Fertility and Miscarriage
Miscarriage
An unexpected miscarriage is difficult for any couple. Two or more can be devastating. But now there is hope, and a solution.
Miscarriage occurs in 15–25% of clinical pregnancies and accounts for more than 50 000 inpatient admissions to hospitals in the UK annually. Without medical intervention, the painful pattern of miscarriage can occur again and again. Increasing maternal age and a higher number of miscarriages at time of initial visit are associated with a significant decrease in the likelihood of having a live birth. Second trimester pregnancy loss is significantly associated with recurrent second trimester loss and future spontaneous preterm birth.
The common Reasons for Miscarriages
One in two hundred couples will experience two or more consecutive miscarriages. There are many reasons of miscarriage but the most common five reasons are:
Subfertility
Miscarriage
An unexpected miscarriage is difficult for any couple. Two or more can be devastating. But now there is hope, and a solution.
Miscarriage occurs in 15–25% of clinical pregnancies and accounts for more than 50 000 inpatient admissions to hospitals in the UK annually. Without medical intervention, the painful pattern of miscarriage can occur again and again. Increasing maternal age and a higher number of miscarriages at time of initial visit are associated with a significant decrease in the likelihood of having a live birth. Second trimester pregnancy loss is significantly associated with recurrent second trimester loss and future spontaneous preterm birth.
The common Reasons for Miscarriages
One in two hundred couples will experience two or more consecutive miscarriages. There are many reasons of miscarriage but the most common five reasons are:
- Chromosome abnormal up to 50%
- Progesterone level low 20%
- Anatomy abnormal 5-10%
- Immune mechanisms 10-50%
- Infection 1%
- Unknown 10%
Subfertility
One in six couples have an unwanted delay in conception. Roughly half of these couples will conceive either spontaneously or with relatively simple advice or treatment. The other half remains subfertile and need more complex treatment.
Chance of spontaneous conception
Conception is most likely to occur in the first months of trying (about 30% conception rate). The chance then falls steadily to about 5% by the end of the first year. Usually investigations are undertaken after a year, although for some couples it may be appropriate to star investigation sooner.
Factors are likelihood affecting conception:
· Age over 35 years
· Duration of subfertility more than 2 years of tying to conceive
· Weight-BMI <20 or >30
· No previous pregnancy
· Infrequent intercourse or incorrectly timed
· Smoking, Alcohol consumption and recreation drugs (male and female)
· Caffeine intake > two cups / day.
Is subfertility getting more common?
It is difficult to separate changes in social, diet and environmental behaviour and the trends in delaying fertility. Some studies have showed some factors have significant impacts on sperm and eggs quality.
Major causes of subfertility:
There are many factors that can affect fertility, the common causes are:
· Ovulation disorder
· Low eggs reserve
· Male factor and poor sperm quality
· Tubal status and possibility of damage
· Others as Endometriosis, fibroids
· Unexplained with no clear cause of subfertility
Preconception advice
Couples who are considering starting a family may want to approach their GP or Specialist for advice but the general advise are:
· Addressing any pre-existing medical problem
· Work to optimise weight and exercise
· Stop smoking / recreation drugs
· Virology screening e.g. Rubella
· Frequent intercourse, ideally 2-3 time per week.
. Being on Folic acid
Impact of subfertility
The impact of experiencing difficulty conceiving should not be underestimated for couples presenting with the problem. Many find it is stressful to seek professional help for such an intimate problem and feel a sense of failure at having to do so. It is not uncommon for the problem to add a strain on the relationship and many couple experience deterioration in their sexual relationship which exacerbate the problem. Psychological support is advisable in these cases and is avialble.
Making a diagnosis
Subfertility investigation determines weather a problem exists and enables a rational discussion about options for treatment. This should be through a infertility specialist for best outcome.
Investigation: who and when
Subfertility is defined as failure to conceive after one year of unprotected regular intercourse. Although usually it would be reasonable to start investigation earlier and referral may be justified where there are important factors or age factors.
Factors that may warrant early referral or investigation
Female
Age>35 years
Endometriosis or significant pelvic pain
Previous ectopic pregnancy
Known tubal disease or history of sexually transmitted disease e.g. Chlamydia
Ovarian cysts or endometrioma
Pelvic / abdominal surgery
Scanty or absence of menstruation
Presence of fibroid or polyp
Male
Undescended testicles
Chemotherapy or radiotherapy
Previous genital surgery
History of sexually transmitted disease
Significant trauma or testicular disease
Starting investigation
Initial investigation that can be done:
Female
· Checking ovarian eggs reserve -Follicular stimulating hormone, luteinising hormone, and estradiol should be measured between
day 2-4 of menstruation.
· Checking ovulation-progesterone test on day 21 or seven days before expected menses.
· Rubella test
· Vaginal swab to exclude common sexually transmitted disease e.g. Chlamydia
· Cervical smear
· Thyroid function test in irregular periods
· Polycystic ovarian blood test in women with suggestive history of this problem
Male
Sperm test for analysis
Specialist level Investigation
These tests are usually request by the specialist and based on the most likelihood is the problem
· Hysterosalpingograme (HSG)
· Ultrasound scan
· Saline infusion ultrasound scans
· Laparoscopy and Dye test
Interpreting results
Prompt investigation and appropriate referral to a specialist allow couples to receive advice and treatment to help them reach their goal of a pregnancy more quickly, and may alleviate some of the distress associated with infertility. Also, referral to infertility specialist with advanced infertility surgical skills is paramount important to afford the high standard of care with optimum outcome.
Chance of spontaneous conception
Conception is most likely to occur in the first months of trying (about 30% conception rate). The chance then falls steadily to about 5% by the end of the first year. Usually investigations are undertaken after a year, although for some couples it may be appropriate to star investigation sooner.
Factors are likelihood affecting conception:
· Age over 35 years
· Duration of subfertility more than 2 years of tying to conceive
· Weight-BMI <20 or >30
· No previous pregnancy
· Infrequent intercourse or incorrectly timed
· Smoking, Alcohol consumption and recreation drugs (male and female)
· Caffeine intake > two cups / day.
Is subfertility getting more common?
It is difficult to separate changes in social, diet and environmental behaviour and the trends in delaying fertility. Some studies have showed some factors have significant impacts on sperm and eggs quality.
Major causes of subfertility:
There are many factors that can affect fertility, the common causes are:
· Ovulation disorder
· Low eggs reserve
· Male factor and poor sperm quality
· Tubal status and possibility of damage
· Others as Endometriosis, fibroids
· Unexplained with no clear cause of subfertility
Preconception advice
Couples who are considering starting a family may want to approach their GP or Specialist for advice but the general advise are:
· Addressing any pre-existing medical problem
· Work to optimise weight and exercise
· Stop smoking / recreation drugs
· Virology screening e.g. Rubella
· Frequent intercourse, ideally 2-3 time per week.
. Being on Folic acid
Impact of subfertility
The impact of experiencing difficulty conceiving should not be underestimated for couples presenting with the problem. Many find it is stressful to seek professional help for such an intimate problem and feel a sense of failure at having to do so. It is not uncommon for the problem to add a strain on the relationship and many couple experience deterioration in their sexual relationship which exacerbate the problem. Psychological support is advisable in these cases and is avialble.
Making a diagnosis
Subfertility investigation determines weather a problem exists and enables a rational discussion about options for treatment. This should be through a infertility specialist for best outcome.
Investigation: who and when
Subfertility is defined as failure to conceive after one year of unprotected regular intercourse. Although usually it would be reasonable to start investigation earlier and referral may be justified where there are important factors or age factors.
Factors that may warrant early referral or investigation
Female
Age>35 years
Endometriosis or significant pelvic pain
Previous ectopic pregnancy
Known tubal disease or history of sexually transmitted disease e.g. Chlamydia
Ovarian cysts or endometrioma
Pelvic / abdominal surgery
Scanty or absence of menstruation
Presence of fibroid or polyp
Male
Undescended testicles
Chemotherapy or radiotherapy
Previous genital surgery
History of sexually transmitted disease
Significant trauma or testicular disease
Starting investigation
Initial investigation that can be done:
Female
· Checking ovarian eggs reserve -Follicular stimulating hormone, luteinising hormone, and estradiol should be measured between
day 2-4 of menstruation.
· Checking ovulation-progesterone test on day 21 or seven days before expected menses.
· Rubella test
· Vaginal swab to exclude common sexually transmitted disease e.g. Chlamydia
· Cervical smear
· Thyroid function test in irregular periods
· Polycystic ovarian blood test in women with suggestive history of this problem
Male
Sperm test for analysis
Specialist level Investigation
These tests are usually request by the specialist and based on the most likelihood is the problem
· Hysterosalpingograme (HSG)
· Ultrasound scan
· Saline infusion ultrasound scans
· Laparoscopy and Dye test
Interpreting results
Prompt investigation and appropriate referral to a specialist allow couples to receive advice and treatment to help them reach their goal of a pregnancy more quickly, and may alleviate some of the distress associated with infertility. Also, referral to infertility specialist with advanced infertility surgical skills is paramount important to afford the high standard of care with optimum outcome.