Dear Inferility_S3_E4_Miscarriage Care: Audio automatically transcribed by Sonix

Dear Inferility_S3_E4_Miscarriage Care: 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 advocate, and co-founder of Rescripted.

Staci Tanouye:
And I'm Dr. Staci Tanouye, a board-certified OB-GYN striving to make reproductive and sexual health fun and empowering for all.

Kristyn Hodgdon:
Welcome to Dear Infertility. This season, we're going back to the basics. From menstrual cycle red flags to what you need to know before you start trying, we're giving you the tools you need to take control of your overall health and fertility.

Staci Tanouye:
Does birth control cause infertility? Do painful periods mean that I have endometriosis? We're here to answer all of your real-life questions and provide you with patient centric advice and support so that you can be your own best health advocate.

Kristyn Hodgdon:
Now let's dive in and talk about everything sex ed failed to fill you in on.

Kristyn Hodgdon:
Hi everyone, and welcome back to Deer Infertility. I'm your host, Kristyn, and I'm here with Dr. Stacy Tanouye. Hi, Dr. Tanouye!

Staci Tanouye:
Hi, Kristyn. How are you?

Kristyn Hodgdon:
I'm doing pretty well. Really excited to talk about today's topic, which is all about miscarriage care. Such a common occurrence, but when it happens, I always say one in four pregnancies end in miscarriage. But when it happens to you, you feel more like one in 4 million because, you know, it's just so stigmatized, and not a lot of people talk about it. And, you know, you're not supposed to announce your pregnancy until 12 weeks. And there's just so much taboo around the subject. So excited to dig in today.

Staci Tanouye:
Yes. I'm like aggressively nodding my head at this point. Yes, all of that.

Kristyn Hodgdon:
Yeah. So I think we always float around that whole one in four known pregnancies end in miscarriage, but 25% seems like a lot. So what are the actual statistics there?

Staci Tanouye:
I mean, it's a pretty accurate statistic. And you'll see ranges of those statistics in multiple different sources. And sometimes it's based on what they're actually looking at, clinically detected pregnancies versus all pregnancies. And if we're thinking about like all pregnancies, no matter if they were really, you know, seen on ultrasound or clinically detected by testing, that, all pregnancies is going to be the higher-end of the range, that's going to really be somewhere between like 25 and 30%. There are some estimates out there that might even be a little bit higher than that. And on the low end of things is things that are clearly clinically detected by ultrasound, people will get in the range of 10 to 20% or so. So really, I mean, there's a wide range of estimates out there. 25 is right on the dot with what we talk about all the time, and yes, it's a very accurate number. It's lower as we're younger, as we get older, that number increases naturally. And it's just because humans are terribly inefficient at reproducing. You hear all the time from all those sources, oh, it's so natural, like your body's built to do this. Well, kind of, but kind of no. Like it takes a lot of going on at the cellular level to, for all of this to work out perfectly. And that's why that number is so high, because we are terribly inefficient and bad at reproduction.

Kristyn Hodgdon:
Yeah. And I think any of us who have been through IVF know that all too well. It's like, I like to call it like the IVF funnel, but basically like from egg retrieval to fertilization to blastocyst to genetic testing, like that dropoff is so real. And like when you're trying to conceive the old-fashioned way like that, that's just happening.

Staci Tanouye:
Right.

Kristyn Hodgdon:
In your body. And that only gives you like, what is it, 20, 25% chance each month of getting pregnant.

Staci Tanouye:
Correct. Exactly.

Kristyn Hodgdon:
So humans are inefficient at reproduction, we know that. Why do you think the topic of pregnancy loss is still so taboo?

Staci Tanouye:
I mean, there's, there's obviously several different reasons for that. I mean, the biggest one that we kind of touched on already is that no one talks about it, no one talks about loss. And I think there's a lot of shame and embarrassment just built into that topic. And that's kind of rooted in this like old school mentality that like a woman's worth is, is based on her ability to reproduce, you know, her fertility and her ability to, to bear children and to pass on her genes and all of that sort of stuff. And yes, we know that that's not really the right mentality, but it's so ingrained everywhere we go. And so there's a lot of shame and embarrassment around this topic. And the second big reason is because pregnancy loss is so deeply personal. It's so deeply personal, everyone experiences it differently, everyone's feelings are slightly different around the topic, and it's really painful for individuals, and it's painful as a society and people don't deal with that personal, physical and emotional pain very well, as, in a group setting. And so outside individuals don't know how to deal with other people's emotional pain. And so as people who are experiencing loss, we're bad at expressing our emotional pain. And then the outside people who are supposed to be our support people are bad at receiving or being receptive to other people's emotional pain. And so, but when you put those two things together, it's just, it's a terrible combination. And every, we all know that people never know what to say in those sorts of situations and hard situations. Everyone says the exact wrong thing. And so that makes you just close up even more because everyone feels like they have to say something reassuring when someone's going through a tough time, regardless of what it is. And so other people feel the need to reassure or feel the need to say, oh, but it'll be fine, oh, but this, but you have this. Oh, but, it's a lot of oh buts, to try to reassure the person, but that's the exact opposite of what we need in that moment, and so.

Kristyn Hodgdon:
At least you are able to get pregnant at.

Staci Tanouye:
Right.

Kristyn Hodgdon:
It was early. At least you have another child.

Staci Tanouye:
Correct.

Kristyn Hodgdon:
And it's like, yeah, it's kind of like with any sort of grief, it's like people just say things to say something sometimes. And infertility and law specifically have made me so much more empathetic and like aware of what not to say. Like, don't just say things to say things, even if it's just being there or just saying, oh, that must be really hard.

Staci Tanouye:
Yeah.

Kristyn Hodgdon:
It's better than, like, kind of minimizing someone's pain.

Staci Tanouye:
Right. Yeah. So if you're a support person out there listening, like the great things that you can say to someone who's close to you that's going through this is basically just, I'm so sorry, that must be really hard for you, I am here, what do you need? What would you like to talk about? I am here for whenever you are ready to talk about anything. If you never want to talk about anything, we never have to talk about it. So just basically just opening it up to that person to invite people into what they want to talk about, invite them into when it's when it feels right for them to talk about it. But also, you don't need to offer reassurance because there is no appropriate reassurance that's going to make anyone feel better. So that's the natural urge, but resist the urge to offer that, just offer yourself say, I am here, I'm happy to listen, I'm here for whatever you need.

Kristyn Hodgdon:
Absolutely. And I think waiting until you're in the safe period after the first trimester is, is fine if that's what you want to do. But then if something happened, like, in my opinion, if something happens, then you don't really have the same support because no one even knew you were pregnant.

Staci Tanouye:
Right.

Kristyn Hodgdon:
And then, of course, you can tell them what happened, but, but then you're telling them anyway. Like, so in my experience, I'm like, okay, let me, if I do get pregnant, let me celebrate this win and maybe tell the people close to me, that way they can support me if something does happen, which has happened numerous times at this point. So everyone's different, and everyone, some people don't want to tell a single soul until 12 or 13 weeks and that's totally fine too. Everyone.

Staci Tanouye:
Right.

Kristyn Hodgdon:
Goes through pregnancy in a different way.

Staci Tanouye:
Yeah. And that's a really common question too, is when people say when should I reveal that I'm pregnant? And there's like, I can never answer that question. Like, that's not a question for me to answer for someone. That really is something that each person has to think about and just think about, like you said, the positives and negatives of every single stage, the positive of telling your close relatives or anyone early on is that, well, if something does happen, you have lots, you could have lots of support there for you. The downside is, is that maybe if those people haven't experienced loss or don't know how to approach that, maybe that supports not the support that you actually need at that time. And so there's positives and negatives to telling people early, there's positives and negatives to waiting. You know, if, if you wait and no one knows and something happens, then you might be very isolated or feel very lonely at that time. Hopefully, you may have a partner that would be supportive about it, but it could be isolating in such a way, or it could be hard to say, well, I'm pregnant, but this is where I'm at right now. And then getting into that too. But at the same time, like maybe it is a really private thing that you want to keep for yourself too. So it's such a personal decision. There is no right or wrong answer. You really just have to weigh what feels right for you and for those around you.

Kristyn Hodgdon:
Absolutely. So getting into the science, what are some common causes of miscarriage and why do they more often happen in the first trimester?

Staci Tanouye:
Yeah, so the vast majority happened in the first trimester, 80%, maybe even more, happen in the first trimester. And again, the majority of these, somewhere between 50 and 60% happen because of completely spontaneous, completely random chromosomal abnormalities. So various DNA or genetic abnormalities that are not inherited, these are things that happen during kind of the replication process of the embryo and the cells kind of multiplying and dividing. So something random happens and then the pregnancy can't continue because it's not something that is supposed to continue or able to be viable because of the error that happened in replication. And again, I always emphasize to people that this is random and spontaneous. This is because whenever people hear genetic abnormality, they think inherited, like it's there, it's always going to happen, and that's not the case. Most of them are random and spontaneous, and non-repeatable sorts of events. But that's why I tell people, you know, humans are really inefficient at reproduction for that exact reason. The vast majority of miscarriages in the first trimester happen for completely random, spontaneous genetic abnormalities.

Kristyn Hodgdon:
Absolutely. Yeah. And it's not your fault?

Staci Tanouye:
No.

Kristyn Hodgdon:
There's nothing you could have done to prevent something like that.

Staci Tanouye:
Nothing. Zero.

Kristyn Hodgdon:
Yeah. And so what are some of the outlying reasons that could cause a miscarriage? Like blood clotting disorders and stuff like that?

Staci Tanouye:
Yeah, we think of things like blood clotting disorders. The primary one that we think of is something called Antiphospholipid antibody syndrome. And there's blood tests that people do and specific criteria that we look at to diagnose people with those sorts of syndromes. Other things like structural abnormalities, you know, if there's different structural changes in the uterus that could lead to miscarriage, there are smaller percentage that are inherited genetic abnormalities. So there are genetic abnormalities that can be passed down that can cause miscarriage. That's a much smaller percentage, it's probably in the range of kind of 3 to 5% or so, but that is a possibility. And then there's other things, you know, we talked in the past about optimizing our health. Well, if our health isn't optimized or we have an underlying serious medical condition that's out of control, that can contribute too, and so those are the main kind of outside factors.

Kristyn Hodgdon:
Okay. And then why do they typically happen in the second trimester?

Staci Tanouye:
So in the second trimester is kind of a different category. We think of first trimester as kind of these random, spontaneous things that are mismatched and don't match up right as the main cause. When we think of the second trimester, it's kind of all of those other causes that are more contributory to second trimester losses. So we think again about things like structural abnormalities within the uterus, structural abnormalities of the cervix. If people have had past procedures or past surgeries on the cervix that affect the cervix's ability to remain closed and hold a pregnancy that can lead to, to miscarriage. Again, things like clotting disorders, antiphospholipid antibody syndrome, underlying out of control medical conditions to a smaller percentage, things like fetal abnormalities and inherited genetic abnormalities. And then also outside forces such as severe trauma or if someone has any sort of illicit drug use, can also contribute to that sort of thing.

Kristyn Hodgdon:
So sometimes these issues just take a little bit longer to kind of show up and, and sometimes it can happen in the second trimester. So when do you typically recommend further testing? Because I know it's a pain point for some people that the doctors say, you know, you have to have two or more miscarriages before you can get further testing. So how would you find out about a blood clotting disorder or a structural uterine abnormality?

Staci Tanouye:
Right. And, you know, in the past, you know, the two or more is also a newer recommendation. In the past, when I trained just, you know, 15, 10 to 15 years ago, it was three or more. So the definition for recurrent pregnancy loss was three consecutive losses. And that's a long time and a lot to go through to wait to take the next step for testing. Or it's been more recent that people within the medical community have kind of tried to really change that for the better. And so now it's two or more consecutive losses is considered the diagnosis of recurrent pregnancy loss. And generally that's when we would recommend start looking for outside modifiable factors like a clotting disorder, uterine structural abnormalities and those sorts of things that are contributing. And that is simply because, again, because such a large percentage of these first trimester early losses are due to random events, that means that most people will not have a second consecutive loss. So 95% of people who have one loss will go on to have a normal pregnancy their next time, 5%, around 5% will have a second loss consecutively, and that's when we prompt workup. So it's just the balance. And, you know, obviously we try to tailor to each person too, it's the balance of what's right at that time, we don't want to do too much if things are going to work themselves out on their own. But we also don't want to do too little because if someone's in the place where they really need to know.

Kristyn Hodgdon:
Yeah.

Staci Tanouye:
That we have to, we have to tailor it to them too. So yes, the technical definition, two or more, we really start evaluation, but we do want to actually approach the individual in front of us and do what's best for them.

Kristyn Hodgdon:
What if someone is over the age of 35 or even over the age of 40? Would that prompt you to test sooner?

Staci Tanouye:
Me personally, no, because as we get older, those random, spontaneous events increase.

Kristyn Hodgdon:
Right.

Staci Tanouye:
So, so it's actually more likely that it is, the random and spontaneous event, genetic event that's happening, because as we get older, we get worse and worse at that DNA replication process because it's just the egg quality. As our eggs get older, it's just the natural process. And so the incidence that it is random in spontaneous increases now because that also increases and miscarriage rates increase as we get older, you are also then more likely to have more than one in a row because you're just more prone to miscarriage in general. But once we get 35 and older, oftentimes I have a very low trigger for referral outside to the specialist. So if we're, if we're 35 and older, I'm usually talking to people about going to the to the specialist because they can just be a little more efficient at evaluation, workup, treatment and solution, whereas I can do evaluation and some initial kind of treatment suggestions. But if someone's really at the point where they're like, I really want to move forward with all of this, I send people out quicker than most.

Kristyn Hodgdon:
Okay, that's good to know. So what are some warning signs to look out for when it comes to miscarriage?

Staci Tanouye:
Yeah. So in early, any early pregnancy, even normal pregnancy, mild menstrual like cramping is very common. If that mild menstrual cramping is getting more severe, we might want to look into that further. Little bits of spotting after something like sex or intercourse can be common because the cervix itself can be very sensitive on the outside, that has nothing to do with the internal pregnancy. And so a little bit of spotting after something like sex usually doesn't bother me too much. But if that spotting is persistent and not resolving, if that light bleeding is now getting heavier, more moderate and not going away, we need to know about that. Those are probably the two most common things that we look for is increasing pain or persistent or increasing bleeding.

Kristyn Hodgdon:
Got it. And how do you know if you have an ectopic pregnancy?

Staci Tanouye:
So ectopic pregnancy, again, it's hard because some of those symptoms can overlap quite a bit between just miscarriage and ectopic pregnancy. But ectopic pregnancy is typically accompanied by more significant pain. So if you're getting a lot of really increasing, more severe, lower pelvic abdominal pain, then we are more concerned for ectopic pregnancy. Ectopic pregnancy can also have persistent bleeding or spotting as well, but the pain portion would really be the thing that's cluing us into possible ectopic pregnancy.

Kristyn Hodgdon:
Okay. And is there anything that causes an ectopic pregnancy and why can it be life threatening? I think we've heard a lot about this recently with the whole overturning Roe v Wade and how common they actually are, I think it's 1 in 50 pregnancies.

Staci Tanouye:
Yeah, it's right around, right around that. And ectopic pregnancy is where the fertilized egg, the pregnancy implants somewhere outside of the uterus or somewhere where it cannot grow appropriately. So this can most commonly happen if it implants too early within the fallopian tube. It can also implant in things like the cervix or the ovary or even outside of the uterus and pelvic structures, or even further, which is more rare if it implants outside of the pelvis, but those reports have happened. Ectopic pregnancy is dangerous because a pregnancy can't grow outside of the uterus and be safe because that, any place outside of the uterus is not meant to carry a growing pregnancy that needs lots of, the placenta needs to implant somewhere and draw lots of blood supply, and that can't happen anywhere but the uterus in a safe manner. And so if that does start happening outside, as that pregnancy grows bigger and bigger and bigger and starts drawing more and more blood supply from, from its surrounding structures, it becomes more and more dangerous. And so that's where we think about like a ruptured ectopic pregnancy that pregnancy cannot sustain within those tissues. And those tissues tear and cause significant bleeding and significant pain. And ectopic pregnancies are dangerous because of the bleeding, because that pregnancy is drawing so much blood supply from the surrounding tissues and structures that if it tears or ruptures, then all that, then that causes bleeding and. And that's what's so dangerous about it.

Kristyn Hodgdon:
Got it. Yeah. It's really scary and hoping and praying that everyone can get the treatment that they need around the country.

Staci Tanouye:
Right.

Kristyn Hodgdon:
So we have an ectopic pregnancy, we have a clinical miscarriage, there are also chemical pregnancy, missed miscarriage, blighted ovum, there's all these different terms. Can you explain kind of the difference between a chemical pregnancy and a clinical miscarriage?

Staci Tanouye:
Yeah. So a chemical pregnancy or some people may call it a biochemical pregnancy is usually just a really early pregnancy, generally five weeks or earlier that then miscarries and doesn't continue beyond that point. This may be detected by a simple home pregnancy test, where you pee on the stick, you get a positive test, but then before you have the ability to get an ultrasound or before the pregnancy is big enough to even show up on ultrasound, you have period like bleeding and have a period and then your test becomes negative. And that's typically what we refer to as a chemical or biochemical pregnancy, a really early pregnancy that hasn't gone far enough to be detectable by ultrasound yet. These are probably the super common because sometimes they could even happen without us even knowing that that pregnancy test had turned positive and we just get what we think is a really heavy period. This doesn't necessarily mean that every heavy period you've ever had is a biochemical pregnancy, but that is a remote possibility that that had happened. And so, yes, so that's a chemical versus, or biochemical pregnancy. A clinical miscarriage is something that does get beyond that five weeks that can be detected by ultrasound. So now ultrasound at its most sensitive can probably see a gestational sac or see a pregnancy in the uterus as early as about five and a half to six weeks, just depending on the technology that we're working with. And once that point happens and we can actually see a pregnancy within the uterus, we would call that a clinical, if that pregnancy doesn't continue, we would call it a clinical miscarriage.

Kristyn Hodgdon:
Yeah. And I've had both a chemical pregnancy and a clinical miscarriage. And I have to say that when I had the chemical, I felt like, I don't know for some reason, like I've heard this a lot in our community, like you're not allowed to mourn because like it wasn't even a real miscarriage, it was just like I was pregnant for a couple of days and then I wasn't. But it really hurts just the same. And, you know, the minute you see that positive pregnancy test, you're so excited and you start planning and in your mind, and especially after IVF, it's like so hopeful. And so when that and, in an early loss, it's, it's really devastating. So all that is to say, if you're grieving any sort of loss, your pain is valid and your feelings are are normal.

Staci Tanouye:
Yeah, people ask that question all the time, like as a chemical or biochemical pregnancy, is that a real pregnancy? I'm like, well, it came from a fertilized egg that was then producing HCG, the pregnancy hormone, that's a pregnancy like, yes! Yes, you were pregnant, that pregnancy test wouldn't a turn positive if that wasn't a real, right, quote-unquote, real pregnancy. So, yes, you can mourn or not mourn, however feels right for you. But yeah, like you can't create HCG in that sense without being pregnant. So yes, it's a pregnancy.

Kristyn Hodgdon:
Exactly. Some of these terms when it comes to women's health are so, kind of even the term miscarriage, like kind of I prefer the term pregnancy loss because miscarriage, like almost makes it sound like you did something wrong or as if it was your fault. And I know that's just like the medical term and it is what it is, but, but, you know, it doesn't sound verym, it doesn't really validate the emotions that come with it.

Staci Tanouye:
Yeah, and I think everyone, you know, feels differently about each of the terms that are kind of thrown out there. Clinically and medically terms that are interchangeable are miscarriage is the same thing as pregnancy loss is the same thing as spontaneous abortion or any sort of variation of missed abortion, etc. All those things are kind of interchangeable and it kind of is a personal thing of what feels right to express what you are experiencing and what you are feeling. And if for some people, pregnancy loss is a better term to describe what they are going through, by all means that we should, we should be using that term. For other people, if they feel that miscarriage feels more appropriate to use, then that's fine too. It's all valid, it's all appropriate, and yeah, there are multiple terms that can be interchangeable, and this may be a preference of which one each person uses.

Kristyn Hodgdon:
Absolutely. So I wanted to talk a little bit about treatment options. We received a lot of questions from our community about the different options when it comes to miscarriage care. I think it kind of hits you in the face when you go through a miscarriage, like you don't realize that you have to make these choices. So can you go a little bit into the difference between like a D&C and I guess the quote unquote abortion pill and some of the different treatment options?

Staci Tanouye:
Yes. And so when, as a clinician, when I diagnosed someone with a miscarriage, whatever type of miscarriage that may be or pregnancy loss, whatever type that may be, I usually prompted by telling them, okay, this is a lot of information. We're going to talk about your options. You may or may not hear what I am telling you. So if you need to call me back or come back later for us to discuss that, let's do that. I'm going to lay it all out for you. And if you can listen, not listen as whatever's appropriate for you. So I usually lay that out there first because it is a lot of information. And when you're already processing a lot of what's happening and feelings and emotions, it is really hard to think rationally about these options. So bookmark this and come back to it when it feels appropriate to you. But in general, there are three categories of options for treatment of a pregnancy loss. There is something called expectant management, there is medical management, and there is surgical management. Expectant management is basically watch and wait, okay? Watch, wait and see and see if that's miscarriage or pregnancy loss basically happens on its own. And again, I should clarify to you that this would be a diagnosis of what we call a missed miscarriage or a missed abortion, which is a pregnancy loss where someone doesn't have any symptoms of loss, and then we diagnose on ultrasound that this is not a viable pregnancy. So we may not have been experiencing any symptoms, but we now we have this diagnosis and these are our treatment options. Some of these treatment options overlap with the various types of pregnancy loss and miscarriages, but that's going to be individual to each person. So back to expectant management, watch and wait. Every, miscarriage will eventually happen spontaneously on its own. Your body will eventually naturally take care of it, so the positive to expectant management is our bodies usually will eventually do the right thing. They do know what to do, eventually, and we can not do a whole lot of intervention at all and let things happen, quote unquote, naturally. So hands off, watch and wait. And that's the positive is, we don't have to do any sort of medical intervention.

Kristyn Hodgdon:
How long did that typically take?

Staci Tanouye:
It completely varies from person to person. It can take anywhere from days to weeks to up to 4 to 6 weeks or more. And obviously, the longer you're getting out, the less likely it is to happen in a timely manner, so we also talk about that, too. And that's the downside to expectant management, right? Is watching and waiting, but I don't know how long I'm going to be doing that for. I don't know when this is going to start. I don't know where I'm going to be if I do start having those symptoms of pain and bleeding. So that's the downside, it's unpredictable and you don't know how long you might have to wait for that to happen. And then the other downside is if we get to a point where it has been multiple weeks and it hasn't happened, then we're kind of right back at ground zero and re-discussing moving forward with other options. So positive to watching and waiting is we can be hands off and let things kind of take their course. Negatives are we don't know when that's going to happen we don't know where you're going to be when that happens. And it could be waiting for quite a while. And if we're waiting too long, we might be right back in the same situation we are right now.

Kristyn Hodgdon:
Yeah.

Staci Tanouye:
So that's watching and waiting, we're expectant management. The second option is medical medications. So taking medications to expedite. In the past, this used to be just a medication called misoprostol. Misoprostol is a medication that causes cervical dilation and uterine cramping. And so it expedites that that loss and that miscarriage into happening. It can be taken orally it can be placed inside your inner cheek to dissolve, or these tablets can be placed vaginally as well. Every single, however you get these pills inside your body, it will work to a certain extent. Now, in the more recent just even in the past couple of years, we have more research to support that you can potentially add a medication prior to the misoprostol as what people think of as the abortion pill, mifepristone. So mifepristone is a different type of medication that is sometimes used in induced abortions. But we have now learned that we might even be able to be use it as a helpful option for people with miscarriages, pregnancy loss, spontaneous pregnancy loss. And so either misoprostol by itself or mifepristone followed by misoprostol, can be used as medication options. And these are medications that, again, try to expedite the process. So the benefit of this is, again, we're kind of minimally invasive at this point, we're just taking medications or pills to try to expedite the process. The other positive is that we can kind of time it to what might be appropriate for us. So if we want to wait to this day, because over the weekend I have downtime and we can try to plan this time-wise, that is also beneficial, is you can try to time it to what is helpful for you.

Kristyn Hodgdon:
And how long does that typically take to kind of expel everything?

Staci Tanouye:
Most commonly within 12 to 24 hours, it should complete by 48 hours, and if we haven't completed by 48 hours, then again we kind of try have to reevaluate and think about moving on to other options. So you've got this 48 hour window that you want to plan for, so timing and planning can be really beneficial for some people. The downside is that, well, you still have to experience the miscarriage and miscarriages are painful. Misoprostol as a medication is painful, that uterine cramping that it causes. Usually I'm also giving people some pain medication to take in addition, because we already have enough pain, we don't need the physical pain on top of it. But yes, you do have to experience it because you're awake during the process. So the bleeding and the cramping that goes along with it, some people are okay with that and some people want nothing to do with that physical experience. So that's the downside to it. And then also medication is not 100% effective. It's somewhere around 85-ish percent effective. So 85% of the time you take these medications and the miscarriage will complete itself with the medications on their own. And about 15% of the time it won't. And again, we'll be back to square one, talking about our other options.

Kristyn Hodgdon:
Wow.

Staci Tanouye:
And then the last option is surgical management. Surgical management, there again, positives and negatives to each option. The positives of surgical management, are again, we can time it because we schedule that so it can be on your schedule. You don't have to physically experience the miscarriage because we sedate you or give you medication so you don't remember and don't feel the pain of that, and you wake up and things are complete. And the other positive is that we know we've completed the miscarriage, it's a definitive end point to, to that. The negatives are it's the most invasive and it is a surgical procedure, so there are some downsides to that surgical procedure. There's a couple of different ways that people can do this, a traditional D&C, or dilation and curettage. This can be done, and some people have office capacity with anesthesia available in the office to do this. Oftentimes we're bringing people to the hospital to do this, so the risks that are involved with anesthesia and surgery. The other downside is cost sometimes for certain people, I hate to say it, but it could be cost prohibitive because surgery is expensive. We wish it wasn't that way. But that that is a reality that we think about, too.

Kristyn Hodgdon:
Absolutely. And what's the recovery on that like?

Staci Tanouye:
Yeah, the, the physical recovery is actually pretty quick. You really only need about 24 hours of just rest, at home recovery, don't plan to do anything after that. You want to recover from your anesthesia, you want to recover from the surgical portion, and then I do talk about some limitations for about two weeks after that, not placing anything in the vagina, no sex for two weeks after that, just to try to decrease risk of infection afterwards. But after that kind of 24 to 48 hour mark, physically, people generally feels fine to continue doing their daily activities, emotionally is a completely different story and that is different for everyone. And so there are kind of two different recoveries to think about with any way, we have a loss or miscarriage.

Kristyn Hodgdon:
Absolutely. It's not just the physical. It's.

Staci Tanouye:
Right.

Kristyn Hodgdon:
For sure. So something a lot of people asked about, how soon should someone wait to try again after they miscarried?

Staci Tanouye:
Right. So the only limitation I usually tell people is for that first like initial 1 to 2 weeks. We want to, we want to minimize infection risk because your cervix has to dilate for that loss to pass through and happen. And we don't want any risk of any ascending infection going up through the cervix. So that's the thought behind telling people to not have sex for 1 to 2 weeks after a loss. Beyond that, you don't have to wait to try again. In the past, people used to say different things, wait 1 to 2 cycles, so your body gets back to normal and starts cycling again. We know now that that's not exactly accurate, that you don't have to do that, that you can get pregnant with a new pregnancy prior to your period returning, and that pregnancy can go on and be a perfectly normal and healthy pregnancy. So it's completely fine to try to conceive again as soon as you would like to do that. Now, again, that's physically, emotionally may be a different story. So not only do our body has to be physically ready, which can happen quite quickly, but the emotionally ready is different and can be longer for some people. Some people may not be emotionally ready to try again.

Kristyn Hodgdon:
Yeah, it's definitely important to take your emotional health into consideration as well.

Staci Tanouye:
Right.

Kristyn Hodgdon:
So I love to ask this question every episode. What would you rescript about how people understand miscarriage or as I like to call it, pregnancy loss?

Staci Tanouye:
You know, I think the biggest thing is what we talked about right in the beginning, just realizing how common it is, how frequently it happens, and opening up that discussion so we can be more open about talking about it. So it's not this kind of closeted discussion that feels bad or feels like shameful in that way. I tell people quite frequently that because it's a very lonely place to be in, I usually tell my patients like, you might not be ready right now, but at some point when you feel ready to talk to other people about it, I think you'll be very surprised with how many people will say, I've been there too, or I've, I've experienced that too, because if you think about it, if it's one in four pregnancies is a miscarriage, most people with the capacity of a pregnancy will have more than one pregnancy in their life. So the number of people out there who have had miscarriages is higher than one in four because each person has multiple pregnancies. So, so many people have been through this common experience. And we don't have to feel so isolated with it that if we are at the place where we feel comfortable talking about it, we will find a lot more support out there than we thought was possible.

Kristyn Hodgdon:
Absolutely. I love ending on that supportive note. Well, thank you, Doctor Tanouye. This is a great episode and we'll chat next time.

Staci Tanouye:
Thank you so much.

Kristyn Hodgdon:
Thank you for tuning into this episode of Dear Infertility. We hope it left you feeling more educated and empowered about your reproductive and sexual health. Whatever you're currently struggling with, Rescripted is here to hold your hand every step of the way. If you like today's episode and want to stay up to date on our podcast, don't forget to click Subscribe and to join Rescripted's Free Fertility Support Community, head to Rescripted.com.

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