Recurrent Pregnancy Loss (RPL)

Recurrent Pregnancy Loss (RPL) is diagnosed after having two or more clinical pregnancy losses. It is important to note that RPL is based on clinical pregnancy (a pregnancy seen by an ultrasound) and not chemical pregnancy (a pregnancy detected by a pregnancy test.) It is also called recurrent miscarriage.[1] 1-2% of women suffer from RPL.[2]

RPL is usually caused by chromosomal or genetic abnormalities. The problem can come from the egg, the sperm, or the embryo itself. Maternal age can also be a problem, as increased age has an increased risk of miscarriage. Additionally, issues in the womb, such as inflammation, poor blood supply, or an irregularly shaped uterus, can lead to a loss. Further, the immune system and hormonal abnormalities may play a role in RPL.[3]

RPL Testing

Karyotyping

Karyotyping is a genetic test that maps the chromosomes and is used to diagnose balanced translation – a disorder in which one section of a chromosome switches with another section. Balanced translation can (but not always) cause special needs, health problems in babies, or recurrent miscarriage.[4] The chance of either parent having a balanced translocation is 4%.[5]

Endometrial biopsy

A sample of endometrial tissue will be tested to determine if the uterus is developed enough for an embryo.

Blood Tests

Bloodwork can be done to see the levels of hormones such as estrogen, progesterone, or prolactin.

Antibody Tests

Bloodwork can also be done to detect immune system abnormalities.

There has been evidence to link Lupus anticoagulant (LA) with late term RPL, and Anticardiolipin lgG antibodies (ACA) have been shown to be associated with early RPL. Screening for these antibodies after RPL is recommended for women with more than two losses.Additionally, screening for thyroid stimulating hormone (TSH) and thyroid peroxdise antibodies (TPO-Ab) is recommended as these antibodies have been found to have a correlation to subfertility and RPL.[6]

Treatment for RPL

There are several different methods of treatment for RPL depending on the circumstances.

RPL due to Karyotyping

For those with an abnormality found by karyotyping, genetic counseling is recommended. A genetic counselor can explain what the abnormality is and discuss likelihood of pregnancy in the future. In vitro fertilization (IVF) with pre-implantation genetic diagnosis (PGD) is also an option. With PGD, created embryos can be screened for genetic abnormalities before being transferred into the uterus for the best chance at a genetically normal embryo.[7] For more information on IVF or PGD, please visit the respective pages in the menu above.

RPL due to antibodies

For those with antibody issues, blood thinning medications are suggested. Low dose aspirin (75-100 mg/day) and the shot Heparin have been observed to help retain pregnancies.[8]

RPL due to uterine issues

For those with endometrial or uterine issues, evaluation of the issue and treatment with surgery may be recommended.

RPL due to thyroid issues

For those with thyroid issues, levothyroxine, also called synthroid, has been shown to help. Levothyroxine is a manufactured form of thyroxine, the thyroid hormone. This treatment can be used before or during early gestation.[9]

Unfortunately, 50% of RPL cases are unexplained and muse be discussed with your doctor for the best treatment options.[10]

[1] “Recurrent Miscarriage.” n.d. Shady Grove Fertility Blog. Accessed April 27, 2018. https://www.shadygrovefertility.com/diagnosing-infertility/infertility-causes/female-infertility-causes/recurrent-miscarriage.

[2] Ford, Holly B, and Danny J Schust. 2009. “Recurrent Pregnancy Loss: Etiology, Diagnosis, and Therapy.” Reviews in Obstetrics & Gynecology 2 (2). MedReviews, LLC: 76–83. http://www.ncbi.nlm.nih.gov/pubmed/19609401.

[3] Affiliated Physicians. n.d. “Recurrent Pregnancy Loss.” UCLA Health Blog. Accessed April 27, 2018. http://obgyn.ucla.edu/recurrent-pregnancy-loss.

[4] “Balanced Translocation.” 2014. Rare Chromosome Disorder Support Group Flyer. https://www.rarechromo.org/media/information/Other/Balanced translocations FTNP.pdf.

[5] Washington University Physicians. n.d. “Recurrent Pregnancy Loss.” Fertility & Reproductive Medicine Center. Accessed April 28, 2018. https://fertility.wustl.edu/getting-started-infertility/multiple-miscarriages/.

[6] ESHRE Early Pregnancy Guideline Development Group. 2017. “RECURRENT PREGNANCY LOSS.” European Society of Human Reproduction and Embryology, 1–61. ESHRE RPL Guideline_28112017_FINAL.pdf.

[7] Assisted Physicians.

[8] ESHRE, 13.

[9] ESHRE, 102.

[10] Assisted Physicians.