Recurrent First trimester pregnancy loss
(under 12 weeks)
Pregnancy loss or miscarriage unfortunately is common in the first trimester.
The majority is due to genetic abnormalities in the embryo formation. This can happen without a family history, and can happen to any couple. Obviously increased maternal age will increase the risk.
Recurrent miscarriages in the first trimester however can be associated with various other problems, including
Inherited genetic disorder - in both men and women
Increased female age
Blood disorders - increased tendency to clotting
Polycystic Ovarian Syndrome
Immunological disorders including lupus
Abnormalities of sperm
Pelvic pathology like endometriosis and
uterine cavity abnormalities like adhesions, uterine septum and intra uterine fibroids
Treatment for recurrent first trimester pregnancy loss:
The treatment will be dictated by the results of the above investigations.
- Uterine Polyp – Hysteroscopy and Polypectomy
- Submucosal Fibroid (fibroid in cavity of uterus) – Hysteroscopy and removal of fibroid
- Large intramuscular fibroid (distorting cavity of uterus) – Laparoscopic Myomectomy
- Intra-uterine adhesions – Hysteroscopy with division of adhesions
- Endometriosis – Laparoscopy with excision of endometriosis
- Polycystic Ovarian Syndrome – there is evidence that Ovulation Induction with Puregon can improve the process of ovulation. Some women will require IVF. An increased miscarriage rate is still seen in women with PCOS who undergo Ovulation Induction or IVF.
- Clotting disorder – Dr Cook may recommend low dose aspirin or clexane.
- Inherited – if either the man or the woman has a chromosomal abnormality, Dr Cook will organise review by a genetics counsellor to understand the implications of the abnormality. The couple can be offered IVF with genetic screening of the embryos prior to embryo transfer. This will enable selection of a genetically normal embryo. This technology refers to Pre-implantation Genetic Diagnosis (PGD) or Pre-implantation Genetic Screening (PGS).
- Immunological – Dr Cook will organise referral to an immunologist if there is evidence of a systemic disease including Systemic Lupus Erythematosis (SLE).
- Natural Killer Cells (NK cells) – there is some evidence that the impact of these can minimised with prednisone treatment. This is usually done in combination with IVF treatment.
- Sperm abnormality – The couple can be offered IVF with genetic screening of the embryo prior to transfer.
Recurrent Second Trimester Pregnancy Loss
(between 16-22 weeks)
Investigations for recurrent first trimester pregnancy loss:
Blood tests – including thyroid, prolactin, karyotype (both man and woman), assessment of ovarian reserve and function (FSH and AMH), CA 125
Pregnancy Loss due to Cervical Incompetence
Cervical incompetence refers to a shortened and weakened cervix. This results in pregnancy loss in the second trimester. It can be congenital or due to procedures such as a LLETZ procedure or cone biopsy (performed to remove abnormal cells on the cervix). Trachelectomy is a procedure to remove the cervix for early stage cervical cancer in a woman who is planning a pregnancy. Cervical incompetence (insufficiency) can be diagnosed early on transvaginal ultrasound in pregnancy. There will be evidence of a shortened cervix which may become progressively shorter.
Fertility Treatments for Women with Cervical Incompetence
A cervical suture (cerclage)is placed laparoscopically at the cervicoisthmic junction. This is a safe and effective procedure for reducing the incidence of spontaneous pregnancy loss in selected patients with cervical insufficiency.
Dr Cook has the expertise to perform a laparoscopic cervical suture. This is a procedure which few fertility experts can perform.