Recurrent Pregnancy Loss and using IVF in the Treatment

IVF IN THE MANAGEMENT OF RECURRENT PREGNANCY LOSS
Recurrent pregnancy loss is often a complex issue as patients generally have
no difficulty initiating pregnancy but maintaining that pregnancy is a problem.
Often times patients will not have an evaluation of the pregnancy loss until
there have been several of them. This unfortunately leads to difficulty in
management when there have been several as the previous losses have
unknown cause.
The number one cause of pregnancy loss and recurrent pregnancy loss is
related to chromosomal or genetic abnormalities of the embryo. We know that
a lot of human embryos are abnormal with a condition called aneuploidy
which means an abnormal number of chromosomes. This is often readily
diagnosed at the time of miscarriage through examination of the products of
conception with D&C. Thus unless one has a D&C specifically with
assessment of the chromosomal status of the loss, one cannot prove that the
loss was indeed due to aneuploidy. Later, often in the face of further
pregnancy losses and repeated non diagnosis, one is faced with the dilemma.
Not knowing the nature of the previous losses, it is difficult to reduce the
probability of future loss in another pregnancy.
Chromosomal and genetic abnormalities cannot be “prevented” per se.
However, with in vitro fertilization one can usually obtain several eggs and
embryos from which to select multiple embryos for transfer. Thus, the
probability that one embryo is normal improves. Thus, the probability of
ongoing pregnancy is improved.
In addition to the process of IVF itself during the in vitro process one can test
the embryos for aneuploidy (again, the most common cause of future
pregnancy loss) with the process of preimplantation genetic diagnosis (PGD)
for comparative genomic hybridization (CGH). Obviously, knowing the
chromosomal status of the embryo prior to transfer in IVF one avoids putting
in abnormal embryos thus improving the probability that the “normal ones”
that were transferred will indeed implant and make a successful ongoing
pregnancy.
Thus in the face of undiagnosed recurrent pregnancy loss cases, we go about
looking at other non chromosomal/genetic causes of this condition such as:
immunologic factors, uterine factors, and clotting conditions such as
thrombophilias. This process of ruling out other conditions is simple and can
be performed rapidly and efficiently. If there are no abnormalities found,
chromosomal/genetic problems become the mostly likely cause of the
recurrent pregnancy loss by default; and one is able to consider IVF as
management with or without PGD/CGH. Unfortunately, “proving” the cause
of the prior miscarriages is difficult in retrospect. Thus, the best management
for pregnancy loss in my opinion is to diagnose every pregnancy loss with
assessment of chromosomal abnormalities at the time of D&C.
Please feel free to contact me if there are any questions or issues in regards to
this topic.