Recurrent pregnancy losses!

It is seen in about 1% of couples who want to get pregnant. The cause of pregnancy loss cannot be determined in 50% of the patients. On the other hand; The patient should be encouraged in this regard, as it is possible to achieve a live birth in 70% of patients without any treatment, even after three pregnancy losses.

It is known that more than 50% of pregnancies result in miscarriage before or during the expected menstrual period. 85% of miscarriages happen in the first 12 weeks. While an increase in the number of miscarriages the person has, increases the possibility of miscarriage again, while giving birth before raises the probability of a pregnancy that will continue until the birth.

To summarize the causes of recurrent pregnancy loss;

Immune System Problems: autoimmunity is the first factor that comes to mind. Antiphospholipid antibodies (anticardiolipin antibodies-ACA and lupus anticoagulant-LA) values ​​increase in the blood in 15-20% of patients with pregnancy loss. Although factors such as thyroid gland antibodies, anti-nuclear antibodies-ANA, and HLA mismatches between couples are also counted among the causes of recurrent miscarriage, recent information is in favor of these factors not having a role in this issue.

Congenital Anatomical Problems:
It is known that congenital shape and structure disorders of the uterus increase the possibility of miscarriage or premature birth. for example uterine septum -(curtain in the uterus) is the pathology that comes to mind first in this regard. in the uterine cavity adhesions-adhesionsIt is another problem that can cause recurrent pregnancy loss (after abortion, polyp or fibroid surgery or tuberculosis).

Infectious Causes:
Infections such as Chlamydia, Ureoplasm, and Mycoplasma rarely lead to recurrent miscarriages, although the clinician should be investigated if possible.

Genetic Issues:
Chromosomal disorders called balanced translocation can be seen in 1-3% of recurrent pregnancy losses. This disorder is 2 times more likely to be of female origin. If the disorder comes from the mother, the chances of miscarriage are much higher. If the translocation happens on the same chromosome, there is no possibility of a normal baby. Diagnosis of chromosomal disorders in pregnancy; It can be detected by methods such as chorionic villus biopsy, amniocentesis or cordocentesis. Only in this type of patients, preimplantation genetic diagnosis (PGD) performed in in vitro fertilization applications before pregnancy occurs, and the possible anomalies are determined at the beginning and the delivery of a healthy embryo can prevent the repetition of losses.

Endocrinological Causes: Luteal phase failure Although its relationship with recurrent pregnancy loss is frequently mentioned, the possibility of this causal relationship is a very controversial issue. Medical treatments such as clomiphene citrate or progesterone can be used in its treatment. Polycystic ovary syndrome (PCOS) It is a clinical picture in which there are rare or no menstruation, hair growth, acne, obesity, infertility complaints, and an increased probability of miscarriage is observed in this clinical picture. It is thought that this increase may be due to insulin resistance in patients or elevations in LH hormone. In diabetes-DM patients whose blood glucose levels are not well controlled, abortion rates may increase due to this type of insulin resistance increase.

thrombophilia: Factor V Leiden mutation, prothrombin G20210A mutation, protein C and S deficiency, increased homocysteine ​​level, MTFHR 677 and 1298 polymorphisms and antithrombin III deficiency increase the likelihood of abortion by causing a tendency in coagulation and should be screened for diagnosis.

Low Ovarian Reserve:Although ovarian reserve decreases with age, ovarian reserve may deteriorate at younger ages in some people and this picture may cause miscarriages.

Other Causes: Smoking, alcohol and stress can be counted among other important factors.

DIAGNOSIS

To screen for genetic factors; If the number of men, women and miscarriages is more than 2, the chromosome structure of the fetus is also checked.
In terms of ovarian reserve, PCOS and hormone evaluation; Progesterone values ​​can be checked on the 21st day of menstruation to investigate fasting insulin/fasting blood sugar ratio and ovulation-ovulation in E2, FSH, LH, TSH, PCOS. In addition, in terms of ovarian reserve; Blood inhibin B and AMH values, antral follicle numbers in ultrasonography can provide valuable information.
Methods such as HSG-uterine film, sonohysterography or office hysteroscopy can be used in the diagnosis of congenital anomalies and structural disorders of the patient.
In terms of the immune system; antiphospholipid antibodies, LA, anti cardiolipin antibodies can be checked. In terms of thrombophilia, all mutation tests mentioned above should be checked, and cervical cultures should be taken for infection.

TREATMENT

For genetic causes, the best course of treatment is preimplantation genetic diagnosis. However, if the patient does not want to resort to in vitro fertilization, diagnostic methods such as amniocentesis can be applied during pregnancy.
If a septum is seen in the uterus for anatomical reasons, it should be removed hysteroscopically. If there is insufficiency in the cervix, stitches can be placed after the 14th week of pregnancy.
If a hormonal disorder is detected due to endocrinological reasons; cause should be treated. In patients with polycystic ovary syndrome, there is no definitive solution. As a result of the suppression of LH with GnRH analogues, no significant difference was observed in the miscarriage rate.
If antiphospholipid antibodies or lupus anticoagulant are positive, heparin and aspirin therapy is applied. If an infection is detected in the cervix, appropriate antibiotic therapy should be initiated. Heparin should be used in the treatment of thrombophilic cases. There is no specific treatment for ovarian reserve reduction. Smoking and alcohol use should be stopped.
Despite all research, no factor can be detected in 50% of patients. In this case; Either the patient is encouraged to become pregnant again, considering that pregnancy may occur up to 70% after three pregnancy losses, or the patient is encouraged to get pregnant again and only after the embryos are genetically examined with PGD after the patient is taken into in vitro fertilization application.
normal embryos are transferred. Studies show that the application of PGD to patients with recurrent pregnancy loss increases the ongoing pregnancy rates.

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