Saturday, January 12, 2013

Recurrent Pregnancy Loss: 5 Miscarriages Since 2009


Hello Dr. Ramirez,

My husband and I have been trying to conceive since 2007. I have PCOS (polycystic ovarian syndrome) and I have had 5 miscarriages, first one in April 2009 at 10 weeks and the others at 6 weeks. I've also lost a baby due to an incompetent cervix at 6 months. My most recent miscarriage was last month after an IFV cycle at 6 weeks. I was on baby aspirin, progesterone shot, metformin and Estrace. My fertility specialist was not able to say why I am having these recurrent miscarriages. My doctor has done blood work and all standard testing.

After numerous IUI cycles we went ahead with IVF which also led to a miscarriage. I still have four embryos left and don't want to pursue with another IVF cycle until I can get some answers as to what might have gone wrong or what I can do to change the outcome. Do you have any suggestions for me? Any feedback is greatly appreciated. N. from Canada


Hello N. from Canada,

I am sorry for all your losses! The incompetent cervix is something that can easily be handled with your next  pregnancy by doing a cerclage (either a TVC or a TAC by the 16th week of gestation--a TAC can also be done pre-pregnancy). But you need to achieve and hold that next pregnancy. First, let me say that you should also read my website page where I have written extensively regarding evaluation of Recurrent Pregnancy Loss (RPL) and a possible protocol for treating this problem. Anyone who has miscarried three times or more needs to have this type of comprehensive evaluation. Some of the possible reasons you may be miscarrying include:
  • Genetic/Chromosomal Causes (you don't state your age, but that could be factor)
  • Polyps, Fibroids & Uterine Disorders
  • Hematologic Disorders
  • Hormonal (you have PCOS, so your cycle day 9 & 10 LH needs to be checked )
  • Infectious, Genetic & Immune Factors
With a diagnosis of "Recurrent pregnancy loss", there is a protocol that is usually followed to evaluate for the possible causes. As stated above, this includes genetic testing (both you and your husband), immunological testing, infectious disease testing, anatomical testing, hematologic testing and hormonal testing. It is quite an extensive array of tests and can take up to two months.This is what should be done BEFORE you proceed with any more IVF cycles. The treatment will then depend on what is found. In some cases, for those with genetic causes, IVF with PGD (preimplantation genetic diagnosis) can be done to test the embryos for viability and chromosomal abherrations.

What is good is that you are able to ovulate, that your eggs fertilize and that you have been able to get pregnant. It is very difficult to go through as many miscarriages as you have and I hope that with proper evaluation you will be able to deliver a beautiful, healthy child in the near future.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

Monterey, California, U.S.A.


  1. Hello Dr. Ramirez:

    My name is E from Honduras, I am 27 years old. I have had 3 miscarriages in la last 3 years. I was diagnosed in 2007 with endometriosis and as a result had a right oophorectomy, had treatment for six months for endometriosis and PCOS for a period of time. Later on in 2009 I had laparoscopic surgery again because I had scar tissue on my left ovary and my uterus, again took treatment with zoladex and progesterone shots to control de endometriosis. I had my first pregnancy in oct 2010 under fertility treatment with letrozol and pregnyl it lasted 5 weeks. The fertility treatment lasted from dec 2009 until aug 2011 when we decided to take a break from it. I had the third surgery (laparoscopy) for a total obstruction and of both tubes and a right salpingitis, got pregnant again on dec 2011 and miscarried at 6.6 weeks this time I got diagnosed with antiphospholipid syndrome. Been taking aspirin ever since.
    I recently had a D&C last week for a 9 week pregnancy which didn´t survive, this is the first pregnancy that has lasted the longest, I was in treatment and observed every two weeks by my rheumatologist and ob/gyn, with the aspirin and heparin shots, I didn´t have any signs of miscarriage, pain or bleeding while it lasted but the embryo just stopped growing.
    I´m afraid I´ll never become a mom, since I´ve lost 3 out of 3. I would really appreciate your expertise and input on my case.

    1. Hello,

      As explained at the beginning of this topic, you should undergo an extensive evaluation for recurrent pregnancy loss, especially genetic testing. Considering how far your pregnancies got, genetics would be high on my list. In terms of APA syndrome, I recommend low dose aspirin, low dose heparin, medrol, estrogen supplementation and progesterone supplementation.
      Good Luck



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