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Can Recurrent Miscarriage Be Prevented?

Miscarriages take an emotional toll. You’re excited about the growing baby inside. You plan for your due date – will it be a holiday? Summer break? Major project with work? Final exam? Will it be a boy or a girl? You make sure to get your folate, keep iron levels high enough, and stay away from too much caffeine. Your life revolves around your pregnancy. And then, you go for an ultrasound, and find out sad news: This baby is not meant to be.

One miscarriage is considered normal, especially in the first trimester, and if followed by a healthy pregnancy. In fact many women experience a first trimester miscarriage in their lives -statistically it’s 15-25% of all pregnancies. On the personal level, when you speak openly to your family and friends, you’ll likely hear, “Yes, that happened to me, too.”

But for women who experience at least two miscarriages in a row, the situation can feel devastating, even hopeless. Longingly, they search for an underlying reason in order to find a solution to carry a healthy baby to term. Thankfully, more medical solutions are available to combat recurrent pregnancy loss (RPL), and we address them here.

The Problem with D&C

Many miscarriages are expelled via D&C, or dilatation and curettage, a surgical procedure for removing tissue from the uterus.  The main problem with D&C is its risk of causing uterine-wall adhesions (depending on the severity, might also be referred to as Asherman’s Syndrome). Uterine adhesions can lead to further miscarriages, or infertility due to inability to conceive or implant.

If the miscarriage doesn’t happen spontaneously, D&C is usually performed, under the premise that infection could occur if the tissue is not expelled within a reasonable time frame. Hospitals might initially provide a drug to induce the miscarriage, however the drug might not work immediately, leading to a D&C.

Reduce the Risk: Perform D&C with Hysteroscopy

To vastly reduce the risk of uterine adhesions due to D&C, a relatively new alternative is now an option: Hysteroscopy before and after D&C. Hysteroscopy uses a thin, lighted, flexible tube that examines the inside of the uterus. The procedure is used prior to D&C, in order to determine the best process for D&C. Afterward, hysteroscopy is used as a follow-up to assess whether extraneous tissue is fully removed. 

In the US, the combination of D&C with hysteroscopy is already taking place in Stanford, California as well as other places. In Israel, the combination procedure is used at Hadassah Hospital on Mount Scopus in Jerusalem, Assaf HaRofeh Medical Center in Beer Yaakov, and the Hillel Yaffe Medical Center in Hadera, and increasingly at other hospitals.

Baseline Assessment
After recurrent miscarriage, it is recommended to undergo a reproductive organ assessment via hysteroscopy, as well as a 3D ultrasound. These procedures check for uterine abnormalities. 

Causes of miscarriage

  1. Unknowingly taking medications contraindicated for pregnancy. Some drugs should be discontinued before conception, as they can cause miscarriage. 
  2. Uterine shape. If the uterus has a division (septum), or is unusually narrow, this can cause second-trimester pregnancy loss. Septums and shape can be assessed by hysteroscopy, and shape alone can be assessed by 3D ultrasound.
  3. Endometritis – inflammation of the inner lining of the uterus. If not treated early enough with antibiotics, a miscarriage can ensue. If all other miscarriage causes are ruled out, a doctor can order a biopsy. Note that doctors might not be aware of this issue as a miscarriage cause.
  4. Sperm health.  If sperm are not optimal, the solution is usually surgical – removing the healthy sperm to use for fertility treatments, such as IVF or IUI. Note: Removing sperm involves serious consultation with a rav regarding the halachot involved.
  5. Hydrosalpinx (fallopian tube fluid build-up). If the fluid build-up spills into the uterus, surgical removal of the fallopian tube(s) is indicated. If fluid build-up is local to the fallopian tube, the couple can go through IVF in order to bypass the fallopian tube. Another option is tubal corrective surgery, however this carries a risk of continued infertility.
  6. Using IVF directly after RPL. IVF is sometimes recommended after RPL, because it allows for testing the embryo for genetic problems before implantation. (The lab test is called PGT-A – preimplantation genetic testing for aneuploidies). However, a new study recommends against IVF after RPL, favoring a full diagnosis to determine the appropriate medical treatment, instead of using IVF as the only resort.
  7. Genetic causes. Assessing whether the miscarriage occurred due to genetic problems is mentally and emotionally advantageous for the couple. If there is no known genetic cause, the couple can know to pursue other causes. If there is a possible genetic cause, the couple can take advantage of fertility assistance laboratory procedures to try to avoid genetic problems before conception. 

Genetic causes can be determined by testing cells from the miscarriage tissue, or via parental blood test. Since hospitals test cells after a D&C, the blood test option is particularly advantageous for women who prefer to avoid the emotional trauma or physical risk of a D&C, or whose miscarriages happened spontaneously, and no cells could be collected.

In Conclusion

Today, we have more advanced procedures for handling miscarriage. For one, it is possible to reduce risks of D&C by using hysteroscopy. Secondly, there are several ways to possibly diagnose the cause of miscarriages, hopefully leading to a plan to enable a healthy pregnancy.  If you or someone you know has recurrent miscarriages, call the Tahareinu hotline for guidance about your medical options.

Medical input from Rabbi Yitzchok Melber, Tahareinu Founder, President, and Head Case Manager, and Chaya Melber, Director, Tahareinu Hotline and Case Manager