24 year old G3 S3 has decided to undergo a basic recurrent pregnancy loss evaluation.
What are the useful tests for recurrent pregnancy loss
The (best) answer to this question is highly controversial. The controversy is allowed to continue since there is not an adequate amount of factual information to strongly suggest one opinion over another. Therefore, everyone gets a reasonably equal opinion since the opinions are (largely) based on personal experience or preference.
I have identified a relatively small handful of tests that have been proven to be clinically useful. I encourage these tests for anyone undergoing a routine evaluation for recurrent pregnancy loss.
There are a large number of immunologic tests that are currently available yet many of these tests are still of “experimental” value with respect to recurrent pregnancy loss. These tests may prove to be clinically useful once good quality clinical trials have been conducted to show their merit.
36 year old G2 S2 has undergone 2 spontaneous losses within the first 8 weeks of gestation and she would like an evaluation to determine the cause of her losses.
When should a diagnostic evaluation for recurrent pregnancy loss be initiated (encouraged)?
A single random early pregnancy loss is not uncommon, occurring in about 20% of all “clinically detected” pregnancies. Following a single spontaneous pregnancy loss, the couple’s chance for a second spontaneous pregnancy loss (with the next pregnancy) remains about 20%-- the risk is not increased or decreased significantly.
When a couple experiences two consecutive spontaneous pregnancy losses the grief and disappointment are often so intense that the partners start to look for a cause. The best epidemiologic (statistical) data (which is scanty at best) suggests that this couple has about a 35% chance for a pregnancy loss with the next pregnancy.
Due to an elevated risk for a future pregnancy loss, and the possibility of identifying a treatable cause of recurrent pregnancy loss, a diagnostic evaluation for causes of recurrent pregnancy loss may reasonably be initiated following 2 consecutive losses (if this is desired by the couple).
Of note, recurrent pregnancy loss is “classically” defined as 3 consecutive spontaneous losses and some insurance companies will not cover a diagnostic evaluation after only 2 such losses. The couple can (should) check their insurance coverage prior to initiating an evaluation.
Although I do not discourage a recurrent pregnancy evaluation after 2 consecutive pregnancy losses, I usually (actively) encourage a recurrent pregnancy loss evaluation if there have been 3 consecutive losses (without a prior evaluation).
31 year old G4 S4 desires a complete recurrent pregnancy loss evaluation except for the hysterosalpingogram (HSG). The patient is concerned about the HSG since she has been told by her friends that the test is “killer painful.”
How much pain is involved with a hysterosalpingogram and is it really necessary for a recurrent pregnancy loss evaluation?
Anatomic causes of recurrent pregnancy loss are usually treatable (if identified) and they are generally easy to diagnose with a hysterosalpingogram. Therefore, I believe that the HSG should be a test routinely performed during the evaluation of couples with recurrent pregnancy loss.
I have heard many complaints from couples that the HSG has a reputation for causing (severe) discomfort. I go to the local radiology center and I perform the HSG tests myself for all of my patients. I do this so that I can see the entire study (not just films from a few seconds of the study) and I have not had patients complain of pain during the procedure. If the HSG is performed in a delicate manner with a very slow insufflation of radiopaque dye then the study (in my experience) is usually not associated with (any significant) discomfort.
Sonohysterography is an alternative method of assessing the uterine cavity. In my experience, sonohysterography is less sensitive at diagnosing uterine cavity abnormalities.