Question:
Dear Dr. Ramirez,
I am writing from Pennsylvania. In 2006, I had two or three
miscarriages. After that, I went to a
fertility clinic and had TSH, prolactin, DRVV, and anti-cardiolipin antibodies
tested. All were normal. I also had progesterone level checked at the
very beginning of one of the pregnancies as well as a non-pregnant menstrual
cycle after ovulation. Both were
normal. I had irregular cycles that were
anywhere from six to ten weeks apart. I
knew when I ovulated because I got pain in whichever ovary released the egg and
always had a luteal phase of 14 days. I also conceived easily.
The doctor felt the lining of my uterus was
getting too old to sustain a pregnancy since so much time elapsed between
cycles. In February 2007, I conceived on one round of Clomid and carried that
child full-term. I then had two more
children in 2009 and 2011 with no help despite still having the same irregular
cycles. My cycles are a little better
now and usually five to six weeks apart, but I have had three miscarriages
again in September 2012, December 2013 and June 2014. All the miscarriages I ever had were missed
abortions with embryo development ending between week 5 and 6 with the
exception of the most recent which ended at 11 weeks 5 days despite fetus
having a strong heartbeat and normal looking development. Since a drop in progesterone causes shedding
of the lining of the uterus, is it safe to assume that since my miscarriages
were not spontaneous that progesterone was not an issue? Could other hormones be issues or was
chromosomal defect the likely issue all these times?
Thank you for your time. Sincerely, M. from Pennsylvania
Answer:
Hello M. from the U.S. (Pennsylvania),
There are basically five known causes of recurrent
miscarriages from the following abnormalities: genetic, anatomic, immunologic,
hormonal and infectious. When a woman
has had two or three miscarriages, she automatically has earned the diagnosis
of "recurrent pregnancy loss" and as such, needs to undergo a
thorough evaluation of these elements.
The most common cause of miscarriages is genetic abnormalities and is
responsible for 85% of miscarriages in women over 35 years old. A recent study showed this cause to be less
in younger women. Genetic abnormalities
can be caused from an inherited disorder or a spontaneous disorder, whereby the
egg makes a genetic error when it is dividing leading to an abnormal embryo. Most of these pregnancies will end before 12
weeks gestational age.
The recommended testing is as follows:
Genetic: wife and husband chromosomal analysis, saliva DNA
analysis
Anatomic: diagnostic hysteroscopy, pelvic ultrasound, end
cycle endometrial biopsy for dating and b-Integrin
Immunologic: Complete antiphospholipid antibodies, natural
killer cells, Factor V Leiden, MTHFR, Antinuclear antibodies, Lupus
anticoagulant, anti-Thyroid antibodies
Hormonal: FSH, LH, TSH, Prolactin, Estradiol, Mid-luteal
Progesterone
Infectious: GC, Chlamydia, Ureaplasma/Mycoplasma,
Toxoplasmosis
Age is probably the most common major cause which leads to
an increase in genetic abnormalities.
Since you don't mention your age, that could be part of the problem if
you are over 35 years old. The good news
is that most women with recurrent miscarriage will eventually have a successful
pregnancy.
Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
