• Recurrent miscarriage occurs when there are three consecutive pregnancy losses before 12 weeks gestation or one loss after 12 weeks
• 1% of couples experience recurrent miscarriage
• Around half of cases are due to chance or 'bad-luck' alone. For the remainder there will be an underlying cause though we may not be able to find it
• Investigations include:
  • Karyotype. This is a chromosome check for both partners. It is abnormal in ~2% of couples. Treatments may include prenatal diagnosis, preimplantation genetic diagnosis (as part of IVF), or egg or sperm donation
  • Pelvic ultrasound scan. If the uterus has a septum dividing it in two then this can be treated surgically
  • Thrombophilia (blood clotting) screen. A proportion of women with recurrent miscarriage have 'sticky' blood that can prevent normal placental development. This can be treated with daily aspirin and injections of heparin during pregnancy
  • Hormone screen. We check for normal function of the ovaries, and thyroid and prolactin levels.
• I am lead clinician for the 'one-stop' Oxford recurrent miscarriage clinic at the John Radcliffe Hospital
• A useful patient information brochure can be downloaded from the Royal College of Obstetricians and Gynaecologists http://www.rcog.org.uk/index.asp?PageID=530
• The patient-support group the Miscarriage Association has been helpful to many of my couples http://www.miscarriageassociation.org.uk/ma2006/index.htm
  

Most gynaecological procedures can now be performed via keyhole laparoscopic surgery. Advantages include a quicker time to recovery, smaller abdominal scars, and fewer internal adhesions (scarring). Most women go home the day after laparoscopic surgery.

• Procedures available include:
  • Myomectomy (removal of fibroids)
    • Fibroids can cause heavy periods, infertility, and pressure symptoms on the bladder/bowel
    • If poking into the uterine cavity fibroids may be removed using an instrument (hysteroscope) passed through the cervix
    • Larger fibroids in the wall of the uterus may be removed laparoscopically via 3-4 small cuts in the abdomen. If the fibroids are >4 in number or >10cm in size then a traditional open operation via a 'bikini-line' cut may be needed
    • Myomectomy carries a low risk of bleeding requiring blood transfusion and rarely, in life saving circumstances, hysterectomy
  • Ovarian cystectomy
    • Ovarian cysts can be of many types. I often find endometriosis cysts in my patients with fertility and/or pain problems. It is better to remove ovarian cysts laparoscopically than via a traditional open operation
  • Tubal surgery
    • Blocked tubes are a common cause of infertility. Often IVF is the best treatment. Sometimes, if the blockage is at the end of the tube with the rest of the tube in good order, the tube can be opened and satisfactory rates of fertility achieved. This is best performed laparoscopically
    • Tubes sterilised. Options are IVF or removing the sterilisation clips and sewing together down a powerful microscope the tube. Reversal of sterilisation is not available on the NHS and requires an open operation
  • Endometriosis
    • Endometriosis is a common cause of pain and/or infertility. It is usually diagnosed at surgery, unfortunately often after a long delay. Laparoscopic excision of endometriosis reduces pain scores and increases the chance of natural conception. Working with my colleagues Mr Enda McVeigh and Professor Phillipe Koninckx (Leuven, Belgium) we have developed Oxford into a National endometriosis centre. We work as part of a multidisciplinary team and so, when necessary, operate with laparoscopic colorectal and urological surgeons.
  • Hysterectomy
    • Hysterectomy's are generally performed for heavy periods, fibroids, or pain. The majority of hysterectomy's can be performed laparoscopically with discharge from hospital the following day. The cervix can either be removed (total hysterectomy) or left behind (sub-total) and the same is true for the ovaries. An alternative to hysterectomy for heavy periods is removal of the lining of the womb (endometrium) via the cervix (TCRE) or inserion of a Mirena coil.
  • Adhesiolysis
    • Adhesions are scar tissue in the abdomen and are a common cause of pain and/or infertility. They are best removed laparoscopically.