recurrent loss 2009

Recurrent Pregnancy LossRecurrent Pregnancy Loss

Mark Perloe, M.D.Mark Perloe, M.D.Georgia Reproductive SpecialistsGeorgia Reproductive Specialists

Atlanta, GeorgiaAtlanta, Georgia

Learning ObjectivesLearning Objectives

Identify possible causes of Identify possible causes of early pregnancy lossearly pregnancy loss

Outline basic evaluation for Outline basic evaluation for recurrent pregnancy loss recurrent pregnancy loss (RPL)(RPL)

Review current treatment Review current treatment approaches for these approaches for these patientspatients

DefinitionDefinition Classical: 3 or more Classical: 3 or more

consecutive pregnancy consecutive pregnancy losses before 20 weeks losses before 20 weeks gestationgestation

Expanded: 2 or more Expanded: 2 or more consecutive lossesconsecutive losses Risk of further loss similar for 2 Risk of further loss similar for 2

versus 3 consecutive lossesversus 3 consecutive losses Initiation of evaluation Initiation of evaluation

appropriate after 2 losses based appropriate after 2 losses based on patient age and desireon patient age and desire

Hill Curr Prob Obstet Gynecol Fertil 1994;37:693-704

RecurrentRecurrent Loss Loss EpidemiologyEpidemiology

5% of couples attempting 5% of couples attempting pregnancy have 2 or more pregnancy have 2 or more consecutive lossesconsecutive losses

1% have 3 or more 1% have 3 or more consecutive lossesconsecutive losses

Most clinicians consider RPL Most clinicians consider RPL even if losses are not even if losses are not consecutiveconsecutive

Lee Semin Reprod Med 2000;18(4):433-40

SPAB SPAB Epidemiology Epidemiology

34% pregnancy loss in 34% pregnancy loss in prospective cohort of healthy prospective cohort of healthy womenwomen 22% unrecognized - detected by 22% unrecognized - detected by

assay onlyassay only 12 % clinically recognized12 % clinically recognized

Obstetrical history predictiveObstetrical history predictive prior success: 4-6 % chance of prior success: 4-6 % chance of

lossloss prior loss: 19-24%chance of lossprior loss: 19-24%chance of lossWilcox NEJM 1988;319:189-194

SPAB or RPL?SPAB or RPL?

A single SAB, unless a A single SAB, unless a successful pregnancy successful pregnancy intervenes, increases the risk intervenes, increases the risk for the next pregnancyfor the next pregnancy

Distinction between “sporadic” Distinction between “sporadic” and “recurrent” loss blurredand “recurrent” loss blurred

Effect of maternal age: SAB Effect of maternal age: SAB risk approaches 50% by age 40 risk approaches 50% by age 40 for both aneuploid and euploid for both aneuploid and euploid losseslosses

Cramer Semin Reprod Med 2000;18(4):331-9

Miscarriage Recurrence Miscarriage Recurrence RiskRisk

OutcomeOutcome Prior Prior LossesLosses

Recurrence Recurrence Risk %Risk %

LivebornLiveborn 00 1212

11 2424

22 2626

33 3232

44 2626

No No LiveLive BirthsBirths

11 1919

22 3535

33 4747

44 5454Warburton D, Fraser FC: Am J Human Genet 16:1, 1964

PCOS & Pregnancy LossPCOS & Pregnancy Loss

Pregnancy loss ↑ with PCOSPregnancy loss ↑ with PCOS Franks S, Ann Int Med 93, Jacobs HS BRJOBGYN 93

GnRH-a ↓ miscarriage in PCOS GnRH-a ↓ miscarriage in PCOS womenwomen

Homburg R, et al: Fertil Steril 59:527, 1993

RSA patients with ↑ LH, DHEAS or RSA patients with ↑ LH, DHEAS or T more likely to miscarryT more likely to miscarry

Tulpalla M, et al: BrJOBGYN 100:348, 1993

GnRH-a ↓ miscarriages in RSA GnRH-a ↓ miscarriages in RSA patients with PCOS compared to patients with PCOS compared to clomid (10% vs 55%)clomid (10% vs 55%)

Johnson P, et al: BMJ 300:154, 1990

Metformin Reduces Metformin Reduces Pregnancy Loss in PCOSPregnancy Loss in PCOS

Retrospective study of PCOS Retrospective study of PCOS women who became pregnantwomen who became pregnant Group 1: metformin during Group 1: metformin during

pregnancy (n=101)pregnancy (n=101) Group 2: control (n=31)Group 2: control (n=31)

Early loss rate 12.9% vs Early loss rate 12.9% vs 41.9% 41.9% (p=0.001)(p=0.001)

Prior SPAB: 15.7% vs 58.3% Prior SPAB: 15.7% vs 58.3% (p=0.005)(p=0.005)

Jakubowicz DJ, et al: abstract P2-427, Endocrine Society, 2001Jakubowicz DJ, et al: abstract P2-427, Endocrine Society, 2001

Etiology Etiology Anatomic Anatomic FactorsFactors

10-15% recurrent 110-15% recurrent 1stst trimester trimester losses have congenital losses have congenital anomalyanomaly

Variations of the double Variations of the double uterus the most commonuterus the most common

Septate loss rates 25-90% - Septate loss rates 25-90% - usually amenable to resectionusually amenable to resection

Bicornuate loss rates 40% - Bicornuate loss rates 40% - uncertain benefit of surgeryuncertain benefit of surgery

Propst & Hill Semin Reprod Med 2000;18(4):341-50


Unicornuate uteri 50% lossUnicornuate uteri 50% loss Uterus didelphys 40% lossUterus didelphys 40% loss DES exposure - many have DES exposure - many have

abnormal uterine structureabnormal uterine structure Cervical incompetenceCervical incompetence Intrauterine synechiaeIntrauterine synechiae


Unclear relationship between Unclear relationship between uterine leiomyomata and RPLuterine leiomyomata and RPL Large submucosal fibroids distort Large submucosal fibroids distort

the cavity or occupy a large the cavity or occupy a large subendometrial areasubendometrial area

? Mechanism(s) - mechanical ? Mechanism(s) - mechanical constriction or inadequate constriction or inadequate placentation resulting from poorly placentation resulting from poorly vascularized endometriumvascularized endometrium

Acquired Uterine DefectsAcquired Uterine Defects

Etiology Etiology InfectionInfection

No infectious agent has been No infectious agent has been proven to cause recurrent proven to cause recurrent pregnancy losspregnancy loss ? Colonization with ? Colonization with Ureaplasma Ureaplasma

urealyticum urealyticum leading to empiric leading to empiric antibioticsantibiotics

Certain infections have been Certain infections have been associated with spontaneous associated with spontaneous lossloss Toxoplasma gondiiToxoplasma gondii, rubella, HSV, , rubella, HSV,

CMV, measles, coxsackieCMV, measles, coxsackie


Etiology Etiology Genetic Genetic FactorsFactors

Trisomy (50%) #16 all lethal 1/3 of all

trisomies #21 Down Syndrome

usually due to meiotic non-disjunction 80% maternatal

Monsomy X (20%) 45X Turner Syndrome

most common Triploidy (15%)

90% from father Tetraploidy (5%) Mosaicism (2%)

% Chromosomal % Chromosomal Abnormal by Abnormal by

Gestational AgeGestational Age

% abnormal% abnormal Gestational Gestational ageage

6060 1212

4545 1616

1212 2020

66 2424

~1~1 4040


Parental abnormalities in Parental abnormalities in 3-5% of couples with 3-5% of couples with recurrent lossrecurrent loss

Balanced translocation Balanced translocation most commonmost common Reciprocal (60%) or Reciprocal (60%) or

Robertsonian (40%)Robertsonian (40%) 25-50% risk of pregnancy 25-50% risk of pregnancy

lossloss May eventually produce May eventually produce

normal offspringnormal offspring


Homologous Homologous Robertsonian Robertsonian translocationtranslocation 1/2500 couples1/2500 couples precludes successful precludes successful

reproductionreproduction Heterozygous may lead Heterozygous may lead

to partial monosomy or to partial monosomy or trisomy; “milder” trisomy; “milder” phenotypical phenotypical expressionexpression

Ward Semin Reprod Med 2000;18(4):425-32


Speculation about single Speculation about single gene mutations gene mutations Blastocyst formationBlastocyst formation ImplantationImplantation Morphogenesis of vital organsMorphogenesis of vital organs


Skewed X inactivationSkewed X inactivation Preferential inactivation(>90%) Preferential inactivation(>90%)

of one of the X allelesof one of the X alleles May be lethal to a male offspringMay be lethal to a male offspring May result in X-autosome May result in X-autosome

translocationstranslocations Trisomy mosaicism in the Trisomy mosaicism in the

germlinegermline


Advanced maternal ageAdvanced maternal age Impact on risk for pregnancy loss Impact on risk for pregnancy loss

cannotcannot be over-emphasized be over-emphasized Increased rates of maternally-Increased rates of maternally-

derived trisomiesderived trisomies Probable “natural selection” of Probable “natural selection” of

better quality oocytes earlier in better quality oocytes earlier in reproductive lifereproductive life

Oocytes recruited later in life Oocytes recruited later in life more likely to be abnormal or more likely to be abnormal or experience meiotic errorexperience meiotic error

Lobo, R. A. N Engl J Med 2005;353:64-73

Decline in the Number of Oocytes from Birth to Menopause

Heffner, L. J. N Engl J Med 2004;351:1927-1929

Fertility and Miscarriage Rates as a Function of Maternal Age

EtiologyEtiology ThrombophiliaThrombophilia

Pregnancy is a Pregnancy is a hypercoagulable statehypercoagulable state

Women with heritable or Women with heritable or acquired thrombophilic acquired thrombophilic disorders have significantly disorders have significantly increased risks of pregnancy increased risks of pregnancy lossloss

Kutteh Semin Reprod Med 2006;24(1):54-65

EtiologyEtiology ThrombophiliaThrombophilia Venous Venous

Most common inherited:Most common inherited: Heterozygous Factor V Leiden Heterozygous Factor V Leiden

(G1691A)(G1691A) Factor II-prothrombin mutation Factor II-prothrombin mutation

(G20210A)(G20210A) Hyperhomocysteinemia (MTHFR Hyperhomocysteinemia (MTHFR

C677T and A1298C)C677T and A1298C)

EtiologyEtiology ThrombophiliaThrombophilia Venous Venous

Most common acquired:Most common acquired: Anti-phospholipid antibodies Anti-phospholipid antibodies

(APAs)(APAs) Activated Protein C resistanceActivated Protein C resistance Hyperhomocysteinemia (MTHFR Hyperhomocysteinemia (MTHFR

C677T and A1298C)C677T and A1298C) Other possible abnormalitiesOther possible abnormalities

Anti-thrombin deficiencyAnti-thrombin deficiency Protein C or S deficiencyProtein C or S deficiency Elevated Factor VIIIElevated Factor VIII

EtiologyEtiology ThrombophiliaThrombophilia Arterial Arterial

HyperhomocysteinemiaHyperhomocysteinemia APAsAPAs Lupus anticoagulantLupus anticoagulant


Factor V LeidenFactor V Leiden Abnormal factor V resistant to Abnormal factor V resistant to

anticoagulant effects of activated anticoagulant effects of activated protein Cprotein C

Majority of patients resistant to Majority of patients resistant to activated protein C will be activated protein C will be heterozygous for Factor V Leidenheterozygous for Factor V Leiden

Present in 3-8% of the White Present in 3-8% of the White populationpopulation

Rare in Blacks, Asians, Native Rare in Blacks, Asians, Native AmericansAmericans


Factor V LeidenFactor V Leiden Autosomal dominantAutosomal dominant Acquired activated protein C Acquired activated protein C

resistance in pregnancy, OCP use resistance in pregnancy, OCP use and in presence of APAsand in presence of APAs

Heterozygotes: 7X increase Heterozygotes: 7X increase lifetime risk thrombosis; 15X lifetime risk thrombosis; 15X increase during pregnancy or increase during pregnancy or OCP useOCP use

Homozygotes: 50-100X increase Homozygotes: 50-100X increase lifetime risk thrombosislifetime risk thrombosis


Prothrombin G20210A Prothrombin G20210A MutationMutation Higher plasma prothrombin Higher plasma prothrombin

concentrations, augmented concentrations, augmented thrombin generationthrombin generation

Heterozygotes: 2-3% WhitesHeterozygotes: 2-3% Whites Conflicting prevalence studies Conflicting prevalence studies

among RPLamong RPL Recent critical review suggests Recent critical review suggests

an associationan association


Hyperhomocysteinemia Hyperhomocysteinemia polymorphismspolymorphisms C677T thermolabile MTHFRC677T thermolabile MTHFR

Heterozygous 10-20% Whites• Normal or slightly elevated

homocysteine• Increased homocysteine when

combined with B vitamin deficiencies

Homozygous 10% Whites• Significantly increased

homocysteine


Hyperhomocysteinemia Hyperhomocysteinemia polymorphismspolymorphisms A1298C often occurs with A1298C often occurs with

thermolabile C677Tthermolabile C677T 33% frequency in Dutch

population Combined heterozygosity

results in hyperhomocysteinemia and decreased plasma folate levels


Hyperhomocysteinemia Hyperhomocysteinemia polymorphismspolymorphisms Significant association between Significant association between

hyperhomocysteinemia and RPLhyperhomocysteinemia and RPL ? Mechanism: interference in ? Mechanism: interference in

embryonic development through embryonic development through defective chorionic villous defective chorionic villous vascularizationvascularization

Known association with later Known association with later pregnancy-related complicationspregnancy-related complications


Anti-thrombin DeficiencyAnti-thrombin Deficiency Physiologic inhibitor of coagulationPhysiologic inhibitor of coagulation

Type I: quantitative; decreased antigen and function; caused by gene deletions, nucleotide changes

Type II: qualitative; normal antigen levels, decreased function; caused by point mutations with single amino acid changes leading to a dysfunctional protein


Anti-thrombin DeficiencyAnti-thrombin Deficiency Autosomal dominantAutosomal dominant Prevalence Type I heterozygous Prevalence Type I heterozygous

carriers: 1/2000 – 1/5000carriers: 1/2000 – 1/5000 Prevalence Type II heterozygous Prevalence Type II heterozygous

carriers: 3/1000carriers: 3/1000 Most thrombogenic of inherited Most thrombogenic of inherited

thrombophilia: 20-50% lifetime thrombophilia: 20-50% lifetime riskrisk

Associated increased risk Associated increased risk stillbirth and fetal lossstillbirth and fetal loss


Protein C DeficiencyProtein C Deficiency Down-regulates coagulation Down-regulates coagulation

cascade; deficiencies lead to cascade; deficiencies lead to unregulated fibrin formationunregulated fibrin formation

Autosomal dominant: > 160 Autosomal dominant: > 160 mutationsmutations

Type I: quantitativeType I: quantitative Type II: decreased functionType II: decreased function Associated with 2Associated with 2ndnd trimester trimester

losseslosses


Protein S DeficiencyProtein S Deficiency Principal cofactor of activated Protein C; Principal cofactor of activated Protein C;

mimics C deficiency: questionable mimics C deficiency: questionable association with pregnancy lossassociation with pregnancy loss

Autosomal dominant: > 160 mutations: Autosomal dominant: > 160 mutations: prevalence 0.15-0.8% general prevalence 0.15-0.8% general population; acquired forms in multiple population; acquired forms in multiple disease statesdisease states

Type I: quantitativeType I: quantitative Type II: decreased functionType II: decreased function Type III: low free protein, normal Type III: low free protein, normal

antigen, reduced activityantigen, reduced activity

EtiologyEtiology Luteal Phase Luteal Phase DefectDefect

Luteal phase defect is a Luteal phase defect is a controversial cause of RPLcontroversial cause of RPL Studies proving LPD as a Studies proving LPD as a

cause of RPL lackingcause of RPL lacking No convincing studies showing No convincing studies showing

LPD treatment improves LPD treatment improves pregnancy outcomepregnancy outcome

Lee Semin Reprod Med 2000;18(4):433-40 80% of women with low 80% of women with low

midluteal progesterone midluteal progesterone proceed to termproceed to term

20% of fertile women have 20% of fertile women have abnormal endometrial biopsiesabnormal endometrial biopsies

P4 drops after meals & P4 drops after meals & standingstanding

Etiology Etiology Endocrine Endocrine FactorsFactors

Poorly controlled diabetesPoorly controlled diabetes Overt hyperthyroidismOvert hyperthyroidism Overt hypothyroidismOvert hypothyroidism No evidence that No evidence that

asymptomatic systemic asymptomatic systemic endocrinologic or metabolic endocrinologic or metabolic disorders are a cause of RPLdisorders are a cause of RPL

EtiologyEtiology Autoimmune Autoimmune FactorsFactors

Certain autoimmune diseases Certain autoimmune diseases are associated with are associated with pregnancy losspregnancy loss Systemic lupus erythematosisSystemic lupus erythematosis

1st trimester loss: 10% risk 2nd and 3rd trimester loss: 6%

Anti-phospholipid syndromeAnti-phospholipid syndrome 2nd trimester loss: 38%

Fausett & Branch Semin Reprod Med 2000;18(4):379-392


Anti-phospholipid antibodies Anti-phospholipid antibodies (aPL)(aPL) autoantibodies recognizing autoantibodies recognizing

various combinations of various combinations of phospholipids, phospholipid-phospholipids, phospholipid-binding proteins, or bothbinding proteins, or both

Anti-phospholipid syndrome Anti-phospholipid syndrome (APS) - clinical association (APS) - clinical association between aPL and syndrome between aPL and syndrome of hypercoagulabilityof hypercoagulability

Levine NEJM 2002;346:752-63


APS diagnostic criteria:APS diagnostic criteria: Clinical featuresClinical features

Vascular thrombosis or Loss of fetus at or after 10

weeks or Preterm delivery at or before

34 weeks or 3 or more consecutive SAB

before 10 weeks


APS diagnostic criteria:APS diagnostic criteria: Laboratory featuresLaboratory features

Anti-cardiolipin (aCL) antibodies: IgG or IgM at moderate or high levels on 2 or more occasions at least 6 weeks apart

Lupus anticoagulant (LA) antibodies: detected on 2 or more occasions at least 6 weeks apart


Other anti-phospholipid Other anti-phospholipid antibodiesantibodies Anti-phosphatidylserine: nearly Anti-phosphatidylserine: nearly

always associated with APS, always associated with APS, highly correlated to cardiolipin highly correlated to cardiolipin bindingbinding

Other antibodies have less Other antibodies have less correlationcorrelation

No consistency among reported studies

No independence from aCL

Fausett Semin Reprod Med 2000;18(4):379-92


Low levels of aPL are not Low levels of aPL are not associated with RPLassociated with RPL

Assays for non-aCL aPL are Assays for non-aCL aPL are not standardizednot standardized

Studies thus far are Studies thus far are contradictorycontradictory


Other auto-antibodies NOT Other auto-antibodies NOT associated with RPLassociated with RPL Anti-nuclear antibodies may be Anti-nuclear antibodies may be

more common among women more common among women with RPL but their presence or with RPL but their presence or absence do not predict absence do not predict subsequent pregnancy outcomesubsequent pregnancy outcome


Other auto-antibodies NOT Other auto-antibodies NOT associated with RPLassociated with RPL Anti-thyrogobulin and anti-Anti-thyrogobulin and anti-

thyroid peroxidase are markers thyroid peroxidase are markers of increased risk for pregnancy of increased risk for pregnancy loss if identified early in loss if identified early in pregnancypregnancy

Some small studies suggest a Some small studies suggest a slight association in RPL; other slight association in RPL; other larger studies do notlarger studies do not

Subsequent pregnancy outcomes Subsequent pregnancy outcomes not affectednot affected

EtiologyEtiology Alloimmune Alloimmune FactorsFactors

Immune response to non-self Immune response to non-self components of pregnancycomponents of pregnancy Cytotoxic antibodiesCytotoxic antibodies Absence of maternal blocking Absence of maternal blocking

antibodiesantibodies Inappropriate sharing of HLAInappropriate sharing of HLA Disturbances in natural killer cell Disturbances in natural killer cell

function and distributionfunction and distribution

Porter Semin Reprod Med 2000;18(4):393-400


Cytotoxic antibodiesCytotoxic antibodies Maternal response to paternal Maternal response to paternal

antigensantigens Present in normal pregnanciesPresent in normal pregnancies More common in fertile couples More common in fertile couples

than those with RPLthan those with RPL No bearing on subsequent No bearing on subsequent

pregnancy outcomepregnancy outcome


Blocking antibodiesBlocking antibodies Theory: maternal anti-fetal Theory: maternal anti-fetal

antibodies block maternal cell-antibodies block maternal cell-mediated response; if absent, mediated response; if absent, then fetal rejection occursthen fetal rejection occurs


Blocking antibodiesBlocking antibodies Not present in normal Not present in normal

pregnancies, yet are often pregnancies, yet are often present in RPLpresent in RPL

Detected by the non-specific Detected by the non-specific mixed lymphocyte response mixed lymphocyte response assayassay


Blocking antibodiesBlocking antibodies Animal model: B-cell deficient Animal model: B-cell deficient

(agammaglobulinemic) mice have (agammaglobulinemic) mice have normal pregnancy outcomesnormal pregnancy outcomes

Human agammaglobulinemics Human agammaglobulinemics have successful pregnancieshave successful pregnancies

Presence or absence not Presence or absence not predictive of subsequent outcomepredictive of subsequent outcome


Parental HLA sharingParental HLA sharing Theory: if parents are Theory: if parents are

antigenically similar, mother is antigenically similar, mother is less likely to develop blocking less likely to develop blocking antibodiesantibodies

Studies contradictory: some Studies contradictory: some show increased sharing in HLA-B show increased sharing in HLA-B and HLA-DR lociand HLA-DR loci

Most show no associationsMost show no associations


Natural killer cellsNatural killer cells Theory: CD56+ NK-like cells Theory: CD56+ NK-like cells

secrete a transforming growth secrete a transforming growth factor-factor--like substance crucial to -like substance crucial to the maintenance of pregnancythe maintenance of pregnancy

Present in endometria and early Present in endometria and early gestational decidua of women gestational decidua of women with RPLwith RPL


Natural killer cellsNatural killer cells Murine models show activation of Murine models show activation of

NK cells increases the rate of NK cells increases the rate of abortion; depletion of NK cells abortion; depletion of NK cells has opposite effecthas opposite effect

Human studies show no Human studies show no association of testing and association of testing and successful pregnancysuccessful pregnancy


T helper (Th1) T helper (Th1) immunodystrophismimmunodystrophism Theory: aberrant or inappropriate Theory: aberrant or inappropriate

Th1 stimulation may result in Th1 stimulation may result in overproduction of cytokines that overproduction of cytokines that have deleterious effect on have deleterious effect on conceptusconceptus

Dichotomous Th1 versus Th2 Dichotomous Th1 versus Th2 cytokine profile associated with cytokine profile associated with human pregnancy loss and human pregnancy loss and successsuccessHill Semin Reprod Med 2000;18(4):401-405

EtiologyEtiology Male Male FactorFactor

No significant difference in semen No significant difference in semen parameters among men whose partners parameters among men whose partners have RPL compared to WHO standards and have RPL compared to WHO standards and men fathering successful pregnanciesmen fathering successful pregnancies

No difference in incidence of anti-sperm No difference in incidence of anti-sperm antibodiesantibodies

Aside from cytogenetic abnormalities,Aside from cytogenetic abnormalities, male male factor contribution to RPL unknownfactor contribution to RPL unknown

Hill ASRM 2002 Course 6 p.56 DNA Fragmentation may result in early DNA Fragmentation may result in early

embryo lossembryo lossHum Reprod. 2006 Nov;21(11):2876-81; Check JH: Arch Androl. 2005 Mar-Apr;51(2):121-4

EtiologyEtiology Male Male FactorFactor

RPL males have higher RPL males have higher incidence of sperm incidence of sperm aneuploidy:aneuploidy: Oligoasthenoteratospermia 35-Oligoasthenoteratospermia 35-

74%74% Fertile donor sperm 4-7%Fertile donor sperm 4-7%

Etiology - Etiology - Environmental FactorsEnvironmental Factors

Confirmed Confirmed associationassociation Ionizing irradiationIonizing irradiation Organic solventsOrganic solvents AlcoholAlcohol MercuryMercury LeadLead

Gardella & Hill Semin Reprod Med 2000;18(4):407-424

Suspected Suspected associationassociation Caffeine (> 300 Caffeine (> 300

mg/day)mg/day) Hyperthermia/feverHyperthermia/fever Cigarette smokingCigarette smoking

Unknown associationUnknown association PesticidesPesticides

Etiology - Etiology - Environmental FactorsEnvironmental Factors

Diagnostic x-Diagnostic x-raysrays

Air travelAir travel Microwave Microwave

ovensovens Diagnostic Diagnostic

ultrasoundsultrasounds ElectromagnetiElectromagneti

c fieldsc fields Video display Video display

terminalsterminals AspartameAspartame

ChocolateChocolate Drinking waterDrinking water BGHBGH PhytoestrogenPhytoestrogen

ss PhthalatesPhthalates HerbicidesHerbicides Hair dyesHair dyes Nail polishNail polish SaccharinSaccharin

Etiology - IdiopathicEtiology - Idiopathic

More than 50% of couples More than 50% of couples with RPL have no explanation with RPL have no explanation despite extensive despite extensive evaluation(s)evaluation(s)

Informative and sympathetic Informative and sympathetic counseling appears to play counseling appears to play an important rolean important role 70% live birth rates reported in 70% live birth rates reported in

couples with unexplained RPL couples with unexplained RPL who undertake an untreated who undertake an untreated subsequent pregnancysubsequent pregnancy


EvaluationEvaluation HistoryHistory

Pattern and trimester of pregnancy Pattern and trimester of pregnancy losses and whether a live embryo or losses and whether a live embryo or fetus was presentfetus was present

Exposure to environmental,toxins or Exposure to environmental,toxins or drugsdrugs

Known gynecological or obstetrical Known gynecological or obstetrical infectionsinfections

Features associated with APSFeatures associated with APS

EvaluationEvaluation HistoryHistory

Family history of RPL or syndrome Family history of RPL or syndrome associated with embryonic or fetal associated with embryonic or fetal lossloss

Previous diagnostic tests and Previous diagnostic tests and treatmentstreatments

EvaluationEvaluation PhysicalPhysical

General physical examGeneral physical exam Pelvic examPelvic exam

EvaluationEvaluation

TestsTests Saline Sonogram or hysteroscopySaline Sonogram or hysteroscopy Hysterosalpingogram Hysterosalpingogram ?? Luteal phase endometrial biopsy; ?? Luteal phase endometrial biopsy;

repeat in next cycle if abnormalrepeat in next cycle if abnormal Placental FISH analysisPlacental FISH analysis Parental karyotypesParental karyotypes Lupus anticoagulantLupus anticoagulant Anticardiolipin antibodies IgG and IgMAnticardiolipin antibodies IgG and IgM

EvaluationEvaluation TestsTests

Antiphosphatidylserine antibody Antiphosphatidylserine antibody IgG and IgMIgG and IgM

Platelet countPlatelet count Thrombophilia mutations and Thrombophilia mutations and

functional assaysfunctional assays Thyroid stimulating hormoneThyroid stimulating hormone

EvaluationEvaluation

Tests NOT usefulTests NOT useful Other anti-phospholipid antibodiesOther anti-phospholipid antibodies ANAANA Maternal anti-paternal leukocyte antibodiesMaternal anti-paternal leukocyte antibodies Mixed lymphocyte maternal-paternal cell Mixed lymphocyte maternal-paternal cell

culturescultures HLA genotypingHLA genotyping Mouse embryotoxicity assaysMouse embryotoxicity assays Immunophenotype panels (CD56, CD16)Immunophenotype panels (CD56, CD16)

Hill ASRM 2002 Course 6 p.58-59

Treatment - Treatment - ThrombophiliaThrombophilia

For heritable or acquired For heritable or acquired thrombophilia: heparin thrombophilia: heparin anticoagulationanticoagulation

For bonafide APS, multiple For bonafide APS, multiple studies support use of heparin studies support use of heparin and aspirinand aspirin

Treatment - APSTreatment - APS Aspirin 81 mg po/dayAspirin 81 mg po/day Subcutaneous heparin 10K-Subcutaneous heparin 10K-

20K units/day divided doses20K units/day divided doses Alternative: low-molecular-Alternative: low-molecular-

weight heparin 2500-5000 weight heparin 2500-5000 units/day single doseunits/day single dose

Calcium supplementationCalcium supplementation

Treatment - Treatment - ThrombophiliaThrombophilia

For elevated homocysteinemia For elevated homocysteinemia without thrombosis historywithout thrombosis history Supplementation with Vitamin B6, Supplementation with Vitamin B6,

B12 and folic acidB12 and folic acid Heparin anticoagulation for Heparin anticoagulation for

history of thrombosis or history of thrombosis or homozygous MTHFR mutation homozygous MTHFR mutation or pregnancy outcomes or pregnancy outcomes unresponsive to vitamin unresponsive to vitamin supplementationsupplementation

Empiric Treatment Empiric Treatment Use of aspirin alone Use of aspirin alone

attractive because of ease of attractive because of ease of use and relative safety use and relative safety profile, barring profile, barring contraindication to low-dose contraindication to low-dose aspirin useaspirin use

Supporting data lackingSupporting data lacking

Treatment - Treatment - ImmunotherapyImmunotherapy ““Blocking antibody” Blocking antibody”

hypothesishypothesis Paternal leukocyte immunization Paternal leukocyte immunization

or desensitizationor desensitization Efficacy disproven May increase risk of loss Potential adverse effects:

transfusion reaction, immunization, infection, IUGR, GVH, thrombocytopenia

Treatment - Treatment - ImmunotherapyImmunotherapy ““Blocking antibody” hypothesisBlocking antibody” hypothesis

Intravenous immunoglobulinIntravenous immunoglobulin Studies and meta-analyses show

no benefit Extremely expensive $7-14,000 Side effects: headache,

hypotension, nausea Potential anaphylaxis in IgA

deficient patients Potential for prion disease

transmission due to large pool of donors

Treatment - Treatment - ImmunotherapyImmunotherapy Progesterone called Progesterone called

“nature’s “nature’s immunosuppressant” due to immunosuppressant” due to inhibition of immune cells at inhibition of immune cells at maternal-fetal interfacematernal-fetal interface

No verification yet through No verification yet through RCTRCT

Safe and inexpensiveSafe and inexpensive Dose: 100 mg BID vaginal Dose: 100 mg BID vaginal

suppositories, beginning 3 suppositories, beginning 3 days after ovulationdays after ovulation

Supportive TreatmentSupportive Treatment

60-90% chance of pregnancy 60-90% chance of pregnancy success with supportive care success with supportive care and ...and ... Timed intercourse for genetic Timed intercourse for genetic

and idiopathic RPLand idiopathic RPL Surgery for selected anatomic Surgery for selected anatomic

factorsfactors PP44 and/or ovulation induction for and/or ovulation induction for

LPDLPD

Supportive TreatmentSupportive Treatment

60-90% chance of pregnancy 60-90% chance of pregnancy success with supportive care success with supportive care and ...and ... Immunosuppresive PImmunosuppresive P44 for for

presumed alloimmune factorspresumed alloimmune factors Thyroid replacement for Thyroid replacement for

hypothyroidismhypothyroidism Appropriate anticoagulation for Appropriate anticoagulation for

APS/thrombophiliasAPS/thrombophilias

Management: Genetic Management: Genetic LossesLosses

Consider Preimplantation Consider Preimplantation Genetic Diagnosis (PGD)Genetic Diagnosis (PGD) IVFIVF Day 3 blastomere biopsy (single Day 3 blastomere biopsy (single

cell)cell) FISH for most common FISH for most common

aneuploidies or single gene aneuploidies or single gene defect (if probe available)defect (if probe available)

Blastocyst biopsy on day 5 allows Blastocyst biopsy on day 5 allows detection of entire genomedetection of entire genome

Van Voorhis B. N Engl J Med 2007;356:379-386

The Process of IVF

Rebar, R. W. et al. N Engl J Med 2004;350:1603-1604

Embryos and Blastocysts during Assisted Reproduction (x20)

Van Voorhis B. N Engl J Med 2007;356:379-386

Biopsy and Preimplantation Genetic Diagnosis of a 3-Day-Old (Eight-Cell) Embryo

Embryo Evaluation Embryo Evaluation “omics”“omics” GENomicsGENomics

FISH – day 3FISH – day 3 Array CGH – day 5Array CGH – day 5 SNPsSNPs

TRANSCIPTTRANSCIPTomicsomics Gene transcriptionGene transcription

PROTEomicsPROTEomics ProteinsProteins SecretomicsSecretomics

METABOLomicsMETABOLomics MetabolitesMetabolites Amino AcidsAmino Acids

Braude P. N Engl J Med 2006;355:541-543

In Vitro Fertilization and Preimplantation Genetic Haplotyping

Elias S. N Engl J Med 2001;345:1569-1571

Analysis by Comparative Genomic Hybridization of a Blastomere Obtained by Biopsy of a Six-to-Eight-Cell Embryo

Management: Genetic Management: Genetic LossesLosses

DrawbacksDrawbacks ExpenseExpense Possibility of no transferPossibility of no transfer 10-25% mosaicism and potential 10-25% mosaicism and potential

for misidentificationfor misidentification No large scale studies supporting No large scale studies supporting

benefitbenefit

Norwitz, E. R. et al. N Engl J Med 2001;345:1400-1408

Blastocyst Apposition and Adhesion


Blastocyst Implantation


Maintenance of Early Pregnancy

SummarySummary

Early pregnancy loss is a frustrating Early pregnancy loss is a frustrating entity for both patients and entity for both patients and providersproviders

Possibility of successful pregnancy Possibility of successful pregnancy outcome high, depending on outcome high, depending on maternal age and number of prior maternal age and number of prior losseslosses

Understanding the potential Understanding the potential underlying mechanisms of loss along underlying mechanisms of loss along with empathetic supportive care with empathetic supportive care decreases emotional stress and decreases emotional stress and facilitates cost-effective evaluation facilitates cost-effective evaluation and therapyand therapy

recurrent loss 2009

Health & Medicine

risk of pregnancy loss

chance of loss prior

loss similar

consecutive pregnancy

pregnancy n

successful pregnancy

pregnancy distinction

loss uterus didelphys