For the better part of the past 20 years I have consulted on or cared for well over 1000 patients with recurrent pregnancy loss (RPL) due to either stillbirths or miscarriages. So this is an area of obstetrics I have thought about quite a bit and it is fair to say that I have been very frustrated by my frequent inability to identify the cause of this tragic condition or to offer effective treatments. A rough classification scheme for RPL To grossly simplify this disorder based on 2 decades of personal observations, I would argue that there are 3 major patient populations affected by RPL. The first are older nulliparous patients who have delayed childbearing until their late 30s or early 40s and present with recurrent pre-embryonic (< 5 weeks) or embryonic (< 10 weeks) miscarriages with or without infertility. In rare cases, they also will have interspersed second- and third-trimester fetal deaths. When the products of conception (POCs) from these patients are accessible and can be karyotyped, they most often display aneuploidy (eg, trisomies, triploidy, or less commonly, deletions and insertions). We really do not understand the pathogenesis of maternal age-associated chromosomal instability and there is not much that we can offer to these patients beyond encouragement, and ultimately donor egg in vitro fertilization.
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