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Question 11: Recurrent pregnancy loss

Question:
Hello Dr Edelstein,

I hope this email finds Dr well.
I really hope dr can assist as I am desperate for some advice on what to do next.

A very short history…
We don’t struggle to fall pregnant, but have miscarriages…

First pregnancy, got pregnant on first try (drank Clomid as cycles was a bit irregular (29-32 days). Saw heartbeat at 8 weeks, missed miscarriage at 12 weeks. – Did not do any tests. (baby stopped growing at 9 weeks)

Second pregnancy, fell pregnant 2nd cycle trying. At 12 weeks, NT measured 6.4mm. Did CVS and little girl was diagnosed with Trisomy 18. Had a missed miscarriage at 16 weeks. (baby stopped growing at 14 weeks).

Third pregnancy, tried to avoid and still fell pregnant… No complications during pregnancy, healthy girl born at 40.1 weeks.

Fourth pregnancy, did not try / avoid. First cycle after birth fell pregnant. Saw heartbeat at 7 weeks. Missed miscarriage at 9 weeks, baby stopped growing at 7 weeks.

My Gynae did a few tests, and all came back normal. (intra phospho lipids, TSH, Glucose, Toxoplasmosis, Cytomegalovirus, Liver, and 2 other, cant remember the names). We’ve also had karyotyping done on my husband and myself, all normal.

Is it time to go to a FS?? And also I have stumbled across a new study about hyperfertility, are you aware of this “condition” and do you know of any studies / treatment for this in SA?

Looking forward to your reply.

Answer:

Hi,

I am so sorry to read about your difficult journey to parenthood.

I do think that you should have a thorough evaluation by a fertility specialist, who can exclude anatomical, hormonal, or auto-immune causes for your pregnancy loss (or even just to review the tests that your gynaecologist has already performed).

Most 1st trimester miscarriages are due to sporadic chromosomal anomalies – as has occurred with you. This is devastating for you to live through, but the odds are in your favour in a subsequent pregnancy that the chromosomal complement will be normal (you have a greater chance of conceiving a normal pregnancy in your next, then having a miscarriage).

The only assisted reproduction option that could be offered, if all the other potential causes of recurrent pregnancy loss are excluded, is in-vitro fertilisation (IVF) with pre-implantation genetic screening. In the IVF treatment protocol, the woman is given hormonal stimulation to promote multiple egg follicles to develop & when they are deemed mature, egg collection is performed and fertilisation occurs within the IVF laboratory.  In this process, the embryo can be biopsied and sent for genetic analysis, so that only chromosomal normal embryos can be transferred back into the uterus.

I understand that the wait and see approach is extremely difficult, with each subsequent loss causing greater psychological hardship. Unfortunately, the assisted reproduction option (IVF with pre-implantaion genetic screening) is costly and may be more interventionist than required.

Wishing you all the best.

Dr Sascha Edelstein

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