Recurrent Pregnancy Loss

Infertility and recurrent pregnancy loss

Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year for most people and six months in certain circumstances.

It is a myth that infertility is always a “woman’s problem.” About one third of infertility cases are due to problems with the man (male factors) and one third are due to problems with the woman (female factors).

Other cases are due to a combination of male and female factors or to unknown causes.

Recurrent First trimester pregnancy loss

(under 12 weeks)

Pregnancy loss or miscarriage unfortunately is common in the first trimester.

The majority is due to genetic abnormalities in the embryo formation. This can happen without necessarily a family history, and can happen to any couple. Obviously increased maternal age will increase the risk.

Recurrent miscarriages in the first trimester however can be associated with various other problems, including

blood disorders,
immunological disorders,
metabolic disorders,
pelvic pathology like endometriosis and
uterine cavity abnormalities like adhesions, uterine septum and intra uterine fibroids

We test for the above and address as appropriate.

Recurrent Second Trimester

(between 16-22 weeks)

Pregnancy Loss due to Cervical Incompetence

Cervical sutures can be either trans-vaginal inserted prophylactically at around 11-13 weeks gestation or Transabdominal cervical suture

Fertility Treatments for Women with Cervical Incompetence

Transabdominal placement of a cerclage at the cervicoisthmic junction appears to be a safe and effective procedure for reducing the incidence of spontaneous pregnancy loss in selected patients with cervical insufficiency.

Potential advantages of transabdominal over transvaginal cerclage are more proximal placement of the stitch (at the level of the internal os), decreased risk of suture migration, absence of a foreign body in the vagina that could promote infection, and the ability to leave the suture in place for future pregnancies.

A disadvantage of this approach is the potential need for laparotomy to place the suture and then C/S for delivery of your baby.

Transabdominal placement of a Cerclage

A disadvantage of this approach is the potential need for laparotomy to place the suture and then C/S for delivery of your baby.

Timing of Transabdominal cerclage

Transabdominal cerclage placement is usually performed either prior to conception or during early pregnancy (at 11 to 14 weeks). Placement of the cerclage later in pregnancy is undesirable since the large size of the uterus makes the procedure difficult and thus may be associated with a higher risk of complications.

Indications and Contraindications

Transabdominal cerclage is a more morbid procedure than transvaginal cerclage. It usually requires a laparotomy for placement and delivery by cesarean. For these reasons, most experts recommend reserving the transabdominal approach for women with cervical insufficiency who have either failed two or more previous transvaginal cerclages or in whom a transvaginal cerclage is technically impossible to perform due to extreme shortening, scarring, or laceration of the cervix.

No studies have compared the outcome of patients who underwent surgery prior to conception versus those whose placement was in early pregnancy. The pre-conception approach is associated with less blood loss and avoids the risk of pregnancy-associated complications (eg, rupture of the fetal membranes).

Contraindications to transabdominal cerclage are similar to those for transvaginal cervical cerclage