Rescripted S02E07_Miscarriage: Audio automatically transcribed by Sonix

Rescripted S02E07_Miscarriage: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Kristyn Hodgdon:
Hi! I'm Kristyn Hodgdon, an IVF mom, current IVF patient, and co-founder of Rescripted.

Lucky Sekhon:
And I'm Dr. Lucky Sekhon, a board-certified reproductive endocrinologist at RMA of New York.

Kristyn Hodgdon:
Welcome to Dear Infertility, the first-ever podcast that doubles as an advice column for the millions of people globally who have trouble conceiving.

Lucky Sekhon:
We're here to answer real questions from real fertility patients about what to expect during each stage of the fertility journey and to provide you with the patient-centric advice and guidance you need to be your own advocate when trying becomes trying.

Kristyn Hodgdon:
Now, let's dive in and help you feel more empowered during this overwhelming process.

Kristyn Hodgdon:
Hi everyone, and welcome back to the Dear Infertility Podcast. I'm your host, Kristyn, and I'm here with Dr. Lucky Sekhon. Hi, Lucky, how are you?

Lucky Sekhon:
Hi, how are you?

Kristyn Hodgdon:
I'm doing well. So excited to talk about today's topic. One in four known pregnancies end in miscarriage and it's the club that no one wants to be a part of, but once you are, it's really heartbreaking and you just want answers. So really happy to be talking about all of this with an experienced board-certified reproductive endocrinologist.

Lucky Sekhon:
I agree. I think this is a topic that thankfully stigma is being lifted from it and people are talking about it more, especially on social media. And I've noticed anytime I've talked about it on Instagram, whether it's during a Q&A or in a post, there's always such a, an amazing amount of support and outpouring feedback that I always get about, about those types of topics, because I think people don't feel as comfortable talking about it in their real lives, quote-unquote. You don't want to make other people feel uncomfortable, so I think forums like that can be really helpful because it's just like knowing you're not alone that it is super common. And I think being able to kind of talk about it and how you feel and how to cope, good to have that place, but I think there's still a lot of work to be done and there's still so many misconceptions. I mean, I'm sure anyone who's had a miscarriage can relate, but that's when everyone comes out of the woodwork with well-meaning but unsolicited advice. And a lot of times there can be a back end to that advice that makes you feel like you did something wrong. So I think that's really something that we need to keep talking about, the fact that miscarriage isn't your fault.

Kristyn Hodgdon:
Absolutely. I came across the New York Times article from a couple of years ago that perfectly described miscarriage as the loneliest experience that millions of women have been through. And I felt like that was so accurate because it is one in four pregnancies, but a lot of times when you're going through it, it can just feel like you're one in a million.

Lucky Sekhon:
Yeah. And I think also being told by your health care provider, this is super common, it happens all the time, sometimes that can be interpreted as being very dismissive and that makes you feel even more alone because the person who's there to help you through this issue is kind of not really understanding the gravity and the toll this is taking on your life, and you can't just walk into the break room at work and bring this up, it's not like coffee talk, right? And maybe you feel like you're burdening your family and friends, you know, by talking through your feelings of grief, and so it's really hard. I think oftentimes we have our preconceived notions of how one should deal with a problem like miscarriage, but until you're actually in it, you don't really know, and I don't think there is a way to adequately mentally prepare oneself. And I think everyone deals with it differently, but having support is by far the most helpful component to getting over it and being able to heal and move forward. And I think that and time are literally the only things that really, truly help.

Kristyn Hodgdon:
Yeah. And despite well-meaning people saying at least it was early ...

Lucky Sekhon:
Oh my god.

Kristyn Hodgdon:
Hurts at any stage. I mean, I had a what was technically called a chemical pregnancy last year, but I consider it an early miscarriage.

Lucky Sekhon:
Yeah.

Kristyn Hodgdon:
And my due date is coming up next week and, or my would be due date and like it still hurts. It's like you never get over seeing a positive pregnancy test and then kind of it being all stripped away from you, it's really devastating, and so, it doesn't matter how early it was, it was your baby. And so, and especially when you're going through fertility treatments, the stakes feel so high. You've just spent all this time and money and energy going through this process. And then when you get that positive, it's such a high.

Lucky Sekhon:
Emotional Rollercoaster.

Kristyn Hodgdon:
Yeah! And then to be told your betas aren't doubling or, you know, or hear a heartbeat and then not hear heartbeat the next time, it's just really heartbreaking. So I wanted to kind of go into like how common are miscarriages and when do most of them occur.

Lucky Sekhon:
Right, so you said the statistic at the beginning. It's true, one in four recognized pregnancies and in loss, and that statistic isn't applying to a particular demographic or age, that's for all comers. But we know that the number one cause of miscarriage is that the embryo that tried to implant or stay implanted had errors in the number of chromosomes. So either was missing some DNA or had extra DNA and it interfered with normal growth and development, and eventually that embryo or fetus stopped growing. And that's really the cause behind a large majority, anywhere from 80 to 90% of miscarriages. Now, this is a problem that is more prevalent as we age, because as you age, a higher proportion of your eggs will give rise to genetically abnormal embryos. So the chance of ovulating an abnormal egg increases as you get older, and this is more market, in your late thirties and early forties and beyond. So that's why miscarriages are more prevalent as we age and get into our thirties and forties. You know, I think someone who gets pregnant in their forties, the risk of miscarriage is quite high, it's hard to quote an exact statistic, but definitely much higher than one in four. And so beyond the chromosomal errors, though, there could be other factors and this might be something that can be a cause of recurrent pregnancy loss, or it could just be sporadic, but we break them into different categories. So another one beyond genetics, I would say, is structural causes. So if you think about the structure of the female reproductive tract, the uterus, it can have things that grow inside of the lining like polyps or fibroids. And if they're present in the top half of the cavity where an embryo may want to try to implant, it could certainly interfere with that process and lead to a higher risk of miscarriage. Another major cause of, a structural cause of first trimester miscarriages is when there's a septum in the uterus and this is something you're born with. Basically, your uterus forms from these two ducts that come together as you are yourself, a fetus forming in your mother's womb. And if, when they're coming together, there is some sort of failure of resorption of that wall that's left behind that's called a septum, and it's basically fibrous tissue, it doesn't have a lot of blood supply, and it has all that surface area, it right smack dab in the middle of the uterine cavity, and it presents this extra surface area for an embryo to implant. And if it does, it doesn't have good blood supply, so a lot of these miscarriages happen in the first trimester because it just can't get past that point. And this is something that you won't necessarily see in an obvious way on a standard ultrasound. So normally you have to fill the uterus with fluid, doing an SIS, saline sonogram or an HSG to be able to really characterize whether someone has a septum in their cavity. And then the other structural thing involves the tubes, the fallopian tubes that connect your uterine cavity to your ovaries. Sometimes they can get inflamed or infected. And if there is inflammation and infected fluid that's dilating one of those tubes, it's feeding back into the uterus, right? That is a continuous environment. And so there's actual data that shows that women who have something called a hydrocele ..., have a two times higher risk of miscarriage and definitely a reduced chance of an embryo implanting in the first place. So I would recommend to a patient with a hydrocele ... to reduce their further chance of a miscarriage, to have that tube disconnected or removed entirely. And then there are some hormonal causes, like having a thyroid stimulating hormone that's completely out of whack. I mean, definitely that affects all body systems and could be playing a role in early implantation and miscarriage. There's autoimmune slash blood clotting factors, we know that there is a condition and it's not that rare called Antiphospholipid syndrome. And you have to have both clinical criteria and lab work that indicates you have this syndrome, and usually we confirm it on two different occasions, 12 weeks apart. But basically, anyone who's had a loss of a fetus or pregnancy over ten weeks, three or more losses under ten weeks, but I'll even do the testing for this if it's two or more or preterm delivery at under 34 weeks due to pre-eclampsia or placental issues, plus having different antibodies being present in their blood work, anti cardio lupine, lupus anticoagulant or beta two glycoprotein. And so these are things that can be tested at your doctor's office. And then going back to genetics, I think it's always a good idea to make sure for anyone that's had multiple miscarriages to look into whether their chromosomes have the proper structure, and we'll talk about that later when we talk about testing. But those are some common causes, just looking at it at a high level.

Kristyn Hodgdon:
So when would you sort of run those additional tests? After two miscarriages, how does that work?

Lucky Sekhon:
So the American Society of Reproductive Medicine used to say you have recurrent pregnancy loss if you've had three or more miscarriages. Just because we know it happens so commonly at baseline, and so many of these are just sporadic errors, a lot of them could be age related where you just have the wrong number of chromosomes. But then they updated their guidance several years ago and basically lowered their threshold and said two or more constitutes recurrent pregnancy loss because it's a lot to go through. And you could be picking up some of these problems earlier. And we know, we know that fertility is a time sensitive problem. So you don't want to waste time because it's not just the time to get pregnant and then the time that you're spending trying. A lot of people might not realize if they haven't been through a miscarriage, but it can take sometimes 3 to 4 months to fully recover, depending on how far along you were. HCG, the pregnancy hormone has a very long half life and even after the pregnancy is out of your body, it can take very, like many weeks, even months for that HCG level to slowly come down back to negative. So I think it makes sense to start that testing and identify any issues earlier on after you've had two or more miscarriages and I would say I agree with you, a biochemical pregnancy loss is a pregnancy loss. So if someone comes to me and they've had two or more biochemical losses, I'm going to run all those tests as well.

Kristyn Hodgdon:
That's so great to hear. And it really helps people advocate for themselves, especially if their doctors are sort of dismissing them. Is it correct that you can, kind of, if you've had two losses, you can you can consult with the fertility clinic, right?

Lucky Sekhon:
Yes, yes. And I mean, different parts of the world have different medical systems. But in the US, if you want to go see a fertility doctor just to talk about your fertility and get a checkup, you can do that. So there's no rule book, you don't have to have a referral.

Kristyn Hodgdon:
Awesome. So definitely ask those questions if you've had two or more losses. So I'm actually really interested, someone wrote in asking about progesterone levels, is it a cause or a symptom of pregnancy loss?

Lucky Sekhon:
Yeah. So this could be its own episode, but I'll try to keep it brief. This is extremely confusing and it's one of those what came first, the chicken or the egg type situations. I think it's important to go back to the biology and understand what the role of progesterone is. Progesterone is pro gestation, so it is something that is there to support the lining of the uterus and stabilize it and to support an early pregnancy, and it is an essential pregnancy hormone. A lot of people think HCG is the essential pregnancy hormone and they are very linked, right? HCG is the pregnancy hormone being produced by an embryo as it's implanting and it continues to be produced by the pregnancy, by the cells that become the placenta. And what it is, is it's a signal that goes back to your ovary and tells your ovary to keep making progesterone. So a lot of times people will throw progesterone at the problem if their HCG levels aren't rising appropriately, and if they feel like this pregnancy not may not be viable, they oftentimes will just point fingers and blame the progesterone and say, well, there's something malfunctioning with my ovaries and it's not producing enough progesterone, but if I replace it, I can salvage this. But I would argue that a majority of these types of situations, that's not going to help, because it's an underlying symptom of the fact that that pregnancy itself is probably not healthy and therefore it's probably being sluggish in the way it's sending feedback or signals to the ovary and therefore the ovaries reacting differently and making less progesterone. So progesterone is a sign or a symptom of an unhealthy pregnancy. People used to think that it was really common to have something called a luteal phase defect, which is basically a fancy medical term for an ovary that is malfunctioning and not producing enough progesterone, and that's the cause for your miscarriages. And that's why it's just really hard to shake. And it's just this antiquated idea that everyone who goes on progesterone, your chance of a miscarriage is lower, but it's not going to be effective if the underlying cause isn't rectified, right? So most of these low progesterone levels is the result of something that can't be rectified. And it is what it is. Could it exist that there is an individual, a human being out there that has some sort of problem with their corpus lithium producing progesterone? Yeah, it's possible, but that is probably the exception to the rule. And that's why sometimes we'll still give progesterone because it's really hard to identify who really needs it and who could stand to benefit from it. But I think if you're not doing it on your own, making those normal progesterone levels, it's usually something that isn't necessarily going to be helped, but it can't hurt to give you the progesterone, and that's why we do it. But I think that's the common misconception. And a lot of people, I think, sometimes are angry, they find out that their levels were on the lower side and they didn't get the supplementation, and I think that this is an important myth to dispel.

Kristyn Hodgdon:
Yeah, I had known a lot of that, so that's really helpful. So when is it okay to start trying again, after a miscarriage? Physically, I know mentally and emotionally, after my miscarriage, I needed to take a break. So you definitely have to take into account the feeling ready emotionally, but physically, when is it okay to begin trying again?

Lucky Sekhon:
So physically, once your HCG levels come back down to negative, which it depends on the lab, but for most labs it's less than five or less than two. That is a sign that everything is cleared up and you could physically go on to start trying or move on to your next fertility treatment, if you're going through that. I would say it's probably a good idea, I mean, I'm a fertility doctor, so I'm much more type-A and controlling over every aspect of the process as much as I can be. In a normal setting where you're just trying on your own and this happened and you followed up with your OBGYN, if your levels are negative, I think it's fine to just start trying again. But if you're going on to like an embryo transfer or something like that, I'm always very careful and we'll say, let's reevaluate the uterine cavity. I just want to make sure there isn't any retained tissue, nothing changed, and that we didn't miss anything in the initial imaging that we always do prior to a transfer. Just because you want to be so careful and cautious, every embryo is so precious. So I often will do that extra step, but I don't think it's a necessary prerequisite to moving on and trying to conceive.

Kristyn Hodgdon:
Okay! And is there any way to prevent miscarriage? And we said, it's not your fault. But I guess besides testing and treating underlying issues, there's no way we can really prevent it, correct?

Lucky Sekhon:
Well, it depends on what the underlying cause is, right? So if you find out that it's the structural, then yeah, you can prevent it. Because if you find out you have a hydrocele ..., well, that can be rectified, we can disconnect the tube from the uterus, we can remove it. If we know that you have fibroids and could benefit from having the fibroids removed, that could definitely reduce your risk or a septum, right? If you found out that you had blood clotting issues like the anti cardio linchpin, sorry, the Antiphospholipid syndrome, there is something that you can do. You could be on baby aspirin while trying to conceive and you could be on injectable blood thinner once you are actually pregnant, and that is a strategy that's known to mitigate the chance of a recurrent miscarriage in the future. If you have underlying hormonal imbalances with your thyroid, with your prolactin levels, these are all things that can be corrected and tuned up before you start trying again. So I definitely think there is room to improve the situation and prevent a recurrence, but it depends what the underlying issue is. If you're older and you're thinking, I've had maybe one or more miscarriages, most likely, logically, we can assume that the embryo was abnormal, maybe you even had a DNC, or you collected, what you pass when you had the miscarriage and your doctor was able to send it off for testing and it showed this is a chromosomal, abnormal pregnancy, then you could do IVF and genetically test embryos and say, I really don't want to go through that again. I know I can't 100% prevent because even genetically normal embryos can miscarry, but at least I'm greatly reducing my risk given my age by screening these embryos ahead of time. So I would argue there's a lot you can do, but a lot of it does not involve just starting progesterone.

Kristyn Hodgdon:
Yeah, but if it is an unhealthy pregnancy, nothing you did could, correct?

Lucky Sekhon:
Yeah. I would not say that eating something differently or refraining from exercise, like definitely, you know to your point, there is really no, this isn't something that doctors just say to make people feel better, this isn't me sugarcoating the situation. If we knew that there were real, everyday lifestyle things, I'm not talking about smoking, right? Like smoking we know increases your risk of pregnancy loss and and obstetrical problems and infertility, that is very clear. But when it comes to lifting things or having worked out or continuing to have a stressful job, there's a lot of guilt around that. But, you know, I think it's important for people to hear it from a fertility doctor that there is really no data, no concrete evidence from a well-designed study has ever shown that emotional or professional stress can cause a miscarriage. And I think that's important because it's already hard enough to go through treatment, go through this journey and juggle it with your life and all of your obligations, including work, to then, on top of it, feel guilty or worried that your day-to-day life and your work obligations might have kind of fed into this outcome. And really nothing could be further from the truth. I think that you're right in saying that if this is obviously an abnormal pregnancy and it's not progressing, there's really nothing you can do to influence the course, and that. I think it's all about prevention and rectifying known causes, but you're not always going to be in the position where you can do that.

Kristyn Hodgdon:
Got it, that makes total sense. So someone asked, why do genetically tested embryos still miscarry? And I feel like that has to be the most frustrating situation because a lot of times you're pursuing genetic testing, which we'll talk about in a later episode to prevent miscarriage. So why does it still sometimes happen?

Lucky Sekhon:
Yes, this is the million dollar burning question. And I get asked this a lot and I think it's really hard because it's so much work to go through the IVF process. And then there tends to be this thought that, okay, well I'm doing everything I can do and I'm controlling everything. By screening this embryo, iut is a guaranteed success and we know that that's not the case because nothing is perfect, right? Like, what are we doing when we're screening an embryo? We're taking away a few of the cells that would one day become the placenta, we're biopsying them and sending them off for analysis. The rest of the embryo is intact, obviously, we're going to transfer it. So we're testing a few cells, maybe 4 to 10 cells of what actually has 100 to 200 cells. So it's always possible that the test that we're using to test that small subset of cells is inaccurate or has error. Any test can be inaccurate. The chance of that is pretty low, it's like less than 2%. So that's one possibility that this was truly an abnormal embryo. It's also possible that the testing was accurate, but it wasn't reflective of what the entire embryo is actually made up of, because we know that embryos can be mosaic, meaning there can be different cell lines running through the same embryo, there could be a small population or even a larger population of cells that are missing or have an extra chromosome. And you just didn't happen to sample those cells. So you falsely called this a normal embryo, and that is a biological phenomenon, and you can't really get around it, until we figure out how to non-invasive test embryos and, and kind of get a sense of what's happening in the overall picture. This is what we have to work with, we're limited to working with a subset of the cells of the embryo. Also, the PGT has a limited resolution, you can only zoom in so far, so you can get to, let's say, 5 million base pairs of DNA, but there could be smaller sections that are duplicated or deleted, and they could involve genes that are critical to early growth and development that if they're missing or not what they should be might prevent proper continued implantation. And there's also the issue of this isn't so simple. It's not just a matter of having the right amount of DNA. What if some of the genes on those segments of DNA that are there and the count is correct are abnormal. What if the genes malfunction, right? We all have, we all may have 46 chromosomes, but it doesn't mean we don't have breakdowns in our body in other ways. So I think there's so many different things related to the embryo itself that could explain this. We know that it's also the uterine environment, and for someone who knows that they have Ashman syndrome, where they have scar tissue in their uterus and they've had it removed in the past, or maybe they've had fibroids or a septum, this is the thing that I would focus on before you move forward with the next transfer to make sure you don't need a revision and that things haven't changed slightly with the uterine cavity, it's always worth a second look because that could have been a causative factor. And then external factors to that that directly affect all aspects of your health. If you have chronic medical conditions, maybe you've had a flare of an autoimmune disorder and it needs to be better controlled with medication. We do know that having a better overall health is going to lead to better outcomes when it comes to fertility treatment, there is some correlation between implantation of embryos being successful and maintaining a normal BMI. So these are all important goals to work towards to just optimize your general health, to optimize the overall picture. And then, of course, this could be bad luck, right? And there may be no explanation, this could just be a sporadic thing that happened. Something just malfunctioned along the way, and it's not necessarily that you're going to have an increased risk of this recurring in the future. And it's a lot of unknown, and I think that's what makes it so disconcerting. But it's important to remember for most clinics we quote rates of around 60% live birth in a normal ... or genetically tested embryo that has good grades, so there's a lot of different things to consider. You know, it's not just about the grading of the embryo, it's also how fast it was able to get to that point where it could be biopsied, the slower growing embryos, like day seven embryos, definitely have lower rates of implantation and higher rates of miscarriage, so these are all things to take into consideration.

Kristyn Hodgdon:
Well, I love that you sort of end it on a positive note that there is a lot of hope for a successful pregnancy after a miscarriage. What would you, would that be sort of your resounding message to those who are currently grieving a loss?

Lucky Sekhon:
Yes. I mean, especially patients who've had recurrent pregnancy loss because they think it's easy to lose hope and think, okay, this is just my destiny and I'm never going to be able to carry a pregnancy to term, and I think nothing could be further from the truth. You know, you look for answers, definitely get testing done, but know that up to 50% of cases, none of the tests that we do or recommend will show up that there's anything positive or any, any sort of target to treat, and that's okay. Studies have shown that even in the absence of a target to treat or something to do differently, up to 60% of patients with recurrent pregnancy loss will go on to eventually have a live birth. So I think it is important to look for problems so that you can rectify them. But even if you don't find them, it doesn't mean that you're not going to be successful. And even in the case of doing recurrent frozen embryo transfers of a genetically screened embryo and not having any answers as to why it's not working or why you've had some miscarriages, even in that setting, I think the answer is typically you just keep trying, let's put back another embryo. And so I think it's it's hard to be resilient in this type of a problem, but it is important to have hope and know that those are real statistics and persistence often does pay off.

Kristyn Hodgdon:
Well, this is so informative. Thank you so much, Dr. Sekhon. And until the next episode.

Lucky Sekhon:
Thanks for having me on. I think this is such an important topic. I feel like we could do a part to on this alone.

Kristyn Hodgdon:
Absolutely. Maybe a bonus episode.

Lucky Sekhon:
I love that idea. Thanks so much.

Kristyn Hodgdon:
Thank you for tuning into this episode of Dear Infertility. We hope it helps you feel more empowered to be your own advocate on your fertility journey. Whatever you're currently struggling with, Rescripted is here to hold your hand every step of the way. If you like today's episode and want to stay up to date on our podcast, don't forget to click Subscribe. To find this episode show notes, resources, and more head to Rescripted.com and be sure to join our free fertility support community while you're there.

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