So when and how should I seek specialty care?
Common Perceptions of Miscarriage Can Get In The Way
The loss of a pregnancy, no matter how early and no matter what it is called, is devastating. Unfortunately for many, those experiencing miscarriage (especially first trimester losses) often find their feelings of grief invalidated by those around them, including their medical practitioners. “Get over it and move on” may be the unspoken message they receive.
Many women report being told that miscarriage “just happens” and that no one really knows the reasons. Most women hear from their obstetrical practitioners that a miscarried pregnancy is most likely a sign that there was something amiss with the growing baby and that no further exploration is necessary, leaving parents-to-be feeling in limbo with their questions. Still others may be told that testing for causes is only possible if remains of the embryo/fetus are available.
The truth is that much is known about the precursors of miscarriage, and there is often preventative treatment. However, the majority of doctors use a three-loss standard: a woman must lose three pregnancies before being considered a “recurrent spontaneous aborter” (RSA) or “habitual aborter,” and therefore become eligible for exploratory testing. Unfortunately, many women take their practitioner’s lack of action as reason to passively (and fearfully) “wait it out and hope” that subsequent pregnancies result in a live birth.
Do You Have To Lose So Many Before Finding Out Why?
The short answer to this is no. This is where being a savvy medical consumer comes in to play. Some doctors and insurance companies will refuse any sort of diagnostic testing before two or three miscarriages. Find out after your first loss where your own insurance and physician draw the lines.
If you have good cause to suspect there is an underlying treatable condition affecting your ability to carry a pregnancy, you have the right to appeal related policies.
Good Causes To Appeal Less Aggressive Policies
First, understand the potential precursors for all pregnancy loss:
- uterine malformations
- growths in the uterine interior e.g. fibroids
- uterine synechiae (scar tissue)
- incompetent cervix
- Luteal phase defect
- Thyroid dysfunction
- Other hormonal imbalances & endocrine disorders, such as diabetes mellitus, hyperprolactinemia
- chromosomal arrangement problems, such as balanced translocation, of either partner
- other chromosomal abnormalities
- autoimmune disorders such as lupus, some forms of thyroid disease
- maternal presence of certain antibodies, such as antiphospholipid, anticardiolipid, antithyroid
- maternal DES exposure in-utero
- maternal age (mid-30’s and older)
- other maternal factors such as overt stress, malnutrition, disease, and infection
Next, if you feel that any of the above factors may have played a part in your miscarriage, bring that to the attention of your doctor. It may be possible that there is corrective or preventive treatment for your situation, treatment which may prevent more loss. However, many of the above causes cannot be known until detected by specific testing.
In your appeal for more aggressive diagnosis, be sure to emphasize the length of time, effort, and money you have already spent on trying to conceive, and also your (maternal) age, as these issues can impact a practitioner’s decision in your favor.
Who Can Assist With Miscarriage Diagnosis/Treatment?
The average obstetrician/gynecologist receives training and gains experience in assisting with normal pregnancies and deliveries. Specialists in maternal/fetal medicine receive additional training in the care of more complicated pregnancies, births, and newborns. A reproductive endocrinologist’s (RE) primary focus is on infertility and other matters related to the body’s reproductive hormonal system. Once a patient has conceived, a reproductive endocrinologist will also see the pregnancy through the first trimester before referring the mother to an OB.
Presumably, any OB/GYN, RE, and even family practitioner has received training in handling miscarriage; however, if a woman has miscarried after experiencing conception difficulties or has miscarried more than once, she may want to talk candidly with her provider about his/her experience in dealing with pregnancy loss. As with any other profession, not all providers offer the same level of experience and skill.
Some questions to ask are:
- What are your typical protocols for handling miscarriage?
- When do you feel a couple should be tested for factors leading to miscarriage?
- What kinds of factors do you look for?
- What can I (the patient) do to assist you (the physician) in this diagnostic, fact-finding phase?
These questions will give you some idea of whether or not you and your provider are thinking along the same lines.
The Case for An Infertility Specialist
If one defines infertility as the inability to have a child by birth, then technically, someone who experiences recurrent miscarriage may be thought of as someone who is experiencing secondary infertility. It is now believed that there is an increased chance of miscarriage with nearly every cause of relative infertility (and with most infertility treatments).
That said, it stands to reason that a background of infertility may be enough reason to investigate the cause of even one miscarriage, through karyotype of the expelled tissue. This test, although expensive, could rule out genetic probabilities (which are generally either random or in correctable conditions), and thereby point to any number of other possible causes. Many RE’s will evaluate a single miscarriage’s etiology without waiting for recurrence.
Because their focus is on conception and the first trimester with women who are already as a group more susceptible to miscarriage, reproductive endocrinologists are by training and experience highly attuned to the latest knowledge on prevention of pregnancy loss.
Take Charge of Your Care to Prevent More Heartache
The important thing to remember is that miscarriage is no longer the mystery it once was, and there are treatments to correct or prevent many of the known causes. Understanding these causes and treatments, using a medical practitioner who believes in aggressive diagnosis, and following through with your practitioner’s advice may just save you from more grief and help you have that longed-for child.