Recurrent miscarriage and infertility: a national service evaluation

Figures & data

Table 1. Respondent demographics and counselling/supportive care.

Respondents	N	Frequency	Percentage
Health professional role	24
Consultant obstetricians/gynaecologists		16	75
Fertility specialists		1	4
Clinical midwife specialists		5	21
Fertility nurse/midwife specialist		2	8
Length of experience in RM or fertility services
<1 year		2	8
1–5 years		7	29
6–10 years		6	25
11–20 years		6	25
>20 years		3	13
Sector
Public		8	33
Private		3	13
Public and private		13	54
Counselling resources	N	Frequency	Percentage
International guidance used^a	24
RCOG		22	92
European Society of Human Reproduction and Embryology (ESHRE)		14	58
American Society of Reproductive Medicine (ASRM)		4	17
British Fertility Society (BFS)		2	8
Society of Obstetrics and Gynaecology Canada		1	4
National Institute for Health and Care Excellence (NICE)		1	4
Additional educational supports^a	24
National Guideline (unspecified)		12	50
Local guideline/protocol		9	38
Online resources		15	63
Onsite training/CPD		8	33
External training/CPD		13	54
Other		2	8
Counselling and supportive care	N	Yes	No	Unsure
Age-related miscarriage risk	24	20 (83%)	1 (4%)	3 (13%)
Age-related aneuploidy risk		18 (75%)	3 (13%)	3 (13%)
Tests of ovarian reserve		19 (79%)	3 (13%)	3 (13%)
PGT-A		12 (50%)	8 (33%)	4 (17%)
Intra-cytoplasmic sperm injection		8 (33%)	12 (50%)	4 (17%)
Egg donation		15 (63%)	6 (25%)	3 (13%)
Semen analysis		14 (58%)	7 (29%)	3 (13%)
Sperm DNA fragmentation		4 (17%)	16 (67%)	4 (17%)
Sperm donation		11 (46%)	9 (38%)	4 (17%)
Surrogacy		8 (33%)	12 (50%)	4 (17%)
Adoption		8 (33%)	12 (50%)	4 (17%)

^a More than one response possible.

Table 2. Structure of care.

Structure of care (N = 24)	N	Frequency	Percentage
No. of women/couples with RM and infertility seen annually	24
0–10		6	25
10–30		6	25
40–65		4	17
100–150		2	2
Not stated/unsure		5	21
Time allocated for consultations	23
15–20 min		3	13
20–30 min		4	17
30–45 min		9	39
Up to 60 min		3	13
Unsure/not stated		5	22
Public RM clinic only (N = 18)
Fertility specialist available to consult where women have experienced RM after infertility?	18
Yes		7	39
No		11	61
If external referral, where are referrals made?	13
Public fertility clinic		7	54
Private fertility		3	23
Patient choice		1	8
No pathway		1	8
Unsure		1	8
Counsellor specialising in infertility?	18
Yes		5	28
No		11	61
Not answered		2	11
Fertility sector only (N = 4)
Obstetrician with training in management of RM available?	4
Yes		3	75
No		1	25
External referrals	4
Public RM clinics		3	75
Private consultant/clinic		1	25
Referral criteria	4
2 consecutive miscarriages		1	25
2 non-consecutive miscarriages		1	25
3 consecutive miscarriages		4	100
3 non-consecutive miscarriages		4	100
Age dependent (>35years)		1	25
Artificial reproductive technology dependent		0	0
Bereavement counsellor experienced in pregnancy loss available?	4
Yes		4	100
No		0	0

Table 3. Investigations and treatments.

Investigations	N	Yes	No, never	If clinically indicated	Don’t know
Anti-phospholipid antibodies (APLA)	24	18 (75%)	0	3 (13%)	3 (13%)
Thrombophilia screen		10 (42%)	4 (17%)	7 (29%)	3 (13%)
Thyroid peroxidase antibodies		11 (46%)	2 (8%)	7 (29%)	4 (17%)
Androgen testing^a		7 (29%)	3 (13%)	10 (42%)	4 (17%)
Autoimmune screen^c		8 (33%)	4 (17%)	9 (38%)	3 (13%)
Anti-nuclear antibodies		9 (38%)	7 (29%)	5 (21%)	3 (13%)
HLA antibodies^a		0	16 (67%)	2 (8%)	6 (25%)
Cytokines^a		0	16 (67%)	1 (4%)	6 (25%)
Anti-HY antibodies^a		0	15 (63%)	3 (13%)	6 (25%)
Natural killer cells^a		0	16 (67%)	2 (8%)	6 (25%)
Additional investigations
Endometrial scratch^a	22	4 (18%)	15 (68%)	0	3 (14%)
If yes:	4
1. Uterine natural killer cells^a		0	3 (75%)	1 (25%)	0
2. Chronic endometritis^a		3 (75%)	0	1 (25%)	0
Endometrial biopsy^a	24	5 (21%)	12 (50%)	0	5 (21%)
If yes:	5
1. Uterine natural killer cells^a		1 (20%)	2 (40%)	1 (20%)	1 (20%)
2. Chronic endometritis^a		2 (40%)	0	3 (60%)	0
High vaginal swab^a	20	4 (20%)	4 (20%)	12 (60%)	0
Spermploidy^a	22	2 (9%)	18 (82%)	0	2 (9%)
Sperm DNA fragmentation^a	22	1 (5%)	19 (86%)	0	2 (9%)
Would you routinely recommend any of the following treatments for women with RM and infertility?	N	Yes	No, never	Only in certain circumstances	Don’t know
Aspirin	24	13 (54%)	0	7 (29%)	4 (17%)
LMWH		3 (13%)	1 (4%)	15 (63%)	5 (21%)
Prednisolone		0	6 (25%)	13 (54%)	5 (21%)
Hydroxychloroquine		0	13 (54%)	6 (25%)	5 (21%)
Progesterone^b		17 (71%)	0	3 (13%)	4 (17%)
Metformin		1 (4%)	0	19 (79%)	4 (17%)
ICSI		0	7 (29%)	11 (46%)	6 (25%)
PGT-A		2 (8%)	6 (25%)	8 (33%)	8 (33%)
IVIG		0	12 (50%)	3 (13%)	9 (38%)
Intralipid therapy		0	13 (54%)	2 (8%)	9 (38%)
Immune therapy (other)^d		0	11 (46%)	3 (13%)	9 (38%)
Hysteroscopy		5 (21%)	1 (4%)	15 (63%)	3 (13%)
Laparoscopy and dye		5 (21%)	1 (4%)	15 (63%)	3 (13%)
Myomectomy for fibroids		2 (8%)	1 (4%)	17 (71%)	4 (17%)
Metroplasty		2 (8%)	8 (33%)	8 (33%)	6 (25%)
Hysteroscopic adhesiolysis		6 (25%)	2 (8%)	10 (42%)	2 (8%)

^a Represents investigations not recommended within CPGs.

^b Sole recommended treatment within KPIs.

^c Extractable nuclear antigen, anti-neutrophil cytoplasmic antibody and rheumatoid factor.

^d Respondents did not specify which other immunotherapies they would consider.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author, [LL]. The data are not publicly available due to their containing information that could compromise the privacy of research participants.