My husband is 38 and I am 35. I have just had my fifth miscarriage. We have had chromosomal testing, thyroid testing, antiphospholipid testing, and a uterine abnormality test. We have taken antibiotics for any infections. Every time we are tested, the tests come back normal, leaving us with no answers as to why we continue to miscarry. The first three times we got pregnant on our own. The last two times we used fertility shots and progesterone shots. We want to keep trying, but we'd love to know your thoughts on our situation. How many times should a couple try before turning to adoption?

Lily

My first thought on your situation is that recurrent pregnancy loss is a complex condition. Rarely do I see a complete and appropriate evaluation, even when patients report that their physicians have completed all the tests.

Although there is great controversy regarding what tests should be used to evaluate this condition, I believe any couple in your position should discuss with their doctor the following tests:

• ovarian reserve screening: a blood test done at a certain point in your cycle to see if your eggs are too old to function reliably.
  
• androgen levels: blood tests to measure male hormone levels.
  

• TSH and prolactin levels: blood tests for hormone levels that indicate whether your thyroid and pituitary glands are functioning properly.
  
• leukocyte antibody detection and embryotoxic factor: blood tests to determine whether your immune system is attacking the pregnancy.
  

• antiphosphotidylserine, PAI-1 levels, MTHFR, prothrombin II mutation, and Factor V leiden: blood clotting tests that may indicate an increased risk of forming blood clots in the small blood vessels of the placenta, which may interfere with continuation of the pregnancy.
  
• fasting insulin levels: a blood test to determine whether you have insulin resistance, which may increase the risk of miscarriage.
  

• endometrial biopsy: a minor surgical procedure to sample the uterine lining (endometrium) approximately 12 days after the urine LH surge indicates impending ovulation; this may show whether the uterine lining has appropriately developed to support a pregnancy.
  
• saline hysterosonogram: an ultrasound test in which a small amount of salt water is injected into the uterine cavity during a scan; this may show uterine scar tissue, polyps or other anomalies that may interfere with growth of the pregnancy.
  
• As the number of losses increase, so does the likelihood that the losses are due to a blood clotting factor or immune disturbance increase. These tests would indicate whether you may benefit from heparin injections and baby aspirin or white-cell immunization.

Every few months, new studies provide us with more and more information about potential explanations for recurrent pregnancy loss. More important, each new study brings the potential for new treatment options, offering hope. I have seen many women who have repeatedly miscarried who were told to quit trying, after their physicians assured them that a complete evaluation had been performed and no cause could be found. When these women completed a comprehensive evaluation, the results indicated potentially treatable conditions that may have been the cause of their miscarriages. After a comprehensive medical evaluation, in which all the above tests have been considered, I believe that your odds for success should be quite high.