Squaring the circle of recurrent pregnancy loss (RPL)
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COMMENTARY
Squaring the circle of recurrent pregnancy loss (RPL) Paul N. Scriven 1 Received: 11 February 2020 / Accepted: 8 April 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract The recent publication of a study into the contribution of embryo chromosomal abnormalities in recurrent pregnancy loss (RPL) affords the opportunity to revisit the hypothesis that women with an aneuploid pregnancy loss have a better chance of a successful pregnancy next time than women with a chromosomally normal loss. A previous miscarriage with an abnormal karyotype (unrelated to a parental chromosome rearrangement) should not be viewed as a marker of an increased likelihood of aneuploidy in a subsequent pregnancy; it is (counterintuitively) likely to be indicative of a reduced risk of clinical miscarriage (with a higher proportion of aneuploid products) and an excellent chance for the live birth of the next pregnancy. Each couple should be treated on their own merits and with appropriate investigations performed where indicated; caution should be advised regarding offering preimplantation genetic testing for aneuploidy (PGT-A). Keywords Recurrent pregnancy loss . Miscarriage . Chromosome abnormalities
The recent publication of a study into the contribution of embryo chromosomal abnormalities in recurrent pregnancy loss (RPL) [1] affords the opportunity to revisit the hypothesis that women with an aneuploid pregnancy loss have a better chance of a successful pregnancy next time than women with a chromosomally normal loss [2, 3]. The reasoning is that the detection of aneuploidy in a product of conception explains the pregnancy loss and is likely to be sporadic; recurrent pregnancy losses which are chromosomally normal may be due to other factors which may persist next time. The paper by Nikitina et al. [1] demonstrates the complexities around studying chromosomal abnormalities in pregnancy loss. Of particular interest to this communication are their estimates of chromosomal abnormality (A) and a normal chromosome complement (N) in the next miscarriage: specifically 35.3% (18/51) AA, 13.7% (7/51) AN, 13.7% (7/51) NA, and 37.3% (19/51) NN. From these estimates, it was calculated that 72% (18/25) of women with a chromosomally abnormal embryo had a chromosomally abnormal embryo next time, and 28% (7/25) had a chromosomally normal embryo; and that 73.1% (19/26) of women with a chromosomally normal
* Paul N. Scriven
1
London, UK
embryo had a chromosomally normal embryo next time, and 26.9% (7/26) had a chromosomally abnormal embryo. Figure 1 shows a hypothetical analysis for 100,000 pregnant women aged around 30 years and up to 2 singleton pregnancies. It is assumed that both partners have a normal karyotype. This illustration assumes that the clinical miscarriage rate (CMR) is 10% [3] for the first pregnancy and that 50% [1] of failed embryos have a chromosomal abnormality. Women who miscarried their first pregnancy have a second pregnancy, and the chromosomal status proportions of a subsequent miscar
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