While not all miscarriages require testing and treatment, identifying women who are at risk of multiple early miscarriages at 6-8 weeks is an important step toward prevention. At CHR, we pay particular attention to the medical history and run a battery of test for early miscarriages to help women overcome this common problem.
In identifying women at risk of early miscarriages at 6 weeks to 8 weeks, like in practically all medical diagnoses, nothing is as important as a detailed medical history. Obtaining a very detailed medical history is, therefore, at CHR always a crucially important first step. It is almost incredulous how often we hear from new patients that their autoimmune diseases were dismissed at other centers as irrelevant to their infertility and/or miscarriages. Autoimmunity is, of course, highly relevant to both.
The importance of a reliable medical history goes, however, far beyond that: For example, whether miscarriages in repeat aborters happen earlier and earlier or later and later, can give us important hints about underlying causes; With immunological causes, miscarriages often start after a first, often successful pregnancy, and then tend to happen earlier and earlier in pregnancy. With congenital uterine abnormalities, the opposite is the case: Miscarriages happen later and later. The importance of medical history-taking can, therefore, not be overemphasized.
With ca. 15% of all pregnancies ending in miscarriages, it is also important to understand that in many instances, miscarriages are a normal part of a woman’s reproductive life. Just because a woman experiences a miscarriage does not mean the event suggests that she has a medical problem that requires intervention. However, once a woman experiences repeat miscarriages and early miscarriages, this assessment must change.
Medical textbooks still describe the diagnosis of being a repeat (or “habitual”) aborter as having experienced three consecutive 1st trimester or two consecutive 1st and 2nd trimester miscarriages. We, here at CHR, consider this a too stringent definition, especially in a patient population already in fertility treatments.
Based on criteria we find more logical, CHR, therefore, starts to search for causes of miscarriages much earlier: So, for example, we consider so-called chemical pregnancies in this context as very early miscarriages and, therefore, count them as such. This conclusion was reached after, a number of years ago, colleagues published a study demonstrating similar predictive values for chemical and early 1st trimester pregnancy losses. These results make sense since chemical pregnancies denote implantations of at least one embryo. Though we do not consider them as “clinical” pregnancies, to consider them within a miscarriage-context makes sense.
CHR, in addition, pays special attention to whether an early 1st trimester miscarriage occurred before or after a fetal heart was detected. Once again, this timing does not categorically differentiate between chromosomal and immunological miscarriages, but miscarriages after fetal heart have a much greater likelihood of being immunological in etiology than earlier losses. As noted earlier, the later a pregnancy loss occurs in pregnancy, the more likely is it immune rather than chromosomal.
Summarizing our diagnostic approach toward causes of miscarriages, CHR will initiate a so-called miscarriage work up in every woman with 2 or more pregnancy losses (chemical pregnancies included) but even after only 1 loss if that loss occurred after a fetal heart was confirmed. In women with autoimmunity, evidence of inflammation and/or with evidence of severe and broadly-based allergies (i.e., in women with a hyper-active immune system) an increased miscarriage risk is assumed even without a history of prior miscarriage (we never understood why one should wait for miscarriages to occur before initiating treatments). The table describes CHR’s general miscarriage work-up. It may be amended if a patient’s medical history calls for additional testing.
In the next portion, we tackle the burning question: How to prevent early miscarriages with proactive treatment.
This is a part of the September 2019 CHR VOICE.
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
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