Evaluation Of Recurrent Pregnancy Loss Research Articles

Expanding the Role of Chromosomal Microarray Analysis in the Evaluation of Recurrent Pregnancy Loss

Multiple factors contribute to recurrent pregnancy loss (RPL). This review highlights the latest international guidelines for RPL workup, including immunological testing, by the American Society for Reproductive Medicine (ASRM), the European Society of Human Reproduction and Embryology (ESHRE), and the Royal College of Obstetricians and Gynaecologists (RCOG). These three societies recommend testing for antiphospholipid syndrome. ESHRE and RCOG also recommend thyroid peroxidase antibody testing, whereas ASRM does not. All guidelines advise against testing of natural killer cells, cytokines, antinuclear antibodies, human leukocyte antigen (HLA) compatibility, anti-HLA antibodies, and anti-sperm antibodies. However, when following ASRM, ESHRE or RCOG diagnostic guidelines, over 50% of cases have no identifiable cause. Genetic testing of products of conception (POC) can improve our understanding of unexplained RPL as aneuploidy is a common cause of RPL. Based on studies reporting results from chromosomal microarray analysis (CMA) of POC, we propose a novel algorithm for RPL evaluation. The algorithm involves following evidence-based societal guidelines (published by ASRM, ESHRE, or RCOG), excluding parental karyotyping, in combination with CMA testing of miscarriage tissue. When utilizing this new evaluation algorithm, the number of unexplained cases of RPL decreases from over 50% to less than 10%. As a result, most patients are provided an explanation for their loss and healthcare costs are potentially reduced. Patients with an otherwise negative workup with euploid POC, are classified as “truly unexplained RPL”. These patients are excellent candidates for enrollment in randomized, controlled trials examining novel immunological testing and treatment protocols.

Evaluation of Recurrent Pregnancy Loss.

Recurrent pregnancy loss (RPL) affects approximately 5% of couples. Although RPL definitions vary across professional societies, an evaluation after a second clinically recognized first-trimester pregnancy loss is recommended. Good quality evidence links parental chromosomal rearrangements, uterine anomalies, and antiphospholipid syndrome (APS) to RPL. In contrast, the relationship between RPL and other endocrine, hematologic, and immunologic disorders or environmental exposures is less clear. Anticoagulant therapy and low-dose aspirin are recommended for patients with RPL who have also been diagnosed with APS. Vaginal progesterone supplementation may be considered in patients experiencing vaginal bleeding during the first trimester. Surgical correction may be considered for patients with RPL in whom a uterine anomaly is identified. Evaluation and management of additional comorbidities should be guided by the patient's history rather than solely based on the diagnosis of RPL, with the goal of improving overall health to reduce complications in the event of pregnancy. Most people with RPL, including those without identifiable risk factors, are expected to achieve a live birth within 5 years from the initial evaluation. Nevertheless, clinicians should be sensitive to the psychological needs of individuals with this condition and provide compassionate and supportive care across all stages.

Increased Live Birth Rate with Dydrogesterone among Patients with Recurrent Pregnancy Loss Regardless of Other Treatments.

Recurrent pregnancy loss (RPL) is defined as the loss of two or more pregnancies. Several treatment options are available, including progesterone, which is one of the few treatments that improve live birth rates in RPL patients. To compare the live birth rates, medical and obstetric characteristics, and RPL evaluation results of women with and without progesterone treatment. These women attended the RPL clinic at Soroka University Medical Center. A retrospective cohort study based on 866 patients was conducted. The patients were divided into two groups and examined: the dydrogesterone treatment group consisting of 509 women and a group of 357 patients who did not receive the treatment. All the patients had a subsequent (index) pregnancy. The two groups were not statistically different in terms of their demographic and clinical characteristics or evaluation results. In a univariate analysis, no statistically significant differences were found between the groups in terms of live birth rates (80.6% vs. 84%; p-value = 0.209). In a multivariate logistic analysis adjusted for maternal age, the ratio of pregnancy losses to the number of pregnancies, other administered treatments, antiphospholipid syndrome, and body mass index, dydrogesterone treatment was found to be independently associated with a higher rate of live births than the control group (adjusted OR = 1.592; CI 95% 1.051-2.413; p-value = 0.028). Progesterone treatment is associated with an increased live birth rate in RPL patients. Studies with larger sample sizes are recommended to strengthen these results.

Role of hysteroscopy in evaluation of recurrent pregnancy loss

Objective: to detect the uterine abnormalities missed in U/S scan and HSG using hysteroscopy, in females presenting with recurrent pregnancy loss &to study hysteroscopic therapuatic potential to that pathology. Methodology: prospective cohort study, conducted in obstetrics & gynecology department of, Beni-suef University Hospital.on one hundred women with recurrent 1st &2nd trimester pregnancy loss recruited for hysteroscopy .A rigid fiberoptic 2.7mm, 0 and 30 degrees angled hysteroscopy along with an operative channel for grasping forceps or scissors were used for both diagnostic and operative indications. The findings, and different types of abnormalities, comparison between<or=3 &>3 cosecutive miscarriage as regarding hysteroscopic findings &impact of the procedure on management were recorded. Results: In this study In the normal hysteroscopy group, 24women (29.3%) achieved a successful ongoing pregnancy without additional treatment, 49 (59.8%) had recurrent miscarriages again, and 4(5%) had persistent secondary infertility .In women who needed and had hysteroscopic correction of a SUA, the number of successful ongoing pregnancies was significantly higher 13 (72.2%) vs (29.3%) in normal group and the number of new abortions significantly was lower than in those who had no pathology 3(16.7%)vs (59.8%) with statistically significance between the 2 groups (p value = 0.002).

Histological Evaluation of Products of Conception, Who Benefits from It?

Background: Histopathological evaluation of the first trimester pregnancy loss has always been controversial. Although it is recommended, it is not a part of guidelines. Methods: Six hundred eighty-six samples in a referral infertility clinic were evaluated microscopically and categorized. Two hundred ninety-five cases were evaluated by genetic methods (Multiplex Ligation-dependent Probe Amplification). Results: From 569 samples with chorionic villi, 361 cases had history of three or more abortions. 18.3% of this group showed chronic intervillous of unknown etiology (CIUE) and 8.3% revealed intervilli fibrin deposition, both pathologies with a high risk of recurrence. History of a live child was significantly higher in CIUE group. 29% of genetically evaluated cases had a chromosomal abnormality. Conclusion: Histological evaluation of recurrent pregnancy loss could illuminate the cause of abortion in relatively acceptable percentage of cases, especially in mothers with higher number of previous abortion, mothers with a history of live child and in referral centers.

Pregnancy outcomes following in vitro fertilization frozen embryo transfer (IVF-FET) with or without preimplantation genetic testing for aneuploidy (PGT-A) in women with recurrent pregnancy loss (RPL): a SART-CORS study.

Can preimplantation genetic testing for aneuploidy (PGT-A) improve the live birth rate in patients with recurrent pregnancy loss (RPL)? PGT-A use was associated with improved live birth rates in couples with recurrent pregnancy loss undergoing frozen embryo transfer (IVF-FET). Euploid embryo transfer is thought to optimize outcomes in some couples with infertility. There is insufficient evidence, however, supporting this approach to management of recurrent pregnancy loss. This study included data collected by the Society of Assisted Reproductive Technologies Clinical Outcomes Reporting System (SART-CORS) for IVF-FET cycles between years 2010 through 2016. A total of 12631 FET cycles in 10060 couples were included in this analysis designed to assess the utility of PGT-A in couples with RPL undergoing FET, including 4287 cycles in couples with tubal disease who formed a control group. The experimental group included couples with RPL (strictly defined as a history of 3 or more pregnancy losses) undergoing FET with or without PGT-A. The primary outcome was live birth rate. Secondary outcomes included rates of clinical pregnancy, spontaneous abortion, and biochemical pregnancy loss. Differences were analyzed using generalized estimating equations logistic regression models to account for multiple cycles per patient. Covariates included in the model were age, gravidity, geographic region, race/ethnicity, smoking history, and indication for assisted reproductive technologies. Analyses were stratified for age groups as defined by SART: <35 years, 35-37 years, 38-40 years, 41-42 years, and >42 years. In women with a diagnosis of RPL, the adjusted odds ratio (OR) comparing IVF-FET with PGT-A versus without PGT-A for live birth outcome was 1.31 (95% CI: 1.12, 1.52) for age <35 years, 1.45 (95% CI: 1.21, 1.75) for ages 35-37 years, 1.89 (95% CI: 1.56, 2.29) for ages 38-40, 2.62 (95% CI: 1.94-3.53) for ages 41-42, and 3.80 (95% CI: 2.52, 5.72) for ages >42 years. For clinical pregnancy, the OR was 1.26 (95% CI: 1.08, 1.48) for age <35 years, 1.37 (95% CI: 1.14, 1.64) for ages 35-37 years, 1.68 (95% CI: 1.40, 2.03) for ages 38-40 years, 2.19 (95% CI: 1.65, 2.90) for ages 41-42, and 2.31 (95% CI: 1.60, 3.32) for ages >42 years. Finally, for spontaneous abortion, the OR was 0.95 (95% CI: 0.74, 1.21) for age <35 years, 0.85 (95% CI: 0.65, 1.11) for ages 35-37 years, 0.81 (95% CI: 0.60, 1.08) for ages 38-40, 0.86 (95% CI: 0.58, 1.27) for ages 41-42, and 0.58 (95% CI: 0.32, 1.07) for ages >42 years. The retrospective collection of data including only women with recurrent pregnancy loss undergoing FET presents a limitation of this study, and results may not be generalizable to all couples with recurrent pregnancy loss. Also, data regarding evaluation and treatment for RPL for the included women is unavailable. This is the largest study to date assessing the utility of PGT-A in women with RPL. PGT-A was associated with improvement in live birth and clinical pregnancy in women with RPL, with the largest difference noted in the group of women with age greater than 42 years. Couples with RPL warrant counseling on all management options to reduce subsequent miscarriage, which may include IVF with PGT-A for euploid embryo selection. There are no conflicts of interest to declare. N/A.

Cytogenetic Screening in Couples with Recurrent Pregnancy Loss: A Single-Center Study and Review of Literature.

Context:Recurrent pregnancy loss (RPL) is a devastating reproductive problem that affects more than 2% of couples who are trying to conceive. Chromosomal rearrangements in either carrier are a major cause of clinically recognized abortion.Aims:The purpose of this study is to report the prevalence of chromosome abnormalities in RPL and provide clinical characteristics of couples with two and more miscarriages.Settings and Design:Genetic counseling in laboratory of histology housed in a Faculty of Medicine of Sfax.Materials and Methods:Karyotype was generated from the peripheral blood lymphocyte cultures and the cytogenetic analysis was performed using R-bands after heat denaturation and Giemsa (RHG) banding. A multiplex polymerase chain reaction wherever necessary was done.Statistical Analysis Used:SPSS version 17.Results:A total of 104 couples with RPL were carried out in this study. The frequency of chromosomal rearrangements was 11.5%, three times more prevalent in men than women (P = 0.08). In addition, the prevalence of chromosomal anomalies increases according to the number of miscarriages (from 4.8% to 7.6%, with 2 or ≥3 miscarriages, respectively; P = 0.9). Finally, a particular familial adverse reproductive background was found in these carriers (P = 0.03).Conclusions:These data highlight that an RPL evaluation is appropriate after the second miscarriage and that cytogenetic evaluation is necessary for an accurate approach to elucidate the causes of RPL. Moreover, familial adverse reproductive backgrounds have an impact of being carrier of chromosome abnormalities and a larger study is mandatory to define reproductive characteristics of carriers.

CHRONIC ENDOMETRITIS: WHAT IS THE PREVALENCE AMONG HEALTHY CONTROLS?

To evaluate the prevalence of chronic endometritis (CE) in women with unexplained recurrent pregnancy loss (RPL) and healthy controls. Cohort Study. IRB approval was obtained. The RPL group included women with ≥ two pregnancy losses, endometrial biopsy (EMB) between 1/2016 and 12/2018, TSH values < 4 mU/L, negative antiphospholipid antibodies and normal uterine anatomy. The control group included volunteers without a history of RPL, infertility, uterine fibroids, polyps, pelvic inflammatory disease or retained pregnancy tissue recruited between 5/2019 and 2/2020. Women 18-50 years of age were included. H&E and CD138 immunohistochemical staining were performed on all endometrial biopsies. A single pathologist blinded to patient history recorded the number of plasma cells per 10 high power fields (HPF) and the presence of endometrial stromal changes (spindling, edema, breakdown, pigment deposition, areas of hypercellularity, and presence of inflammatory cells). Assuming a 3% prevalence of CE in controls and 30% in RPL, 25 controls and 50 women with RPL were needed to detect a difference in the rate of CE with 80% power and alpha of 0.05. 76 women were included, 50 with RPL and 26 controls. The cohort had a mean age of 34.6 (SD 4.1) years and mean BMI of 26.0 (SD 6.2) kg/m2. Women with RPL had a mean of 3.1 (SD 0.9) prior pregnancy losses, while controls had no prior pregnancy losses. When the presence of plasma cells alone was used to define CE, the prevalence among women with RPL was 56% (28/50) with ≥ 1 plasma cell, 44% (22/50) with ≥ 2 plasma cells and 26% (13/50) with ≥ 5 plasma cells by CD138 staining. Using these same criteria, the prevalence of CE among controls would be 31% (8/26) with ≥ 1 plasma cell, 27% (7/26) with ≥ 2 plasma cells and 8% (2/26) with ≥ 5 plasma cells. However, when both endometrial stromal changes and plasma cells were required for CE diagnosis, there were no cases of CE in the control group. Using this definition, the prevalence in the RPL group was 30% (15/50) with ≥1 plasma cells, 28% (14/50) with ≥2 plasma cells and 16% (8/50) with ≥5 plasma cells by CD138 staining, and was statistically significantly higher in women with RPL compared to controls (P=0.0015, 0.0016, and 0.04, respectively). Establishing specific diagnostic criteria for CE is necessary for both research and evidence-based treatment guidelines. We demonstrate that while rare plasma cells were found in EMB samples from healthy controls, the presence of plasma cells and endometrial stromal changes was isolated to the RPL cohort. Given that no controls were found to have both plasma cells and endometrial stromal changes, we propose that the definition of CE include 1 or more plasma cells in addition to the presence of endometrial stromal changes. Cases in which endometrial stromal changes are visualized, but no plasma cells are identified by H&E, would benefit from CD138 staining to identify plasma cells. We demonstrate that when using strict criteria to define CE, women with RPL have a significantly higher rate of CE compared to controls. An EMB should be considered as part of the evaluation for RPL.

A new algorithm for the evaluation of recurrent pregnancy loss redefining unexplained miscarriage: review of current guidelines.

Couples with recurrent pregnancy loss (RPL) are often referred to reproductive specialists to help determine the reason for their repeated losses. This review will help to develop a strategy that is effective in providing a diagnosis, efficient to administer, and cost-effective to the healthcare system. International societies have published different recommendations for the evaluation of RPL, they consider it appropriate to initiate an evaluation after two (or three) clinical miscarriages. On the contrary, the clinician who follows these guidelines will only be able to offer a possible explanation to fewer than half of the couples being evaluated. Recently, genetic testing of miscarriage tissue using 24-chromosome microarray (CMA) analysis at the time of the second pregnancy loss coupled with testing based on society guidelines has been shown provide an explanation in more than 90% of cases. New guidelines for the complete evaluation of RPL should consider adding 24-CMA testing on the miscarriage tissue. Providing couples with an explanation for recurrent loss assists them in dealing with the loss and discourages the clinician from instituting unproven therapies. Truly unexplained pregnancy loss can be reduced to less than 10% with this new algorithm. Incorporation of these strategies will result in significant cost savings to the healthcare system.

Clinical Utility of a High-Resolution Melting Test for Screening Numerical Chromosomal Abnormalities in Recurrent Pregnancy Loss

Recurrent pregnancy loss (RPL) occurs in approximately 5% of clinically identified pregnancies. Determining the cause of RPL is essential. Genetic testing, accompanied by an evidence-based workup, is the well-accepted process for evaluating RPL; however, current genetic tests have limitations in clinical practice. We, thus, developed a high-resolution melting analysis-based test (HRM test) to screen for the most common numerical chromosomal abnormalities present in the products of conception. We examined 765 products-of-conception samples with known karyotypes retrospectively using the HRM test, which showed high technical sensitivity (96.1%) and specificity (96.3%) as well as a high positive predictive value (95.9%) for the screening of chromosomal abnormalities. The cost-effectiveness of four RPL evaluation strategies that employ different genetic tests, karyotyping, chromosomal microarray/next-generation sequencing, the HRM test, and a combination of the HRM test and chromosomal microarray/next-generation sequencing, was then compared. The costs of diagnosing an explained RPL using karyotyping or the HRM test alone were similar. Performance of the HRM screening test before chromosomal microarray/next-generation sequencing analysis improved cost-effectiveness by approximately 30%. Cost-effectiveness was more prominent in the advanced maternal age group. Thus, the HRM test could be used as an initial screening tool, followed by other diagnostic methods to improve the cost-effectiveness of RPL evaluation, or as an alternative genetic test when other methods are unavailable or unaffordable.

Is Fetal Karyotyping A Significant Tool in Evaluation of Recurrent Pregnancy Loss?

Karyotyping is a technique to examine the chromosomes-abnormality or structural defects. Karyotyping can be used to detect a variety of genetic disorders. For example, a woman who has premature ovarian failure may have a chromosomal defect that karyotyping can pinpoint. In a developing country like India where cost dictates the patient courses of action it is up to government funded hospitals to make judicious decisions and make use of this technology.

Antimullerian hormone is a predictor of live birth in patients with recurrent pregnancy loss

BackgroundOvarian reserve testing is not routinely performed in the evaluation of recurrent pregnancy loss (RPL). The objective of this study was to determine if AMH levels are predictive of live birth rate in RPL patients pursuing expectant management (EM).MethodsRetrospective cohort study of RPL patients. Patients tried to conceive spontaneously for 12 calendar months or until they achieved a live birth, whichever occurred first. All patients with the intent to conceive were included regardless of final outcome.ResultsOne hundred fifty-five RPL patients treated from 2009 to 2017 were included. In a univariate logistic regression, AMH < 1 ng/mL was associated with decreased likelihood of live birth (OR 0.38; CI 0.16–0.87, p = 0.03) and increasing age (OR 0.91; CI 0.83–0.99, p = 0.04). Likelihood of live birth was not significantly associated with BMI (OR 1.21; CI 0.83–1.77, p = 0.31), three or four or more prior pregnancy losses (OR 0.93; CI 0.40–2.22, p = 0.87 and OR 0.52; CI 0.19–1.42, p = 0.20, respectively) and prior live births (OR 1.00; CI 0.48–2.08, p = 0.99). AMH < 1 ng/mL was shown to be a stronger predictor of live birth than age using a multivariate model adjusting for age, AMH, and time to conception.ConclusionsAMH < 1 ng/mL is associated with decreased likelihood of live birth among RPL patients pursuing EM, and may be a stronger predictor of live birth than age in this population.

The male contribution to recurrent pregnancy loss.

There are several known causes of recurrent pregnancy loss (RPL) in a couple, which include endocrine abnormalities, immunologic abnormalities, structural uterine abnormalities and karyotype abnormalities. The evaluation largely focuses on the female. The male contribution to RPL remains understudied. With the exception of the karyotype analysis, there is currently no other recommended testing for the male partner of a woman who has suffered multiple pregnancy losses. Chromosomal abnormalities are well defined causes of pregnancy losses in the literature. However, despite the fact that abnormal DNA fragmentation has been implicated in the pathogenesis of unexplained RPL, it is not routinely checked during the evaluation of RPL. This is likely due to the fact that abnormal DNA fragmentation is the end result of multiple different mechanisms including environmental exposures, varicoceles, gene alteration and epigenetic changes resulting in an inherent susceptibility to DNA damage? We are just beginning to scratch the surface of our understanding of the male contribution to RPL and more studies especially focusing on epigenetic modifications and gene alterations are needed.

Recurrent Pregnancy Loss Evaluation Combined With 24-Chromosome Microarray of Miscarriage Tissue Provides a Probable or Definite Cause of Pregnancy Loss in Over 90% of Patients

(Abstracted from Human Reprod 2018;33:579–587) Recurrent pregnancy loss (RPL) occurs in up to 4% of reproductive age couples. The American Society for Reproductive Medicine (ASRM) issued a guideline on the evaluation of RPL in 2012.

Contemporary Evidence-Based Approach to the Couple Experiencing Recurrent Pregnancy Loss: Standardizing Terminology, Testing, and Treatment

The objective of this review is to highlight central issues relating to recurrent pregnancy loss (RPL), including use of updated terminologies, updated criteria for initiating an RPL evaluation, and an evidence-based standard diagnostic evaluation. RPL is a condition characterized by repeated spontaneous demise of pregnancy. It is a multifactorial disorder that affects approximately 5% of couples in the general population who are trying to have a child. RPL should be defined as two or more pregnancy losses at any gestational age; these do not necessarily need to be consecutive. As 50 to 70% of pregnancy losses of less than 10 weeks gestational age are due to random numeric chromosome errors, we recommend chromosome testing of miscarriage tissues with the second and all subsequent miscarriages less than 10 weeks gestational age. If the second pregnancy loss is “unexplained,” meaning that the chromosome content is euploid (46,XX of pregnancy origin, 46,XY, or a balanced structural chromosomal rearrangement), then an RPL diagnostic evaluation is indicated. Despite a comprehensive evaluation, approximately 40% of couples with RPL will not have a specific etiologic factor identified. In these couples, as with all couples experiencing RPL, empirical management with close monitoring and supportive care during the first trimester is associated with encouraging subsequent live birth rates. This review contains 10 figures, 5 tables and 57 references Key words: factors associated with recurrent pregnancy loss, idiopathic recurrent pregnancy loss, miscarriage chromosome testing, nonvisualized pregnancy loss, pregnancy of unknown location, recurrent miscarriage, recurrent pregnancy loss

Recurrent pregnancy loss evaluation combined with 24-chromosome microarray of miscarriage tissue provides a probable or definite cause of pregnancy loss in over 90% of patients.

Will the addition of 24-chromosome microarray analysis on miscarriage tissue combined with the standard American Society for Reproductive Medicine (ASRM) evaluation for recurrent miscarriage explain most losses? Over 90% of patients with recurrent pregnancy loss (RPL) will have a probable or definitive cause identified when combining genetic testing on miscarriage tissue with the standard ASRM evaluation for recurrent miscarriage. RPL is estimated to occur in 2-4% of reproductive age couples. A probable cause can be identified in approximately 50% of patients after an ASRM recommended workup including an evaluation for parental chromosomal abnormalities, congenital and acquired uterine anomalies, endocrine imbalances and autoimmune factors including antiphospholipid syndrome. Single-center, prospective cohort study that included 100 patients seen in a private RPL clinic from 2014 to 2017. All 100 women had two or more pregnancy losses, a complete evaluation for RPL as defined by the ASRM, and miscarriage tissue evaluated by 24-chromosome microarray analysis after their second or subsequent miscarriage. Frequencies of abnormal results for evidence-based diagnostic tests considered definite or probable causes of RPL (karyotyping for parental chromosomal abnormalities, and 24-chromosome microarray evaluation for products of conception (POC); pelvic sonohysterography, hysterosalpingogram, or hysteroscopy for uterine anomalies; immunological tests for lupus anticoagulant and anticardiolipin antibodies; and blood tests for thyroid stimulating hormone (TSH), prolactin and hemoglobin A1c) were evaluated. We excluded cases where there was maternal cell contamination of the miscarriage tissue or if the ASRM evaluation was incomplete. A cost analysis for the evaluation of RPL was conducted to determine whether a proposed procedure of 24-chromome microarray evaluation followed by an ASRM RPL workup (for those RPL patients who had a normal 24-chromosome microarray evaluation) was more cost-efficient than conducting ASRM RPL workups on RPL patients followed by 24-chromosome microarray analysis (for those RPL patients who had a normal RPL workup). A definite or probable cause of pregnancy loss was identified in the vast majority (95/100; 95%) of RPL patients when a 24-chromosome pair microarray evaluation of POC testing is combined with the standard ASRM RPL workup evaluation at the time of the second or subsequent loss. The ASRM RPL workup identified an abnormality and a probable explanation for pregnancy loss in only 45/100 or 45% of all patients. A definite abnormality was identified in 67/100 patients or 67% when initial testing was performed using 24-chromosome microarray analyses on the miscarriage tissue. Only 5/100 (5%) patients, who had a euploid loss and a normal ASRM RPL workup, had a pregnancy loss without a probable or definitive cause identified. All other losses were explained by an abnormal 24-chromosome microarray analysis of the miscarriage tissue, an abnormal finding of the RPL workup, or a combination of both. Results from the cost analysis indicated that an initial approach of using a 24-chromosome microarray analysis on miscarriage tissue resulted in a 50% savings in cost to the health care system and to the patient. This is a single-center study on a small group of well-characterized women with RPL. There was an incomplete follow-up on subsequent pregnancy outcomes after evaluation, however this should not affect our principal results. The maternal age of patients varied from 26 to 45 years old. More aneuploid pregnancy losses would be expected in older women, particularly over the age of 35 years old. Evaluation of POC using 24-chromosome microarray analysis adds significantly to the ASRM recommended evaluation of RPL. Genetic evaluation on miscarriage tissue obtained at the time of the second and subsequent pregnancy losses should be offered to all couples with two or more consecutive pregnancy losses. The combination of a genetic evaluation on miscarriage tissue with an evidence-based evaluation for RPL will identify a probable or definitive cause in over 90% of miscarriages. No funding was received for this study and there are no conflicts of interest to declare. Not applicable.

Chromosomal microarray analysis as the first-tier clinical diagnostic test for miscarriage analysis

Despite the high failure rate and inherent limitations of conventional cytogenetic/karyotype analysis for products of conception samples (POCs) and high success rate and diagnostic benefits of chromosomal microarray analysis (CMA), testing of this sample type by CMA remains low. This underutilization may be due to a lack of awareness of the technology's diagnostic power, and more importantly, lack of clear opinions or recommendations in support of this testing by professional committees, such as The American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM). We undertook a retrospective analysis of over 13 thousand consecutive POCs evaluated by CMA with the purpose of determining analytical success, failure rates, and frequency/rates of causative and non-causative abnormalities. In addition, potential challenges, either sample-related or test-related, were cataloged. Materials and Methods Of the 13,711 cases received for evaluation by CMA, 12,324 were successfully analyzed and reported (90%); 83% of samples were ascertained for recurrent pregnancy loss (RPL) or spontaneous abortion (SAB). About 78% of samples were fresh and 21% of samples were FFPE. The majority of samples (88%) were analyzed by whole-genome SNP-based CMA allowing detection of whole chromosome or segmental copy number changes (greater than 20kb; and greater than 5% mosaicism), triploidy, whole-genome uniparental isodisomy (molar pregnancy), and maternal cell contamination. In 54% (6665/12324) of cases, a clinically significant abnormality was identified, and over 96% of those abnormalities were deemed causative of the pregnancy loss. Normal results were obtained in 44% of cases, and variants of uncertain significance (VOUS) were detected in the remaining2% of cases. The most common abnormalities detected were autosomal trisomies (single trisomy, 62%; multiple trisomies, 4%), triploidy (12%), molar pregnancy (1%) and monosomy X (11%). Autosomal monosomies were rare (<1% of cases). Clinically significant segmental deletions and duplications were detected in 4.6% cases. This data shows the continued diagnostic value of CMA for the evaluation of POCs and further supports its use for miscarriage analysis. The success rates and diagnostic power in providing a high resolution genome-wide evaluation of POCs for causative abnormalities should be the primary determining factors for the establishment of recommendations or guidelines for routine genetic evaluation of RPL and SAB. Unfortunately, recommendations for miscarriage analysis by CMA remain unclear. As seen in this large, retrospective study, the high success rate (90%) and the ability to provide a causative genetic diagnosis for over 50% of samples make CMA the best testing option for POCs and support its use as the first-tier diagnostic test for evaluation of all miscarriages.

The role of parental microRNA alleles in recurrent pregnancy loss: an association study

The medical evaluation of recurrent pregnancy loss (RPL), the occurrence of two or more consecutive pregnancy losses prior to 20th week of gestation, is mainly focused on maternal factors. However, paternally expressed genes may also play a role in implantation and placenta quality. This study aimed to investigate the possible association between parental miR-196a2C>T and miR-499aT>C polymorphisms and RPL in a case-control study including 200 RPL couples and 400 healthy men and women. Genotyping was performed using Tetra-ARMS-PCR and PCR-RFLP for miR-196a2C>T and miR-499aT>C polymorphisms, respectively. In men, the association was observed between miR-499a and RPL under dominant (P = 0.006; odds ratio [OR] = 2.36; 95% confidence interval [CI], 1.28–4.37), recessive (P < 0.0001; OR = 2.89; 95% CI, 1.92–4.36) and additive (P < 0.001; OR = 2.77; 95% CI, 1.52–5.10) models. In women, the association was found between miR-196a2 and RPL under recessive (P = 0.02; OR = 2.19; 95% CI, 1.16–4.14) and additive (P = 0.03; OR = 1.53; 95% CI, 1.04–2.27) models. Hence, evidence was provided for association of genetic variation in parental microRNA polymorphisms with RPL. Further studies are required to validate the significance of the studied genetic variations in diverse ethnic populations.

Guidance for the evaluation and treatment of hereditary and acquired thrombophilia.

Thrombophilias are hereditary and/or acquired conditions that predispose patients to thrombosis. Testing for thrombophilia is commonly performed in patients with venous thrombosis and their relatives; however such testing usually does not provide information that impacts management and may result in harm. This manuscript, initiated by the Anticoagulation Forum, provides clinical guidance for thrombophilia testing in five clinical situations: following 1) provoked venous thromboembolism, 2) unprovoked venous thromboembolism; 3) in relatives of patients with thrombosis, 4) in female relatives of patients with thrombosis considering estrogen use; and 5) in female relatives of patients with thrombosis who are considering pregnancy. Additionally, guidance is provided regarding the timing of thrombophilia testing. The role of thrombophilia testing in arterial thrombosis and for evaluation of recurrent pregnancy loss is not addressed. Statements are based on existing guidelines and consensus expert opinion where guidelines are lacking. We recommend that thrombophilia testing not be performed in most situations. When performed, it should be used in a highly selective manner, and only in circumstances where the information obtained will influence a decision important to the patient, and outweigh the potential risks of testing. Testing should not be performed during acute thrombosis or during the initial (3-month) period of anticoagulation.

Pregnancy outcomes in women with chronic endometritis and recurrent pregnancy loss

To evaluate the prevalence of chronic endometritis (CE) in women with recurrent pregnancy loss (RPL) and compare pregnancy outcomes in women with and without CE. Case-control observational study. Academic fertility practice. Women with two or more pregnancy losses. Hematoxylin and eosin (H & E) staining was performed on all endometrial biopsies and plasma cells were identified by morphology. Immunohistochemical (IHC) staining for CD138 was later applied to all tissue samples. Charts were reviewed to evaluate the outcome of the next clinical intrauterine pregnancy. Miscarriage rate and live birth rate. A total of 107 women met inclusion criteria. The use of CD138 IHC staining resulted in a significantly higher prevalence of CE compared with the use of H & E staining and morphological assessment alone (56% [60/107] vs. 13% [14/107]). The 51 women with untreated CE were compared with the 45 women without CE by CD138 staining. Among those women with a subsequent pregnancy, the live birth rate in the next clinical intrauterine pregnancy after endometrial evaluation was 67.6% (23/34) in women with untreated CE and 87.1% (27/31) in women without CE. Age, body mass index (BMI), results of RPL evaluation, and number of prior losses were not significantly different between the two groups. CD138 IHC staining of endometrial biopsies in women with RPL provides increased sensitivity when screening for CE compared with H & E staining and morphological assessment alone. Untreated CE may contribute to poor pregnancy outcomes and deserves further investigation in a larger cohort.