Thursday, August 21, 2014
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
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.
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program