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Recurrent Pregnancy Loss · Love and Science Fertility

• 0:29
  Speaker 1: Hello, my loves, welcome back to the Love and Science podcast.
• 0:33
  Speaker 1: This week we're going to be talking about recurrent pregnancy loss, which basically is when somebody has two or more consecutive losses in a row.
• 0:43
  Speaker 1: There are other definitions of recurrent pregnancy loss, such as needing three or more pregnancy losses in a row, although, I will tell you, as a fertility specialist, I see a lot of patients with recurrent pregnancy loss in a row.
• 0:55
  Speaker 1: Although, I will tell you, as a fertility specialist, I see a lot of patients with recurrent pregnancy loss in my practice, and anxiety levels are usually pretty sky high after the second loss and sometimes even after the first loss, and so most of us initiate an evaluation after the second loss to really try to understand the why of things.
• 1:13
  Speaker 1: And so my goals in speaking to you today are really to elucidate what recurrent pregnancy loss is and what the tests are that help someone understand if they have an identifiable cause, although, as we'll talk about, over half of couples don't actually get an identifiable cause.
• 1:33
  Speaker 1: Half of couples don't actually get an identifiable cause.
• 1:38
  Speaker 1: You know sort of how to approach it if you do have unexplained recurrent pregnancy loss, and then also ways that I found helpful in terms of breaking it up into small parts in terms of the journey to move forward in a way that is grounded in authentic hope and really helps to really keep grounding and faith throughout the process, because it can be really challenging.
• 2:00
  Speaker 1: So you know, the first challenge when you've had two or more consecutive losses is really to try to understand the why of things, and I think about recurrent pregnancy loss like I think about spokes on a wheel the losses are in the center and then there's all these different pathways to getting the diagnosis, and so sometimes it can be a hormonal issue where there's sort of thyroid abnormalities or diabetic abnormalities like the physiology of the person is not optimal for carrying a pregnancy abnormalities like the physiology of the person is not optimal for carrying a pregnancy.
• 2:37
  Speaker 1: There can be prolactin issues.
• 2:41
  Speaker 1: Those sorts of things can be implicated sometimes and those are not too hard to diagnose because they're usually just blood tests.
• 2:44
  Speaker 1: Another reason why somebody can have consecutive losses is genetic problems, and so usually this is when a woman is on the older side, and the losses, if you test them, really just don't have a viable set of chromosomes, and so we all know that as we get older see my episode last week the body just doesn't do what it's supposed to.
• 3:10
  Speaker 1: All of the time the eggs get tired, they have a harder time shuttling the chromosomes and really giving the energy for those cell divisions.
• 3:18
  Speaker 1: And so a lot of the times, especially in older women, but in younger women too, you can have losses that are due to chromosomal abnormalities of the embryo, which, of course, there's nothing.
• 3:31
  Speaker 1: There was no faults, right.
• 3:32
  Speaker 1: This is not anything that can be changed.
• 3:34
  Speaker 1: It's just one of those biological realities that can explain why somebody is having losses, especially at older ages.
• 3:43
  Speaker 1: There is also another genetic problem that can happen, called a translocation.
• 3:47
  Speaker 1: That is actually a problem of either of the parents.
• 3:51
  Speaker 1: I will say in all couples with a current pregnancy loss, a translocation is found in 5% or fewer.
• 3:58
  Speaker 1: So it's not like the most common thing, but I do think that if it is found it can certainly change the trajectory because those people are more likely to have more and more losses because the eggs or the sperm get less stable as they go to reproduce and there's typically the correct amount of genetic material under the surface is just rearranged and so those gametes are unstable and a lot of times in the offspring they have unbalanced amounts of genetic material which can lead to losses, or sometimes you know children with intellectual disability as well and other sorts of problems like that.
• 4:40
  Speaker 1: So again, you know, I always take a keen eye when I'm looking at these things, because genetic abnormalities can be part of things, as hormonal abnormalities can be part of these things.
• 4:52
  Speaker 1: Other sort of reasons why people can have losses, from an environmental standpoint, is some women are just more predisposed to clotting than others.
• 5:02
  Speaker 1: And this is where it gets a little tricky because there are some evidence-based things and some non-evidence-based things.
• 5:09
  Speaker 1: Typically, the evidence-based things to test for are what's called antiphospholipid antibodies, or APLS for short, and so basically these are antibodies that can be acquired, sort of like an autoimmune condition, that make a woman predisposed to larger blood clots, like you can have, like a blood clot in your leg or in your lungs, but also like these little micro blood clots that can interfere with the developing circulation of the embryo.
• 5:40
  Speaker 1: So basically, if somebody has had three or more consecutive losses, or a loss that's at 10 weeks or greater, or even actually a severe preeclampsia, those are indications for testing for this.
• 5:52
  Speaker 1: Those are indications for testing for this.
• 5:56
  Speaker 1: It's a little tricky because if you have a positive test you need to check another set 12 weeks into the future to make sure it's not a false positive.
• 6:00
  Speaker 1: So again, if you are listening to this podcast and you have RPL, I'm sure you wanted a child yesterday and you don't want to have to wait three additional months beyond the initial set of testing to figure it out.
• 6:12
  Speaker 1: And being in a pregnant state as many of my patients with losses are or they're coming off of their most recent miscarriage it interferes with the APLS testing to test when a person is actually pregnant, and so it just sort of means that we generally have to wait until the beta-HEG is negative before we can initiate the testing.
• 6:33
  Speaker 1: So there are some pesky things to it, but it is, you know, thankfully, one of the things we can intervene on, and so, if that is found for you, baby aspirin and heparin are the treatment, and I've seen many, many, many people have a long history of losses and then we discover this and then they're treated and then they go along to have, they go on to have a very healthy term delivery, and that's the goal, right is to walk home from the hospital with a healthy baby at the end of the day.
• 6:57
  Speaker 1: So that's another environmental thing that we can test for.
• 7:00
  Speaker 1: That can be treated.
• 7:02
  Speaker 1: And something else we can look at is the uterine cavity, and so oftentimes there can be a fibroid or a septum or a polyp, or even chronic endometritis, which is inflammation of the endometrium, and this can make it harder to get pregnant and stay pregnant.
• 7:19
  Speaker 1: I will also say there's, you know, other things that are a little bit less, um, you know, sort of less testable but like sort of lifestyle stuff.
• 7:30
  Speaker 1: So, for instance, if somebody is smoking a lot, then we look at that.
• 7:34
  Speaker 1: If there's a lot of marijuana or marijuana exposure, secondhand exposure, we look at that.
• 7:37
  Speaker 1: So there's other sort of environmental characteristics that we look at as well when we're thinking about recurrent loss.
• 7:44
  Speaker 1: Now I will also say that there is a subset of people who may not even be on the older side but who have ovarian reserve values which are suggesting that the ovaries are acting older than your age.
• 7:58
  Speaker 1: This is very controversial and I think different REIs have different practice patterns around this, but generally say I see somebody who's like 33, 34, they're having multiple losses in a row.
• 8:09
  Speaker 1: I will check ovarian reserve markers because I think sometimes they can help me understand the physiology of the person and even though that person has a young age and their overall prognosis is quite good.
• 8:20
  Speaker 1: I do want to understand their physiology, for a few different reasons.
• 8:24
  Speaker 1: Right, because it may be implicated in some of the losses that they're having in terms of egg quality, and also if they do want treatment.
• 8:31
  Speaker 1: I want to understand what their physiology is so I can intervene in the best way possible.
• 8:36
  Speaker 1: So I just wanted to mention that as well, because that's typically part of what I check.
• 8:42
  Speaker 1: Generally speaking, it doesn't make too much sense to check the sperm just because if somebody is getting pregnant, then you know that's the sperm are probably doing their job.
• 8:53
  Speaker 1: But in terms of like, sometimes we see the spectrum of recurrent loss and infertility.
• 9:01
  Speaker 1: So, like, say, somebody is getting pregnant, it just takes nine to 12 months between attempts or between pregnancies to get pregnant again.
• 9:11
  Speaker 1: You know, I think about those people a little bit differently because they have recurrent loss but there's also infertility in the meantime.
• 9:18
  Speaker 1: So for those people I actually initiate an infertility evaluation as well to try to understand if there's endometriosis or maybe there are sperm issues in that situation or maybe there's some ovulation issues.
• 9:31
  Speaker 1: And so I will say one thing I've learned about infertility over the years and recurrent loss is that it's not usually one giant thing, it's usually a few things that line up to create the subfertility.
• 9:43
  Speaker 1: And so you know I am a no like, leave no stone unturned kind of a person.
• 9:47
  Speaker 1: Just because I find one diagnosis that leads to infertility doesn't mean I'm going to stop there and not get the full thing, because I've seen so many people with more than one small problem going on and those things can add up over time and if you just treat one another, then that can be, you know, not serving the patient or the client at the highest level.
• 10:08
  Speaker 1: So you know, I want to transition to say my second sort of big point here is that most people end up actually not having an explanation for their losses, and so it's very frustrating, right, because you have this problem.
• 10:22
  Speaker 1: It's heartbreaking, you want nothing more than to have a healthy child and you know all the tests come back normal.
• 10:29
  Speaker 1: It's like whenever I see someone like this in my office, I'm like there's good news and there's bad news.
• 10:34
  Speaker 1: The good news is that the testing is normal, but the bad news is the testing is normal because we want to hang our hat on something, and so I think that what I help people understand in those situations is that if you look at the data, over 70% of people, of couples, will conceive a live birth even without any assistance.
• 10:54
  Speaker 1: Right, it might take a little bit longer, but people who have recurrent loss generally do get to their goal.
• 11:03
  Speaker 1: It's just really hard to predict how many more losses they might have in the meantime, before that happens.
• 11:09
  Speaker 1: And if you're going through this yourself, you understand that each loss tends to get harder and harder.
• 11:13
  Speaker 1: So we look at the data, we take the full picture, we try to understand what's going on.
• 11:19
  Speaker 1: But even if you have unexplained recurrent pregnancy loss, I like to say look at what is actually working.
• 11:25
  Speaker 1: And so maybe you're 30 years old and so you're expected to have good egg quality.
• 11:30
  Speaker 1: Maybe you know you've been pregnant before and you know and you just had a fever at the time that you conceived, and so maybe the loss was due to an unfortunate constellation of being actually sick at the time that you were pregnant and that was a sort of an unlucky event and the next time you might have better success.
• 11:52
  Speaker 1: You know there are some people who have like this combination of polycystic ovarian syndrome and recurrent pregnancy loss.
• 11:57
  Speaker 1: I will often give those people a little bit of letrozole in my clinical practice, because by helping to augment the ovulation and the luteal phase, sometimes that will really help people in their quest to build their family.
• 12:09
  Speaker 1: And so, you know, as you know, I'm a big believer in authentic hope.
• 12:14
  Speaker 1: I always like to look at what the good prognostic factors are and then we go from there.
• 12:19
  Speaker 1: Maybe somebody had one healthy child and then has had three losses and they're coming to see me.
• 12:25
  Speaker 1: I still think that that's a good thing that they have one healthy child, because it tells me that they've done it before and they are likely to do it again.
• 12:33
  Speaker 1: We just got to figure out how.
• 12:35
  Speaker 1: So, you know, in those situations we really look at the data, we stay the course, we get this, you know, emotional support that's needed and we move on forward, understanding that most people at the end of the day are actually not going to have a diagnosis that people can hang their hat on.
• 12:51
  Speaker 1: And so, you know, either you move forward with some sort of an intervention or you move forward with an unexplained diagnosis, and in that situation I usually say it's either minimal intervention or maximal intervention.
• 13:05
  Speaker 1: Right, and you know we all think that, oh well, ivf is the most successful thing we have.
• 13:10
  Speaker 1: Let's just generate some chromosomally normal embryos, but a lot of people have recurrent loss even in the face of normal embryos, and there's some people for whom that may not be the best strategy.
• 13:21
  Speaker 1: So this is why a good relationship with your REI is really important, because there's a ton of nuances with recurrent loss and you really want somebody who can do the testing but then also interpret the results in the context of your particular situation and I do comment on this as a coach.
• 13:38
  Speaker 1: In my coaching role.
• 13:39
  Speaker 1: It's not medical advice, but I've had so much experience helping couples with this.
• 13:44
  Speaker 1: It's very gratifying.
• 13:45
  Speaker 1: When it works, the rainbow babies are just beautiful and celebrated, and we know how much it took to get there, and so I always love commenting on these things as well, to just see if my perspective might shed some light as well.
• 14:01
  Speaker 1: So, right, like I said, you're moving forward in some way and you're trying to keep your sanity right, and this is what I call the messy middle.
• 14:10
  Speaker 1: So how do we deal with the messy middle?
• 14:12
  Speaker 1: The third point I wanted to say in this podcast episode is really that when you are moving forward with your current pregnancy loss, it's really helpful to break it up into the small parts, and so maybe that's cycle by cycle, maybe you get a pregnancy test that's positive and you call your doctor's office right away so you can get some testing.
• 14:33
  Speaker 1: Or, you know, maybe, maybe you learned about the study that said that people with recurrent loss who had an ultrasound every week and had frequent contact, or three more times, until everyone feels confident that you're going on to your general OBGYN and that the pregnancy is well-established and it looks like it's going to continue, because we've all had situations where we helped somebody.
• 15:13
  Speaker 1: We saw a heartbeat, we said, okay, you're good to go, and then we get the call that they saw their OB for the first time and there wasn't a heartbeat.
• 15:20
  Speaker 1: It's just so devastating, and so whatever we can do to prevent that heartbreak and to hold the hand of people and support people throughout this very difficult time, which I call the messy middle, I think it's really important to do that, and I also think just to acknowledge that having a miscarriage is very traumatic, and when we have trauma, we try to process it the best we can, but we also end up with some PTSD oftentimes from those events, and so if we think about it, you know, the next pregnancy can actually be very traumatic, even the thought of being pregnant again, understanding what can happen.
• 15:57
  Speaker 1: You know it can bring up a lot of complex emotions and, as you know now, I love helping people navigate complex emotions.
• 16:04
  Speaker 1: But I always say, well, the options are stopping to try right, and the consequence of that is not building the family.
• 16:12
  Speaker 1: Or you could try with support and just understand that not every miscarriage can be prevented.
• 16:19
  Speaker 1: But to have loving support, to have somebody who sees you, who cares about you, who's invested in you and who ultimately wants a good outcome for you, I think that's a really, really important thing.
• 16:30
  Speaker 1: So, if you're listening to this podcast and you've struggled with recurrent losses and either you're on the fence about moving forward with trying to build your family or you really just feel that your mental state is really, really suffering, I would love to help.
• 16:45
  Speaker 1: Book a call with me, let's talk, let's see what you need, let's see how I can connect your resources.
• 16:50
  Speaker 1: I really, really love to help people to finally build their families and to feel supported.
• 16:58
  Speaker 1: I think that's the most important thing right, to feel supported while they're doing it.
• 17:00
  Speaker 1: To feel supported.
• 17:00
  Speaker 1: I think that's the most important thing right, to feel supported while they're doing it.
• 17:02
  Speaker 1: So, as you know, I love you.
• 17:03
  Speaker 1: I hope you found this valuable.
• 17:05
  Speaker 1: Remember that the three pillars are number one to try to do a thorough evaluation to figure out why, if you do have an explanation, then to treat it at that level.
• 17:13
  Speaker 1: If you don't have an explanation, then to figure out what the treatment strategy is going to be right Either maybe minimal intervention and some slight augmentation with some adjuncts, or maybe IVF is going to be beneficial for you.
• 17:25
  Speaker 1: It's hard to say, the data haven't really borne out with that, but I always say, if you're 38 or above and you have recurrent loss, it might be time to think about IVF with genetic testing.
• 17:33
  Speaker 1: But again, every situation is nuanced and that's why having a really wonderful and well-curated care team is so important.
• 17:41
  Speaker 1: And then my third thought to leave you with is to break it up into small parts and have an action plan for when you are pregnant, you know, and um, just figuring out what the monitoring will look like, what the ultrasounds will look like, so that eventually, hopefully, you can graduate and and then walk home from the hospital with a healthy baby in your arms.
• 18:00
  Speaker 1: So with that, I will see you next week.
• 18:03
  Speaker 1: Talk to you soon.
• 18:04
  Speaker 1: Bye.