Human reproduction is remarkably inefficient; Only 420 are born alive out of 1000 fertilizations, nearly 70% of human conceptions do not survive to live birth. The stillbirth in india is highest in the world 7% to 14% in different states Odisha 8% Karnataka 14% (of course reported only) Recurrent pregnancy loss is a psychologically stressful diagnosis for couples, in approximately 50% of cases, no cause will be found. The number of evidence-based practices available for guidance is limited. This confluence of factors presents a challenge for clinicians. However, in studies of interventions aimed at reducing rates of miscarriage in women with otherwise unexplained RPL, control groups experience a live birth rate of up to 87% with no intervention. Thus, one of the most significant things we can do when caring for these complex patients is to offer them emotional support and accurate information. As more work is done in this emerging area of reproductive science, we will be able to shed more light on this complex problem.

1. Impact Of Genetic
Testing For RPL
Couples
Dr. Sujnanendra Mishra
MD (Obgyn)

3. RPL
Recurrent Spontaneous Abortion (RSA),
Recurrent Miscarriage (RM)
Idiopathic Recurrent Miscarriage (IRM)
Unexplained Recurrent Spontaneous Abortion (URSA)
“Habitual Abortion”.
Recurrent spontaneous miscarriage (RSM)

4. CONTROVERSIES in RPL
• Is Pregnancy confirmed?
• Is there Consensus definition of RPL?
• How many losses diagnose RPL?
• What counts as a pregnancy loss?
• What about the other half?
• What are all tests to be done?
• Should we get karyotypes on all?
• Should we get karyotypes on POC?
• What is the chance of a live birth?
• If any other impacts other than Reproductive?

5. What is a pregnancy.
PATIENT’S perception
• A positive pregnancy test from
home (or their doctors office)
that does not result in a baby.
• It also includes Bio-Chemical
Pregnancy.
FACT
• Pregnancy is defined as a clinical
pregnancy documented by
ultrasonography or histopathologic
examination
ASRM Committee Opinion Fertil Steril. 99:63, 2012
ASRM Practice Committee Fertil Steril 98:1103-1101, 2012
Kutteh experience over last 20 years of clinical
practice

6. Terminology
PREGNANCY LOSS
MISCARRIAGE
(< 20 WKS)
PREGNANCY OF
UNKNOWN
LOCATION (PUL)
EARLY EMBRYONIC
(< 6 WKS)
EMBRYONIC
(> 6 TO 9 WKS)
FETAL LOSS
(> 9 TO 20 WKS)
STILLBIRTH
(> 20 WKS)

7. Is there Consensus definition of RPL?
• Williams OB 24th Edition “most generally accepted
definition” The American Society for Reproductive
Medicine (2008) proposed that recurrent pregnancy
loss be defined as two or more failed clinical
pregnancies confirmed by either sonographic or
histopathological examination. A thorough evaluation
certainly is warranted after three losses, and
treatment is initiated earlier in couples with
concordant subfertility (Jaslow, 2010; Reddy, 2007).
Three or more spontaneous, consecutive pregnancy
losses (fathered by the same partner)
• ACOG Practice Bulletin No. 24, February 2001
• “RPL is typically defined as two or three or more
consecutive pregnancy losses”
• “Patients with two or more consecutive, spontaneous
losses are candidates for an evaluation to determine the
etiology”

8. ? What # to Define RPL
Incidence of RPL
Two 1/45
Three 1/300
Four 1/2000
Five 1/13,000
Six 1/90,000
Seven 1/600,000
Eight 1/4,000,000
Incidence based on mean sporadic
miscarriage rate of 15%
Incidence=number of miscarriages (μ =
sporadic miscarriage rate of 15%) or 6.67
times rarer.
Saravelos SH, Regan LR. Obstet Gynecol
Clinics N Am. 2014.

9. Theoretical Incidence of RPL
occurring by Chance
for Women with one, two and
three miscarriages
AGES
(years)
1
miscarriage
By chance
2
miscarriages
By chance
3 miscarriages
By chance
20-24 11% 1.21% 0.13%
25-29 12% 1.44% 0.17%
30-34 15% 2.25% 0.34%
35-39 25% 6.25% 1.56%
Saravelos SH and LiTC. Human Reprod. 27:1882-1886, 2012 Saravelos SH, Regan LR. Obstet Gynecol
Clinics N Am. 2014
Theoretical Incidence for
Sporadic miscarriages for
Women

10. Estimates of Pregnancy Loss from
Conception
1000 Fertilized Egg (27% are lost)
728 embryos implanted at 7 days (22% are lost)
568 clinically recognized pregnancies with missed
menstrual period(12% are lost)
514 pregnancies at second trimester(3% are lost)
500 full term births(420 live births 80 Stillbirth)

11. CAUSES
Genetic Factors
• Accounts For >50% Of Cases if we
include peri-implantation loses.
• Whole-chromosome Abnormalities
• Partial-chromosome Abnormalities
• Single-gene Disorders
• Micro-RNA Defects and Changes In
Gene Function Reflecting
Epigenetic Changes.
Non-Genetic Factors
• Disorders Of Thrombosis And
Hemostasis,
• Uterine Anomalies,
• Immunologic Disorders,
• Endocrine Disorders,
• Infectious Etiologies, (Non-TORCH)
• Environmental Influences Such As
Cigarette Smoking and many
others.

12. In RPL>>>
Its time to say goodbye to TORCH tests…….
Cochrane Review has categorically proven in
multiple meta-analysis that none of the “TORCH”
group of infections are responsible for
RECURRENT SPONTANEOUS ABORTIONS

13. 1
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.
First Group
2 Patients with recurrent severe fetal growth restriction and stillbirths, which
generally occur at progressively earlier gestational ages. These patients
have a heterogeneous set of etiologies that ultimately involve severe
uteroplacental vascular insufficiency
Second Group
3 Generally younger, often multiparous, and prone to intermittent fetal loss
at or after 10 weeks, although the occasional patient also presents with
recurrent intermittent embryonic loss.
Third Group
In Practice……..

14. GENETICS
A timeline showing the development of genetics from Gregor Mendel’s work on pea plants to the current era of genomics
and its many applications in research, medicine, and society.

15. CHROMOSOME MUTATION:-
• The failure of chromosomes to properly separate during meiosis results in variation in the
chromosome content of gametes and subsequently in offspring arising from such gametes.
• Plants often tolerate an abnormal genetic content, but, as a result, they often manifest unique
phenotypes. Such genetic variation has been an important factor in the evolution of plants.
• In animals, genetic information is in a delicate equilibrium whereby the gain or loss of a
chromosome, or part of a chromosome, in an otherwise diploid organism often leads to lethality
or to an abnormal phenotype.
• The rearrangement of genetic information within the genome of a diploid organism may be
tolerated by that organism but may affect the viability of gametes and the phenotypes of
organisms arising from those gametes.
• Chromosomes in humans contain fragile sites—regions susceptible to breakage, which leads to
abnormal phenotypes.

16. ABNORMALITIES
• Complete haploid sets of
chromosomes are present =
Euploidy.
• Polyploidy
• 2 Sets = Diploidy
• 3 sets = Triploidy
• Like that Tetraploidy, pentaploidy, etc.
• Gains/loses of one/more
chromosomes but not a complete
set.= aneuploidy.
• Monosomy
• Di-somy
• Trisomy
• Tetrasomy, pentasomy, etc.
• A Translocation Involves
Transposition Of Chromosome
Material Usually Between
Chromosomes. Three Types are
Recognized:
• Centric Fusion Or ‘Robertsonian’
(code: ‘rob’) ,
• Reciprocal (code: ‘t’)
• Insertional (code: ‘ins’)
Variation in Composition and ArrangementVariation in Chromosome Number

17. :
Genetic Approach
to
Recurrent Fetal Loss
• Genetic consultation after 2-3 episodes
• ≈ 50 % of all first trimester spontaneous abortions show a
chromosomal abnormality (most « de novo »)
• ≈ 5% abnormal parental karyotype, esp. translocations.
• Provide risks for offspring (theoretical + empirical)
• PND Options
• Discuss implications for other family members

18. Chromosome Rearrangements
• Rarely, a parent may carry a “balanced” chromosome rearrangement
that can lead to imbalance of chromosomal material in eggs or sperm
• Mothers and fathers are equally likely to carry a rearrangement
• Rearrangements are the cause of only 2% of miscarriages, but 1/25
couples with repeated miscarriage will have such a rearrangement.
• Rearrangements can be detected by chromosome analysis of
embryonic material, or by chromosome analysis of parental blood.
• Rearrangements predict an increased risk of miscarriage and the
possibility of children with birth defects.

19. - indirect
- detection by indirect means
Prenatal Diagnosis
What can be detected today ?
• Chromosomal disorders
• detection depends on level of resolution
• Monogenic/ polygenic disorders
• Direct analysis
• gene known in detail, mutation defined.
• Indirect analysis
• gene located, linkage analysis)
• Multifactorial disorders
• Detection by indirect methods
• US, markers in maternal serum, amniotic fluid.
PND always = attempt to answer a specific question.
No screening of genes !

20. Genetic testing
• Definition: the analysis
of human DNA, RNA,
chromosomes, proteins,
and certain metabolites
in order to detect
heritable disease-related
genotype, mutations,
phenotypes, or
karyotypes for clinical
puroses
Holtzman NA, Watson MS, eds.
Promoting safe and effective genetic
testing in the United States: final report
of the Task Force on Genetic Testing.
Baltimore: Johns Hopkins University
Press, 1999

21. • Preconception care is primary prevention. The goal is to affirm
pregnancy intention, reduce any potential harm, and recognize
modifiable risk factors related to pregnancy while stratifying
pregnancies on a continuum of low- to high-risk. The Centers for
Disease Control and Prevention (CDC) has defined preconception care
as “a set of interventions
Trimester zero
Pregnancy wellness begins before the positive pregnancy test.

22. Prenatal Diagnosis Methods
• Non invasive Techniques
• A. Fetal visualization :-
• Ultrasound
• Fetal echocardiography
• Magnetic resonance imaging (MRI)
• Radiography
• B. Screening for neural tube defects (NTDs) : -
• Measuring maternal serum alpha-
fetoprotein (MSAFP)
• C. Screening for fetal Down syndrome:
• Measuring MSAFP
• Measuring maternal unconjugated estriol
• Measuring maternal serum beta-human
chorionic gonadotropin (HCG)
• D. Separation of fetal cells from the mother's
blood:
• Invasive Techniques
• a. Fetal visualization
• Embryoscopy
• Fetoscopy
• b. Fetal tissue sampling
• Amniocentesis
• Chorionic villus sampling (CVS)
• Percutaneous umbilical blood sampling (PUBS)
• Percutaneous skin biopsy
• Other organ biopsies, including muscle and liver biopsy
• c. Preimplantation biopsy of blastocysts obtained by in vitro
fertilization
• d. Cytogenetic investigations
• Detection of chromosomal aberrations
• Fluorescent in situ hybridization
• e. Molecular genetic techniques
• Linkage analysis using microsatellite markers
• Restriction fragment length polymorphisms (RFLPs)
• Single nucleotide polymorphisms (SNPs)

23. Ultrasound markers
• Down syndrome
• Nuchal translucency (end first trim.), absent nasal bone, hydrops,
• Duodenal, oesophageal atresia
• Skeletal signs (humerus, femur short), growth
• Malformations ( esp. heart, kidney, CNS,..)
• Chromosomal anomalies in general
• Growth retardation
• Malformations (heart, kidney, CNS, intest (CF)..)
• Amniotic fluid: oligohydramnios, hydramnios.
• Fetal movements decreased.

24. What Are The Tests?
TEST METHOD WHEN WHAT
SIPS
1st Blood test
2nd Blood Test
9w to 13+6w
15w to 20+6w
PAPPA
AFP, HCG, UE3, and
Inhibin A
IPS
1st Blood Test and
Nuchal Translucency US
2nd Blood Test
9w to 13+6w
15w to 20+6w
PAPPA
AFP ,HCG, UE3, and
Inhibin A
QUAD Blood test
15w to 20+6w AFP, HCG, UE3, and
Inhibin A
FTS
Blood test and US: NT, nasal bones,
Ductus Venosis flow, and fetal heart
rate
11w-14w PAPPA, AFP, HCG
NIPT Blood test 10w plus Cell free fetal DNA

25. Combined or integrated screening?
• COMBINED
• Earlier diagnosis of nuchal
translucency.
• One single blood sample
• Organisation more simple
• INTEGRATED
• Two-step process
• two serum tests on different
appointments
• Cost effectiveness?
• Same sensitivity
• More complex for women and
clinicians.
• Failing to attend the second
appointment renders the test
invalid.
« Contingent screening »
The best of two worlds?

26. Prenatal Genetic Screening
First Trimester Screen (FTS) alternative to IPS or SIPS
• 11-14 weeks
• Ultrasound and one blood sample: T, nasal bone, fetal heart rate, Ductus
Venosis flow, PAPPA-A/fbHCG
• Advantage? result same day as US; fewer false positives
Non Invasive Prenatal Test (NIPT) prior to amniocentesis
• 10+ weeks
• Fetal DNA in maternal blood
• Highly accurate screen to detect T21 and T18
• Advantage?: result 10 days after blood draw. Fewest false pos.
• Does not screen for open neural tube defect

27. ~ 10% of DNA in maternal plasma is FETAL
Non Invasive Prenatal TestingNon Invasive Prenatal Testing

28.  Placental origin
 Increase during
pregnancy : 3-10 % of
total plasmatic DNA
 Cleared from maternal
circulation in <24 h after
delivery
(1/2 life=15 min)
Non Invasive Prenatal Testing (NIPT)
Cell-free Fetal DNA

31. Benefits of Prenatal Diagnosis:
• Prenatal diagnosis determines the outcome of pregnancy.
• It is helpful for couples to decide whether to continue the pregnancy.
• It indicates possible complications that can arise at birth process.
• Prenatal diagnosis is helpful for the management of remaining weeks
of pregnancy.
• It prepares the couple for the birth of a child with an abnormality.
• Prenatal diagnosis can be helpful for the improvement of the
outcome of pregnancy using fetal treatment.

32. Pros & Cons:- Things to Keep in Mind
• Local resources - What prenatal screening options are available in your area?
• Not all that can be done must be done or is good to be done!
• PND is a couple’s (in the end the pregnant woman’s) free choice
• Information must be neutral and complete about all available options
• Informed choice - Before ordering the test, discuss benefits, risks and limitations
(screening vs. diagnosis)
• The ethical aspects need to be addressed thoroughly
• Each case should be an individual one
• Shared decision making

33. True Unexplained RPL? Impact of evaluation
• Current evaluation completed
• Test results all return as normal
• Chromosomes on POC are normal
• Subsequent live birth is 40% to 80%
• Depends on maternal age
• Depends on number of prior losses
• The most effective way to reduce
pregnancy losses, chromosome
abnormalities detected at the time
of prenatal diagnosis and the
demand for assisted reproductive
technology?
• Reverse the pattern of delaying
child-bearing until late in
reproductive life !!!!

34. Limitations
• True fetal mosaicism
• Confined placental mosaicism
• Maternal karyotype abnormality
• Insufficient counting due to low fetal fraction
• Sample from Vanishing twin
Depending on the methodology used, reasons for discordancy
between CFDNA results and fetal karyotype can include:

35. Guidelines / Genetics committee
SOGC Feb 2013
• Non-invasive prenatal testing using massive parallel sequencing of cell-free
fetal DNA to test for trisomy 21, 18, and 13 should be an option available to
women at increased risk in lieu of amniocentesis. Pretest counselling of
these women should include a discussion of the limitations of non-invasive
prenatal testing. (II-2A)
• No irrevocable obstetrical decision should be made in pregnancies with a
positive non-invasive prenatal testing result without confirmatory invasive
diagnostic testing. (II-2A)
• Although testing of cell-free fetal DNA in maternal plasma appears very
promising as a screening test for Down syndrome and other trisomies,
studies in average-risk pregnancies and a significant reduction in the cost of
the technology are needed before this can replace the current maternal
screening approach using biochemical serum markers with or without fetal
nuchal translucency ultrasound. (III-A)

36. The Other Half: What about Men and
Miscarriages?
• Men are half of the equation in a couple that is having recurrent miscarriages.
• Factors in men that may increase risk of miscarriage for a couple include
advanced age, obesity, chronic illness, environmental toxins, and lifestyle factors,
• The only test recommended by expert groups for a man in a RPL couple is a blood
test for karyotype to evaluate for a balanced translocation (genetic issue found in
3-5% of couples with RPL).
• Other tests like semen analysis, aneuploidy testing in sperm, DNA fragmentation,
and epigenetic testing have limited research and limited utility at this time.
• Lifestyle factors that focus on improving a man’s overall health and well-being
may be beneficial in decreasing miscarriage for the couple.
• The emotional impact of RPL on men is important to remember and address.

37. Possible role of male factors in
recurrent pregnancy loss
• Amongst male partners of women with RSA 3 (4%) had varicocele, 23 (30.6%)
had infection, 1 (1.3%) immunological and 1 (1.3%) had genetic abnormality
• Sperm motility, viability and sperm function tests were significantly lower in
the RPL group as compared to the control group (P = 0.000)
• Male factor might be a contributing factor towards RPL
• Both the partners should be evaluated
• Infection treated in both
Saxena P, Misro MM et al. Indian J Physiol Pharmacol.
2008 Jul-Sep;52(3):274-82

38. Preimplantation genetic diagnosis (PGD)
• Pre-implantation genetic diagnosis.
• Which genetic conditions are eligible for PGD ?
• Who determines whether a condition is eligible?
• The role of the clinical genetic service in the provision of this publically
funded process.
• The effect of resource constraints in the provision of PGD.

39. Pre-implantation genetic screening (PGS)
• Screening for large chromosomal imbalances (implantation failure, early
miscarriage, viable trisomies e.g. T21)
• Who is being offered this technology?
• Recurrent pregnancy loss
• Recurrent implantation failure
• Advanced maternal age
• ?Everyone
• What is the evidence to support use of PGS?
• Not currently covered in public system but offered by private fertility
providers

40. Preimplantation Genetic Screening (PGS)
• Conflicting evidence
• Improves implantation rate and live birth rate (Dahdouh, 2015. Fertil Steril 2015;
104:1503–1512. Meta-analysis 3 trials included)
• Intention to treat analysis. Among all attempts at PGS or expectant management among
recurrent pregnancy loss (RPL) patients, clinical outcomes including pregnancy rate, live
birth (LB) rate and clinical miscarriage (CM) rate similar. (Murugappan 2016; Human
Reproduction 31:1668–1674)
• PGS decreased chances of live birth in association with IVF. National improvements in live
birth and miscarriage rates reported with PGS in older women are likely the consequence
of favourable patient selection biases. (Kushnir 2016. Fertil Steril 106: 75–9)
• Concern of accuracy of diagnosis and high rate of false-positives. (Gleicher 2016. Reprod
Biol Endocrinol doi 10.1186/s12958-016-0193-6)

41. Limitations
• Mosaicism – some embryos considered
unsuitable for transfer develop into
healthy pregnancies (Greco 2015.
NEJM 373:2089–90).
• ?Couples choice to transfer non-
euploid embryo
• Pre and post test counseling essential
• Different platforms – inconsistent
results. Discordance in results seen in
published reports (Tortoriello 2016. J
Assist Reprod Genet 33:1467–1471)

42. Limitations of genetic testing
• Somatic mosaicism and operator error mean that genetic tests are
never 100% reliable.
• DNA testing can reveal mutations that are not necessarily expressed
as disease because, for example, they may occur in an unimportant
part of the gene, or the mutant allele is incompletely penetrant.
• Genetic testing may not detect all the disease alleles of a specific
gene.
• Genetic testing can introduce unwanted social and ethical problems.

43. SUMMARY
• Recurrent pregnancy loss is a psychologically stressful diagnosis for couples,
• in approximately 50% of cases, no cause will be found.
• The number of evidence-based practices available for guidance is limited.
• This confluence of factors presents a challenge for clinicians. However,
• in studies of interventions aimed at reducing rates of miscarriage in women with
otherwise unexplained RPL, control groups experience a live birth rate of up to
87% with no intervention.
• Thus, one of the most significant things we can do when caring for these complex
patients is to offer them emotional support and accurate information.
• As more work is done in this emerging area of reproductive science, we will be
able to shed more light on this complex problem.