Miscarriage

Two days ago, I went in for my ultrasound at what was supposed to be 9 weeks, and it turned out that the embryo had stopped developing.  From the looks of it, it probably stopped developing shortly after my ultrasound around 7 weeks.

It’s certainly a sad and disappointing turn of events.  In the 5 weeks since I’d found out I was pregnant, I had started to get excited about what’s to come.  We wondered if it would be a boy or a girl.  I started thinking about the timing of my maternity leave, and how the new baby and WZW would both be September babies.  We’d told our families and a few close friends.  But I’d also noticed in the past week that my nausea had improved a bit, rather than worsening at 9 weeks as with WZW’s pregnancy.  So it did make me wonder, but then I thought about all the women who have different symptoms in different pregnancies and told myself not to worry so much.

It’s a loss, and over the years I’ve learned to treat it as such for my patients.  All of the hopes and dreams attached to this baby that was to be are now gone, and it’s very hard for many people.  So I remind myself of that, because as a doctor on the other end, it’s sometimes hard to completely understand how devastating it is.  On our end, there is an element of knowing that it’s not that bad in the scheme of things.

Last year, I read this Lenny article by Jessica Grose regarding her experience with miscarriage:

https://www.lennyletter.com/story/the-wait

It was very eye-opening for me in terms of how deep the pain and grief associated with a miscarriage can be for some women.  More so than the article itself, what spoke to me was her intro in the email that was sent with the articles in that Lenny newsletter, which had the theme of grief:

“I had a miscarriage in late fall 2014. I wrote the story that appears in today’s newsletter in real time, as I was experiencing it over a two-week period that included Thanksgiving. The loss wasn’t something that happened spontaneously; I had a sonogram that showed the fetus probably wasn’t developing properly, and I had to wait fourteen days to confirm that initial diagnosis and schedule the procedure to remove it. It was awful.

It’s taken me over two years to feel ready to publish this story. Whenever I would think about trying to run it, I would balk. So many women have miscarriages (somewhere between 10 and 20 percent of “known pregnancies” end in a loss), and so many of them are much more crushing than mine. I did end up having another healthy baby. What right did I have to keep talking about the miscarriage like it was some big fucking deal?

But the thing about grief is that it’s incomparable. There’s no universal pain arbiter who gets to decide whether your upset is worthwhile.”

For me, it helps immensely that I’ve seen so many patients go through it before.  I already know that it’s a very common occurrence.  I had to look up the statistics since I didn’t know them off the top of my head.  According to ACOG (The American College of Obstetricians and Gynecologists), 10% of clinically recognized pregnancies end in an early miscarriage (under 13 weeks).  The frequency of these early miscarriages for women aged 20–30 years is 9–17%, and this rate increases sharply from 20% at age 35 years to 40% at age 40 years and 80% at age 45 years.

Studies have shown that half of these miscarriages are due to chromosomal abnormalities.  In other words, the older a woman gets, the more likely it is for her eggs to have chromosomal abnormalities.  And therefore the higher the risks of a significant abnormality that is not compatible with life.  So in someone like myself over 35, this is the likely cause.

What I’ve also seen from experience is that the vast majority of my patients that have a miscarriage go on to have normal, healthy pregnancies.  In clinical practice, one or two early miscarriages are considered common enough that no further workup is recommended.  It’s not until a woman has had 3 miscarriages in the first trimester that it’s recommended to do things like labs for the patient and chromosomal studies of the couple to determine a possible underlying reason for the pregnancy losses.

Based on the above, I know that there is nothing that I did or didn’t do to contribute to the miscarriage.  I always try to remind patients of that, so that they hopefully don’t blame themselves.  For myself, I’m thankfully not sitting here feeling guilty or wondering, “Why me?”  Based on my age, why not me?  I didn’t even realize how high the rates of miscarriage were until I looked into the stats above.  So at 37 years old, my chances of miscarriage are somewhere between 20 and 40%.

For me, just the fact that I was finally able to conceive after trying for so long was a victory.  And that it was accomplished on the first try of Clomid.  So I’m hoping to conceive again on it, but in case that doesn’t occur, we haven’t even tried IVF.  It’s comforting to know that there is still a great chance for a future viable pregnancy.  This loss is just a hurdle on the way there.

Once a nonviable pregnancy is diagnosed, there are a few options in terms of what to do.  One is to wait.  In the majority of cases, if you wait long enough, the body will realize that it’s not a normal pregnancy, and will start to pass the tissue.  As long as it’s not months and months, it’s not harmful to wait.  The downside is that the bleeding may occur at an inopportune time, so the next option is to use a medication to induce the miscarriage.  That medication is called misoprostol, and will cause the uterus to contract so that the miscarriage can occur at a time that is more convenient for the patient.

The third option is a D&C procedure, which involves suctioning out the contents of the uterus.  This is a preferable option for women who prefer not to have the painful cramping and heavy bleeding at home.  Or occasionally it is helpful in situations where we want to send the sample for further evaluation for chromosomal abnormalities.  For pregnancies that are farther along where there is more tissue and therefore more pain associated with the miscarriage, I tend to offer the D&C more.  For the earlier pregnancy losses, the medication (or waiting) is the less risky approach over the procedure, so I encourage it more.  But ultimately it’s up to the patient depending on the situation and her preferences, as each option has its pros and cons.

I decided to go ahead with the medication that afternoon.  There are two ways the misoprostol can be used- orally or vaginally.  If you take it by mouth, it tends to work better if you dissolve the tablets between your cheeks and lower gums for 30 minutes, and then swallow the remainder.  It’s called buccal administration, and the medication absorbs through that area on the side of the mouth which helps it take better.  The other option, preferable for those who are prone to vomiting, is to place all 4 tablets in the vagina.  The medication absorbs and works through that route as well.

I went the oral (buccal) route, and started having the bleeding 4 hours after I swallowed the remainder of the tablets.  I surprisingly didn’t have all that much cramping, granted my pregnancy had ended pretty early on.  I’ve occasionally had more painful periods.  If anything, it caused my stomach to cramp and make me nauseous, which is a common side effect.  The bleeding was heavier initially, and I changed my pad frequently just to make sure it didn’t get on my clothes.  But it was like a very heavy period.  I suspect that some of my patients with problematic periods have had heavier bleeding than this.

Since the bleeding started in the early evening, it was still on the heavier side when I went to bed.  By the next morning, it was lighter.  Still like a full flow period, but not crazy heavy.  Despite not sleeping all that well overnight, I still went to work and the bleeding was not bothersome.  I was just tired, but nothing I haven’t experienced before with a young baby.  And I think it helped keep my mind off of it.  And in fact I spoke to a patient on the phone who went through a very similar experience.  She’d had a normal fetus with a heartbeat at 6 weeks, then a month later there was no longer a visible fetus.  So I talked her through the decision of what to do.

Of course, every woman’s experience is different, so some women have more pain than others.  But my experience solidified my current clinical practice that the misoprostol is often the better choice for the earlier losses.

I don’t regret telling our families and close friends, and I don’t regret blogging about my pregnancy.  We always knew that it was a possibility that this might happen.  I think that given my experience as a doctor, I wasn’t as afraid of people finding out in case I miscarried.  Yes, it’s disappointing and there have been tears, but I thankfully haven’t felt the kind of grief that Jessica Grose did.  Besides the support of my husband, it has been comforting to have an innocent toddler who doesn’t know what’s going on, and continues to provide me immense joy.  Interestingly enough, some of the most comforting words came from a text from my mother-in-law, someone I’m not particularly close to, but nonetheless whose words were very meaningful and appreciated.

I tell myself that it’s a matter of time until a better outcome occurs.  I have so much respect for women who have had miscarriage after miscarriage and keep trucking on.  I have a couple of patients that easily come to mind who have done so, having 3+ miscarriages.  They kept trying and trying, and went on to have healthy babies.

Despite the disappointment, I have to say one upside is finally being able to eat normally again.

Advertisements

Here We Go Again!

At long last, after over a year of trying:

IMG_6456

It was a little unreal to finally see the positive test result.  I’d left a specimen cup with my urine and the test stick with my husband, thinking we’d do the test together when things calmed down with our son.  But then I saw my son running around, holding the stick flashing Pregnant and couldn’t quite believe it.  I started thinking, “But I didn’t tell my husband how long to dip it, so what if he did it wrong?”  But then once my husband came into the room, it hit me, and I started crying tears of joy.  Much to my toddler’s confusion.

We’d done two cycles of IUI (insemination), then decided to go to the next step, which was an ovulation medication.  My fertility doctor decided to start with Clomid, because he said it had better rates of success for unexplained fertility compared to letrozole, the other alternative under consideration for me.  Clomid causes you to ovulate more than one egg, so the way he described it is that rather than just having one egg per month, this gives you the chances of 2-3 months.  Especially in someone like myself who’s apparently been ovulating but it’s just not taking, the chances of multiples is low.  So even if the Clomid works as intended and you get 2 or 3 eggs in a given month, it’s not like you’ll necessarily end up with twins or triplets.  When they did my ultrasound prior to ovulation, there appeared to be 2 dominant follicles developing.

Because it was around the holidays, the scheduling for doing the insemination was more tricky, so we just decided to time intercourse on our own with the help of the ovulation predictor kits I already had.  And frankly, aside from timing things, I’m not sure there was much of a point in the IUI for our particular situation.  The most beneficial use of IUI is for men with poor sperm quality, because the process concentrates the sperm with the best quality for insemination.  It was kind of a relief for us not to have to go to the office, for my husband to use the “collection room,” and that whole bit.  It’s certainly necessary in many cases, but adds to the stress of it all.

The fertility office had me confirm with hCG levels, so at least very early on, the levels were going up appropriately.  They also like to check progesterone levels.  It’s not something I order routinely for my patients, but the levels can also suggest whether it’s a normal pregnancy or not.

At 7 weeks, I had an ultrasound which confirmed a viable pregnancy.  Just one baby.  Phew!  So far so good, even though I know it’s still early.

With WZW’s pregnancy, I started feeling nauseous right at 7 weeks, and it peaked from 9 to 12 weeks.  This time, at 5+ weeks I started to feel it.  That gross feeling in my stomach, where I’m not sure if I’m hungry or what.  I have to remind myself not to eat too much at one time, because then I’ll feel worse.  And if I get overly hungry, then I feel desperate for food, so that’s not a good feeling either.  Like they say, eat small amounts frequently.  Not always the most practical, though, as you get busy with work and such.

I’ve been eating mostly carbs.  Since I don’t feel great as it is, it makes me want to eat less healthy.  I feel like snacking on crackers and chips.  Last time I started wanting sandwiches in the 2nd trimester, but this time I’ve started feeling that now, mostly because I want the bread.

Despite this fun nausea (and fatigue), I’m very grateful that I was able to conceive on my first round of Clomid.  I was prepared for it to potentially take a lot longer, and perhaps require the IVF route.  I really think my stress levels are what affected my fertility.  I cut down my schedule several months ago, and it’s made a huge difference.  I knew I was burnt out and stressed out, but being on the other side of it magnified how bad it was.

Supposedly the research on stress and fertility is mixed, meaning there isn’t definitive evidence that stress affects fertility.  In fact, when I was having a difficult time and seeing a therapist, she reminded me of this with the best of intentions.  That may be the case, but I strongly believe there is a correlation between stress and infertility.  Maybe it doesn’t happen for everyone, and there are women who conceive despite war and famine.  But it makes sense to me that given the significant suck of resources that pregnancy is on a woman’s body, our bodies would avoid it if already under stress.  From early on, we feel exhausted, can’t eat normally, and our immune systems are compromised.  Why would you want to be put in that vulnerable state if you’re in a stressful situation already?

On the Chinese medicine side, they definitely think stress affects fertility.  Part of the purpose of acupuncture is to help relieve stress to aid in fertility.  The acupuncturists say that it takes about 3 months for the eggs to mature, so the interventions can take at least that amount of time.  I told one of the ladies that I was planning on going to part-time in November, and she said she thought I’d conceive in February.  Well, I ended up cutting down my schedule in October, and I was pregnant in January.  While there are many reasons for infertility, for someone like me who had “unexplained infertility,” I think stress was the factor for sure.  And my aging ovaries didn’t help, either.

The other thing that happened is that as I got less stressed, I began to lose a little weight.  I lost about 5 lbs in the course of a month or two without trying.  I wasn’t stress eating as much, so the extra few pounds came off easily.  Maybe the other thing that helped is that in Chinese medicine, they advise you to eat hot foods.  If you must eat a salad, then at least balance it out with some hot soup or tea.  So I started drinking a lot of broth, which is very comforting with the cold winter weather.  I think it also helped me avoid snacking as much.  That wouldn’t have happened in the summer, though, because I can’t imaging wanting hot broth when I’m already feeling warm.

I have to say, the first trimester is tough because you feel nauseous and tired, but it’s too early to tell people you’re pregnant.  So it can be a pretty miserable existence.  I’m starting to see patients that are around the same gestational age as me, and I wish I could say to them that I understand what they’re going through.  Like really understand.  But that will have to wait a bit.  Despite the nausea, I’m really grateful it happened and am cautiously excited about what’s to come.