Embryoscopy: A superior method for the evaluation of miscarriage

Recurrent miscarriage, which is defined as 3 or more miscarriages, affects 1% of reproductive aged females. The internet is a huge resource for snake oil salesman hoping to take advantage of these couples with useless, expensive and sometimes dangerous treatments for presumed problems.

Problems with D&C for evaluation of miscarriage

Chromosomal abnormalities in the embryo are the main cause of early pregnancy losses . It is extremely important to identify these abnormalities, particularly among couples with recurrent miscarriage. The traditional means for evaluating fetal tissue for chromosome abnormality is with a procedure called dilation and curretage or D&C.

During a D&C, a woman is given anesthesia in a hospital or surgical center. While laying on her back, the legs are placed in stirrups and a speculum is placed in the vagina. The cervix is grasped and the opening (the cervical canal) is dilated using metal rods of increasing diameter. Once the cervical canal has been opened sufficiently, a long plastic tube attached to a suction machine is placed into the uterus. The suction machine is turned on and the contents of the uterus are aspirated. The tissue obtained has traditionally been sent to a lab that specializes in growing cells and extracting and identifying the chromosomes. Depending on a number of factors, this method took a few to several weeks to grow the cells obtained.

One of the problems with D&C is that when the tissue is aspirated from the uterus, it contains a mixture of cells. There are cells from the fetus itself, cells of the placenta and gestational sac and cells from the mother’s uterine lining. The mother’s cells are typically healthy and grow well whereas the fetal cells can often be barely viable.

In the past, when the genetics lab grows the cells from a D&C, there was no way to ensure that only the fetal cells grew. Consequently, the results of a chromosome analysis often reflected the mother’s chromosomes and not that of the fetus.

In general, the results of a chromosome analysis from a D&C returned one of four results:

1. The cells did not grow and no chromosome result could be obtained
2. A normal female
3. A normal male
4. A fetus with a chromosome abnormality either male or female

If the cells did not grow, there was no result and no helpful information was obtained. A normal male is a helpful answer. It indicated that it was not the mother’s cells that were analyzed. It also showed that the miscarriage was not due to chromosome abnormality. Other causes for miscarriage must be investigated even if this was the only miscarriage the couple has had. A fetus with a chromosome abnormality is also a helpful result. It reveals the cause of the miscarriage. No further evaluation is necessary. The couple may consider IVF with PGD for their next pregnancy attempt. PGD is the only method available to reduce the chances for a miscarriage due to chromosome abnormality.

A chromosome result indicating a normal female is not a helpful result. It cannot be determined if this came from the fetal cells, as desired, or the mother’s cells. Unfortunately, a large number of chromosome analyses from miscarriages return a result showing a normal female. Studies have shown that 30-80% of the results obtained from a D&C may come from the mother’s cells. Until recently, there was nothing that could be done about this.

Embryoscopy for evaluation of  the cause of miscarriage

Recently, a new technique has been used by a few highly skilled physicians. This new technique uses fiber optics to look inside the uterus (hysteroscopy) and has been called embryoscopy or fetoscopy. Like a D&C, a hysteroscopy is usually performed in a hospital or surgical center under anesthesia. The cervix is dilated large enough to allow passage of a fiber optic telescope. Salt water (saline) is used under high pressure to hold the uterine cavity open to allow adequate visualization.

With direct visualization, the implantation site of the pregnancy can be located in the uterus. The fetus grows inside of a spherical structure called the gestational sac. The sac can be opened and the placental tissue and sometimes the fetus can be identified inside.

The hysteroscope has multiple channels. These channels allow for the insertion and removal of fluid to keep the uterine cavity clear to the observer. Another channel transmits the optics and yet another provides the light. A final channel allows for the passage of instruments into the uterus. Using grasping instruments, the placental tissue or fetus can be removed.

This is a great advantage over the D&C because the tissue removed is essentially “pure”. That is, only the tissue of interest is obtained. There is little or no chance for the mother’s uterine cells to “contaminate” the specimen. Thus, when a result indicating a normal female is obtained, it can be relied upon as easily as when a normal male result is returned.

There are several benefits of the hysteroscopy approach for the evaluation of the causes for miscarriage. In some cases, when a fetus is present, abnormalities in the development of the fetus can be seen. Collecting the fetal tissue in this way, the specimen is kept sterile and so the chances for the cells to be grown by the genetics lab is enhanced. As stated above, the mixing of the mother’s cells with the fetal cells does not occur, so there is much better reliability.

Another advantage occurs when there is loss of a twin pregnancy. During a D&C, the tissue from both twins gets mixed together. A result may indicate one, both or neither of the fetuses. With the hysteroscopy method, each fetus and its respective placenta can be removed separately.

A recent study compared the results obtained with D&C with that obtained using the the embryoscopy technique. The researchers found that overall, chromosome abnormalities were responsible for miscarriage in 67% of the cases studied. In a significant number of cases, the D&C technique would have provided an incorrect result. This occurred when the D&C result indicated a “normal female” where in reality, the fetus was abnormal.

Microarray for chromosome analysis

Recently, a new technology has become available to evalute the chromsomes called microarray. Microarray has several advantages over the older method of cell culture.

• It is not necessary to grow the cells for several weeks in the laboratory
  • This dramatically reduces the chance of getting “no result”
  • Results are available in 7-10 days instead of 4-6 weeks
• Sophisticated software algorithms can determine if contamination by the mother’s uterine cells have occurred
• It is possible to get results even on non-viable cells

Who is a candidate for Embryoscopy?

Any woman who has been diagnosed with a non viable pregnancy and who wants to try to determine the cause for the miscarriage can have embryoscopy performed instead of a D&C. Women for whom this is especially important are:

• Women who have a history of recurrent miscarriage
• Women who have lost a pregnancy after a heartbeat was seen on ultrasound
• Women who were receiving treatment  to prevent miscarriage but were diagnosed with a non-viable pregnancy

If I am not currently a patient of IVF1, how do I arrange to have an embryoscopy with Dr. Morris?

If you have had a pregnancy ultrasound which previously showed a fetus with a heart beat but a subsequent ultrasound showed that the fetal heart is no longer beating, then call our office immediately. You will need to do several things fairly quickly.

• Call our office and state you have a nonviable pregnancy and would like to arrange for an embryoscopy
• Email of fax a copy of your medical records for this pregnancy, including ultrasound results
• You will need to electronically complete your medical history online through our patient portal
• Schedule an appointment in our office for an ultrasound followed by a brief consultation with Dr. Morris

Due to the need to perform embryoscopy rapidly, we may not have time to verify insurance coverage. In this situation, you will be asked to pay for the procedure in advance. Our billing office will work with you to help maximize the chances for insurance coverage. Ultimately, you are responsible for all charges. Please contact our billing office for more details.

What can I expect on the day of the embryoscopy?

After being admitted to the hospital or surgery center, you will be seen by the anesthesiologist. He or she will review your medical history and discuss the type of anesthesia that is appropriate for you. You will have an intravenous line placed in your arm.   In the operating suite, you will be anesthetized for the duration of the procedure.

The embryoscopy typically takes about an hour to perform. After the procedure is over, you will be taken to the recovery area. Normally, it will take about an hour for you to wake up completely. You will be allowed to go home after the nursing staff verifies you are stable and you can demonstrate that you can tolerate something to eat or drink and can go to the bathroom.

For the remainder of the day, you should plan to rest at home. You will need a responsible adult to bring you to the surgery center and bring you home again afterward. You cannot drive or operate machinery for twenty four hours. It is likely you will have some cramping and vaginal bleeding after the procedure.

Normally, over the counter medications such as Motrin or Advil will be sufficient to control any discomfort. We will provide you with a prescription for pain medicine in case you need something more.

One week after the procedure, you will need to be seen in the office to review the procedure and make sure you are not having any problems post operatively. It is recommended that you have blood tests to determine your hCG levels every week or two until it has returned to negative. This may be done at IVF1 or with your regular OB Gyn.  

Once the chromosome results are available (usually about 4-6 weeks later), you will be notified by phone or through the patient portal. If you wish, you may consult in the office and discuss the results and / or further treatment options.