Management of couples with recurrent pregnancy loss
- Togas Tulandi, MD, MHCM
Togas Tulandi, MD, MHCM
- Professor of Obstetrics and Gynecology
- Milton Leong Chair in Reproductive Medicine
- McGill University, Canada
- Haya M Al-Fozan, MD
Haya M Al-Fozan, MD
- Assistant Professor, Infertility and Reproductive Endocrinology
- King Saud bin Abdulaziz University for Health Sciences
High-quality data on management of recurrent pregnancy loss (RPL) are limited; therefore, therapeutic recommendations are largely based upon clinical experience and data from observational studies. Nevertheless, the prognosis for a successful future pregnancy is generally good: the overall live birth rates after normal and abnormal diagnostic evaluations for RPL are 77 and 71 percent, respectively .
Therapeutic intervention is guided by the underlying cause of RPL. In all cases, emotional support is important in caring for these often anxious couples, and may enhance therapeutic success [2-4].
Management of RPL will be discussed here. Causes and evaluation of RPL are reviewed separately. (See "Definition and etiology of recurrent pregnancy loss" and "Evaluation of couples with recurrent pregnancy loss".)
PARENTAL KARYOTYPE ABNORMALITY
Couples in whom chromosomal abnormalities are discovered in one or both partners or the abortus are generally referred for genetic counseling . They should receive information regarding the probability of having a chromosomally normal or abnormal conception in the future. In the latter case, the risk of miscarriage and bearing a chromosomally abnormal offspring who may be phenotypically normal or abnormal and a carrier of a chromosomal defect should be discussed. The magnitude of these risks varies according to the specific chromosomal abnormality and the sex of the carrier parent. (See "Chromosomal translocations, deletions, and inversions" and "Congenital cytogenetic abnormalities".)
Couples with karyotypic abnormalities may choose to undergo prenatal genetic studies, such as amniocentesis or chorionic villus sampling, to determine the fetal karyotype. Pregnancy termination is an option if the fetus is affected. In vitro fertilization (IVF) with preimplantation genetic diagnosis (PGD) can be used to avoid transfer and implantation of an affected embryo [6-8]. PGD improves the pregnancy outcome of translocation carriers with a history of repeated pregnancy loss . On the other hand, this procedure reduces the live birth rate after IVF if preimplantation testing is performed solely because of advanced maternal age . (See "Preimplantation genetic diagnosis".)
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- PARENTAL KARYOTYPE ABNORMALITY
- UTERINE ABNORMALITIES
- ANTIPHOSPHOLIPID SYNDROME
- SUSPECTED IMMUNOLOGIC DYSFUNCTION
- THYROID DYSFUNCTION AND DIABETES MELLITUS
- POLYCYSTIC OVARY SYNDROME
- TREATMENT OPTIONS FOR UNEXPLAINED RPL
- Lifestyle modification
- Human menopausal gonadotropin
- In vitro fertilization and preimplantation genetic diagnosis
- Oocyte donation
- Gestational carrier
- Combination therapy
- INEFFECTIVE OR UNPROVEN THERAPIES
- Aspirin with or without heparin
- Low-molecular weight heparin
- Human chorionic gonadotropin
- Clomiphene citrate
- FUTURE PREGNANCY PROGNOSIS
- Continued pregnancy loss
- Other obstetric issues
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS