When and how are miscarriages investigated?

We need to establish there is no one one size fits all. Obviously we will be investigating the miscarriage or we will be investigating miscarriages depending on some risk factors. There might be women that have got more risk factors or higher risk of miscarriage that require investigations sooner than later and the women that appeared not to have any risk factors, in that case investigation can be postponed. Also it is important that we bear in mind the maternal age as a single risk factor because the risk of having a miscarriage in a woman that is over the age of 39 is at least twice as high as some reason under the age of 39. So higher is the chronological age of the mother and higher will be the risk of miscarriage and so that is something that has to be said and something that women need to be aware of. Otherwise, the investigations for miscarriage can be instigated after three consecutive miscarriages and it has to be said that we are not including biochemical pregnancies as a definition of miscarriage nor an indication for investigating investigations.

I have worked in both NHS and I have worked in private practice for 14 years now. Definitely the practice can be very different based on the policies. The human reproduction is a very inefficient process and one miscarriage is way more common than someone otherwise imagines so, one miscarriage is very common and based on the NHS policy, they have fixed the number of three so, in the third miscarriage they promote that if this happens, this time, the third time, then the products of the conception are checked for the genetic problem in the product of conception first and if the products of conception have any genetic abnormality then, both the parents are checked for the genetic problems. This works a bit differently in the private practice though because in the private practice, patients are paying for themselves or their insurances and they have the right to ask the doctor to do the tests either after first or mainly second so, having two miscarriages also can be mentally very traumatizing, not an easy thing both for the man and the woman to see even one miscarriage but two sometimes can affect the couples massively enough that they do come to us and tell us to test. So, the same test we do at the second miscarriage. We try to do the just the TLC – the tender loving care thing at the first miscarriage and this large percentage of the people do not have any problem but if someone has has two miscarriages and they ask to do more tests and they are prepared financially to just test that and find out what’s going on then we do check like I just mentioned. First of all, we tell them if at all the products of conception are available, in the second one, we test that. We do the genetic testing of both the parents. We check for any antibodies especially depending on the age of the conception at what age so, if it was under 10 weeks so, first of all early miscarriage, first trimester miscarriage is most common causes are the genetic abnormalities. So, the largest chunk of the first trimester miscarriage is the genetic abnormality. We definitely would promote the patients to bring the products of conception or if it is a surgical, we send it from the hospital and then we check the parents for the genetic abnormalities. We also check for like I mentioned the antibodies, infections, any problems related to the NK cells. We check the blocking antibodies, we take the biopsy of the endometrium. There is a test called endometrial immune profile that we do in which we see the CD56 (immune marker) and the interleukin levels whether they are acceptable or they are to be treated. We can always do more tests. There are newer tests called KIRS which is an endometrial biopsy so, we wait for the day 21 making sure that the patient is not pregnant and they are asked to have abstinence because otherwise on day 21, very initial pregnancy can be present so, we take the biopsy. EMMA and ALICE can always be done but they are not very relevant at this point but sometimes this biopsy is associated with EMMA and ALICE also. I generally carry a cover of doxycycline for such patients for the next treatment anyway – regardless of the reports of the EMMA and ALICE.
We go more horizontal and cover all the various aspects th1, th2 ratios are counted and checked. LED, the leukocyte antibody detection test is done. So, we have this whole battery based on the typical history of the patient. Some of the tests might not be relevant in some couples but I can’t go into detail in the interview because this actually is related to a lot of history points on both sides of the couple. Checking horizontally means checking every area is very important. Why I’m emphasising is because I know of some teams where a lot of testing is done in one aspect and quite a lot of grams of pounds patients have spent but something else which is very basic like an antiphospholipid antibody was not checked. We shouldn’t be missing things like that, so the protocol setting of the unit has to be very carefully planned so that at least we go step wise because this can involve massive financial aspects which affects everybody very differently and it should make sense what we’re doing. Miscarriage can be a very tedious situation for some but the good thing is that without doing anything, also the chance of having a successful life birth in the next chance is massive, even after three miscarriages just because the human reproduction is a very inefficient process per se on its own.

It’s not always the same everywhere and the good news is there is a real drive for us to start seeing women who’ve had two miscarriages. Historically, we’ve tended to investigate miscarriages after three pregnancy losses but I think there’s an understandable and correct view, that women shouldn’t have to wait that long. So, very often, if they have the capacity, many early pregnancy units and clinics will now see women who’ve had two pregnancy losses.