Except for the Modular test, which prioritized sensitivity, it appears that the positive cutoff values suggested by the pharmaceutical companies are very high (either for economical or for safety reasons). Among the 406 serum samples, we did not find any false-positive values by two different tests for the same serum sample. For all the immunoassays tested, the following relative sensitivity and specificity values were found: 89.7 to 100% for the Access II test, 89.7 to 99.6% for the Immulite test, 90.2 to 99.6% for the AxSYM test, 91.4 to 99.6% for the Vidas test, 94.8 to 99.6% for the Access I test, and 98.3 to 98.7% for the Modular test. Using the 175 serum samples with positive results, we evaluated the standardization of the titrations obtained (in IU/ml) the medians (second quartiles) obtained were 9.1 IU/ml for the AxSYM test, 21 IU/ml for the Access I test, 25.7 IU/ml for the Access II test, 32 IU/ml for the Vidas test, 34.6 IU/ml for the Immulite test, and 248 IU/ml for the Modular test. Of the 406 serum samples tested, the results for 35 were discordant by the different techniques. The Toxo II IgG Western blot (LDBio, Lyon, France) was used as a reference technique in the case of intertechnique discordance. In rare patients with unexplained RPL, the use of in vitro fertilization with transfer of the embryos in a host uterus (gestational surrogacy) may be considered.A comparative study of the Toxoplasma IgG I and IgG II Access (Access I and II, respectively Beckman Coulter Inc.), AxSYM Toxo IgG (AxSYM Abbott Diagnostics), Vidas Toxo IgG (Vidas bioMerieux, Marcy l'Etoile, France), Immulite Toxo IgG (Immulite Siemens Healthcare Diagnostics Inc.), and Modular Toxo IgG (Modular Roche Diagnostics, Basel, Switzerland) tests was done with 406 consecutive serum samples. In this situation, the success rate with PGS is generally quite low, once again limiting its usefulness. Patients greater than 38 years of age will often produce few eggs. So PGS will be expected to be of limited use. This makes sense because in younger patients with RPL the products of conception are abnormal in only 35% of cases. The role of in vitro fertilization with preimplantation genetic screening (PGS) of embryos remains unclear.
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Its use in this situation is not recommended. The use of heparin in patients with normal autoimmune tests has been evaluated and did not show any improvement in outcomes.
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If the karyotype is normal and a full investigation using evidence-based diagnostic tests for definite or probable causes of RPL is negative, we encourage the couple to wait at least 2 months and then try again for a successful pregnancy. If the karyotype is abnormal, this knowledge helps the couple come to terms with the loss and may help avoid unproven therapies. If there is another loss in a patient with previous RPL and with the second early miscarriage, we recommend a chromosomal analysis (karyotype) on the products of conception.
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There have been at least three large trials confirming that this strategy results in a successful delivery rate of about 70% to 80%. It is important to continue with regular emotional support in these patients. Early ultrasonography examinations are scheduled and continued weekly until the pregnancy has progressed beyond the point of the patient’s prior losses. We will often check a progesterone level and if it is less than 15 ng/mL, we prescribe vaginal progesterone (usually Crinone 8% once every morning until 11 gestational weeks). This includes two measurements of hCG levels and positive feedback at every opportunity. Early pregnancy monitoring is an excellent way of providing supportive care. Often, we will advise the couple to try again and to call us with a missed period. These include tests for checking the uterine cavity (hysterosalpingogram, sonohysterogram, or hysteroscopy), hormonal tests, parental chromosomes, autoimmune tests and (in selected cases) a thrombophilia panel. In approximately half the couples with recurrent pregnancy loss (RPL) the tests will all come back normal.