December 30, 2010

Recurrent Pregnancy Loss: Nongenetic

The treatment for recurrent pregnancy loss should depend on the underlying causes contributing to loss. Unfortunately the precise cause for loss remains unknown in many cases and thus effective treatment modalities remain elusive. Many empiric therapies involving immunologic phenomena such as intravenous immunoglobulin, leukocyte immunization and even low dose aspirin therapy have been proposed, but studies to date have disproven their effectiveness and health related issues potentially caused by these now disproven empiric therapies further limit their use.

Outpatient surgery involving hysteroscopy with removal of any intrauterine filling defect (polyps, fibroids, or adhesions) or resection of a uterine septum should be done in cases where an anatomic abnormality has been found. Consideration for surgery should also be given in cases where there are large fibroids (>5cm) within the muscle of the uterus even if the uterine cavity appears normal.

Hormonal problems are treated with medical therapies such as thyroid hormone replacement in cases of hypothyroidism where there is an elevated TSH level, dopaminergic drugs in cases where there is an elevated Prolactin, and insulin-sensitizing agents if there is evidence of high insulin levels as often occurs in cases of PCOS associated severe ovulation dysfunction. Ovulation induction with gonadotropins is also used in cases of disordered ovulation. However, clomiphene citrate has no place in the management of recurrent pregnancy loss associated with ovulation dysfunction due to it’s anti-estrogen effects. Luteal support with progesterone may be warranted in some cases but the efficacy of this empiric therapy has not been properly studied.

Anti-infectious interventions are not justified unless specific evidence exists for inflammation or an infectious organism has been identified.

Treatment for recurrent pregnancy loss associated with either antiphopholipid antibodies, the lupus anticoagulant, or other thrombophillic disorders involves antithrombotic medications such as low dose aspirin (81 mg/day) and subcutaneous low molecular weight heparin (10,000 units once daily). There is no place in the modern medical management of recurrent pregnancy loss for empiric therapy of these potentially dangerous medications unless a thrombophillic disorder has been identified as the cause of pregnancy loss.

Tags: , ,
Joseph A. Hill, III, M.D.

Joseph A. Hill, III, M.D. Board-Certified in Reproductive Endocrinology and Infertility