodies, maternal antipaternal antibodies or antibodies to infectious agents. And there is NO KNOWN benefit for RPL with treatment with leukocyte immunization or intravenous immunoglobulin (IVIG).
Thrombophilias (inherited disorders that may increase a woman’s risk of serious blood clots) may increase the risk of fetal death in the second half of pregnancy but there is NO KNOWN benefit in the first half of pregnancy.
Other Unproven Tests and Treatments:
Routine testing (such as cultures) for bacteria and viruses, as well as routine testing for insulin resistance and embryotoxic factors have not been shown to improve the outcomes in women with recurrent miscarriages. We do not recommend routine screening for infection unless there are symptoms.
Routine Tests that May be of Value:
Women who have had two or more early pregnancy losses (RPL as defined by the American Society for Reproductive Medicine-ASRM), should be screened for thyroid dysfunction with TSH, diabetes if Body Mass Index (BMI) or history justifies, serum prolactin and antiphospholipid antibodies (anticardiolipin and lupus anticoagulant) at least once and repeated in 6 weeks if positive when the addition of heparin is being considered. Any other testing should be justified by additional history or physical findings.
Diagnostic Workup and Treatment/Monitoring:
After appropriate diagnostic testing, treatment with low dose aspirin and possibly heparin may be effective. Recent evidence also suggests that increasing androgens (male hormone levels) in some women may benefit oocyte (egg) function. Several other supplements, in addition to progesterone, may be of benefit too. Contact us for more details about treatment and monitoring for recurrent pregnancy loss (repeated miscarriages).
Insurance Coverage for RPL:
Insurance coverage for infertility-->fertility treatment is usually not provided unless it is specifically stated in the policy. RPL, however, according to the American Society for Reproductive Medicine (ASRM) is a diagnosis distinct from infertility and we can legitimately bill accordingly. This may provide partial or complete coverage for the care. However, women who are treated for RPL will have to be responsible for paying all charges that are not reimbursed by insurance.
Will the Treatment Always Work?:
We believe that the appropriate treatment and monitoring based upon diagnostic testing outlined above can be effective for those miscarriages (about 25%) that are not due to random genetic or chromosomal defects in the embryo. If the fetus is normal we believe that there is sufficient evidence to support the use of our treatment protocol. Our protocol or any protocol is not likely to work when the fetus is abnormal due to a random genetic event. There is no evidence that treating as outlined above will cause an abnormal pregnancy to continue to any greater extent than would happen without any treatment.
Call 970-382-9505 or email Karen Zempel today to schedule a consultation with Dr. Gambone.
P: 970-382-9505 F: 970-382-9558
1199 Main Avenue - Suite 218, Durango, CO 81301
Located in the Bank of Colorado Building