DOCSLIB.ORG

Evaluation and Treatment of Recurrent Pregnancy Loss: a Committee Opinion

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Evaluation and Treatment of Recurrent Pregnancy Loss: a Committee Opinion PRACTICE COMMITTEE Evaluation and treatment of recurrent pregnancy loss: a committee opinion The Practice Committee of the American Society for Reproductive Medicine American Society for Reproductive Medicine, Birmingham, Alabama The majority of miscarriages are sporadic and most result from genetic causes that are greatly influenced by maternal age. Recurrent pregnancy loss (RPL) is defined by two or more failed clinical pregnancies, and up to 50% of cases of RPL will not have a clearly defined etiology. (Fertil SterilÒ 2012;-:-–-. Ó2012 Use your smartphone by American Society for Reproductive Medicine.) to scan this QR code Earn online CME credit related to this document at www.asrm.org/elearn and connect to the discussion forum for Discuss: You can discuss this article with its authors and with other ASRM members at http:// this article now.* www.ASRM.org/fns-xx-x-xxx * Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace. linically recognized pregnancy cal evaluation may proceed following agrees that genetic causes should be loss is common, occurring in two first-trimester pregnancy losses. evaluated and appropriate treatments C approximately 15–25% of preg- considered (4–6, 9).Unfortunately, nancies. The majority of sporadic losses ETIOLOGY OF RECURRENT clinical genetic testing remains ’ before 10 weeks gestation result from PREGNANCY LOSS rudimentary and rarely includes random numeric chromosome errors, molecular studies which show promise specifically, trisomy, monosomy, and Studies that focus on RPL have exam- in helping to elucidate mechanisms for polyploidy (1). In contrast, recurrent ined factors related to genetics, age, RPL. There is a very high frequency of pregnancy loss (RPL) is a distinct disor- antiphospholipid syndrome, uterine sporadic karyotypic abnormalities in der defined by two or more failed clinical anomalies, thrombophilias, hormonal products of conception while the pregnancies (2). It is estimated that or metabolic disorders, infection, incidence of karyotypic abnormalities fewer than 5% of women will experience autoimmunity, sperm quality, and life- in the parents is low. two consecutive miscarriages, and only style issues (Table 1). Several recom- Of the examined products of 1% experience three or more (3). mendations have been published (5, 6) conception, approximately 60% of early regarding the evaluation and man- pregnancy losses are associated with agement of RPL. These publications do sporadic chromosomal anomalies, WHO TO EVALUATE fi not support de nitive conclusions primarily trisomies that are, in part, The challenge for clinicians is to differ- about the causes of RPL because most entiate sporadic miscarriage from RPL. age related (1, 10, 11).Inthoselosses studies of pregnancy loss have focused with a normal karyotype, gross Self-reported losses by patients may on sporadic miscarriage and not RPL. not be accurate. In one study, only morphological abnormalities in the A putative diagnosis will be made and fetus diagnosed by transcervical 71% of self-reported clinical pregnancy treated in approximately 50% of fi embryoscopy have been described in losses could be veri ed in hospital re- patients with RPL (7, 8). The following cords (4). For the purposes of determin- 18% of patients (12). The risk of overview acknowledges that our sporadic miscarriage between 6 and 12 ing whether evaluation for RPL is understanding of this field is in flux. appropriate, pregnancy is defined as weeks of gestation in women less than a clinical pregnancy documented by ul- 35 years of age is 9% to 12% (13, 14). trasonography or histopathological Cytogenetic Abnormalities in The risk increases in women over examination. Ideally, a threshold of Pregnancy Loss 35 years of age due to the markedly three or more losses should be used Virtually every published set of recom- increased incidence of trisomic for epidemiological studies while clini- mendations and reviews on this topic pregnancies (10). In women older than 40 years of age, the sporadic Received June 22, 2012; accepted June 25, 2012. miscarriage rate approaches 50% (1, 14, Correspondence: American Society for Reproductive Medicine, 1209 Montgomery Highway, Birming- ham, AL 35216 (E-mail: [email protected]). 15) (Fig. 1). The risk of aneuploidy at each age is lower in women with RPL Fertility and Sterility® Vol. -, No. -, - 2012 0015-0282/$36.00 than in those who undergo sporadic Copyright ©2012 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2012.06.048 miscarriages (11). VOL. - NO. - / - 2012 1 PRACTICE COMMITTEE 2 TABLE 1 Suspected causes of recurrent pregnancy loss. Cause Contribution to RPL (%) Recommended screening Supportive scientific evidence Controversial scientific evidence Not recommended Cytogenetic 2–5 Balanced reciprocal translocations aPL syndrome 8–42 (mean, 15) Lupus anticoagulant, IgG and IgM antibodies, IgG or IgM anti-annexin A5, ANA, antithyroid antibodies anticardiolipin IgG aPL testing for other anti-factor XII, anti- or IgM antibody, phospholipids and b2 prothrombin, IgA aPLs anti-b2-glycoprotein I glycoprotein I Anatomic 1.8–37.6 (mean, 12.6) Hysterosalpingography Congenital uterine Uterine fibroids, polyps Cervical incompetence Sonohysterography abnormalities Hormonal or metabolic Prolactin Uncontrolled diabetes Polycystic ovary syndrome and TSH or thyroid disease, prolactin insulin resistance, luteal Hemoglobin A1c phase progesterone Infectious None Bacterial vaginosis, endocervical infections Male factors None Abnormal sperm DNA Psychological None Psychological effects on uterine receptivity Alloimmune None Mucosal CD16À NK cells, Circulating CD16À NK cells embryotoxic factor, cytokine profiles, blocking antibodies, HLA typing, anti-paternal leukocyte antibodies, circulating CD16À NK cells Environnmental, occupational, History Not related to recurrent or personal habits pregnancy loss Note: ANA ¼ antinuclear antibodies; aPL ¼ antiphospholipid. Practice Committee. Recurrent pregnancy loss. Fertil Steril 2012. VOL. - NO. - / - 2012 Fertility and Sterility® carrier status. Currently, routine preimplantation embryo FIGURE 1 aneuploidy screening is not justified (20, 21). If the evaluation of RPL identifies a remediable cause, cy- togenetic analysis of subsequent losses can be employed to evaluate whether the event was random and not a treatment failure per se. Testing of the products of conception may also be of psychological value to the couple (6). There are pitfalls to this approach, however, including: the possibility of maternal tissue contamination of the specimen; failure to seek other causes of RPL if cytogenetic assessment reveals an abnormal karyotype; and the occurrence of non-cytogenetic embryonic abnormalities (e.g., dimorphic fetal development has been documented via hysteroscopy prior to dilatation and evacua- tion in the setting of normal fetal karyotype) (12). In the event that cytogenetic analysis of the products of conception re- veals a 46,XX karyotype, reflex DNA extraction and analysis of a sample of maternal blood by means of microsatellite analysis can permit differentiation between a fetal source vs. maternal contamination (22). Kaplan-Meier plot showing percentage of women in the recurrent miscarriage cohort who have had at least one live birth after first Antiphospholipid Syndrome consultation by number of miscarriages before first consultation. (Lund et al. Recurrent miscarriage and prognosis for live birth. The antiphospholipid syndrome is associated with recurrent Obstet Gynecol 2012.) pregnancy loss. The diagnostic criteria are outlined in Practice Committee. Recurrent pregnancy loss. Fertil Steril 2012. Table 2 (23, 24). Although it is generally agreed that between 5% and 20% of patients with recurrent pregnancy loss will test positive for antiphospholipid antibodies (aPLs), In the evaluation of RPL, parents should undergo periph- the actual reported range varies between 8% and 42% (24, eral karyotyping in order to detect any balanced structural 25). Several groups of investigators have characterized these chromosomal abnormalities. Balanced reciprocal transloca- antibodies in laboratory-specific assays that have not been tions and Robertsonian translocations (6) are observed in standardized (23). The most widely accepted tests are for lupus about 2%–5% of couples with recurrent miscarriage. Genetic counseling is important when a structural genetic fi factor is identi ed. The likelihood of a subsequent healthy live TABLE 2 birth depends on the chromosome(s) involved and the type of rearrangement. When one of the partners has a structural International Consensus Classification criteria for the genetic abnormality, preimplantation genetic testing (PGT), antiphospholipid syndrome (APS) (23, 24). amniocentesis, or chorionic villus sampling are options to APS is present if one of the following clinical criteria and one of the detect the genetic abnormality in the offspring. Treatment laboratory criteria are met. options include preimplantation genetic diagnosis (PGD) Clinical criteria fi 1. Vascular thrombosis for speci c translocations, with transfer of unaffected 2. Pregnancy morbidity embryos, or the use of donor gametes. While data are limited a. One or more unexplained deaths of morphologically normal comparing in vitro fertilization (IVF)/PGD versus medical fetuses after the 10th week of gestation by ultrasound or management (defined as natural conception and observation) direct examination of the fetus.
Load more

Recommended publications
  • Adenomyosis in Infertile Women: Prevalence and the Role of 3D Ultrasound As a Marker of Severity of the Disease J
    Puente et al. Reproductive Biology and Endocrinology (2016) 14:60 DOI 10.1186/s12958-016-0185-6 RESEARCH Open Access Adenomyosis in infertile women: prevalence and the role of 3D ultrasound as a marker of severity of the disease J. M. Puente1*, A. Fabris1, J. Patel1, A. Patel1, M. Cerrillo1, A. Requena1 and J. A. Garcia-Velasco2* Abstract Background: Adenomyosis is linked to infertility, but the mechanisms behind this relationship are not clearly established. Similarly, the impact of adenomyosis on ART outcome is not fully understood. Our main objective was to use ultrasound imaging to investigate adenomyosis prevalence and severity in a population of infertile women, as well as specifically among women experiencing recurrent miscarriages (RM) or repeated implantation failure (RIF) in ART. Methods: Cross-sectional study conducted in 1015 patients undergoing ART from January 2009 to December 2013 and referred for 3D ultrasound to complete study prior to initiating an ART cycle, or after ≥3 IVF failures or ≥2 miscarriages at diagnostic imaging unit at university-affiliated private IVF unit. Adenomyosis was diagnosed in presence of globular uterine configuration, myometrial anterior-posterior asymmetry, heterogeneous myometrial echotexture, poor definition of the endometrial-myometrial interface (junction zone) or subendometrial cysts. Shape of endometrial cavity was classified in three categories: 1.-normal (triangular morphology); 2.- moderate distortion of the triangular aspect and 3.- “pseudo T-shaped” morphology. Results: The prevalence of adenomyosis was 24.4 % (n =248)[29.7%(94/316)inwomenaged≥40 y.o and 22 % (154/ 699) in women aged <40 y.o., p = 0.003)]. Its prevalence was higher in those cases of recurrent pregnancy loss [38.2 % (26/68) vs 22.3 % (172/769), p < 0.005] and previous ART failure [34.7 % (107/308) vs 24.4 % (248/1015), p < 0.0001].
    [Show full text]
  • The Role of Endometrial Stem Cells in Recurrent Miscarriage
    REPRODUCTIONREVIEW Success after failure: the role of endometrial stem cells in recurrent miscarriage Emma S Lucas1,2, Nigel P Dyer3, Katherine Fishwick1, Sascha Ott2,3 and Jan J Brosens1,2 1Division of Biomedical Sciences, Warwick Medical School, Coventry, UK, 2Tommy’s National Centre for Miscarriage Research, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK and 3Warwick Systems Biology Centre, University of Warwick, Coventry, UK Correspondence should be addressed to J Brosens; Email: [email protected] Abstract Endometrial stem-like cells, including mesenchymal stem cells (MSCs) and epithelial progenitor cells, are essential for cyclic regeneration of the endometrium following menstrual shedding. Emerging evidence indicates that endometrial MSCs (eMSCs) constitute a dynamic population of cells that enables the endometrium to adapt in response to a failed pregnancy. Recurrent miscarriage is associated with relative depletion of endometrial eMSCs, which not only curtails the intrinsic ability of the endometrium to adapt to reproductive failure but also compromises endometrial decidualization, an obligatory transformation process for embryo implantation. These novel findings should pave the way for more effective screening of women at risk of pregnancy failure before conception. Reproduction (2016) 152 R159–R166 Introduction Successful implantation of a human embryo is commonly date (Fragouli et al. 2013), each implanting blastocyst attributed to binary variables; i.e. nidation of a ‘normal’, is arguably unique. Furthermore, transient aneuploidy but not an ‘abnormal’, embryo in a ‘receptive’, but during development may not be unequivocally as not a ‘non-receptive’, endometrium is required for ‘bad’ as has been intuitively presumed because of the a successful pregnancy.
    [Show full text]
  • Recurrent Miscarriage
    Elizabeth Taylor, MD, FRCSC, Mohammed Bedaiwy, MD, PhD, Mahmoud Iwes, MD Recurrent miscarriage Management of pregnancy loss includes investigating causes, addressing modifiable risk factors, and providing supportive care in the first trimester of pregnancy. ABSTRACT: Early miscarriages are arly miscarriage has been re­ Genetic causes those occurring within the first 12 ported to occur in 17% to 31% The risk of miscarriage increases completed weeks of gestation. Re- E of pregnancies,1,2 and is de­ with maternal age. At age 20 to 24 current miscarriage, defined as two fined as a nonviable intrauterine the risk is approximately 10%, with or more consecutive pregnancy loss- pregnancy with either an empty ges­ risk increasing to nearly 80% by age es, affects 3% of couples trying to tational sac or a gestational sac con­ 45.5 The relationship between mis­ conceive and can cause consider- taining an embryo or fetus without carriage risk and maternal age can be able distress. The risk of miscarriage fetal heart activity within the first explained by the increasing rate of oo­ increases with maternal age. Genet- 12 completed weeks of gestation.3 cyte aneuploidy that occurs as women ic abnormalities, uterine anomalies, Recurrent miscarriage occurs in 3% grow older. In one study, oocytes and endocrine dysfunction can all of couples trying to conceive. The examined during in vitro fertilization lead to miscarriage. Other causes of American Society for Reproductive (IVF) treatment had only a 10% risk miscarriage are autoimmune disor- Medicine (ASRM) defines recurrent of being aneuploid in women younger ders such as antiphospholipid syn- miscarriage as two or more failed than age 35, but by age 43 the risk of drome and chronic endometritis.
    [Show full text]
  • World-Renowned Expert in Infertility Presents Findings to European
    World-Renowned Expert in Infertility Presents Findings to European Conference After Two Recurrent Miscarriages, Patients Should be Thoroughly Evaluated for Risk Factors Dr. William Kutteh, M.D., one of the world’s leading researchers in recurrent pregnancy loss (RPL), was invited to present his latest discoveries to theEuropean Society of Human Reproduction and Embryology (ESHRE). Dr. Kutteh’s research on recurrent pregnancy loss calls for early intervention after the second miscarriage, a change in how physicians currently treat the condition. RPL is defined as three or more consecutive miscarriages that occur before the 20th week of pregnancy. In the general population, miscarriage occurs in 20 percent of all pregnancies, but recurrent miscarriage occurs in only 5 percent of all women seeking pregnancy. Dr. Kutteh’s study, the largest of its kind on recurrent miscarriage, scientifically proved what many physicians intrinsically knew. The 2010 study, published in Fertility and Sterility-- Diagnostic Factors Identified in 1020 Women with Two Versus Three or More Recurrent Pregnancy Losses--found that even after only two pregnancy losses, a definitive cause for RPL could be determined in two-thirds of patients in the study. Dr. Kutteh’s research showed that there was no statistical difference in women with RPL who had two pregnancy losses, and those who had three or more losses, proving that earlier intervention was appropriate. Patients with RPL are now encouraged to begin testing for known risk factors for infertility after the second miscarriage. Determining Risk Factors for Recurrent Miscarriage Recurrent miscarriage causes include anatomic, hormonal, autoimmune, infectious, genetic, or hematologic issues. Expeditiously determining the causes of miscarriage can lead to more targeted treatment, and for 67 percent of patients, a successful full-term pregnancy.
    [Show full text]
  • Endometrial Immune Dysfunction in Recurrent Pregnancy Loss
    International Journal of Molecular Sciences Review Endometrial Immune Dysfunction in Recurrent Pregnancy Loss Carlo Ticconi 1,*, Adalgisa Pietropolli 1, Nicoletta Di Simone 2,3, Emilio Piccione 1 and Asgerally Fazleabas 4 1 Department of Surgical Sciences, Section of Gynecology and Obstetrics, University Tor Vergata, Via Montpellier, 1, 00133 Rome, Italy; [email protected] (A.P.); [email protected] (E.P.) 2 U.O.C. di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Laego A. Gemelli, 8, 00168 Rome, Italy; [email protected] 3 Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168 Rome, Italy 4 Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; [email protected] * Correspondence: [email protected]; Tel.: +39-6-72596862 Received: 17 September 2019; Accepted: 24 October 2019; Published: 26 October 2019 Abstract: Recurrent pregnancy loss (RPL) represents an unresolved problem for contemporary gynecology and obstetrics. In fact, it is not only a relevant complication of pregnancy, but is also a significant reproductive disorder affecting around 5% of couples desiring a child. The current knowledge on RPL is largely incomplete, since nearly 50% of RPL cases are still classified as unexplained. Emerging evidence indicates that the endometrium is a key tissue involved in the correct immunologic dialogue between the mother and the conceptus, which is a condition essential for the proper establishment and maintenance of a successful pregnancy.
    [Show full text]
  • Recurrent Pregnancy Loss: Diagnosis and Treatment
    Medical Coverage Policy Effective Date ............................................. 2/15/2021 Next Review Date ....................................... 2/15/2022 Coverage Policy Number .................................. 0284 Recurrent Pregnancy Loss: Diagnosis and Treatment Table of Contents Related Coverage Resources Overview .............................................................. 1 Comparative Genomic Hybridization Coverage Policy ................................................... 1 (CGH)/Chromosomal Microarray Analysis (CMA) General Background ............................................ 3 for Selected Hereditary Conditions Medicare Coverage Determinations .................. 11 Genetic Testing for Reproductive Carrier Screening and Coding/Billing Information .................................. 11 Prenatal Diagnosis Hydroxyprogesterone Caproate Injection References ........................................................ 14 Immune Globulin Infertility Services INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service
    [Show full text]
  • The Causes and Treatment of Recurrent Pregnancy Loss
    Research and Reviews The Causes and Treatment of Recurrent Pregnancy Loss JMAJ 52(2): 97–102, 2009 Shigeru SAITO*1 Abstract Recurrent pregnancy loss is the syndrome that causes repeated miscarriage and/or stillbirth impairing the ability to have a live birth. Recently, the Japan Society of Obstetrics and Gynecology proposed screening tests for recurrent pregnancy loss and reported the frequencies of various causative factors. It has been shown that appropriate treatments after screening tests are effective in achieving a respectable rate of live births. While cases of recurrent pregnancy loss with chromosomal aberrations were previously associated with a high rate of miscarriage and inability to have a live birth, such patients can now expect to have a live baby at a probability of about 60% in the next pregnancy. It has also been shown that patients presenting no abnormality on various tests may achieve a good rate of live births without special treatment. Many couples with recurrent pregnancy loss are now given the chance of having a live birth through appro- priate screening and the best treatment available for the inferred cause. Key words Miscarriage/Stillbirth, Antiphospholipid antibodies, Coagulation factor disorder, Heparin miscarriages: 59.0%, 55.3%, 38.9%, 38.9%, and Introduction 28.6% after 2, 3, 4, 5, and 6 miscarriages, respec- tively. These clinical facts strongly suggest that an Miscarriage occurs in approximately 15% of increasing number of past miscarriages is associ- all pregnancies. When miscarriage takes place ated with further repetition of miscarriages and repeatedly 3 times or more, she is diagnosed with stillbirths attributable to factors in the mother or habitual miscarriage.
    [Show full text]
  • Recurrent Miscarriage
    The Investigation and Treatment of Couples with Recurrent First- trimester and Second-trimester Miscarriage Green-top Guideline No. 17 April 2011 The Investigation and Treatment of Couples with Recurrent First-trimester and Second-trimester Miscarriage This is the third edition of this guideline , which was first published in 1998 and then in 2003 under the title The Investigation and Treatment of Couples with Recurrent Miscarriage . 1. Purpose and scope The purpose of this guideline is to provide guidance on the investigation and treatment of couples with three or more first -trimester miscarriages, or one or more second-trimester miscarriages . 2. Background and introduction Miscarriage is defined as the spontaneous loss of pregnancy before the fetus reaches viability. The term therefore includes all pregnancy losses from the time of conception until 24 weeks of gestation. It should be noted that advances in neonatal care have resulted in a small number of babies surviving birth before 24 weeks of gestation. Recurrent miscarriage, defined as the loss of three or more consecutive pregnancies, affects 1% of couples trying to conceive. 1 It has been estimated that 1–2% of second -trimester pregnancies miscarry before 24 weeks of gestation. 2 3. Identification and assessment of evidence The Cochrane Library and Cochrane Register of Controlled Trials were searched for relevant randomised controlled trials, systematic reviews and meta-analyses. A search of Medline from 1966 to 2010 was also carried out. The date of the last search was November 2010. In addition, relevant conference proceedings and abstracts were searched. The databases were searched using the relevant MeSH terms including all sub-headings.
    [Show full text]
  • A- Oral Presentations Medical Adjuvant Therapy Was Reviewed
    Abstracts of 16th Congress of Iranian Society for Reproductive Medicine of the fibroids. Surgical methodology and use of A- Oral Presentations medical adjuvant therapy was reviewed. Results: Most of the evidence that associates 1- Infertility, Gynecology fibroids and infertility is from observational series using the patients as their own controls and from O-1 meta-analysis of these series. Myomectomy by Prognostic models in infertility any access route (laparotomy, laparoscopy, or hysteroscopy) confers subsequent pregnancy rates Al-Inani H. ranging from 10-75%. Mode of access does not Department of Obstetrics and Gynecology, Cairo seem to influence subsequent pregnancy rates. University, Giza, Egypt. Myomectomy has also been associated with a E-mail: [email protected] reduction in spontaneous pregnancy losses. Conclusion: The available evidence suggests that There is a strong need for distinction between fibroids that distort the endometrial cavity couples with a relatively good prognosis and couples (whether submucosal or intramural) appear to with poor fertility prospects. Clinical experience or adversely affect fertility and should be removed. ‗gut-feeling‘ of clinicians was the only available Further investigation is required to conclusively ‗tool‘. Comparison of the predictions made by demonstrate a cause-effect relationship. In clinicians based on clinical experience addition, the optimal surgical technique and the demonstrated a substantial reproducibility of the usefulness of adjuvant medical therapy require assessment of spontaneous conception chances, but further study. a very slight to fair reproducibility of the Key words: Fibroids, Infertility, Surgical technique. assessment of IVF-ET success rates, thereby demonstrating the need for models that predict the O-3 outcome of IVF-ET.
    [Show full text]
  • Endometrial Scratching in Women with Recurrent First Trimester Pregnancy Loss: a Randomized Controlled Trial
    ARC Journal of Gynecology and Obstetrics Volume 1, Issue 2, 2016, PP 13-18 ISSN No. (Online) 2456-0561 http://dx.doi.org/10.20431/2456-0561.0102004 www.arcjournals.org Endometrial Scratching in Women with Recurrent First Trimester Pregnancy Loss: A Randomized Controlled Trial Abdelhamid Shaheen Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt [email protected] Abstract: Objective: to assess the role of endometrial scratching prior to ovulation induction to improve live birth rate in recurrent first trimester pregnancy loss. Methods: This randomized controlled trial included 126 patients with recurrent first trimester spontaneous miscarriage with no obvious cause who were assigned into two groups; the study group (n=62) who underwent endometrial scratching once with a pipelle de Cornier and the control group (n=64) who underwent placebo procedure, followed by ovulation induction. Live birth rate was the primary outcome in this study. Data was collected and tabulated. Results: There was a significant difference between the two groups regarding the miscarriage rate which was higher in the control group (p<0.05) and live pregnancy rate which was higher in the study group (p<0.05). There was no significant difference between the two groups regarding clinical pregnancy rate, multiple pregnancy rate, preterm delivery, admission to NICU and neonatal death (p>0.05). Conclusion: Endometrial scratching may improve live birth rates in couples with unexplained recurrent first trimester spontaneous miscarriage. Larger multicenter studies are warranted to confirm or refute these findings. Keywords: Endometrial scratching, recurrent miscarriage. 1. INTRODUCTION Endometrial scratching or injury is defined as intentional damage to the endometrium, such as biopsy or curettage, in women undergoing assisted reproduction technology (ART) to improve endometrial receptivity (1).
    [Show full text]
  • Recurrent Pregnancy Loss
    Recurrent Pregnancy Loss November 2017 Version 2 0 ESHRE Early Pregnancy Guideline Development Group [1] Version 2 was published 1 April 2019 and includes a correction in the numbers mentioned in section 4.2 on page 39 (changes were marked in green). No further changes were made as compared to version 1 (published November 2017) DISCLAIMER The European Society of Human Reproduction and Embryology (hereinafter referred to as 'ESHRE') developed the current clinical practice guideline, to provide clinical recommendations to improve the quality of healthcare delivery within the European field of human reproduction and embryology. This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. The aim of clinical practice guidelines is to aid healthcare professionals in everyday clinical decisions about appropriate and effective care of their patients. However, adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not override the healthcare professional's clinical judgment in diagnosis and treatment of particular patients. Ultimately, healthcare professionals must make their own clinical decisions on a case-by-case basis, using their clinical judgment, knowledge, and expertise, and taking into account the condition, circumstances, and wishes of the individual patient, in consultation with that patient and/or the guardian or carer. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose.
    [Show full text]
  • Primary Amenorrhea Secondary to Mullerian Anomaly
    ical C lin as f C e R Sagsak et al., J Clin Case Rep 2014, S1 o l e a p n o DOI: 10.4172/2165-7920.S1-007 r r t u s o J Journal of Clinical Case Reports ISSN: 2165-7920 Case Report Open Access Primary Amenorrhea Secondary to Mullerian Anomaly Elif Sagsak, Asan Onder*, Fatma Doga Ocal, Yasemin Tasci, Sebahat Yilmaz Agladioglu, Semra Cetinkaya and Zehra Aycan Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital Pediatric Endocrinology Clinic, Turkey Abstract Mullerian developmental anomalies are rare causes of primary amenorrhea in 46, XX adolescent girls. The aim to report this case is that Mullerian anomalies should be considered between the differential diagnosis of primary amenorrhea to prevent the delaying of the diagnosis. A 15 year-old female patient presented with a complaint of not menstruating. Medical history revealed an appendectomy at the age of 9 years, and surgical intervention due to a right para-ovarian hemorrhagic cyst at the age of 12 years. Apelvic Magnetic Resonance Imaging (MRI) evaluation revealed two uteri, one of which was rudimentary. Normal-sized uterus was not continued by vaginal lumen; however, the rudimentary uterus was connected with vaginal lumen. A hemorrhage to peritoneal cavity was suspected by pediatric endocrinologist and referred to gynecologist and radiologist for detailed investigation. It was concluded that the previously excised cyst might be bleeding into the peritoneal cavity as a result of menstruation. Then, the patient was scheduled for surgery. Keywords: Mullerian anomaly; Amenorrhea; Adolescent content was observed adjacent to the right ovary (Figures 1 and 2).
    [Show full text]