Monday, May 14, 2018

IVF for treating recurrent miscarriages

Recurrent pregnancy loss ( repeated miscarriages or habitual abortions) is one of the most frustrating problems in medicine. It is hard for patients , because getting pregnant , and then losing the baby again and again is traumatic. It's bad for doctors, because patients have so many questions , and we don't have any answers ! The truth is that our tests are not very good, and there is little we can do to make n accurate a diagnosis. This is why, in about 80% of patients with recurrent pregnancy loss , inspite of extensive testing, we will not be able to find an underlying cause.
Based on experience over many years, the one thing we do know is that the commonest reason for a miscarriage is a genetic problem in the embryo.                What makes this so tricky is that these are random genetic errors which we cannot pinpoint; cannot test for; and cannot prevent. This is why pregnancy becomes such a hit and miss affair for these patients. It's literally a gamble, and there are patients who have had three and four miscarriages , who have then gone on to have a healthy baby with no intervention other than TLC - tender, loving care !
So what is the poor patient to do? She can, of course, keep on trying in her own bedroom but, obviously, every time she loses her baby, her heart breaks.
One option is to do IVF. Now, logically , this seems to make no sense at all !  Patients say, " Isn't IVF a treatment for infertile couples ? Since  I'm getting pregnant in my own bedroom, this means I am fertile, so why would IVF help me ?"
The reason is because it saves these patients precious time. In a fertile woman , off the eggs which she produces every month, in 11 of the 12 months this egg is healthy and genetically normal, so that if it forms an embryo and implants , she goes on to have a healthy pregnancy. However, even in these women, 10% of the time the egg will be genetically abnormal , and give rise to a genetically abnormal embryo, which will miscarry. This is why about  10% of all pregnancies miscarry , even in fertile women, and there is nothing much we can do about it.
Now, it's possible that for women with recurrent pregnancy loss the rate , at which they produce genetically abnormal eggs is higher than it is for normal women. Let's assume that 80% of the eggs which they ovulate are genetically abnormal, which means these will form genetically abnormal embryos, which then have a much higher chance of miscarrying.
There is nothing much we can do about this when she is trying in her bedroom, but if we did IVF , we would get lots of eggs in that one cycle. We could create lots of embryos, and allow these embryos to grow to day five ( blastocysts) , which means that a lot of the genetically abnormal embryos would not develop up to this stage. By transferring only top-quality blastocysts , we'd reduce the risk of a genetically abnormal embryo implanting, because the chances of the blastocyst coming from a genetically normal egg are that much higher.  So why not test the embryos by doing PGS before transferring them. Sadly, this  has not been shown to be helpful , because the PGS technology is still very immature, and only allows us to count the number of chromosomes in the embryos.  Yes, the holy grail is to improve the genetic technology to screen for all abnormalities, but  until we reach that point I think this is a perfectly acceptable option for trying to improve the odds of a woman with recurrent pregnancy loss having a healthy baby more quickly rather than allowing nature to take its own. Yes, she may still miscarry even after doing IVF, but the chances will be lesser, so this is an option she may want to pursue.
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