Pregnancy Loss: What Nobody Tells You About Miscarriage | Causes, Treatments, and Healing After Loss

One in four pregnancies will end in a miscarriage. And maybe it is as simple

miscarriage. And maybe it is as simple as we've ruled out everything we can.

Let's try baby aspirin and progesterone after [music] ovulation. Maybe it's

ovulation induction medications, thyroid medications or something to manage your insulin resistance. Maybe you're going

insulin resistance. Maybe you're going to try to decrease inflammation or we're going to do surgery for endometriosis.

Maybe we need to do IVF for genetic [music] factors or for other chronic inflammatory factors that we can't rule out. I had four pregnancy losses. Each

out. I had four pregnancy losses. Each

one felt devastating in its own way. and

I had the really unfortunate experience [music] of feeling dismissed by my own doctors. This was the first moment that

doctors. This was the first moment that I really realized and understood that I didn't [music] know what I needed to know.

[music] Welcome back to the Asoman podcast. I'm

your host, Dr. Natalie Crawford, and today we're talking about a painful but important topic in women's health, pregnancy loss. One in four pregnancies

pregnancy loss. One in four pregnancies will end in a miscarriage. And yet,

despite how common that is, few of us are really ever truly prepared for it emotionally or physically. I know this not only as a fertility doctor, but as a woman who's been there myself. I had

four pregnancy losses. Each one felt devastating in its own way. And while I understood the science, I still felt broken. And I share this because loss is

broken. And I share this because loss is something we don't talk about enough.

It's lonely. It's misunderstood. And it

deserves honesty and compassion. So in

this episode we are going to talk about what actually causes pregnancy loss and it is not your fault. How miscarriage

can be managed and how to choose what's right for you and what we know about recurrent pregnancy loss. Finding

answers when it happens more than once.

So whether you've experienced a pregnancy loss or you simply want to support somebody who has or understand this side of your fertility, this conversation is for you because pregnancy loss is not the end of your

story. But understanding what is

story. But understanding what is happening in the first place is key towards healing. All right, friends.

towards healing. All right, friends.

Well, a little bit of a heavier topic here today, but this one is really personal and important to me. As I said in the introduction, I had my own pregnancy losses before I conceived my children. And I remember how

children. And I remember how heartbreaking everyone was. My first

pregnancy loss, I remember reciting statistics and acting like it wasn't that big a deal. One out of every four pregnancies and in a miscarriage, I remember telling my husband. The second

pregnancy loss was the first one that truly felt like it broke me. I was the senior resident of OBGYn. I was in my residency and I was working on labor and delivery on a night shift. And I

remember being so excited because I felt more pregnant. My symptoms were all a

more pregnant. My symptoms were all a lot stronger. But during that night, I

lot stronger. But during that night, I started bleeding and miscarrying in the bathroom. And none of my co-workers, my

bathroom. And none of my co-workers, my colleagues knew I was pregnant. So I

didn't feel like I could tell them that I was losing the pregnancy. And it

certainly wasn't the culture that hopefully a lot of people have today because nobody talked about fertility or infertility or pregnancy loss. And the

culture at my residency was definitely a this is something to button up and do your job what you're here to do. So I

went on and delivered babies that night, showing other families their child while I knew I was losing mine. And it really broke me in a way to start saying, gosh,

there's so much that I don't know. I had

really approached my own fertility as I'm preventing pregnancy while I'm going through medical training and I'm on birth control and then I stopped it just expecting to get pregnant and have it be easy. And this was the first

moment that I really realized and understood that I didn't know what I needed to know. There were questions I had and I had the really unfortunate experience of feeling dismissed by my

own doctors saying something's wrong or having questions and I was told just relax, just keep trying. Oh, you're

pretty young. It'll just happen or it must just be stress. And that was heartbreaking to hear.

Our journey continued and I had another pregnancy loss right at the end of residency in the beginning of fellowship. And then my fourth pregnancy

fellowship. And then my fourth pregnancy was an ectopic pregnancy. And that was the one that really made me feel like what is happening? I didn't have any of the classic risk factors to have an

ectopic pregnancy. But suddenly I was

ectopic pregnancy. But suddenly I was getting methtoresate with it which is a chemotherapy medication that's injected to try to stop the ectopic pregnancy and

I couldn't get pregnant for 3 months.

IVF was the next step in our journey but we had to sit out. It wasn't a good time for me professionally and this is when I really started to do a deeper dive into what was going on in my own body, learning more about natural fertility

and ultimately something that changed the course of my career and everything that I talk about online. But I know that feeling of having hopes and dreams for a pregnancy that doesn't come true.

I know the feeling of having that room in your house that you're avoiding decorating because you want it to be the baby room. And I know that idea of just

baby room. And I know that idea of just waiting on plans because even if you see a positive pregnancy test, that doesn't mean it's going to end up in a baby in your arms. And I started to have that

experience of saying, I'd rather just not see a positive pregnancy test than lose another pregnancy. So, we know what it's like to

pregnancy. So, we know what it's like to be on that side of the story. And we're

going to rewind and just talk through why pregnancy loss can happen, what to know about it, how to manage your pregnancy loss, because part of the time this is a very emotional experience, and

you have to make big decisions, and you're often not in the right mindset to make them. [snorts] And then we're going

make them. [snorts] And then we're going to talk about recurrent pregnancy loss, and what I want you to know about that.

So, let's start at the beginning. A

pregnancy loss is officially any positive pregnancy test that doesn't end in a liveborn baby. And this is defined as before 20 weeks. So it's considered a loss if it's happening before the first

20 weeks of gestation. There's different

types of pregnancy loss and you'll hear them referred to as different things. So

officially the word miscarriage is a pregnancy loss and you'll hear that medically if you ever get your medical chart you'll hear that also listed as an abortion. So we talk about things like a

abortion. So we talk about things like a missed miscarriage. You might hear that

missed miscarriage. You might hear that talked about as a missed abortion. That

doesn't mean it's an abortion, just abortion is a pregnancy loss. But I just reference that because it's important to know if you're ever looking at your medical records that that might be the

medical terminology that you see. So

depending on when the pregnancy is lost or when it stopped developing and if intervention was needed or not, that goes to a lot of these words. So let's

start at the beginning. A chemical or a biochemical pregnancy is when you had a positive pregnancy test, whether that's a urine pregnancy test or a blood pregnancy, but you lost that pregnancy.

you started bleeding before you ever had an ultrasound that demonstrated what's called a clinical pregnancy, meaning a gestational sack inside the uterus on ultrasound. So, this is classically you

ultrasound. So, this is classically you get the positive test, but somewhere in the next couple weeks, you start bleeding, you have your period, and you miscarry. You then have what's known as

miscarry. You then have what's known as a missed miscarriage, and this is where a pregnancy stops developing. So, you

got your positive test, everything seems fine, you still have symptoms probably, but by the time you go in for an examination, the pregnancy doesn't have a heartbeat and it stopped developing.

Having really good dates, meaning knowing when you ovulated, can be helpful in determining if the pregnancy is just small and appropriate or if it has stopped developing based on

how far along that you should be. So, in

a mist miscarriage or a missed abortion, you are pregnant. the pregnancy is no longer viable, but you haven't miscarried yet. You haven't passed the

miscarried yet. You haven't passed the pregnancy. You haven't started bleeding

pregnancy. You haven't started bleeding everything. And this often requires some

everything. And this often requires some type of intervention. We then have an incomplete miscarriage. And this is

incomplete miscarriage. And this is where you have started bleeding, but there is still what we call retained pregnancy tissue. And this can be

pregnancy tissue. And this can be retained placal tissue for the most part or even a gestational sack. But this is a pregnancy that is in process. This can

sometimes be a medical emergency because the bleeding can be so heavy, can be hemorrhaging, you might need a blood transfusion or an urgent scenario. So if

you ever hear about somebody who's bleeding so heavy and they have to go to the hospital emerently, this might be an incomplete miscarriage. [snorts] And

incomplete miscarriage. [snorts] And then we have a complete miscarriage, which is when the pregnancy has actually completed the loss process.

So you had, let's say, a positive pregnancy test. You went, you had your

pregnancy test. You went, you had your ultrasound, showed a pregnancy, and then you started miscarrying, but now your uterus is empty. The process is completed, your hormone levels are zero.

We also have some other kind of interesting terminology to throw in here. So there is a ectopic pregnancy,

here. So there is a ectopic pregnancy, which is any pregnancy officially that's outside the uterus. The most common place being the fallopian tube. So an

ectopic pregnancy is one that you see on ultrasound. that is a gestational sack,

ultrasound. that is a gestational sack, a fetal pole, potentially a heartbeat developing outside the uterus and a pregnancy is not viable in this location. You also can have what's known

location. You also can have what's known as a PL or a pregnancy of unknown location. This is a not normal pregnancy

location. This is a not normal pregnancy by definition. Typically, hormone levels

by definition. Typically, hormone levels are not rising appropriately or development does not match where your gestational stages, but the pregnancy is

not 100% defined in the uterus. Meaning

if I see a gestational sack, which is the sack that the pregnancy grows inside, and I see a fetal pole, and I see that inside the uterus, I know this is an intrauterine pregnancy. Even if

this is going to be a pregnancy loss, it is one of the other types. A pregnancy

of unknown location means I don't know where it is. It could either be maybe early intrauterine, just hasn't gotten to that stage of development. It could

be ectopic outside the uterus, just I can't see it yet. But it is some abnormal pregnancy for the most part that is undefined in location and we have to approach that a certain way as

well. And then you also can have

well. And then you also can have something called a molar pregnancy which is worth describing. A molar pregnancy is essentially where you have overgrowth of placental cells. There's a few

different types but this can become an emergency as well based on some of the hormone changes that happen from this let's say overactive placental component. It can be just placenta with

component. It can be just placenta with no baby. You can also have a fetal

no baby. You can also have a fetal component with this overgrowth of placenta. Typically molar pregnancies

placenta. Typically molar pregnancies have very high hCG levels and can present in different ways. And in my fellowship I was covering gyn call and one night I had a patient come in with a

partial molar pregnancy was a twin pregnancy. One pregnancy was developing

pregnancy. One pregnancy was developing fine, but the other overgrowth of the placenta had some of these really serious consequences which can be severe blood pressure to the level where you

could have a stroke and something called thyroid storm where her thyroid was so kind of off the charts abnormal that it was damaging to her life. And this is a

situation we had to intervene and she needed a medical termination to save her life and unfortunately had to lose both pregnancies. And it was heartbreaking

pregnancies. And it was heartbreaking for everybody involved. But just another underscoring that pregnancy is not a benign health state. And just because you see a positive pregnancy test, if

you start feeling abnormally, always go and seek care because you never know what is really going on. So there's a lot of different types of pregnancy loss and abnormal pregnancies that can exist

and probably a few more than you knew.

So, let's think about normal gestation, how these get diagnosed and managed, and then after that, we'll go through typical causes and what you should know.

So, for the most part, when you miss your period, the day that you get your period, if you get a positive pregnancy test, you are now considered 4 weeks gestation. Well, if you can do math, you

gestation. Well, if you can do math, you might think that doesn't really make sense because I only ovulated 2 weeks prior to that. That's when an egg was released and when egg and sperm can meet. And you're absolutely correct.

meet. And you're absolutely correct.

Pregnancy dating and gestational timeline is always so confusing for everybody. And what I want you to

everybody. And what I want you to understand is that we have fancy technology now. We have ultrasounds and

technology now. We have ultrasounds and we can tell where you are as far as the development of the baby. But way before that, women were getting pregnant and the pregnancy was simply dated by when

your last period should have happened because that's the only outward sign you had. You didn't know when you ovulated.

had. You didn't know when you ovulated.

You didn't know when an embryo implanted. So all period dating and

implanted. So all period dating and terminology works back to your last menstrual period assuming that you have a normal ovulation that happens at about

2 weeks or around cycle day 14. So

there's inherent flaw in this system. I

say this because if you did fertility treatments, if we made you ovulate, if we put an embryo inside or if you know when you ovulated because of tracking, that is going to be a more sensitive

marker for how far along you are versus using your last menstrual period. But

pregnancy calculators and pregnancy timelines work back using a last menstrual period ideology. So with this ideology, your last period at two weeks

gestation is when you ovulated, the embryo implanted around two weeks 5 days and then you actually miss your period, get a positive pregnancy test

for the first time and you're considered 4 weeks pregnant. A couple weeks after that and the 6 week mark is when you can see an ultrasound that is going to have a gestational sack. Think about the

amniotic sack have placental development. You can see a yolk sack

development. You can see a yolk sack inside which is nutrients to the baby until the placenta is fully grown in around 9 to 10 weeks and you'll have a fetal pole. You start seeing a heartbeat

fetal pole. You start seeing a heartbeat usually around 6 and 1/2 weeks. By the 8 week mark, you're going to see this kind of change and enlarge. The fetus then doesn't look like a grain of rice. It

actually looks more like I always say a gummy bear where you can actually see the head, see the body, see limb buds.

and you should have a very strong heartbeat at this time frame. And then

that placenta is fully grown in around the 9 to 10 week mark. One of the reasons why this is so important is understanding that the placenta makes so many important hormones. One of them is

progesterone. But until the placenta is

progesterone. But until the placenta is fully grown and at that 9 to 10 week mark, your progesterone is completely coming from the corpus ludium. And the

corpus ludium comes from the follicle that you ovulated. So the first step towards having a healthy early pregnancy is having a healthy ovulation. So if the

follicle that your body is growing, so remember a group of eggs comes out of the vault. Each egg grows inside a

the vault. Each egg grows inside a follicle. The brain is going to send out

follicle. The brain is going to send out follicle stimulating hormone or FSH. FSH

gets that follicle to grow. As it grows, it makes estrogen. Estrogen tells the brain there's a mature egg. Ovulation

happens. That same follicle becomes the corpus ludium. The corpus ludium is then

corpus ludium. The corpus ludium is then going to make progesterone in the ludial phase and progesterone is going to open and close that implantation window. In

fact, we know the early pregnancy is so dependent on progesterone production that it is both how an abnormal pregnancy communicates with your body but also low progesterone levels can

contribute to pregnancy loss. There's a

definite chicken and egg hypothesis here. One thing we know is that brain LH

here. One thing we know is that brain LH allows the corpus ludium to make progesterone for only about two weeks.

After two weeks, the corpus ludium will die. Progesterone levels will drop and

die. Progesterone levels will drop and you'll get a period unless you get pregnant. And the pregnancy when it

pregnant. And the pregnancy when it starts to implant makes the pregnancy hormone hcg or human corionic gonadotrien. HCG is going to come in and

gonadotrien. HCG is going to come in and it can actually bind to the same receptors that LH did. So now you have LH hCG. They can bind to the same

LH hCG. They can bind to the same receptors making progesterone. But now

progesterone is made a little bit differently because in the ludal phase progesterone is actually made in pulses stimulated by brain pulses of LH. So

you're going to have a pulsatile progesterone. But then as soon as an

progesterone. But then as soon as an embryo implants now you're going to have a constant and increasing stimulus of progesterone. So now you have a lot more

progesterone. So now you have a lot more progesterone made accounting for a lot of the pregnancy symptoms but also a bigger progesterone requirement. Well,

hCG is supposed to double approximately every 2 days if the pregnancy is dividing and growing at a normal rate.

And if that is not happening, one of the signs the body might communicate is that your hCG level is now not enough to sustain that constant and increased

progesterone production. Therefore, your

progesterone production. Therefore, your body senses progesterone dropping, allowing you to misaryry an abnormal embryo. Because humans can't have tons

embryo. Because humans can't have tons of kids most of the time. Our body is not made that way. And so your uterus, your body is really made to make sure that this embryo has the highest chance

of turning into a baby. If cells aren't dividing normally at an embryionic level, this is highly concerning that the embryo is not going to be able to continue and grow normally. So low

progesterone is sometimes the way that your body is communicated that the pregnancy is abnormal. so that you will misarry it, give your body a reset, and

give another embryo a chance. However,

it's also important to understand that ovulatory dysfunction can present with abnormalities in the production of progesterone because progesterone's coming from that follicle, and if you

have a bad follicle, you're not ovulating well, you might not make enough progesterone. So, there's

enough progesterone. So, there's definitely a two-ended hypothesis here.

Giving progesterone as a treatment for pregnancy loss is sometimes done because it's very low risk. However, trying to get to the root cause of what may be going on is always important instead of

just giving progesterone. I see a lot of women who might have bleeding or who are in the process of having a pregnancy that looks like it's not going in the right direction and they start taking progesterone expecting it to do a

miracle. It's not wrong to give

miracle. It's not wrong to give progesterone, but you have to understand the reason your progesterone may have been low in the first place may just be that the pregnancy doesn't have the competency. Cells aren't dividing right,

competency. Cells aren't dividing right, maybe it's genetically abnormal. And

this is part of your body's own protective mechanism. So with that said,

protective mechanism. So with that said, the first part of this early pregnancy from embryo implantation at 2 and 1/2 weeks gestation or mid ludial phase

until that placenta is fully grown in 9 to 10 weeks. Your pregnancy is dependent on progesterone production which comes from a combination of the brain LH from

the brain. So obviously your HPO axis or

the brain. So obviously your HPO axis or the brain's ability to communicate to get you to ovulate well is key and then from a normal pregnancy. So both of

these, a normal rapidly dividing pregnancy to make hCG, both of those things are required in order to have enough progesterone to get through this first trimester. And the vast majority

first trimester. And the vast majority of pregnancy losses do occur before 8 weeks because of this. Because the

number one cause of pregnancy loss is a genetically abnormal or an abnormally dividing embryo, a pregnancy that it doesn't have the ability to become a normal baby. And this is part of your

normal baby. And this is part of your body's own protection. That being said, there are other factors which can contribute to pregnancy loss that we always need to evaluate for and these

can be things that can impact ovulation.

So thyroid disease, prolactin levels, having potentially hypothalamic dysfunction or ludial phase issues that might be due to chronic disease,

inflammation, insulin resistance, PCOS.

You also might have an increased risk of autoimmune disorder, clotting disorders.

There's genetic factors that can play a role besides random genetic abnormalities in addition to anatomical factors and sperm factors. So, I just listed off a slew of things and I'm

going to work these through in the recurrent pregnancy loss kind of workup so we can frame how we think about them and what we should do for them all.

Before we go over these different causes and thinking about it from a recurrent pregnancy loss, let's quickly dive into what should you do if you find out you have a pregnancy loss. So, there's

different management styles. So, one is what's called expectant management.

Waiting and seeing if your body will naturally miscarry the pregnancy. Of

course, if your body can do it naturally and you don't need any intervention, that's always the preferred option. But

the further along the pregnancy is when you had the loss and the longer you've had from when the loss started, if you haven't started to misaryry, the lower the likelihood that this is going to be

able to achieve the goal. A lot of my patients might have gone through fertility treatments. they might be on

fertility treatments. they might be on progesterone. So sometimes an important

progesterone. So sometimes an important note is if you're taking progesterone that progesterone might be preventing this natural process from happening and we might have you stop the progesterone

so that we can have you have that lowering of progesterone and see if that allows your body to start bleeding and miscarry naturally. But if you are not

miscarry naturally. But if you are not taking supplemental progesterone, you want to do expected management. It's not

wrong. But know that if you don't start bleeding at some time, we will need to intervene because having miscarriage tissue inside your uterus can put you at risk for infection and for scarring of

the uterine cavity. And of course, I tell every patient, pregnancy loss is devastating. You deserve time to grieve.

devastating. You deserve time to grieve.

We need to do an evaluation for why. But

none of that is going to happen right now. Our first step is simply going to

now. Our first step is simply going to be starting to make sure that we recover from this loss appropriately and then we can start looking at all of these next steps. So outside of expectant

steps. So outside of expectant management, what other options exist?

One option is medication. So medication

that can sometimes antagonize progesterone and cause uterine contractions. And these are pills which

contractions. And these are pills which also can be used for medical termination as well. Misoprosttol is the common one

as well. Misoprosttol is the common one that is used. You also can use mphrene.

So these are different medications that can work in different ways depending on how far along you are or what the circumstance is. But typically

circumstance is. But typically misoprosttol is used. It can be either oral or vaginal. It can cause progesterone levels to lower because it's a progesterone antagonist and can

cause uterine contractions. So this is one medication that you can use can open up the cervix, but it doesn't always cause the uterus to expel all the uterine contents. I've taken this

uterine contents. I've taken this medication before. It can be very

medication before. It can be very painful. The bleeding can be very heavy.

painful. The bleeding can be very heavy.

If you're using this, you need to make sure that you've got proper pain control. It can make you nauseous. You

control. It can make you nauseous. You

can have diarrhea from it. And you need to be able to know what your followup is so that you can make sure that everything was completed. Another option

can be a surgical procedure. And a

surgical procedure is usually called a DNC for dilation and curage. This means

we dilate the cervix up. And we used to use these sharp curettes which would get rid of the pregnancy. But now it's typically a suction DNC which is usually just a tube just light suction.

Therefore there's less risk of damage to the uterine cavity. With a DNC this is a quick surgical procedure. You get

anesthesia for it. We are able to kind of remove the pregnancy contents. They

can often be sent off for genetic analysis if need be. That can be one of the advantages. It often can be faster

the advantages. It often can be faster and there's less typical overall blood loss. There's an inoff version of this

loss. There's an inoff version of this procedure depending on how early the pregnancy loss can be where there's a small vacuum aspiration. This is called a manual uterine aspiration or manual

vacuum aspiration where a small catheter is inserted into the cervix and you kind of pull back on this suction creating a vacuum impact that can get some of the

pregnancy tissue to kind of come into this vacuum or this suction. This one

can sometimes be done with less anesthesia, but I always recommend some version of anesthesia. Usually a block at the cervix level, some type of numbing. Some offices have some nitrous,

numbing. Some offices have some nitrous, which can be a gas that you can use, but this is not going to be an option if you're further along in the pregnancy.

No matter what option we're using here, we want to make sure that there's appropriate followup so that you know that your hCG levels were all the way to zero and that everything is out of the

uterus. Granted, I have a very specific

uterus. Granted, I have a very specific line of work and I see people who struggle to get pregnant, but I have seen women who have had a pregnancy loss before and then struggle in the future

and sometimes they had a very prolonged course of trying to get their pregnancy test back to negative and they now have developed scarring inside the uterine cavity from retained products of

conception. So, this is why I always say

conception. So, this is why I always say when can you try again? Number one, you need a negative pregnancy test. So if

that's immediate because you had a chemical pregnancy, you can try right again in the next month. If you had a further along loss and it took many weeks for that to get back down, don't try for another pregnancy until we know

that your pregnancy test became negative. And if it doesn't become

negative. And if it doesn't become negative, this is a huge red flag that there might still be some retained pregnancy tissue that you need to intervene on. intervention is with

intervene on. intervention is with typically a DNC procedure or hysteroscopy where we put a camera inside the uterus and we can look and see what is going on.

If you have a pregnancy of unknown location, so this is an abnormally rising hCG where ultrasound doesn't demonstrate where this pregnancy is, management's a little bit different. We

are typically following these levels at first. If we feel confident it's not a

first. If we feel confident it's not a normal pregnancy based on the lack of a rise of hCG, it's not falling on its own, then we want to intervene with

either a surgical procedure like a uterine aspiration. See if that was just

uterine aspiration. See if that was just a failing intrauterine pregnancy, then hormone levels should drop or do we want to give methtoresate, which is similarly the early treatment for an ectopic

pregnancy. Methtotexate is a folic acid

pregnancy. Methtotexate is a folic acid antagonist, meaning it prevents folic acid from being utilized. And folic

acid's essential in cell division. So if

you use methtoresate, it stops cell division. That's how it's used for

division. That's how it's used for cancer treatment for chemotherapy. But

in a one-time dose, it can actually stop rapidly dividing cells of a pregnancy.

So if this pregnancy is extra uterine or intrauterine, it can often prevent it from continued growth and then can have your hCG levels lower and bleed and recover from the pregnancy. However, if

you have an ectopic pregnancy and we know it, depending on how far along things are, sometimes surgical removal of the pregnancy or the fallopian tube is a better treatment strategy because a

rupture of the fallopian tube can also be a surgical emergency. You can have severe internal bleeding and obviously we don't want anything bad to happen to you. So, you see there's a lot of

you. So, you see there's a lot of different treatment strategies and we're using your exact clinical scenario, maybe your next steps. One of the negative side effects of methtotate as I

said earlier is you can't get pregnant for three months because of how it works on folic acid and the risk for future potential birth effect if you get pregnant too soon. So depending on your

age, your goals, your treatment, how far along you are, your symptoms, that requires a personal game plan for what you should do. And important side note,

if your blood type is Rh negative, this means you might need a rogam shot in order to prevent future complication in a subsequent pregnancy. So always make sure to ask your blood type of your doctor. Recurrent pregnancy loss is

doctor. Recurrent pregnancy loss is defined or two or more pregnancy losses.

And this is actually a lower number than it was when I experienced pregnancy loss where the definition was three. I

appreciate that as a field we've redefined this and said we don't need to make women suffer for another loss if something is wrong. And so if you've had two pregnancy losses, you should absolutely go see your doctor and we

should start the evaluation for recurrent pregnancy loss. And the same things that can cause any miscarriage can cause a recurrent pregnancy loss.

And this is how we should frame what we should test and how we should treat. The

number one cause is going to be random genetic abnormality. And this is called

genetic abnormality. And this is called annuploloy. Remember that your

annuploloy. Remember that your chromosomes are inside your eggs inside your body your entire life. Therefore,

the rate of annuploly is really tightly tied to maternal age or how old you are.

Be it the older you are, the greater the likelihood. That doesn't mean though

likelihood. That doesn't mean though that all eggs are bad if you're older or that age is the only factor because we know that inflammation and chronic inflammation. We know that sperm factors

inflammation. We know that sperm factors also can impact the genetic normaly of an embryo. But maternal age has a strong

an embryo. But maternal age has a strong correlating factor. So random annuploy

correlating factor. So random annuploy is often the presumed cause either known because we were able to test miscarriage contents from a DNC or based on the fact

of how old you are or by doing other testing and all coming back normal. But

the top cause is going to be random genetic abnormalities. There's nothing

genetic abnormalities. There's nothing we can do to necessarily prevent this when it comes to age related changes. We

always want to focus on trying to decrease inflammation so we don't have other annuploid issues or egg competency issues or sperm issues because the sperm DNA is half of the genetic material as

well. But what I want you to think about

well. But what I want you to think about is those lifestyle changes we should always be trying to make to decrease inflammation. But age related changes

inflammation. But age related changes might only be overcome sometimes with IVF and genetic testing. And sometimes

that's the right answer for some patients after recurrent pregnancy loss.

Another genetic abnormality is called a transllocation. A balanced

transllocation. A balanced transllocation. A balanced

transllocation. A balanced transllocation is where two of your chromosomes have essentially swapped spots. So if they have swapped spots,

spots. So if they have swapped spots, what is then happening is that when the chromosomes go and split to make the embryo, you have an unbalanced embryo that can have a very high likelihood of

a pregnancy loss, 70 to 80%. This can

come from either maternal or paternal.

So both partners need to be tested. And

again, there's not a specific treatment here except IVF with genetic testing so that you can identify the normal or balanced embryos, transfer those and lower the rate of loss. If three out of

every four pregnancies you have ends in a loss, it's not a benign thing because pregnancy is not healtheneutral can result in uterine scarring and other issues. And so at some point if you have

issues. And so at some point if you have a balanced transllocation, we may be in the position where we have so many losses that we have to go and find those normal embryos.

Outside of genetic factors, we then want to look at anatomic. So one thing that many people don't know is that anatomic factors can contribute to a pregnancy loss. The top one being a uterine

loss. The top one being a uterine septum. The uterus is actually formed in

septum. The uterus is actually formed in two different components. Two different

what we call mularian buds. These

elongate, fuse together, and then the midline portion reabsorbs. This tissue

becomes the top one-third of the vagina, the cervix, the uterus, and the fallopian tubes. The ovaries are a

fallopian tubes. The ovaries are a different embryologic source, so they're not involved in this. You can have failure along any part of this pathway.

So, you can only have one half of the uterus form or two separate halves or failure of fusing. But the most common birth defect is failure of complete reabsorption of that midline connecting

tissue leaving almost a dangling piece of tissue inside the uterus and this is called a uterine septum. This is not frequently known. You don't have any

frequently known. You don't have any menstrual side effects. This is

typically something that does not get diagnosed until we find out on fertility testing or because you're having pregnancy loss. A uterine septum we can

pregnancy loss. A uterine septum we can do something about it. So for a uterine septum, we can do hysteroscopy, putting a camera inside the uterus, and we can cut this septum out. Then we then

usually have to have about four to six weeks of healing before you can get pregnant again, make sure the scar tissue doesn't form. But this is one of those things that we find that we actually can do something very tangible about and expect a different outcome.

Similarly, for anatomic factors that can contribute to pregnancy loss, can it be uterine fibroids or uterine polyps? So

those fibroids that are inside the uterine cavity, specifically uterine scar tissue. I see this higher if we're

scar tissue. I see this higher if we're postpartum or if we're after another loss or we've had anything inside our uterus in the past, any instrumentation

of our uterus. Maybe you've had a DNC, maybe had an IUD, fibroid surgery in the past, or we could have abnormalities of the fallopian tubes. Even those early

fallopian tubes. Even those early ectopic pregnancies can present as biochemical losses because most do resolve on their own and so evaluating the fallopian tubes is really important

as well. So a uterine evaluation which

as well. So a uterine evaluation which potentially could lead to a surgical evaluation for you. We then have endocrine causes and so these are things like diabetes, insulin resistance,

thyroid disease, PCOS and ludial phase abnormalities. So having a great

abnormalities. So having a great understanding of your cycle, tracking your cycle is going to be important and hormonal blood work for thyroid, prolactin, hemoglobin, A1C or fasting,

insulin, that's going to be very important. So this is blood work and

important. So this is blood work and they have dedicated treatment strategies that we can try to do depending on what we find. Sometimes there can be a subtle

we find. Sometimes there can be a subtle ovulation issue. This might be a ludial

ovulation issue. This might be a ludial phase defect and so depending on what we find, we might consider lowd dose ovulation induction. So medication like

ovulation induction. So medication like Clomid or sometimes lept which tell the brain to make more FSH hopefully getting you to ovulate a better follicle that makes more progesterone. Sometimes we

add progesterone on with this in the ludial phase as well. But remember you do not need daily progesterone. If

you're diagnosed with estrogen dominance, daily progesterone is not the answer because it will prevent that implantation window from opening and closing. Next is going to be autoimmune

closing. Next is going to be autoimmune factors. So, some of these overlap,

factors. So, some of these overlap, things like autoimmune thyroid disease, but we see all other autoimmune diseases or chronic inflammatory states can contribute to a higher rate of pregnancy

loss. In my case, celiac disease was

loss. In my case, celiac disease was strongly contributing and I had no idea I even had that. One autoimmune disease also overlaps with other clotting disorders and this is called any

phosphoipid antibbody syndrome. The

easiest way to explain this is that when you are pregnant, your body has more clotting factors that allows small clots to get inside the placenta leading to a pregnancy loss. Any phospholipid

pregnancy loss. Any phospholipid antibodies syndrome can be really scary, but we see improved pregnancy outcomes when we know that you have this and you are treated with both baby aspirin and an injectable blood thinner like

lovenox. There's some other clotting

lovenox. There's some other clotting disorders that depending on your history, your family history, things like factor 5 liden might be worth checking. So knowing your own family

checking. So knowing your own family history, if there's been any blood clots or pregnancy losses is really important in making sure that you understand the full process. Other inflammatory factors

full process. Other inflammatory factors can include things like endometriosis, PCOS, and we have adnomiiosis. And some

of these have very specific management strategies. But understanding what's

strategies. But understanding what's going on with your body, if you have pain, if you have had any change in the bleeding pattern, if you're having regular cycles, is going to be the key for your doctor getting to the root

cause of what may be happening. Other

lifestyle factors and choices can contribute to pregnancy loss. Things

like smoking cigarettes, marijuana use, even in just the male partner, obesity, alcohol use, chronic stress have all been associated in different ways with a

higher likelihood of pregnancy loss. And

so this is just saying it is not your fault. But if you've been in my shoes

fault. But if you've been in my shoes before and you are having an increased rate of having a pregnancy loss or you've been through one, I know that you're in the position where you want to try to control every factor that you

can. And so this is a place where we

can. And so this is a place where we want to say, how can we decrease inflammation? How can we eliminate

inflammation? How can we eliminate things that might be harming our egg or sperm quality if we remember that our eggs and our sperm are responsible for bringing those normal chromosomes in and setting us up for success?

In up to 50% of the case of recurrent pregnancy loss, no true cause is found.

And this can be very frustrating.

There's no one right answer in this circumstance. It will completely depend

circumstance. It will completely depend on your menstrual cycle history, your pregnancy loss history, your other medical history, your pregnancy goals, your age, and this is where having a

doctor you trust to walk you through the process. Try to get to the root cause

process. Try to get to the root cause that you can, and come up with the best treatment plan you can. I am never somebody who believes the right treatment plan is just keep trying

without being offered some type of option for trying to prevent this from happening again. And maybe it is as

happening again. And maybe it is as simple as we've ruled out everything we can. Let's try baby aspirin and

can. Let's try baby aspirin and progesterone after ovulation. Maybe it's

ovulation induction medications. Maybe

there's thyroid medications or something to manage your insulin resistance. Maybe

you're going to try to decrease inflammation or we're going to do surgery for endometriosis.

Maybe we need to do IVF for genetic factors or for other chronic inflammatory factors that we can't rule out. There's no one right or wrong

out. There's no one right or wrong answer for every single person, but knowing that you had the right evaluation is going to be key to coming up with that personalized treatment plan so that you can prevent the cycle of

recurrent pregnancy loss from happening over and over again.

Even after multiple pregnancy losses, more than 70% of women will go on to have a successful pregnancy. So, the

odds are on your side, but you deserve to make your decisions from a place of data and knowledge. So, hopefully this episode has helped give you some of that fund of knowledge so that you can ask the right questions and be the best

advocate for your own health. If you've

had a pregnancy loss before, I've been there, too. It's not your fault, but it

there, too. It's not your fault, but it is heartbreaking. I encourage you to do

is heartbreaking. I encourage you to do what I did not. Please tell people in your world who are important to you, who can show up and support you because I know there are people who will provide

that support if you let them in. I kept

my pregnancies a secret, didn't tell anybody. Then I felt awkward telling

anybody. Then I felt awkward telling them that we were struggling and that we had had a pregnancy loss. But I know there's people who would have shown up had I given them the opportunity to do so. So I encourage you to take that step

so. So I encourage you to take that step that I didn't and tell your sister or your mom or your best friend or your coworker. let somebody in so that they

coworker. let somebody in so that they can be a support for you along the way because this is hard. As always, I appreciate you so much for being here.

Remember that you can pre-order the fertility formula at nataliecrawford md.com/book.

md.com/book.

And until next week, thank you, [music] friends.

Thank you for listening to the Asoman podcast. If you're ready to take control

podcast. If you're ready to take control of your reproductive health, [music] my new book, The Fertility Formula, is your next step. It's a sciencebacked guide to

next step. It's a sciencebacked guide to understanding your hormones, optimizing [music] your fertility, and owning your reproductive future. You can order your

reproductive future. You can order your copy and learn more at nataliewrfordmd.com/book.

nataliewrfordmd.com/book.

And as always, [music] follow along at nataliecrawford MD for even more support. Because knowledge is power, and

support. Because knowledge is power, and your health [music] deserves a formula made just for you as a woman.