A new approach to miscarriage
Pregnancy and miscarriage are always a matter of chance. For a healthy, fertile couple in their 20s, having regular sex, the chance of conception each month is around 20%. For couples in their 30s, this drops to 10%. In women over the age of 39, the chance of getting pregnant drops rapidly well before menopause.
Female age is considered to be the most important factor increasing the risk of miscarriage. At 20 years of age, there is just a 13% chance of miscarriage but for women over the age of 42, more than 50% of pregnancies will miscarry. The biological process of becoming pregnant is complex. There is so much that has to go exactly right, and so much that can go wrong. Most miscarriages occur because of a chromosomal abnormality in the baby. The risk of these abnormalities increases as you age.
Recurrent miscarriage is defined as 3 or more consecutive miscarriages. However some people are distressed after only 1 or 2 miscarriages and may want investigation sooner rather than later even if it is only for reassurance. There are a number of causes of recurrent miscarriage including:
- Parental (mum or dad) chromosomal rearrangements- translocations
- Immunological – antibodies being made against the early pregnancy
- Clotting disorders
- Structural changes in the uterus
- Hormonal problems
In 50% of couples with recurrent miscarriage no underlying abnormality is found.
Investigations
Our aim is to leave no stone unturned in finding out which of these things is causing your miscarriages. We have devised a comprehensive series of tests. These tests will screen both you and your partner looking for genetic, immunological, haematological, anatomical, hormonal, infectious and biochemical factors that could be contributing to your miscarriages. We are constantly improving and broadening these tests as new research becomes available.
Early pregnancy support
When you do become pregnant again it can be very stressful. During the early stages of pregnancy we are able to closely monitor your progress with weekly blood tests and regular ultrasounds. We understand that the next pregnancy after a miscarriage is a time of great anxiety and stress. Along with the scientific testing, we offer support. Your counsellor is available to talk to you and your nurse coordinator will be there to speak to or see you throughout the stressful early part of the pregnancy.
In the unfortunate event that you do experience another miscarriage it may be helpful to test the baby’s chromosomes. Tissue obtained at the time of your curette can be sent for genetic analysis.
Preventing miscarriage
There are a wide range of possible preventative measures that can be undertaken to minimize the risk of miscarriage. Exactly what is done depends on the causes we find during the investigation program. It is possible to work out a specific course of action for you. Some treatments will occur before the next pregnancy and some during. For example, where anatomical abnormalities are found that are treatable with surgery, this will occur before the next pregnancy. Conditions such as the clotting abnormalities (thrombophilias) are treated with anticoagulant drugs once you are pregnant. Unfortunately, it is not possible to guarantee that any treatment will completely eliminate the risk of miscarriage. Listed here are some, but by no means all, of the treatment options available to us.
It helps to be happy and healthy if you are trying to get pregnant and avoid miscarriages. Experts in fertility management say that you should aim to be in peak health for a good 4 months before conceiving. Here are some guidelines for keeping yourself in shape for pregnancy.
Relax
The role of stress and psychological barriers is emphasized according to whom you speak to. Whether or not it does affect fertility or miscarriage, it will certainly improve how you feel in the meantime. It is always a good idea to reduce stress in your life and your counsellor can give you some tips and suggestions if you need help in this area.
Maintain a sensible diet
Try to have a healthy balanced diet with plenty of fruits, vegetables and cereals. If you decide to supplement your diet with multivitamins, make sure that they are safe to take in early pregnancy and that they do not exceed the recommended daily limits. We do recommend that you take folic acid to minimize the risk of spina bifida (a birth defect). You should take 500 micrograms a day from the time you start trying to get pregnant until you are at least 3 months pregnant.
Exercise
It is a good idea to have a regular exercise regimen to maintain general health and well-being. In particular, exercises that strengthen the back, buttocks, abdominal and pelvic floor muscles are recommended. Generally, during treatment you can continue with your normal exercise unless it causes you discomfort or your SIVF specialist advises against it. You should avoid heavy exercise after procedures.
Alcohol
It is not known what amount of alcohol is safe in pregnancy, but a small amount (2 -3 glasses of wine a week) is allowable during your treatment.
Smoking
Cigarette smoking has been shown to affect the quality of sperm and eggs, and is poisonous to very early embryos. While this might not be critical when reproduction is normal, it is very likely to have an effect when embryos are stressed, as in those at risk of miscarriage. We strongly recommend that you stop smoking altogether, or failing that, don't smoke during your treatment cycle.
Caffeine
Caffeine is found in tea, coffee and cola. There are a few studies that suggest that caffeine can have an adverse effect on fertility, so you might want to decrease your intake.
Herbs
The content of herbal preparations and their effects are not always fully researched. Please let your doctor or nurse coordinator know if you are taking anything. Herbal preparations that contain progesterone or oestrogen should definitely be avoided.
Infection control
Some infections that could affect pregnancy can be present in foods (eg. listeria and salmonella). Some precautions that you can take are:
. ensure that all meat, eggs and fish are well cooked,
. avoid pâté and products containing raw eggs (eg. mayonnaise) unless pasteurised
. ensure milk and soft cheeses are pasteurised
. wash fruit and salad vegetables before consumption
. make sure re-heated foods are heated through properly
Toxoplasmosis is an infection that can be carried by cats or in the soil. It is most commonly acquired from eating raw meat. Wear gloves when gardening, and, if you have cats, when emptying their litter tray. Wash your hands thoroughly before eating if you have been handling a cat. Do not eat raw meat.
Medications
Check with your pharmacist if you are unsure.
- Paracetamol (Panadol) is safe to take during treatment, but you should avoid aspirin-based products unless specifically prescribed by your doctor. It can cause bleeding at the time of your procedures. Other anti-inflammatories should also be avoided e.g. neurofen, brufen, ponstan
- Most antibiotics are safe, but tell your doctor you are trying to get pregnant
- Generally a drug that is safe in pregnancy is safe to take while you are on the Miscarriage Management program. Check with your doctor or pharmacist.
- Some vaccinations are safe, but others (such as rubella) need to be given 30 days before you start the program.
Therapies to reduce the risk of miscarriage
Surgery
Some women have structural abnormalities of their uterus that increase the risk of miscarriage. Surgery prior to conceiving again may help to reduce this risk. E.g. Division of a uterine septum.
Anti-coagulant therapy
The formation of clots in the small newly forming blood vessel of an early pregnancy can reduce blood flow and nutrient supplies. It is possible to reduce this effect by using drugs which 'thin the blood' reducing this tendency. Aspirin and Heparin are examples. Heparin requires daily injection and careful monitoring.
Immune system
In some cases, the embryo has to deal with more rejection than tolerance in the uterus. If the balance is too far towards rejection, miscarriage occurs. The use of immune moderators can shift the response of the mother more to tolerance and help the early pregnancy to continue. Heparin (clexane) is an immune modulator as is progesterone.
Hormone treatments
If a hormonal disorder is discovered, specific medications can help reduce the risk of another miscarriage. Quite often, improving the processes of egg development and ovulation achieves a stronger pregnancy more able to survive. One such condition we often deal with is the polycystic ovary syndrome. Losing weight and using metformin may be recommended if you are having miscarriages due to PCOS.
In some women extra progesterone may be given in the early pregnancy to help support the embryo. Progesterone pessaries placed in the vagina daily may be helpful for some women.
Pre-implantation genetic diagnosis
Pre-implantation genetic diagnosis (PGD) involves extracting cells from embryos created using standard IVF techniques. It is possible to test these cells for chromosomal abnormalities and then to not use embryos that have a high risk of miscarriage. Sydney IVF has a world-leading record of successfully applying PGD for the purpose of avoiding miscarriages from balanced chromosomal translocations. Sometimes where recurrent miscarriage has occurred in a background of an abnormal gene, screening embryos for the gene can raise the chance of holding onto a pregnancy.
Comprehensive information on PGD is available in a separate patient handbook.
