Pregnancy

Q. With my first husband, I lost a baby at 8 months and 4 months. My current husband and I lost two babies, both at 6 weeks. The doctors haven't determined the reason. I'm now 38 years old and am overweight. I have no other health problems.

A: Pregnancy losses such as these are very emotionally difficult and it takes a lot of courage to attempt again. Nevertheless, there is certainly some chance that you can yet have a baby. The most important thing is to see a specialist who can review your medical history to try to determine why your pregnancy losses have occurred. Usually, the pregnancy losses at 8 months and 4 months will be due to obstetrical complications such as placental abruption, infection, high blood pressure, or any of a number of medical problems. The pregnancy losses at 6 weeks are most commonly caused by genetic factors, meaning that the embryo was not normal and "natural selection" determined that these embryos were not able to develop further into a healthy baby. However, it is reasonable to check for some causes of first trimester repeated pregnancy loss.

With repeated pregnancy loss, it's important to rule out hormone problems such as hyperprolactinemia, thyroid disease, adrenal gland disease, diabetes mellitus and inadequate luteal phase. Tests that can be performed include serum prolactin, thyroid stimulating hormone, cortisol, dehydroepiandrosterone sulfate, 17 hydroxyprogesterone, fasting blood sugar and insulin, serum progesterone and endometrial biopsy. Decreased ovarian reserve can be measured with cycle day three follicle stimulating hormone and estradiol. However, it is uncommon for these problems to occur to such a degree that they cause repeated pregnancy loss. Progesterone supplementation is commonly given in the luteal phase, again with little known risk of adverse effects, but with unproven efficacy for repeated pregnancy loss.

It's also important to ascertain that there are no intrauterine polyps, myomas, adhesions or congenital anomalies that can be contributing to pregnancy loss. Tests to identify such problems include sonohysterography, which is ultrasound with a small amount of fluid in the uterus, or a hysterosalpingogram, which is an X-ray study of the uterus and fallopian tubes, or a hysteroscopy, which is a minor surgical procedure. Incompetent cervix can be a cause of mid-trimester pregnancy loss and can be tested by cervical dilation.

The Male

It is important not to forget the male in this situation. Although it is very unlikely his situation is playing a role in your history, some clinicians feel that an evaluation of sperm shape by strict morphology (shape) can help determine if sperm abnormalities might be contributing to repeated pregnancy loss.

Cervical cultures for chlamydia and mycoplasma can be performed, although the evidence for their role in repeated pregnancy loss has been difficult to prove. Often, empirical treatment with doxycycline is given instead. In isolated cases, rubella, toxoplasmosis, cytomegalovirus, herpes, and syphilis can cause a single pregnancy loss, but this occurs uncommonly and by themselves these organisms do not cause repeated pregnancy loss. Prior exposure to these diseases can be determined through blood tests. The male can also be tested or treated empirically with doxycycline.

Karyotyping of the fetus can sometimes be of assistance, but after three repeated pregnancy losses most reproductive endocrinologists would recommend karyotyping of the male and female partners themselves.

When tests for anticardiolipin antibody syndrome are normal, no treatment for autoimmune disease is indicated. You appear to have been checked for this. Other systemic diseases of the liver, kidneys and blood system should also be ruled out in the case of repeated pregnancy loss.

Most of these are fairly simple blood tests, but the important thing to do is see a sub- specialist in reproductive endocrinology or high-risk pregnancy to try to identify why these pregnancy losses have occurred. If a cause can be found, it might be possible to treat it to improve your chances. Even if a cause is not found, steps might be taken to help you conceive again. At age 38 it is important not to wait too long to try again. And finally, it would be very helpful for your pregnancy and general health if you were as close to your optimal weight as possible. Weight loss programs recommended by your physician with group support are often the best.