Recurrent Miscarriage & InfertilityHow to Prevent Pregnancy Loss and Recurrent Miscarriages
Part One: Identifying the Underlying Causes
Identifying the Underlying Causes
As a practicing obstetrician and gynecologist, I have been helping and healing patients for over 18 years. During this long span of time, I have learned things about my patients that I never learned during my four years of medical school and four more years of residency training. In particular, my understanding and treating of their pregnancy loss.
I will never forget the day that a patient came to see me because she hadn’t felt her baby move in 24 hours. She was 35-weeks pregnant. In most of these cases, the baby is absolutely fine and and it is only a false alarm. Unfortunately, this was not the case with my patient. I tried to find the heartbeat with the mini-ultrasound monitor, but after a few minutes of searching I couldn’t hear anything. I brought her into an ultrasound room to try to see the heart directly. She saw the look on my face when the ultrasound confirmed what I already suspected: there was no heartbeat.
Nothing prepared me for how to handle my patient’s loss, nor to help her move through it. I felt very inept as a doctor. Not only because there was no way to diminish my patient’s grief, but also because of my inability to reassure her that the next pregnancy would be okay. However, I soon realized that there was something I could do to help my patient, as well as others, deal and even prevent pregnancy loss. That something was to help these women not only understand what causes pregnancy loss but also what they could do to prevent it.
For anyone who has had a prior pregnancy loss, it makes sense to want to search for a reason or cause to explain WHY the loss occurred and if it could be prevented in the future. Knowing this kind of information offers peace to patients because it gives them the hope that future attempts to conceive will not be for naught.
WHY AREN’T ALL PREGNANCY LOSSES INVESTIGATED?
Why Aren’t All Pregnancy Losses Investigated?
About 15-25% of all pregnancies may result in a miscarriage. In fact, it is so common that experts recommend doctors avoid doing a full evaluation to determine the cause of a miscarriage if the patient in question has experienced only one loss. The good news is that fewer than 5% of women will have two consecutive miscarriages and only 1% will have three or more
BUT WHAT CAUSES REPEATED PREGNANCY LOSS?
But What Causes Repeated Pregnancy Loss?
This is a very frustrating question for doctors and patients. Even with a comprehensive review of a patient’s medical history and a physical exam, more than 50% of couples who look into the cause of miscarriage or pregnancy loss will not find an answer to explain why they have miscarried
(1). This is not necessarily related to lack of scientific knowledge in this area but most likely related to the complexity of the reproductive process. The combination of genetic factors, environment, physiology, hormone and metabolism that make up the female reproductive system is hard to figure out. Regardless, a standard evaluation can be an effective tool in determining the cause of miscarriage.
During a standard evaluation, doctors will assess whether the patient possesses or is at risk for any of the following and consequently at risk for pregnancy loss
Approximately 60% of early pregnancy losses are associated with chromosomal abnormalities
1) Abnormal Genetics
Approximately 60% of early pregnancy losses are associated with chromosomal abnormalities. Abnormalities may occur sporadically if the cell division process is unexpectedly disrupted OR if one parent carries a genetic defect that results in an abnormal amount of genetic material being passed on to the fetus.
2) Birth Defects
Even if the fetus does not have a chromosomal abnormality, 18% of patients may still have significant abnormalities. Such abnormalities or “birth defects,” such as a severely abnormal heart defect, put the pregnancy at high risk for early miscarriage.
3) Abnormally Shaped Uterus
Unlike chromosomal abnormalities and birth defects which typically cause loss earlier in the pregnancy, pregnancy loss due to an abnormally shaped uterus tends to occur at a later pregnancy stage. An abnormally shaped uterus causes pregnancy loss because it can lead to preterm labor or cervical weakness.
4) Anti-Phospholipid Antibody Syndrome
This is an autoimmune condition in which antibodies attack fats in the blood making the blood “stickier” and more likely to clot. These antibodies may prevent proper implantation of the pregnancy or may interfere with adequate blood flow through the placenta causing the body to lose the pregnancy.
5) Other Blood Clotting Problems
Similar to loss stemming from an abnormally shaped uterus, pregnancy loss due to other clotting problems such as Factor V Leiden, Prothrombin Gene Mutation, Protein C and Protein S deficiency typically occur after 14 weeks of pregnancy.
6) Environmental Or Occupational Exposures
While the aforementioned factors relate to conditions inside the body, environmental or occupational exposures such as toxic fumes, chemicals and solvents encountered in the work environment or at home are conditions outside the body that can cause pregnancy loss. Toxic exposures through smoking, excessive alcohol intake, inhaled gases (anesthetic agents), paints, gasoline, cosmetics, etc., can also cause early miscarriage.
Being knowledgeable of the above factors and risks is a positive step toward preventing pregnancy loss. In fact, when standard evaluations of the patient are conducted which assess and determine whether such factors are present, 50% of the time an important predisposing factor will be uncovered and treatment recommendations will be made based on the underlying cause. Unfortunately, sometimes a standard evaluation fails to uncover the reason for such losses (otherwise known as unexplained recurrent pregnancy loss). Thus, in addition to the above, it is also important to consider other factors not typically acknowledged in conventional medical circles.
HOW DO I KNOW IF I SHOULD SEARCH FURTHER?
How Do I know If I Should Search Further?
The short answer to this question is perhaps EVERYONE should dive deeper into their own health to see if there is something that predisposes them to infertility or pregnancy loss. As a conventionally-educated physician, I was trained to treat disease. I wasn’t particularly trained to look for problems that precede disease or more importantly, to identify early signs of imbalance that will eventually cause disease. However, after eighteen years of practice it is absolutely clear to me that in younger women of childbearing age, pregnancy losses and infertility often times are the body’s “call for help” because they signal that the body is dealing with imbalances that are interfering with one of the most essential aspects of human physiology: human reproduction.
While a patient who miscarries or loses a pregnancy in the 2nd or 3rd trimester may not have a “diagnosis” of a specific condition that could alert her to potential problems with pregnancy, she may have symptoms that precede a formal diagnosis. Such symptoms can give us very important clues about unidentified imbalances that could impact fertility. For example:
- You may not have Irritable Bowel Syndrome or Gastro-esophageal reflux, but you have occasional bloating and heartburn.
- You may not have Polycystic Ovarian Syndrome, but you have periods that are irregular and have difficulty keeping weight off.
- You may not have diabetes, but you had recent blood work that falls into a pre-diabetic range and are experiencing sugar cravings or jitteriness when missing a meal.
- You may not have endometriosis, but you are experiencing heavier, painful periods and pelvic pain.
- You may not have been diagnosed with a luteal phase defect (progesterone deficiency), but you have PMS and prolonged, crampy periods
- You may not have been diagnosed with a formal autoimmune disease like Celiac Disease, Ulcerative Colitis, Hashimoto’s Thyroiditis, but you have mildly elevated autoimmune screening markers on recent blood work that don’t yet meet criteria for diagnosis.
If you have experienced pregnancy loss but you do not have any of the above mentioned symptoms or pre-disease states, are otherwise healthy, and you…
- have no symptoms of physical or mental ailments,
- are normal weight, exercise, eat a healthy diet and
- don’t have a family history of genetic disorders
…then there are two possibilities to consider. Such possibilities are:
- the pregnancy loss was a completely random event that is not attributable to a specific problem making the risk of another pregnancy loss is minimal. Your next step is to simply try to get pregnant again or
- the pregnancy loss or miscarriage is your signal that you have an underlying problem that may require a different level of evaluation.
I HAVE BEEN EVALUATED AND THERE ARE NO VISIBLE RISK FACTORS: WHERE DO I GO FROM HERE?
I Have Been Evaluated And There Are No Visible Risk Factors: Where Do I Go From Here?
Once you have completed a standard evaluation including a detailed medical history, physical exam and specialized tests to determine any immediate causes of miscarriage, the next step may be to consider a further evaluation. In cases where a routine standard evaluation is unrevealing, a Functional Medicine Evaluation may help to determine the underlying cause. This approach attempts to determine the root cause of imbalance WITHIN your physiology, looking at different body systems to uncover what other internal factors could lead to infertility and pregnancy loss.
For more information, read the second installment of this series: “How to Prevent Pregnancy Loss and Recurrent Miscarriages Part Two: The Functional Medicine Approach to Identifying the Underlying Causes”