Is defined as the loss of two or more consecutive or three alternate gestations.
It is advisable to isolate and personalise each case, taking into consideration the age of the woman, previous pregnancy loss, whether she has children already, individual and family history, the anxiety of the couple and other factors.
In Segrelles IVF, we advise a study by protocols, reviewed every 6 months. The important thing is the avoidance of repeating the psycho-emotionally moving situation of changing from the joy of achieving pregnancy, to anxiety, sadness and desolation of losing the baby. It is assumed that in depth knowledge of reproductive endocrinology and both theoretical and practical experience are required in order to take charge of the situation and use both evidence based medicine as well as intuition to take appropriate measures.
Every such case is important and whilst we recognise each patient lives theirs, we physicians at Segrelles IVF have lived hundreds of similar cases.
When it comes to investigating the alleged causes of Recurrent Miscarriage, which can differ between demonstrable, probable or unprovable, my opinion is not to belittle any of them.
The experience gained by the large number of cases treated successfully, has taught us that some causes that seemed unimportant, once corrected, can lead to achieving full term pregnancy.
Sometimes the causes can be multiple.
- Genetic: we always advise the genetic study of both members of the couple, although we only find structural alterations in 5% of cases. This low percentage of anomalies contrasts with the high incidence of chromosomal abnormalities in embryos, in 50% of first trimester abortions. It is due to random errors that occur in the meiosis of gametes, the most frequent trisomy. Hence in predetermined cases we advise and would carry out Preimplantation Genetic Diagnosis (PGD), in order to transfer only healthy embryos.
- Anatomic: account for between 10-20% of cases. The availability of the most advanced equipment in the ultrasound diagnosis, 3D and 4D ultrasound, endoscopic techniques and a very experienced medical-surgical team, provides us the facility to detect and treat of such anomalies. Special attention is given to cervical incompetence or the inability to maintain a pregnancy because at some point the cervix dilates in place of contractions. In this case, an early ultrasound diagnosis and treatment (cerclage by Palmer), avoiding miscarriage. Also noteworthy are the changes acquired in uterus related to recurrent miscarriage due to adhesions after aggressive scrapes, which may hinder the subsequent attainment of a pregnancy or encourage further miscarriage. It is important to always take care of the uterus, and where a scrape is recommended for emptying of the cavity, less aggressive methods such as aspiration with smooth canulas, plastics without sharp edges, connected to a vacuum system are recommended, thereby reducing the maximum number of these complications. It is important to know the aspiration method well and have extensive experience in this type of intervention.
- Endocrinologists: endocrinopathies are associated with 15-20%, the most common are thyroid dysfunction and diabetic disease.
- Infectious: it is estimated that these contribute to 5% of cases. Any severe infection can cause sporadic miscarriage however those that persist in the genital tract can contribute to multiple recurring miscarriages.
- Autoimmunity: antiphospholipid syndrome consists of the association of antiphospholipid antibodies, thrombosis or thrombocytopenia. They usually cause arterial and venous thrombogenic effect or a hormonal imbalance between production and poor trophoblast invasion, so often cause miscarriage after the 10th week of gestation.
- Alloimmunity: the most prominent hypothesis is the partner immuno dystrophy where inappropriate immunostimulation in the mother, leads to excessive production of certain cytokines, with adverse effects on the embryo.
- Systemic diseases: are associated to 5% of cases. They have been linked with the following factors: heavy metal toxicity, hyperthermia, drugs, organic solvents, addictions to alcohol, tobacco and coffee, although the minimum levels for the last three factors are not defined.
- Male factor: certain seminal alterations may predispose recurrent miscarriages, such as oligospermia or teratospermia.
- Psychogenic: the successive loss of pregnancies leads to stress, and this is associated with an imbalance in the regulation of cortisol and catecholamine, which can cause the reduction of oxygen supply to the foetus, hence the importance of adequate psychological support.
- Thrombophilia: are characterized by an imbalance between the coagulation system and fibrinolysis, the latter being most common.
In Segrelles IVF, we pay special attention to these factors, because in our opinion, they are underestimated. Sometimes a patient does not have a disease, just an alteration affecting the mother and child. Each couple is a unique case and each factor can influence quite differently in one or the other, so that treatment is always customised. The study should be complete to provide all the necessary information in order to conclude with a correct diagnosis. Unlike Segrelles IVF, not all centres can count on over 35 years’ experience in treating these cases.
- Unknown causes: once all of the above causes have been discounted, there are approximately 30% of cases who face recurrent miscarriages of alleged unknown causes that many authors include in unidentified immune factors.
We recommend that all couples facing this particular situation to come to our clinic, since we have extensive experience in such cases and appropriate physical and human resources that allow us to reach the correct diagnosis and treatment.
In Segrelles IVF no treatment will be commenced until the complete study is concluded and during this time we strongly advice contraceptive measures be taken so as to avoid the potential devastation of a failed gestation.
A complete and thorough pre-conception physical evaluation should take place, regardless so as to arrive at a true diagnosis and correct course of treatment.
In Segrelles IVF these studies have been notarised.
Once a study is concluded, we are able to arrive at a personalised treatment in each case. Once pregnancy is achieved, with proper treatment, it is important to monitor the patient.
Patients should be considered high-risk pregnancy.
The role of high-resolution ultrasound is very important for the assessment during the course of the pregnancy and early detection of embryonic anomalies.