Dear Friends,
Spring is in the air – and we hope this beautiful season finds you healthy and happy.
At Tahareinu, every season finds us exploring the latest innovations in women’s health and fertility – and today, we bring you a comprehensive guide on yet another topic that affects an unfortunately high number of couples in our community.
Thank you for your incredibly positive feedback on our previous two guides; we hope this one provides valuable guidance as well.
May we know only Simcha in our families and throughout Klal Yisroel.
Rabbi Yitzchok Melber
RPL (Recurrent Pregnancy Loss):
A GUIDE FOR COUPLES AND MEDICAL PROFESSIONALS
Although traditionally RPL has been an underacknowledged topic in reproductive health, in the past couple years there has been a significant uptick in its research by the medical community. This is specifically beneficial to our community, where couples may be searching for solutions even after giving birth to several children.
Today, the medical world has recognized this as a medical condition that requires research, guidelines, and treatment.
Over the past several years, Tahareinu has amassed a tremendous amount of knowledge in this area, gleaned from numerous medical conferences, intense research, and vast experience with struggling couples.
A TRIO OF KEY FACTS ABOUT RPL:
1.
In today’s advanced medical climate, there are solutions for this challenge. In many cases, the cause can be detected, and even if not, the case can be managed effectively. In the past, the treatment took on a “guessing game” nature. Now, we have protocols and various treatment approaches. Many couples, even those who have suffered numerous miscarriages and even those who think they have exhausted all avenues, can experience a successful birth.
➡ In general, couples are advised to perform a complete workup even once they pinpoint a problem, because in more than 50% of cases there are multiple causes.
2.
The vast majority of RPL couples do not need IVF to give birth successfully.
Contrary to popular belief, the journey of RPL does not usually need to end in an IVF clinic. Of course, if a couple approaches an IVF specialist with their history, they will “sell” them an IVF protocol. But in most cases, according to the guidelines in both the US and ESHRE, it is not the recommended solution. This can be very confusing to couples, which is why Tahareinu will clarify further in this guide.
Most people who struggle with RPL and do IVF/PGTA without the prior proper workup, will still have miscarriages. The proper testing is cheaper and less stress-inducing than even one IVF cycle.
➡ IVF is a viable solution in less than 2% of the RPL cases.
3.
Most of the available options for RPL treatment are not in consensus. There are differing guidelines because this is a relatively new topic with not enough conclusive research.
Tahareinu’s guidance is based on the guidelines of ESHRE and the textbooks written by Professor Howard Karp and Professor Asher Bashiri, who are both international leaders in this specialty and have treated hundreds of patients in Israel successfully at their RPL clinics
Recently, ESHRE (European Society of Human Reproduction and Embryology) published an updated paper as of 2022. This is the most up to date guidance in the world; in the States there have been no new guidelines published since 2012.
Their research has been conducted on millions of women and is widely accepted, below, we present an extensive compendium using both their guidelines and our experience.
RPL: THE RUNDOWN
Most miscarriages occur in the first trimester, and if a woman has more than one miscarriage, that is considered RPL. Of course, treatment will vary based on numerous factors, such as number of live births, number of miscarriages, and others.
One of the most common questions we get asked is: What kind of doctor should we see for RPL?
Ideally, one should visit an RPL clinic with a multidisciplinary approach. The big challenge here is that in many countries, there are no real RPL clinics, which necessitates going to the local experts.
Therefore, it is especially important for patients to be educated and empowered by learning what’s available and what they’re seeking.
Tahareinu helps people from all over the world with education, guidance, and referrals. Often, we will direct a couple to a doctor in a different country to develop the protocol for treatment which can then be implemented locally.
WHAT HAPPENS AFTER ONE MISCARRIAGE?
After one miscarriage in the first trimester, there is no medical need to do any workup; however, Tahareinu recommends doing hormonal profile via blood test on day 3 of the cycle, including TSH, Vitamin D, and AMH. This is an easy and non-invasive way to test for and correct simple common hormonal problems with medication or vitamins, so there is no reason to wait for another miscarriage.
In the US it is suggested taking micronized progesterone after one miscarriage for the following pregnancy. Her is the outline for taking it properly:
- For 1 or 2 unexplained miscarriages, she can either wait until she’s pregnant or even start 2 days after ovulation.
- She should use only the vaginal suppository form of progesterone, as the pill has been proven to have zero impact.
- The correct dosage is 400 mg, taken as two suppositories in the morning and 2 at night.
- If she lives in a country that has Duphaston (such as Europe or Israel, she should request that as it is by far the most effective. This is a pill, and should be taken as 1 pill every 8 hours or 1 pill in the morning and 1 at night.
- Progesterone is taken until about week 12 unless the doctor recommends differently.
- Although progesterone is in debate and a lot of research is still being conducted regarding its efficacy, there are no downsides or negative side effects to taking it.
SECOND MISCARRIAGE: WHAT NOW?
Women who experience two pregnancy losses largely follow the same protocol as after one, with the addition of several tests:
- A panel for clotting issues, both thrombosis and acquired thrombophilia. These are treated with blood thinners, a low dose of aspirin, and/or heparin via injection.
- Rule out uterine abnormalities either inside the uterus (septum, adhesions) via hysteroscopy or the shape via 3D ultrasound. Septum is the most common abnormality, and if found it is generally recommended to remove it with a hysteroscopy procedure.
If either of the above issues is detected, we treat them and use progesterone in the following pregnancy.
THREE MISCARRIAGES: WHAT TO ADD
After 3 pregnancy losses, we do all of the aforementioned testing, with the addition of the following:
- Clotting issues such as Factor 2, Factor 5, MTHFR, Protein C and S, and others. This workup is in debate, but most experts and Tahareinu recommend it.
- Look for chronic endometritis via hysteroscopy and a biopsy. It has been shown to be very beneficial. Because endometritis has no symptoms, no pain, and no bleeding, the only way to know about it is a miscarriage (or RIF).
- Karyotype for both parents to check for balanced translocation which will cause miscarriages.
- Check the karyotype of the fetus or via CMA. There is a great benefit to knowing if this was a healthy pregnancy, so although we avoid extraneous genetic testing, this is a singular test to know if there are healthy chromosomes. An additional benefit is the emotional relief of knowing one is not at fault and that the child would likely not have been healthy. Medically, of course, this will have implications for treatment: if there was a genetic issue, we won’t continue the workup but if it was a healthy pregnancy, we will continue to search for causes.
Please note: This is a Halachic (when one is taking cells from a fetus) and Hashkafic issue, and should be discussed with one’s Rav. In general, when there is a medically indicated reason, one will get the go-ahead.
If the testing on the fetus comes back problematic, IVF with PGT-A will often be recommended ONLY, after many miscarriages with chromosomal abnormalities.
- There is an HCG injection which is controversial, but supported by ESHRE.
AFTER FOUR OR FIVE MISCARRIAGES:
Test for autoimmune/immunological issues at this point. It’s a very expensive test in most countries, and is recommended on an individual basis. If these problems are diagnosed, the treatment is IVIG (immunotherapy) or Prednisone.
THE MALE FACTOR
Although in the medical world one would begin testing the husband after 2 miscarriages, we wait longer due to halachic concerns. We can offer first-line treatment such as vitamins right away, which can be helpful in some instances.
We test the DFI (DNA Fragmentation Index) by semen analysis. We also check for a varicocele if the DFI is high, and correct it if necessary. Sometimes, IVF is necessary, often with halosperm or other technology to extract the undamaged sperm.
One can ask their Rav to get a heter for DFI testing after 2 miscarriages as well, if the situation warrants it.
IN CONCLUSION:
Even if RPL is unexplained, we still do our utmost to treat it:
| Number of miscarriages | Testing/action |
|---|---|
| 1 | Micronized progesteroneVitamin D |
| 2 | Clotting issues Abnormalities in uterus |
| 3 | Genetic testing/karyotype Autoimmune testing HCG injection Endometritis IVF where indicated |
| 4+ | DFI/varicocele IVIG/Prednisone IVF where indicated |
TAKEAWAYS FROM THE ESHRE GUIDELINES:
- There is no need to perform any testing before taking micronized progesterone
- It is strongly recommended for couples with RPL to asses the lifestyle in the male partner, such as exercise, body weight, smoking, and drinking, in order to improve the quality of the sperm.
- This is the first time DFI testing is officially specified in the guidelines.
- There are no high quality studies to show that the shape of the uterus affects pregnancy loss probability, but on an individual basis it can be recommended to widen the uterus.
- IVIG is recommended for unexplained RPL as well.
UNEXPLAINED RPL:
While we now have a clear, step-by-step workup for explained RPL, unexplained RPL is more vague and needs to be assessed on a case-by-case basis. In general, one would follow this list of treatments:
- Progesterone for the first 12 weeks of pregnancy. The vaginal suppository is the most important but others may be added.
- Prednisone (This is inexpensive, widely available, and doesn’t cause side effects)
- HCG injections (after 3)
- IVIG/LIT (after 4)
We hope this guide has been helpful, but of course, our most fervent wish is for it be unnecessary. Wishing all of Klal Yisroel the Bracha of healthy children without pain or hardship.
Call the Tahareinu Hotline!
Got a question about relieving tahara problems, infertility, reproductive health, pain or other related issues?
call the Tahareinu hotline
For ongoing infertility, recurrent pregnancy loss, or reproductive genetic issues,
you and your spouse are warmly invited to schedule an in-person, phone or Zoom consultation with our founder and president, Rabbi Yitzchok Melber.
Please send an email to rabbimelber@tahareinu.com Include your first name and location, and briefly describe your issue.
Personal consultations are for more involved reproductive issues. Note the Israel
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