Last month, my article focused on micronutrients, what our current best evidence has to say on a few of them and their impact on fertility. This was information I learned from one of the Western Medical docs who spoke at this years Integrative Fertility Symposium (IFS). This month, I want to share information from another Western Medical doctor, Lora Shahine, MD, FACO. She practices at Pacific NW Fertility and IVF Specialists in Seattle, WA where she focuses on treating women suffering from recurrent pregnancy loss (RPL).
RPL is a topic I have addressed from several different angles in my newsletter and blog. Due in no small part to the pain I have seen it cause patients of mine, but also because in my opinion, many providers are not proactive enough in their approach to helping patients suffering from RPL. While it is true there are many things about RPL that we do not yet understand, in fact, 50% of patients who go through all the appropriate tests will still end up in the “unexplained” category, but on the flip side, that also means that 50% of patients may avoid another heartbreak by receiving treatment for their diagnosis. Dr. Shahine walked us through the current best practices for RPL care.
I want to share with you some of her key points so that you can have a better understanding of what type of care is appropriate if you are faced with RPL. We will also look at some really hopeful statistics even once you have found yourself in the unfortunate camp of women dealing with RPL, including this happy tidbit: “Most women with RPL WILL go on to have a baby with or without treatment!”
Probably the most important place to start is here – the American Society of Reproductive Medicine (ASRM) changed their recommendations in 2013, recommending providers start looking for an underlying cause of miscarriage after a patient has suffered from 2 miscarriages. Previously, the recommendation was to wait until after 3 miscarriages had occurred. I will admit that, although this recommendation was changed years ago, this was actually news to me. It was news to me because I know of only one OBGYN in the Twin Cities who is not making patients wait until after 3 miscarriages! So, apparently I am not alone in my ignorance. If your provider is making you wait, please let them know the largest group of reproductive medicine specialists in our country disagrees with them, and find a new provider! This recommendation wasn’t just changed because asking a woman to suffer 3 miscarriages before intervention seems cruel, but because the current best evidence shows that it actually makes a difference, and can prevent that third miscarriage altogether.
Another topic that I will also admit was new to me was this . . . there is no evidence that a “chemical pregnancy,” a conception, which has measurable HCG but does not develop far enough to be seen on an ultrasound, should be treated any differently than what we traditionally think of as a miscarriage, which is the loss of a “clinically” recognized pregnancy, one documented by ultrasound or histopathologic examination. This means that even if your pregnancies have ended within a few days or hours of that positive test, you should still be evaluated for known causes of RPL after two of them.
OK, so here are the tests you should be expecting from your provider (these are not listed in order of importance, they are all important!):
First, an evaluation of your uterine cavity should be done to rule out congenital anomalies such as septum or uterine fibroids. These are physical issues of or in the uterus that can prevent implantation or progression of an otherwise healthy pregnancy.
Second, is what is known as parental karyotypes. This is looking for a very rare condition known as balanced translocations, which is found in about 5% of couples that have suffered 3 or more miscarriages. With a balanced translocation you are genetically normal, but your gametes, or at least 30-50% of them (I’m talking about sperm or egg) are not “normal.” These couples can absolutely conceive a genetically normal child, but they may suffer many miscarriages along the way. It is also possible that they could conceive a child who would be born with genetic differences. This could be valuable information for decisions related to prenatal screening.
Third, is testing for antiphospholipid syndrome, which is found in 10-20% of women with RPL. It is basically the presence of antibodies that shouldn’t be there, which cause blood flow issues. Blood flow issues can have consequences throughout pregnancy, and at implantation, which can cause miscarriage. There are very specific guidelines to diagnosing this syndrome. Another piece of important information I want to get out there in regards to this syndrome is this – patients with a single loss of a pregnancy over 10 weeks (this is when blood flow from placenta is established) need to be screened for antiphospholipid syndrome. Any patient with placental insufficiencies in previous pregnancies also needs to be screened. And of course anyone who has suffered 2 miscarriages. How will you know if you have been screened properly? Here is a list of the test that should be done: Lupus anticoagulant (aPTT and dilute Russell’s viper venom time), Anticardiolipin IgG and IgM antibodies, Anti-B2-glycoprotein IgG and IgM antibodies. Testing needs to occur more than 6 weeks after a pregnancy has resolved.
Fourth, is testing for thyroid dysfunction. In the first 13 weeks of pregnancy, your fetus is dependent on your thyroid, which has to work 30% harder in early pregnancy, which is why the range for thyroid health in women trying to conceive is different than it is for those who are not. The goal is to have a TSH below 2.5. Dr. Shahine tests before and in early pregnancy. It can take 4-6 weeks for medication to start working.
Fifth, is testing for elevated prolactin levels known to affect implantation and the luteal phase. Again, if this is found, just as the rest of this list, there is treatment for it.
Last, screening for diabetes/insulin resistance with a Hemoglobin A1c.
After all of this, as mentioned above, 50% of patients will have no answer. Dr. Shahine believes anueploidy (chromosomal abnormality) is the likely cause for these undiagnosed couples. IVF with chromosomal screening is an option for these couples, but so is continuing to try naturally. Neither is right or wrong, and there is still a lot of hope for these couples with unexplained RPL.
For those who choose to pursue IVF with chromosomal screening, if a euploid (chromosomally normal) embryo is found for transfer they have a very similar rate of live birth as women who have never suffered a miscarriage. And, for couples who choose to keep trying naturally, it is important to remember that even after 5 consecutive miscarriages your chances for having a live-birth with your very next pregnancy are still high. For a woman in her 20’s they are as high as 85%, for women between 35-40 there is still a 60% chance for a live birth after 5 losses, and this is with no treatment at all!
Dr. Shahine also mentioned studies I have written on in a previous blog post (Recurrent Miscarriages and Acupuncture), illustrating that women who receive regular compassionate care in early pregnancy through the first trimester (such as in an acupuncture clinic) lower their risk of miscarriage.
I hope this information will empower you to get the diagnosis and treatment you deserve if you are suffering from RPL. I hope it also gives you hope to know that even when a treatable diagnosis is not found, it is still more likely than not that this challenging journey will end in the family of your dreams!