Multiple miscarriages? Be an advocate for yourself: When to ask more from your provider…
Women with miscarriages tell me they feel broken and often ignored. When they are feeling the most vulnerable and grieving a loss of pregnancy they can hear statements from their providers and friends like:
“Miscarriage is common – just try again.”
“At least you conceived, that’s the first step, it will be fine next time.”
“One or two miscarriages can happen but we do not do testing until you have 3 losses.”
As the Director of the Center for Recurrent Pregnancy Loss at Pacific NW Fertility in Seattle, WA, I often hear the following:
“My provider wouldn’t do testing.”
“The office wouldn’t see me until 12 weeks of pregnancy but I always have a miscarriage between 6-8 weeks.”
“I was told to just try again but I am scared.”
Providers go into medicine to care for people and they want the best for their patients. The fact is, miscarriages make many providers uncomfortable. Why?
- Many women will have one miscarriage but recurrent miscarriage is (fortunately) not very common so many providers do not have a lot of experience with recurrent pregnancy loss
- Most providers do not have formal training on testing and treating recurrent miscarriage
- 50% of patients with multiple miscarriages will be unexplained (meaning all the tests come back normal and there is no obvious explanation as to why someone is miscarrying)This last one is a tough one for most medical providers. They go to school for years to cure illness and fix people. The thought of doing testing and then having to tell the patients that they have no idea why they are losing pregnancies is scary to some providers. They want to have answers for patients just as much as patients want to have the answers to the question: Why did this happen?Why are many patients with RPL considered unexplained?Because the most common cause of first trimester miscarriage is a genetic issue or chromosome imbalance in the embryo. It is unique to each pregnancy and it happens at conception and no abnormal tests will show up in the patients trying to conceive. If this is the case, options include continuing to try naturally or screening the embryos for chromosomal imbalances via in vitro fertilization (IVF) and preimplantation genetic screening.
This does not mean that patients with multiple miscarriages should not be evaluated. If a reason is found – it can decrease the risk of a future miscarriage.
Many providers do not do testing for recurrent miscarriage until after the 3rd pregnancy loss, however, the American Society of Reproductive Medicine states that it is reasonable to start an evaluation after 2 losses. They argue that the risk of a subsequent miscarriage after 2 losses is similar than after 3 so that if a cause is found and treated, then a 3rd loss may be prevented.
I encourage patients to be an advocate for themselves. Ask questions and find the right provider for you.
- Some general practitioners and obgyns will have experience with recurrent miscarriage but many will not – ask about their experience and what they are willing to do – ask when they consider referring to a specialist
- Reproductive endocrinologists are the specialists for recurrent miscarriage – they are physicians who train in obstetrics and gynaecology and then do specialty training in reproductive endocrinology and infertility. Not all reproductive endocrinologists care for patients with recurrent miscarriage but most will have had the training in their fellowship.
- Some maternal fetal medicine physicians or perinatologists (specialty training for high risk pregnancy after training in obstetrics and gynaecology) have a special area of interest in recurrent miscarriage but not all
- If you are seeing a specialist, ask about their experience, comfort level, plans for evaluation, and treatment
- Find someone that will listen to you and answer your questions
- Read online but be careful – not everything you read online is true or safe. Patients with recurrent miscarriage are vulnerable and can get to the point when they will ‘try anything.’ Review supplements, vitamins, treatments with a medical provider
- Find a support network to help – some communities have miscarriage support groups – look online. One good resource is the national organization: resolve.org
Most importantly – do not lose faith in your body and your ability to conceive. Some of those statements that providers say to women with miscarriage are based on good science – they could just be said in a different way and with more empathy. Most women with multiple miscarriages go on to have healthy babies as long as they keep trying. The right support team, including your medical provider, can help give you the courage to keep trying.
Find a provider that says something like this:
“Miscarriage is common but that doesn’t mean it’s ok or that you’re not allowed to ask questions, get an evaluation, and grieve. The vast majority of the time the cause has something to do with the embryo – not stress, a glass of wine you had before you knew you were pregnant, or a cup of coffee. We should do testing to see if we can find a cause but even without any testing or intervention – the very next time you conceive it might be successful. When you are ready to try again, I know a positive pregnancy test is just the beginning, and I’ll be with you each step of the way.”