Rescripted_Dear Infertility_S6_Ep8: Audio automatically transcribed by Sonix

Rescripted_Dear Infertility_S6_Ep8: 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, proud fertility and women's health advocate, and co-founder of Rescripted. Welcome to Dear Infertility, the first-ever podcast that doubles as an advice column for all things fertility and women's health. This season, join me along with Dr. Nicole Yoder, a fertility specialist at Spring Fertility in New York City, as we explore what to do when you're trying to conceive and feel like nothing is working. From when to seek the help of a fertility specialist to what questions to ask when IVF fails, we'll address all things fertility troubleshooting so you can become your own best reproductive health advocate. Now, let's dive in.

Kristyn Hodgdon:
Hi, everyone, and welcome back to Dear Infertility. I'm your host, Kristyn, and I'm here with Dr. Nicole Yoder, a fertility specialist at Spring Fertility in New York City. Hi, Dr. Yoder.

Nicole Yoder:
Hi.

Kristyn Hodgdon:
So excited to chat with you today about miscarriage and recurrent pregnancy loss. I always say it's the club that no one wants to be a part of.

Nicole Yoder:
Absolutely.

Kristyn Hodgdon:
Yeah. It's so heartbreaking. And it happens to be pregnancy, at the time of our recording, it's Pregnancy and Infant Loss Awareness Month. So very top of mind right now to just chat about some of the common causes of miscarriage and troubleshooting for when you've had multiple losses and don't know what's going on.

Nicole Yoder:
Yeah, it is definitely a very, it's a hard topic. There's a lot that comes along with this, but hopefully, we can give people a little bit of information, accurate information to hold on to.

Kristyn Hodgdon:
Yeah, and thinking about it recently during this awareness month, you don't have to be going through infertility to experience pregnancy loss. Like, the more I open up about my losses, the like you almost always hear, I mean it is 1 in 4 pregnancies or known pregnancies end in loss. It just affects so many more people than even infertility, and I think because it's not always talked about, it feels very isolating, even though it is something that's so common. It feels so, it really does feel like you're alone. And a lot of times, until you bring it up, no one really even mentions that they had one. And then all of a sudden, you're like, oh my gosh, were you just suffering in silence this whole time?

Nicole Yoder:
Yeah. It's crazy the number of people who never talk to anybody about it, because it is a very private thing, but it still has stigma around it and guarantee you somebody who's had a miscarriage, like it's super prevalent. And people, I think, don't really know that. And they feel like, what's wrong with me? It's just like my body, and it's incredibly common. So I'm happy that we're starting with that.

Kristyn Hodgdon:
Yes, and first and foremost, your miscarriage is not your fault. We actually were a part of a campaign this week with Poppy Seed Health, and they did a campaign that instead of calling it miscarriage, it was called the Thiscarried campaign because, miss, like just the word miss means wrong, and it's almost like you carried wrong, and the word itself carries a lot of blame. But this body carried your baby, and no matter how early it was, and so it was a really empowering video and campaign. Yeah, for sure. So your body, I feel like after my losses and infertility and postpartum and all that stuff, it's like you realize how strong women's bodies really are.

Nicole Yoder:
It's, really are, they are, it's stronger than you would think. But I love that, like it's such a like on-point-like way to look at it.

Kristyn Hodgdon:
Yeah. So going off of, you did not cause your miscarriage, what are some of the most common causes of miscarriage?

Nicole Yoder:
Yeah, so it's a really good point. I always try to emphasize to people it's nothing you did or didn't do. Most of these causes are beyond our control, but the common cause is probably the number one cause is genetics. So usually that comes down to just the embryo did not have the correct number of chromosomes and is what we call an aneuploid embryo. It really, an ideal embryo has 23 pairs of chromosomes, and sometimes we end up with some extra, sometimes we end up with missing some, and sometimes they're normal enough to start being a pregnancy, but not enough to continue to a live birth. Aneuploidy, and then sometimes as a translocation, which is a different type of genetic cause, but that can also lead to miscarriages. Uterine causes can also lead to miscarriage, that could be a structural thing. Maybe there is a septum, maybe there's fibroids, something structural about the uterus, or maybe there's inflammation going on. So maybe there's what we call chronic endometritis, maybe that's leading to the pregnancy, not having a good, healthy environment to continue. Environmental causes also come into play, so that can be stuff like smoking. So we know that smoking is pretty much bad for all aspects of our health, but also reproductive health, specifically for miscarriage rates, drug use, or excessive alcohol use can cause an environment that's not very good for an embryo to continue growing in. Medical conditions can contribute to those that they are maybe not optimized, so uncontrolled diabetes, hypertension, obesity, thyroid issues that might be wildly out of control, autoimmune issues, thrombophilias. So sometimes there's an underlying medical condition that maybe you either know you have or you don't know you have yet that can come to light. But even after all of these causes are looked at, probably about 50% to 75% of cases, we don't actually come up with the good reason. So don't always know what the cause actually was at the end of the day.

Kristyn Hodgdon:
And I'm so curious, why do, I know that embryo issues are the leading cause, but why do genetically tested normal embryos miscarry?

Nicole Yoder:
Aha, the million-dollar question. Yeah, so it's important to note when tests where we're saying, yep, this is genetically normal, the screening test, which has its own set of limitations. One of the leading thoughts is that there are probably some chromosomal abnormalities that exist that we just don't have good ways of testing for yet, so they're probably normal enough for our tests to say that they're normal, but abnormal enough to not be able to progress to a healthy pregnancy. My hope is that as technology gets better, that we have more ability to test for subchromosomal things as a screening test. A screening test is just that, it gives us our best information that we can, but it doesn't have all the information, and it certainly, there are some things that we just don't have great tests for yet.

Kristyn Hodgdon:
Yeah, it can be really frustrating. So, after how many losses should someone seek sort of additional testing or treatment? Maybe they're not currently in the care of a fertility specialist.

Nicole Yoder:
Yeah, so we're talking about how loss is, miscarriage is incredibly common, so very common that somebody will have one in their lifetime. But when you've had two or more, that's when we start, that's when we start thinking like, okay, maybe we should start this workup. So I would draw the line in the sand at two, three, absolutely. But I personally would say if you've had two losses or more, it's time to start to see if there are any causes we can identify.

Kristyn Hodgdon:
And what are some of those tests that you typically run after two or more?

Nicole Yoder:
Yeah. So, a lot of it is going to be blood work that is looking for these medical conditions that we spoke about earlier. So a lot of blood work is going to look at the thrombophilia. So do you have an underlying clotting disorder? Maybe you never had a history of a blood clot. But sometimes, we only discover these things after you've had a few miscarriages. So thrombophilia workup, we're going to do look at hormonal issues, so check your thyroid. We're going to check to make sure that there aren't any metabolic concerns, check your A1c. So we're going to do the basic blood work and make sure that there isn't any underlying health conditions that we can identify as well. We're probably also going to take a look at your uterus. The first pass, maybe by doing just a 2D ultrasound or a saline ultrasound. But a lot of times, we're going to do a history and just take a look inside and see if there's anything structurally or if there's anything about the endometrium that looks abnormal. And if you had a loss, there's always a chance of maybe there's some retained tissue, and maybe that tissue has caused some inflammation that might make it less hospitable for a future embryo. Blood tests primarily, and then also looking, doing some uterine evaluation, those are going to be the staples of the beginning of that workup.

Kristyn Hodgdon:
Okay. And for treatment options, if someone has a blood clotting disorder, would they typically do in order to prevent another loss?

Nicole Yoder:
Yeah, so it would do fine, depending on what the specific disorder is. A lot of times you're going to end up on something like heparin or maybe, in cases depending on the hematologist's recommendation, maybe lovenox. But a lot of times you're going to start you on something that's going to help reduce the risk of those clots forming, and hopefully, that'll give you a better prognosis for the pregnancy, having a better chance to continue.

Kristyn Hodgdon:
And what's the role of progesterone supplementation in preventing miscarriages? Because I know during IVF, obviously standard practice to do progesterone in oil injections before and during the transfer. But what about, for miscarriage?

Nicole Yoder:
... not going to be our first line of treatment, mostly because most of the causes of miscarriage are not going to be fixed by giving you progesterone. Now, if we think you truly do have an ovulatory dysfunction, and we've tested your progesterone in the luteal phase, and we've seen it as super low all the time, then yeah, we're going to start progesterone as a supplement to help prevent that decreased level. But usually, that's not the cause. So it's really not, it's not our go-to for this type of scenario.

Kristyn Hodgdon:
Okay. Do you think that miscarriages are more common during IVF?

Nicole Yoder:
I wouldn't say, yes, because there's a little bit of a selection bias. So you're already looking at a group of people who have had, who may have had miscarriages prior to coming into your office, or who may be poor prognosis to begin with, and mean that in a way, if there's some underlying issue. Not that they can't ultimately have a good prognosis, but you're already working with a group of people who have selected themselves out as not having the most straightforward reproductive journey. So we're going to see it more than probably the general population in our office, but it doesn't mean you can't ultimately have success.

Kristyn Hodgdon:
Yeah, because I do think being a part of the fertility community, you tend to see it more, but also you find out that.

Nicole Yoder:
You're thinking about it more.

Kristyn Hodgdon:
We're talking about it more, and you're also finding out you're pregnant way sooner.

Nicole Yoder:
Absolutely. So a lot of times people will have what we call like a biochemical pregnancy, and it just seems, oh my period was five days late and was heavy. It might have actually been a loss, but when we're tracking things very closely, very meticulously on that day, like the first time we can detect your HCG, were probably testing it. So you do get a lot more information because we're looking for more, so that is another way that we're seeing more of it.

Kristyn Hodgdon:
When do you typically let out that sigh of relief? The chance of miscarriage has gone down a lot? Is it upon hearing the heartbeat?

Nicole Yoder:
Yeah, really, the heartbeat is sort of like your chances of miscarriage definitely go down after we get to that heartbeat. Not that it can still happen, but that really is signaling that this pregnancy is really taken and the chances of miscarriage are going to go down significantly after that point.

Kristyn Hodgdon:
Yeah, absolutely. And I wanted to talk about the hopeful note of the chances of actually experiencing recurrent pregnancy loss, because if you've experienced one miscarriage, devastating, obviously, but it's pretty rare to experience recurrent loss, is that correct?

Nicole Yoder:
Demands for recurrent pregnancy loss, most studies are looking at about 5%, but depending on how you define it, it's anywhere from 5% to 15%. But generally, it's a pretty low population to have recurrent losses. Despite the fact that miscarriages are very common for someone to have at least one. Having multiple is not terribly common.

Kristyn Hodgdon:
Yeah, well, when you troubleshoot, how often, you don't have to get super granular, but like how often is it that you do find some sort of underlying reason for the miscarriage?

Nicole Yoder:
And to put our finger on it? But if you are 35 and above and you have a miscarriage, a lot of times we don't test that pregnancy tissue, but we can assume it's probably an abnormal embryo. So sometimes you don't have the diagnosis. None of these things that I've pointed my finger at or listed as causes, they don't call up testing abnormal, but if those are the cases, we assume that it's probably genetically abnormal.

Kristyn Hodgdon:
Okay. Yeah, it's process of elimination in some cases too, right?

Nicole Yoder:
Yeah, a lot of times it's process of elimination. But I guess to answer your question, I said earlier like 50% to 75%, we don't find this cause for. But if that's the case, a lot of times our assumption in the back of our head is like, probably the embryo wasn't normal. Yeah.

Kristyn Hodgdon:
I know you mentioned genetic testing obviously of embryos, but is there any other tests that you would recommend for just making sure that it's not an embryo issue?

Nicole Yoder:
Yeah, so we actually do have multiple miscarriages. We'll also recommend doing karyotypes on both the egg and sperm source. So this is really looking at things like translocation. So sometimes people walk around with some of their genetic material, a little flip flop on their gene, which they in themselves have the correct amount of genetic DNA, they are normal, they are healthy, it's just that when they go to make eggs or sperm, the egg and sperm doesn't get a balanced amount of the genetic material, and this can manifest as recurrent miscarriages. So sometimes people will say, oh yeah, my mom actually had multiple miscarriages too. That always piques my ears to say, oh, let's test you for your ..., but that's another form of genetic testing that we can do just to make sure that there isn't any translocation that we're missing. Just because people seem healthy, you wouldn't suspect that you have that, but that can be something that can only be unearthed once you go to try to have kids, and you keep having these failed pregnancies.

Kristyn Hodgdon:
No, that's such great advice. Something else I wanted to discuss that just popped into my mind because I felt like after my miscarriage, this wasn't fully explained to me in a way that made me feel empowered to make my own decision, but just miscarriage care in general. You're having a miscarriage, and what are your options? Whether it's medication, just waiting, the waiting game, seeing if it passes on its own, or the DNC route. Do you have any thoughts on that? What do you typically advise your patients to do?

Nicole Yoder:
Well, there are pros and cons to either approach. If it's very early on, oftentimes we will take a wait-and-see approach, because a lot of times that will pass on its own spontaneously, and you don't need any intervention and you're not having to take a medication, you're not having to have a surgery. So super early on, sometimes we'll say, hey, let's just wait and see, and if it completes on its own, then that's great. Pros and cons of doing medication versus doing a surgery. So with surgery, which is a lot of times, I should call it a procedure, doing something like a DNC, or dilation and curettage, basically what we're doing is we're going to remove the tissue from your uterus. The benefit of that is that we can test the embryo, so we can test the tissue that comes out, and that can give us some information about was this chromosomally normal or was this chromosomally not normal? So when we're trying to do our workup, that can give us a little bit of a sense of where the issue might be, so that's one of the main benefits. Other benefits is that you're not playing the waiting game of, oh my gosh, am I going to bleed through my pants at Target, or am I going to be waiting for five days for this to pass? It's a scheduled thing. So a little less in terms of that can be emotionally really hard to just wait for pregnancy.

Kristyn Hodgdon:
So that's what I wish that was explained to me. Like the emotional, because I was given misoprostol or cytotec, and I bled a ton, and I had a history of postpartum hemorrhage, and it was very triggering, and it was, and then just the fact that it was my ... and it was a genetically normal embryo and just all of the like mental health reasons why I shouldn't have gotten that.

Nicole Yoder:
Yeah, no, and that can be, it can be like, it can be a lot of blood. It can be, and people have miscarriages at home, at work all the time, but it's a lot of luck sometimes. And if you're not really up for emotionally, that's maybe another reason why, maybe just go to do a procedure, have it done for you. But on the other hand, a procedure has its own risks. The primary thing that we get concerned about is creating scar tissue. So generally, for somebody who is cognizant of the fact that you want to use your uterus in the future, we're going to do it as gently as possible. We always want to be as efficient as possible, so it's a balance of being thorough enough but not doing any harm, but there's always a risk that you can have some scar tissue that form. And having a procedure done is more and less accessible for some people. They can't get into somewhere where they can have it done easily, and for some people, they have easy access to it.

Kristyn Hodgdon:
But I think that's the part that people don't talk about a lot. It's, they'll maybe announce that they lost their pregnancy or something, but then that after part where you're sitting in your bathroom and you're grieving and like experiencing the loss it, so unnerving. And no one prepares you and.

Nicole Yoder:
Yeah, and that is definitely a factor that should go into the decision of which route is more appropriate.

Kristyn Hodgdon:
Yeah. And that's why it's so important to have this discussion because in my case, I felt like hindsight is 2020. But in, but you just want to go in like feeling your options.

Nicole Yoder:
Yeah, exactly. And for some people they, maybe they're not a good candidate for going under anesthesia, or maybe they want to avoid having a procedure. But if we give a medication to hopefully help the process along, the timeline is a little unpredictable, you might respond right away, you might start bleeding right away, and it might be completed very quickly, or it might take a few days, you might have to give you a second dose, and still, after all of that, it might fail. You may end up having the procedure anyway. There's definitely pros and cons, but the emotional component of which option makes most sense should definitely be discussed and factored in as well, because that is, it's hard, especially if this is not your first rodeo with the miscarriage. It can trigger some certain feelings. It can, some people are more or less.

Kristyn Hodgdon:
And the million-dollar question of how long do you need to wait after a miscarriage to start trying again?

Nicole Yoder:
So we really want to make sure that hormone, the pregnancy hormone, has gone back down to zero. So typically, we're going to be tracking your blood work after that miscarriage complete to make sure that the hormones go back down and get that reset point. Now, usually medically speaking, at this point you can jump back into trying unless maybe there's some complication that you need more healing from. Usually, if you're doing something like embryo transfers, it's a little different if you're trying in your own versus embryo transfers. But if you're doing embryo transfers, we're going to want to take a look and make sure that uterus looks good after your miscarriage, because there was tissue in there that grew and left, and sometimes that can leave scar tissue or tissue can be left there. So a lot of times, we're going to want to just at least take a peek at the uterus by doing probably a saline ultrasound, and just make sure that everything looks okay on the inside before you start trying again.

Kristyn Hodgdon:
Yeah, the going into the office for the HCG draws after your miscarrying or you did miscarry is torture, but it does help to be like really closely monitored and to make sure that you don't have that scar tissue and get that like seal of approval before you try again, gives you somewhat of a peace of mind for sure. Awesome, I think this will help a lot of people just be able to again, go to their physician and ask the right questions, and you don't have to have five miscarriages before you get a workup done.

Nicole Yoder:
You do not.

Kristyn Hodgdon:
For sure.

Nicole Yoder:
You can definitely start that workup earlier.

Kristyn Hodgdon:
For sure. Thank you, Dr. Yoder. This was great.

Nicole Yoder:
Of course. My pleasure.

Kristyn Hodgdon:
Until next time, talk to you soon.

Kristyn Hodgdon:
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