Recurrent Pregnancy
Recurrent Pregnancy Loss Testing
Almost anyone who has suffered a miscarriage or stillbirth worries about the risk of having subsequent losses. Recent information indicates that women should look into RPL testing after two losses when it used to be common to wait until three. This is especially important for women in their 30s and 40s. Newer studies indicate a miscarriage rate of 26-40% after a woman has suffered two losses, so earlier testing makes sense emotionally, physically, and in many cases financially as well.
The tests and procedures listed below are a mixture of the common elements of a recurrent pregnancy loss (RPL) work-up and some of the more controversial immunological screenings. A doctor might choose to do any or all of them depending on the patient’s needs.
Along with basic description, there is an average cost or a price range listed for most tests. A pretty small sample was used to get these numbers, so please just use them as a general idea, nothing definite. You’ll have to check with your doctor to get his or her prices, and check with your insurance to see what will be covered.
Infectious
* Ureaplasma culture
* Ureaplasma & Mycoplasma billed together
* Gonorrhea culture
* Chlamydia culture
* Syphilis
* Toxoplasmosis
* Rubella
* CMV
* HEP B&C
* HIV I & II
Some of these are infections that can be treated with antibiotics. For ureaplasma, for example, the standard treatment is 10 days of doxycycline for both partners, and condoms used during intercourse until a negative culture is obtained.
With rubella, your immunity to the disease will be tested. If you show low immunity, you may receive an MMR vaccine. It’ll be suggested that you put off trying to get pregnant for three months following the immunization, even though no known cases of rubella syndrome have been linked to the vaccine. It should be noted that you are more likely to have a low rubella immunity if you are over 30 years of age.
There’s lots of information out there about these infections out on the web, so I won’t go into any more detail here.
Autoimmune
* Anti-phospholipid Antibodies
* Anti-cardiolipin Antibodies
* Lupus Anticoagulant
Note that anti-cardiolipin antibodies (ACA) are part of the group of anti-phospholipid antibodies (the other six are Phosphoethanolamine, Phosphoinositol, Phosphatidic acid, Phosphoglycerol, Phosphoserine, and Phosphocholine). It is fairly common to test for ACA, but a full work-up includes all seven anti-phospholipid antibodies being checked for three markers: IgG, IgA and IgM markers (so 21 different markers in all).
These tests diagnose a condition that can cause mainly 2nd trimester losses due to blood clots forming in the vascular system of the placenta. The condition is also responsible for some late 1st trimester losses, after heartbeat is identified and some intra-uterine growth retardation has been observed.
This is the cause of about 10% or so of RPL. The treatment usually involves low-dose aspirin and heparin.
* Anti-Nuclear Antibodies
* Anti-Thyroid Antibodies
Thyroid
* Thyroid panel (TSH) – Thyroid problems can result in both fertility problems and miscarriage. If a problem is found, your physician will in many cases attempt to regulate the thyroid before another pregnancy is achieved.
Chromosomal
* Chromosome Testing on Fetal (Miscarriage) Tissue This can only be done right at the time of miscarriage. It is an analysis of the genetic makeup of the fetus. It can indicate genetic problems that lead to RPL. Many miscarriages are caused by chromosomal abnormalities that are unlikely to repeat. To know if the problem is likely to recur, it is necessary to study the genetics of both parents as well.
* Karyotyping of Parents – Chromosome analysis of blood of both parents. It can show if there is a potential problem with one of the parents that leads to miscarriage, but often has to be done in conjunction with fetal testing to provide answers.
These tests help rule out the 3% or so of partners that carry a “hidden” chromosomal problem called a balanced translocation.
Anatomical
* Abdominal Ultrasound -This is performed by moving a transducer across the bare skin of the abdomen. It’s usually recommended that you have a full bladder for this test — that’s the uncomfortable part. It doesn’t usually hurt, although the lubricant is cold and the person performing it sometimes presses a bit too hard.
* Transvaginal Ultrasound – The transducer on a transvaginal ultrasound is a long probe. Before insertion, it will be covered with a condom and some lubricant. Once inside, it will be moved about a bit to get the best view. It can be a little unpleasant if handled roughly, but mostly it’s just awkward.
* Hysterosalpingogram (HSG) -A hysterosalpingogram is where dye is injected into the uterus to look for anatomic problems, such as fibroids, polyps, or structural problems with the uterine cavity, which are thought to cause about 15% of RPL. This test is usually done in the first half of a woman’s cycle, around day 8-9. A small catheter is inserted through the cervix in order to inject the dye. You’ll be expected to turn a little as the doctor / radiologist takes pictures or views the process through something that looks a lot like an ultrasound. It should only last about 5 minutes. Some cramping and discomfort is common during the procedure and for a little while afterward. Also, some spotting is to be expected. Your doctor may prescribe antibiotics and suggest a painkiller be taken.
* Hysteroscopy – This is usually done under local or general anesthesia. Your cervix is dilated in order to insert a tiny scope which the doctor uses for viewing the inside of your uterus. Often carbon dioxide gas is used to expand the uterus for better viewing. Minor abnormalities may be fixed during this procedure, and it is sometimes done in conjunction with a laparoscopy, hysterosalpingogram, and/or an endometrial biopsy. Timing within the cycle varies — alone it might be done at the beginning of a cycle, with a laparoscopy it is usually done around ovulation, and with a biopsy it would be performed a few days before your period. Expect some discomfort and cramping afterward, spotting, and some shoulder pain if gas was used. It’s probably a good idea to take the rest of the day off and relax. Have some over-the-counter pain relief available or ask your physician for a prescription.
* Laparoscopy A laparoscopy is done to look for endometriosis, adhesions and organ malformations. The patient is usually under general anesthesia for this. First, carbon dioxide gas is used to expand the abdominal cavity to provide better viewing. The doctor will then insert a scope through a small incision inside the navel or just below it to view the outside of the uterus, ovaries and fallopian tubes. Often a second incision is made just below the pubic hairline through which an instrument is inserted to gently manipulate the organs to allow the scope to examine different angles. If found, endometriosis and adhesions may be removed during this surgery. Expect some pain and cramping, some shoulder pain from the gas, perhaps some nausea from the anesthesia, and some spotting. Definitely take at least a day to relax and recover, more time if you can manage it. Ask your physician about pain relief.
Luteal Phase Defect
A luteal phase “defect” is when the length of time between ovulation and menses is under 10 days (some say 12) and/or the lining of the uterus does not develop enough to sustain a pregnancy
* Endometrial Biopsy (EMB) The endometrial biopsy is used to “date” the lining to see if it is out of sync hormonally. It is considered out of phase if it the lining appears to be more than 2 days off. It is common to repeat the biopsy in another cycle, if it is found to be out of phase, before a diagnosis of a luteal phase defect is made. These tests are somewhat insensitive and I was told “about as good as the pathologist reading it.”
The biopsy is performed in the second half of the cycle, usually just a few days before menstruation is expected. It can be done in the same cycle as one in which you are trying to get pregnant because the risk of miscarriage from the biopsy is only about 1% (combine that with your chances of getting pregnant in a given cycle and there isn’t much to worry about at all).
The biopsy is done by inserting a narrow catheter through the cervix and into the uterus. A small sample of tissue is sucked into the tube and sent to the lab for analysis. Expect a bit of discomfort with this test — about the same as a bad menstrual cramp. The biopsy doesn’t take long, and the pain usually subsides when the procedure ends. You may have some spotting afterward.
Some suggest taking Advil or Aleve about a half hour before the test to relieve discomfort. Check with your doctor first, since this may not be recommended during a cycle in which you are trying to get pregnant. My own experience is that the pain relievers didn’t make any difference.
Serum Progesterone Level
The serum progesterone level is a blood test. These also have reliability problems. Several physicians contacted about this issue said that 2-3 tests are needed, and one said that for best results it should be done early in the morning and after fasting. A good result is over 10, 15, or 20 ng/ml, depending who you listen to.
Treatment:
A common treatment for a luteal phase problem is progesterone supplementation in the form of suppositories, injections, pills, or a combination of the above. The progesterone must be started at the time of conception (ovulation) in order to be useful. If started later, there is no statistical change in the rate of miscarriage.
Other doctors will suggest that a better ovulation is key to solving the luteal phase issue, and will recommend Clomid, Metrodin, Pergonal, and/or hCG injections.
Alloimmune
# Leukocyte Antigen crossmatch and Natural Killer Cells – $245
# Embryo Toxicity Panel – $242
A very few researchers are working on HLA, human leukocyte antigen, testing to determine if, simply put, the sperm and egg are “allergic” to each other. This is very controversial, and many people just don’t believe it’s a cause of RPL. The research in this area is fairly new and it may take some work to find a doctor to run these tests.
Diabetes
* Fasting Blood Sugar – $30 There is a link between elevated blood sugar/diabetes and stillbirth. The connection to miscarriage may more closely associated with insulin, but it makes sense to check both glucose and insulin levels.
* Fasting Insulin This is a relatively new thing to look into, but insulin resistance comes before adult onset diabetes and there is a clear link between elevated insulin levels and miscarriage. Often insulin resistance is found in women with polycystic ovary syndrome (PCOS).
* Glucose Tolerance Test with Insulin The GTT can detect diabetes and insulin resistance earlier than the fasting levels alone.
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