Of course, far from all miscarriages are chromosomal. In fact, if you’re under 35, it could be just as likely that your miscarriage was caused by one of the following problems:
Infections
One of the surprising things about the role of infections in miscarriages is that the more common ones are not considered responsible. So, having a bad cold, the flu, or a fever during pregnancy is not likely to harm your fetus. But there are certain infections that might, including mycoplasma, toxoplasmosis, chlamydia, and listeria.
In addition, there are infections associated with specific procedures and sources that may cause a miscarriage, including those from a cervical stitch used to tighten a weak cervix or prostaglandins in semen during intercourse itself. If a cervical or semen sample reveals an infection, you and your partner may be prescribed an antibiotic.
Finally, certain viruses are dangerous during pregnancy, including the notorious German measles or rubella, as well as herpes (if the initial viral attack occurred during the first 20 weeks of pregnancy). Others that may also cause miscarriages include mumps, measles, hepatitis A and B, and parvovirus.
Endocrine (Hormonal) Problems
One of the most common hormonal problems leading to early miscarriages is that of an abnormal luteal phase. As you’ve read, in order for a fertilized egg to have a chance to implant and mature, the corpus luteum in typical cycles should maintain the latter phase of the cycle for at least 10 days. In addition, once pregnancy occurs, it must continue to live long enough for the developing placenta to take over the function of providing nutrition for the embryo. The corpus luteum should live about 10 weeks beyond conception, so if you had a miscarriage that was within the first few weeks of pregnancy, one of the first things the doctor might suspect is a corpus luteum deficiency.
Of course, you yourself should suspect a potential problem if your basal temps reflect a luteal phase of fewer than 10 days. If it does, your doctor will most likely perform a blood test and endometrial biopsy to confirm this. If you do indeed have a problem with progesterone production in the latter phase of your cycle, your doctor may prescribe a form of progesterone, to be taken as soon as you ovulate each cycle. (But remember that the best time to test for a progesterone deficiency is either 7 days after your thermal shift, or through a Pooled Progesterone Test, as discussed here.) Many doctors also prefer to prescribe an ovulatory drug like Clomid in the first phase of the cycle, in the hopes that it will promote an optimal ovulation and a healthy postovulatory progesterone level.
Uterine Abnormalities
One of the most common causes of miscarriages in the second trimester is regrettably referred to as an “incompetent cervix.” As the name implies, it is a weak cervix that tends to dilate before the fetus has reached full term. In addition, some women are born with congenital abnormalities of the uterus so that it is shaped in a way that the baby can’t grow big enough before it runs out of room, causing the cervix to dilate.
If your physician suspects that recurring miscarriages may be due to structural problems of your uterus, she may perform a hysterogram—basically an X-ray that uses injected dye to determine its shape. Two other diagnostic procedures often used to view the uterus are a laparoscopy, in which a narrow tube is inserted through the navel, and a hysteroscopy, in which a similar device is inserted through the vagina and cervix. Both procedures allow the doctor to look inside the uterus.
One of the least-invasive treatments, especially in the case of a weak cervix, is to place a suture in it to prevent it from dilating prematurely. But if the uterus is malformed or has uterine adhesions, the condition can usually be successfully treated only through surgery.
Finally, if you have fibroids (or benign tumors) in or on your uterus, you are not alone. By age 40, about 40% of women have them. They generally don’t require any treatment unless they grow exceedingly fast or cause severe bleeding or pelvic pressure. Your physician will often recommend doing nothing, in the hope that the fibroids themselves will not interfere with the pregnancy, since their removal is often more invasive than necessary.
Antibodies and Other Immune System Risk Factors
One of the most serious types of problems implicated in recurrent miscarriages is when the mother produces antibodies that, in essence, reject her own fetus. Through blood tests, tissue typing, or an endometrial biopsy, the doctor can determine if you are producing such antibodies, and, after a precise diagnosis is made, he may treat you with baby aspirin throughout your pregnancy to prevent blood clots, or even prescription antiinflammatory drugs to treat autoimmune problems such as rheumatoid arthritis or lupus. This is because if these conditions are not addressed, they can lead to the production of antibodies that can attack the uterus and the embryo’s placenta.
In recent years, there’s also been intensive research into the role that the unsettlingly termed “natural killer” or NK cells play in recurrent miscarriage, since it’s known they are a major factor in the way the fetus and the mother interact biologically. Among possible treatments are the following:
•immunoglobulins, which act to absorb these excess killer cells;
•the drug Enbrel, which significantly reduces the activity of NK cells as well as certain other destructive immune system cells, including macrophages;
•certain steroids, which bind to NK cells and prevent them from increasing excess blood vessel growth.
Medical Disorders
Finally, miscarriages occur more frequently in women who have medical conditions such as uncontrolled diabetes, thyroid disease, high blood pressure, or heart disease. If your physician diagnoses any of these, she may refer you to an internist for treatment before you attempt to get pregnant again.
TYPES OF PREGNANCY LOSS BEYOND VAGINAL MISCARRIAGES
In addition to regular miscarriages in which the fetus is expelled through the vagina, there are a few other types you should be aware of, all summarized in the chart below.
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Getting the Expertise You Need
Solving the problem of miscarriage continues to be one of the great reproductive challenges today. Yet advances are continuously being made in the treatment of its most significant causes, so if you are dealing with recurrent miscarriages, I strongly encourage you to find a clinician who specializes in their treatment. Given the complexity of this issue, it’s the most important step you can take toward solving the problem and hopefully having the child you want.
CHAPTER 17
Idiopathic Infertility: Some Possible Causes When They’re Not Sure Why
Undoubtedly, the most frustrating of all diagnoses is that of “idiopathic infertility,” a fancy way of saying, “We just don’t know.” Often though, what this really means is that diagnostic tests have not been thorough enough to identify one or more causes. In fact, infertility is frequently the result of several issues, and thus you might have been treated for one, only to find that you still can’t get pregnant. For this reason, among others, the causes often elude even the best practitioners in the field. However, renowned experts have zeroed in on a variety of conditions that likely cause the vast majority of these exasperating cases.
This chapter will go into further detail about certain conditions that may have been overlooked or not discovered in the battery of tests that you’ve already had done. Most of these are discussed elsewhere in the book, but are more fully covered here in the context of unexplained infertility.
The following are the five suspected causes of idiopathic infertility discussed in this chapter:
•Premature Ovarian Aging (POA)
•Disorders of (seemingly normal) Ovulation
•Endometriosis
•Fallopian Tube Issues
•Immunological Infertility
PREMATURE OVARIAN AGING (POA)
Women in their early 30s and sometimes even younger may be given the devastating news that they can no longer get pregnant because their FSH levels are too high. Yet FSH is notoriously i
nconsistent from cycle to cycle as women age. The only thing that is certain is that a woman is no longer fertile if she has gone through menopause, which is defined as having gone an entire year without having had a period. So, even if a woman has high FSH levels and is still menstruating, albeit irregularly, there is still hope.
One of the most frequently overlooked diagnoses of female infertility is Premature Ovarian Aging, which is basically having too few eggs relative to what is expected at a particular age. As you will recall, the viable eggs you have left in your ovaries are known as your ovarian reserve. It naturally declines with age, but it’s the extent to which it does so in younger women that defines whether or not they are experiencing POA. Approximately 10% of women face this condition.
The timely identification of POA is crucial, because once ovarian reserves start to decline, they will only continue to do so. If women are not properly diagnosed, they may be unable to conceive even with assisted reproductive technologies. The proper diagnosis is usually made using age-specific hormone values as opposed to universal cutoffs typically used at many clinics. A woman is presumed to have premature ovarian aging if FSH levels are too high or Antimullarian Hormone (AMH) levels are too low. In fact, AMH, especially in younger women, is considered a better predictor of ovarian reserve.
So, for example, a 40-year-old may have an AMH level that would be normal for her age, but in a 28-year-old would reflect premature ovarian aging. Unfortunately, above age 42, this hormone loses its predictability.
The good news is that with an accurate diagnosis, women respond surprisingly well to a comprehensive treatment approach that usually involves the following three elements:
•DHEA supplementation
•proactive ovarian stimulation
•individualized management of other health conditions associated with their POA
With this strategy, women can often get pregnant using their own eggs, and even better, their miscarriage rate is actually lower than normal. However, for such an approach to be effective, it’s crucial that women receive the correct individualized plan of DHEA supplementation for the appropriate length of time, and that ovarian stimulation is precisely adjusted to the individual woman’s needs.
It’s imperative that women are properly diagnosed, because there is another related condition that POA is often confused with, briefly discussed next.
Premature Ovarian Aging (POA) and the Confusion with Primary Ovarian Insufficiency (POI)
Primary ovarian insufficiency is also a loss of ovarian function before age 40, and can even affect teens. Unlike POA, though, a diagnosis of POI is usually made if FSH levels are above 40 miU/ml, measured twice at least one month apart. But POI is rarely an idiopathic cause of infertility, because women who stop having periods or have menopausal symptoms by age 40 will usually seek a medical diagnosis. Those with this disorder are often put on hormone therapy until about age 50, since the most serious symptom is diminished estrogen, which can lead to high risk for health issues such as osteoporosis and heart disease.
In addition, primary ovarian insufficiency, unlike premature ovarian aging, may emerge suddenly, or more gradually over several years, with the appearance of irregular cycles along with classic premenopausal symptoms such as hot flashes and vaginal dryness. Unfortunately, women with POI will rarely be able to get pregnant with their own eggs, but can often carry a baby to term with donor eggs, using IVF.
The chart below summarizes how to distinguish between POA and POI:
Premature Ovarian Aging (POA) Primary Ovarian Insufficiency (POI)
Younger than 40 Younger than 40, and can occur even in teens
FSH high but below 40 miU/ml FSH above 40 miU/ml
Often no symptoms Irregular or nonexistent cycles, hot flashes, or vaginal dryness
Highest miscarriage rate of any infertility diagnosis if untreated Only a small chance of getting pregnant
May be able to get pregnant with own eggs, with the supplementation of DHEA before IVF Good chance of getting pregnant with donor eggs and IVF
DISORDERS OF (SEEMINGLY NORMAL) OVULATION
As you know by now, charting can help you observe major hallmarks of your cycle, most notably if you are ovulating, whether you are producing fertile-quality cervical fluid, and whether your luteal phase following ovulation is long enough. However, occasionally, when a woman is not able to get pregnant even after charting and medical diagnostic tests indicate that she is ovulating, it may be time to delve deeper into the possibility of ovulatory dysfunction.
The fact is that even though regular cycles usually mean normal ovulation, it may not always be the case. In women dealing with infertility, up to half of those with apparently regular cycles are not ovulating normally. And thus for those women, the traditional means of testing for ovulation may not be enough. As you’ll recall, these include the following:
•biphasic BBT pattern
•positive ovulation predictor kits
•midluteal phase progesterone levels
•normal endometrial biopsies
However, in order to look more extensively for a hidden ovulatory dysfunction, you may need to be seen by a radiologist who is skilled in diagnosing a variety of potential problems that specifically relate to the viability of the follicle. Such issues include its lack of integrity and maturity as well as its ability to break through the ovarian wall. Those that do not break through are called Luteinized Unruptured Follicles, and are particularly confusing because they typically cause your charts to reflect ovulation even though it didn’t occur. For more on this topic, click here.
In addition to these various follicular problems, it’s also possible that there are potential luteal phase issues. A luteal phase of less than 10 days has already been discussed as a widely recognized cause of infertility and is easily observable in your charts. But it’s also possible that it may seem normal when in fact you are producing too little progesterone or estrogen throughout the entire postovulatory phase, or perhaps just for certain crucial days. Either way, various blood tests and daily ultrasound around the expected time of ovulation can often reveal the problem, and if precisely identified, there are drugs such as Clomid that may successfully resolve it.
ENDOMETRIOSIS
As you read in Chapter 8, endometriosis is a mysterious condition in which the cells that line the uterus attach where they don’t belong, usually elsewhere in the pelvic cavity. The condition is especially problematic for women trying to get pregnant, in part because it’s often so difficult to diagnose. With its numerous paradoxes and contradictions, it could actually be fairly intriguing if you, yourself, weren’t the subject of its unfortunate effects.
For starters, the degree of pain you may experience is totally unrelated to the extent of the disease. So, for example, you may have only one microscopic spot, but experience debilitating menstrual cramps. Or your whole pelvis could be covered with endometrial implants, but you might feel nothing. Similarly, you may be struggling to get pregnant with a minuscule amount of endometrial tissue, while someone else may have an extensive case throughout her pelvis, and yet has still given birth to three kids. Even more troubling, the surgery performed to alleviate pain and infertility could cause further scarring that only exacerbates the condition later. Such is the often frustrating reality of this very common malady.
So what gives? If you’ve been diagnosed with idiopathic infertility, endometriosis is one of the first conditions that you should suspect, regardless of whether or not you have any symptoms. And even if you have already had a laparoscopy, remember that the endometrial cells are often so microscopic that they could easily be missed unless the practitioner performing the procedure has a thorough grasp of the various ways in which they appear, and is highly trained in “near-contact” laparoscopy (click here).
Effects of Endometriosis on Fertility
Most doctors today will acknowledge that even mild endometriosis can compromise fertility in many ways, most frequently by causing fal
lopian tube adhesions. This is because the slightest scarring on the delicate tubes can prevent them from being able to grasp the egg. In addition, it can cause the release of toxic substances that can prevent implantation as well as lead to an increased risk of miscarriages.
Probably the most significant effect on long-term fertility pertains to what it can do to a woman’s ovarian reserve and function if the endometrial cells adhere to her ovaries. And, as I mentioned earlier, many women who have surgery specifically to remove ovarian endometrioses ironically risk even further diminished ovarian reserve and premature ovarian aging.
So How Can Women with Endometriosis Be Treated for Infertility?
This is the million-dollar question. Clearly, if the issue were simply pain alleviation, then hormones and medications that alter a woman’s cycle often work well, albeit with many potential side effects. Yet even they don’t cure the underlying disease—they only delay its recurrence. And they are completely inappropriate for women desiring pregnancy. Still, several options exist:
Fertility medications alone or with IUI
If this disease has affected your cycles, you may be prescribed any number of drugs such as Clomid or Serophene. This treatment alone may be enough for you to get pregnant without further intervention, but regardless, your age will help determine how aggressive you should be in moving on to the next option.
In addition, if you have not been able to conceive within a few months with drugs alone, your doctor may suggest trying the same drugs, but this time with IUI (intrauterine insemination). One of the rationales is that Clomid, especially, may dry up the cervical fluid necessary for the sperm to travel to the egg. Bypassing the cervix with IUI would give the sperm a better chance.
Taking Charge of Your Fertility Page 27