One in six Australian couples will have a fertility issue at some point in their lives and one in 10 couples will have trouble conceiving their second child. You are not alone.
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Heartbreaking as they can be, sadly miscarriages are not uncommon. While we realise it’s of little comfort, if you’ve lost a baby through miscarriage, you are not alone. Approximately 15 to 20 per cent of all pregnancies end in miscarriage - often in the first trimester. The Australian Longitudinal Study on Women’s Health found for every three women who have given birth in their early 30s, one has had a miscarriage, and these figures increase with age.
Unfortunately, miscarriage is a sad but normal part of human reproduction.
Miscarriage is the spontaneous loss of a pregnancy before 20 weeks and most miscarriages can’t be prevented. Most of these babies will have already died in the uterus before the miscarriage occurs - unfair as it seems sometimes it’s nature’s way of ending a pregnancy that isn’t developing as it should.
The loss of a pregnancy, at any stage, can be an extremely difficult and emotional time for many couples, particularly if it happens repeatedly or following infertility. But most miscarriages are what we call a single pregnancy loss - an isolated instance of miscarriage that conversely enough actually shows your body’s reproductive system is working. Most women who miscarry can conceive again and go on to have a baby. While talking about it with your family and friends is a good idea, miscarriage myths can be emotionally damaging so try not to take the old wives tales to heart and read our advice on what’s right and wrong.
However, some women devastatingly experience more than one miscarriage. We call this recurrent pregnancy loss or recurrent miscarriage and while still not unusual – one in 20 couples experience two miscarriages in a row - it is obviously a sign that something isn’t working.
If you’ve experienced two or more miscarriages in a row, come and talk to one of our Genea Fertility Specialists with miscarriage management expertise about how GeneSure may be able to help you have a baby. We also run a Miscarriage Management Program for people who have experienced a number of miscarriages and would like to understand what is happening and how we can help get to the bottom of the problem.
Some women devastatingly experience more than one miscarriage. We call this recurrent pregnancy loss or recurrent miscarriage and while still not unusual – one in 20 couples experience two miscarriages in a row - it is obviously a sign that something isn’t working.
We understand that you often desperately want to know what causes a miscarriage but unfortunately there are a number of reasons why a pregnancy might end unexpectedly and it’s not always straightforward for your doctor to figure out why. While it’s worthwhile investigating for underlying causes, in 50 per cent of cases we will not find a medical explanation. And for these couples, the likelihood of a pregnancy after a miscarriage leading to the birth of a healthy baby is not that different to the overall chance of success based on the woman’s age.
Some of the more common causes include:
- chromosomal abnormalities
- abnormalities of the uterus
- blood clotting disorders (thrombophilias)
- immunological problems
- hormonal disorders
- genetic abnormalities
- problems with the placenta
- lifestyle factors such as smoking, alcohol and recreational drugs
Chromosomes are tiny structures inside the centre of all cells that come in pairs, one from each parent. Each chromosome carries many genes and it is these genes that define all of a person's physical characteristics (such as sex, blood type, hair & eye colour ... to mention just a few). Having too much or too little of a chromosome causes an imbalance in gene activity.
This imbalance or random genetic abnormality is the most common cause of miscarriage, about nine out of 10 genetically abnormal pregnancies will not survive past the first trimester. In normal human cells there are 46 chromosomes, which contain DNA and genes. When cells have the wrong number of chromosomes, the error is known as aneuploidy. You’ve most likely heard of Down syndrome - it’s the best-known example of aneuploidy and is the result of having three copies of chromosome 21.
Around seven out of 10 first trimester losses are caused by chromosome problems.
These miscarriages happen by chance. In most cases, there is nothing wrong with the mother or father's health and miscarriage is not likely to occur again in a later pregnancy.
There is, however, an important exception - something called balanced translocations
If one of you has a balanced translocation, it means that you have the correct amount of each chromosome, and so no outward signs of genetic abnormality, but your chromosomes are arranged incorrectly, which will cause problems when the chromosomes divide - as in the creation of sperm and eggs.
If a translocation is suspected as the cause for recurrent pregnancy loss, both parents can be tested. If it’s possible we can also test the tissue from your lost pregnancy to confirm the finding.
Once we’ve confirmed that a translocation is causing the problem, there are several options we can help you with. As you can see in the diagram, there’s a 50 per cent chance the embryo will have a normal balance of chromosomes - although there is a chance that it will carry a translocation itself.
If you continue trying to get pregnant naturally, these odds determine your chance (other factors aside) of carrying a child to term and that child being healthy.
The alternative that we recommend to overcome miscarriage is Preimplantation Genetic Diagnosis (PGD). It’s a treatment which involves you undergoing a course of IVF and then having the resulting embryos tested as they develop in the laboratory. Genea achieve significant success using this expertise for our patients. Through PGD, we can avoid using embryos with unbalanced chromosomes and therefore maximise the potential of having a baby.
Several abnormalities of the uterus are commonly linked to repeated pregnancy loss. Most of them can be treated with surgery. These abnormalities include:
- Congenital abnormalities. These are defects present in your uterus from birth. For instance, you might have a uterus that is divided into two sections by a wall of tissue (septate uterus).
- Uterine fibroids (leiomyomata). Uterine fibroids are benign growths (not cancer) made up of uterine muscle tissue. Fibroids are common but they are only rarely a cause of miscarriage.
- Blood clotting disorders (thrombophilias)
Although we’ve known for a considerable amount of time that a woman's blood becomes thicker in pregnancy, it’s only recently been established that this process can be more pronounced in some women compared with others. Blood clotting disorders (thrombophilias) can be genetic or acquired - that is you can inherit them from your parents or you might develop them as you age.
It can be a bit hard to get your head around but Antiphospholipid antibodies cause your blood to clot more easily - the two most important types of antiphospholipid antibodies are the lupus anticoagulant and the anticardiolipin antibodies.
If you have a history of recurrent pregnancy loss and you have persistently tested positive for either lupus anticoagulant and/or high levels of anticardiolipin antibodies then your diagnosis is Antiphospholipid Syndrome.
Inherited versions of thrombophilias include Factor V Leiden. If blood clots occur in the blood vessels of the placenta, the blood flow to the baby is decreased and this can lead to either second trimester miscarriage or, if the pregnancy proceeds, to the birth of a baby that is smaller than he or she ought to be. Women with these disorders are also at risk of developing high blood pressure later in pregnancy.
For a long time, it was believed that thicker, "sticky" blood could cause first trimester miscarriages because it led to blood clots in the developing placenta which prevented the embryo from getting the oxygen it needs. We now know that the first trimester placenta doesn't actually have any blood flowing through it - blood vessels are developing but they are plugged by placenta cells. Also, our experience with embryos in IVF has taught us that oxygen is toxic to early embryos, so direct blood flow would be damaging.
What we believe now is that the antiphospholipid antibodies in acquired thrombophilias (or the proteins made by genes in inherited thrombophilias) prevent the placental cells from properly attaching to the mother's uterus. Without normal placenta development, the embryo cannot grow.
Our immune system is designed to recognise and attack foreign substances within the body. Antibodies are formed to help the body fight off disease and heal itself in case of infection. These disorders are called auto-immune diseases - Antiphospholipid Syndrome which we mentioned above is one example.
Normally in pregnancy, the mother's body protects the "foreign" fetus from attack by her own antibodies but we believe this protection might be missing from the blood of some women who have had repeated pregnancy loss.
Other immune system problems can be caused by differences between the mother and the fetus and even between the mother and the father. There are tests we can conduct to help find out if you have a problem in your immune system.
There are a number of hormonal disorders that are commonly associated with recurrent pregnancy loss. The four most common hormonal disorders are:
Low levels of progesterone hormone are frequently found in women who are suffering recurrent miscarriage. However, low progesterone levels in early pregnancy reflect the fact that the pregnancy has not implanted successfully in the womb lining, rather than the fact the developing placenta is not producing enough progesterone to maintain the pregnancy. This is an important point - low progesterone is the effect, not the cause of the miscarriage. This explains why giving women progesterone and/or hCG hormone injections in early pregnancy won’t help you avoid a miscarriage. There is an exception to that rule and that’s when we take advantage of the immunosuppressant effects of progesterone in women who are found to have immune problems.
Follicle stimulating hormone (FSH) drives the ovary to start growing follicles. Some women with a history of pregnancy loss are also found to have high FSH levels because unfortunately their ovaries have become prematurely menopausal. Although rare, this is obviously a very important problem to identify. If your FSH levels are high, one of Genea's Fertility Specialists can help you make a plan to deal with the problem.
Currently, the only way to determine how your endometrium will respond to implantation is to take a sample of it and look at the histological (microscopic) evidence of the state of the tissues. We can perform an endometrial biopsy - fortunately it’s no more uncomfortable than undergoing a cervical smear (pap smear) test.
Often, a pelvic ultrasound shows women who are suffering recurrent miscarriage have polycystic ovaries (PCO). This is a common condition, found in 25 per cent of all women, which involves multiple small cysts within the ovary or ovaries.These cysts aren’t dangerous but they can’t be removed as they are within the ovary. Polycystic ovaries can sometimes be associated with a number of hormonal imbalances such as increased production of luteinizing hormone (LH) and testosterone. A number of carefully designed studies have shown that neither PCO nor high LH levels are a cause for recurrent miscarriages.
The role that vaginal infections may play in recurrent pregnancy loss is the subject of a new field of research. Infection may well play a role in causing late pregnancy losses (14 weeks gestation) in a small number of women but it is unlikely to be important in causing early miscarriages.
The risk of miscarriage may be increased in pregnant women who:
As Genea Fertility Specialist and Miscarriage expert Dr Devora Lieberman says: “Almost every time a pregnancy fails, it’s about the embryo. It’s almost never about anything that the woman has done or not done”. It’s also important to remember that there is almost always nothing that could have been done to prevent a pregnancy being lost and nothing that can be done to hang on to a pregnancy that is destined to end in miscarriage.
Within the first 12 weeks of pregnancy, there are three different types of miscarriage that can happen (once a pregnancy reaches the 12 week mark, the risk of miscarriage falls to just two per cent):
Your pregnancy has ended and all of the tissue has been passed.
Some, but not all of your pregnancy and remaining tissue has been passed. You will need a dilation and curettage (D&C) to minimise risk of infection and haemorrhage.
Your pregnancy has failed and your fetus has stopped growing but nothing has been passed yet. The only way to diagnose a delayed miscarriage is through ultrasound.
Sometimes women will experience cramping and heavy bleeding, but for some women there are no symptoms and the fetus dies but stays in the uterus. This is known as a ‘missed’ or ‘silent’ miscarriage and women are usually given the option of having a surgical procedure or waiting for nature to take its course and for the fetus to be passed from the uterus.
If you have three miscarriages in a row, you will usually be referred to a specialist who may order some tests to see if there is an underlying cause. If you get a referral from your GP or Gynaecologist, you can come to see a Genea Fertility Specialist for these tests.
However, more than half of the time these investigations don’t find any explanation for the miscarriages – while it may be frustrating not to find a reason, this is actually good news. It means you are likely to achieve a healthy pregnancy in the future without medical intervention. That said, because fertility declines and the risk of chromosome problems increases as we age, women in their mid to late 30s might be referred for investigations after two consecutive miscarriages.
Depending on what is discovered through these tests, we can work with you to make a plan to maximise the potential of having a baby.
Depending on what is discovered through these test, we can work with you to make a plan to maximise the potential of having a baby. Contact us for more information.
Random chromosome problems are thought to be the cause of the majority of miscarriages – where a genetically abnormal embryo implants in the uterus, but is destined to fail. While normal advice to couples is to keep trying, we understand that the emotional toll of repeated miscarriage can be immense. Another fact to keep in mind is that the chance of chromosome errors increases as you get older.
As we mentioned earlier, one treatment option is Preimplantation Genetic Screening (PGS) - a technique that allows scientists to screen your embryos in the lab during the IVF process to ensure it has the correct number and sequence of chromosomes in the DNA. The technique, is usually recommended for older women who have suffered recurrent miscarriage or repeated IVF failure and can maximise the potential of having a baby. Genea have seen some excellent success rates for women who are a more advanced maternal age.
A long spiral string of genetic material (DNA) wound around supporting proteins. There are 46...
DNA is an abbreviation of deoxyribonucleic acid, a molecule made of a variable sequence of...
Penetration of the egg by a sperm cell which results in combining of genetic material.
The hormone produced by the pituitary gland which controls growth of ovarian follicles and...
Used to gauge the genetic health of an embryo prior to implantation. It is the process of...
The second principal hormone of the ovary, produced only after ovulation and...
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