A 35-year-old woman, gravida 3 para 0 aborta 3, comes in for evaluation of recurrent pregnancy loss. The patient has had 3 first-trimester spontaneous abortions in the last year and is becoming increasingly worried that she will never carry a pregnancy to full term. She has regular, monthly menses with 4-5 days of moderate bleeding and cramping. The patient has no chronic medical conditions and takes a daily prenatal vitamin. Family history is noncontributory. Vital signs are normal. BMI is 24 kg/m². On pelvic examination, the uterus is small, anteverted, and nontender. There are no adnexal masses. Urine pregnancy test is negative. Transvaginal ultrasound reveals a 2-cm submucosal fibroid at the uterine fundus. Thrombophilia workup is negative. Which of the following is the most appropriate treatment for this patient's recurrent pregnancy loss?

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This patient has had ≥3 consecutive pregnancy losses (ie, spontaneous abortions) consistent with recurrent pregnancy loss. Initial workup for these patients includes pelvic ultrasound, karyotype, and thrombophilia testing because anatomic, genetic, and thrombotic disorders are the most common causes. This patient's recurrent pregnancy loss is likely due to her submucosal fibroid, a benign smooth muscle (myometrial) tumor that can cause abnormal intrauterine anatomy by extending into the cavity or impinging on (ie, disrupting) the endometrium. This compromises embryo implantation or growth, likely due to decreased endometrial thickness and the reduced vascularity of the fibroid (relative to the myometrium). Therefore, the most appropriate treatment for recurrent pregnancy loss due to submucosal fibroids is hysteroscopic myomectomy (even if the fibroids are not causing heavy menses). This procedure restores normal intrauterine anatomy, thereby reducing the risk of future pregnancy loss. (Choice A) Clomiphene is a selective estrogen receptor modulator that treats ovulatory infertility by increasing FSH levels and promoting ovarian follicular development. Clomiphene does not treat recurrent pregnancy loss and has antiestrogen effects on the endometrium (which decreases endometrial thickness). (Choice C) Low-molecular-weight heparin is used in women with recurrent pregnancy loss due to an inherited thrombophilia; it does not improve live birth rates in women with a negative thrombophilia workup. (Choice D) Uterine artery embolization decreases blood flow to the uterus, thereby reducing fibroid size. It is not recommended for patients desiring future fertility because the resultant decreased uterine perfusion increases the risk of obstetric complications (eg, fetal growth restriction) and decreases live birth rates. (Choice E) Vaginal progesterone is used in patients with an incidental shortened cervix (≤25 mm) on ultrasound to decrease the risk of preterm delivery. It does not reduce the risk of recurrent pregnancy loss. Educational objective: Recurrent pregnancy loss (≥3 consecutive pregnancy losses) may be caused by submucosal fibroids due to impaired embryo implantation or growth. Patients are managed with hysteroscopic myomectomy, which restores normal intrauterine anatomy and reduces the risk of future pregnancy loss. References: Recurrent pregnancy loss: generally accepted causes and their management. (http://www.ncbi.nlm.nih.gov/pubmed/27455203) Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage. (http://www.ncbi.nlm.nih.gov/pubmed/16707507) Hysteroscopic myomectomy: techniques and preoperative assessment. (http://www.ncbi.nlm.nih.gov/pubmed/26928414)

A 35-Year-Old Woman, Gravida 3 Para 0 Aborta 3, Comes