CHAPTER 11
Beginning Again After a Loss
NO MATTER HOW LONG YOU’VE been trying to conceive, the excitement of a positive pregnancy test is overwhelming. But when the pregnancy ends abruptly in loss, the heartbreak can be overwhelming, too. The blow can be harder still if this is not your first miscarriage, or even your second, or if your path to conception was a long and bumpy one.
A loss can leave you longing for that baby more than ever, but it can also leave you with far more questions than answers as you consider your future fertility—and wonder how you can best improve your odds of carrying a next pregnancy to term. Why did I lose the pregnancy? Are there any treatments that can help prevent a repeat miscarriage? And when can I start trying to conceive again? Whether you’ve suffered one miscarriage or several, this chapter may help provide you with the answers and reassurance that you’re looking for—so you can look forward to a new beginning.
Wondering About a Repeat
It’s only natural to wonder—or worry—about having a repeat miscarriage after you’ve already suffered one loss, or more. Fortunately, in the vast majority of cases, a miscarriage is followed by a healthy pregnancy. Knowing that this happy ending is most likely around the corner for you can make turning that corner much easier.
Chance of a Repeat Miscarriage
“I had a miscarriage last year, and I’ve finally gotten up the nerve to TTC again. Do I have a higher chance of having another miscarriage?”
All moms-to-be worry about miscarriage at some point in their early pregnancies (some worry pretty much nonstop)—and as someone who’s already suffered a pregnancy loss, it’s only natural that your stress is stepped up. But happily, it doesn’t have to be. Having had one miscarriage does not increase your risk of having another—and, in fact, you have the same excellent chances as someone who’s trying for the first time that your next pregnancy will bestow on you the baby you’ve been hoping for. It’s even possible that you can up your odds for a healthy pregnancy by reducing any miscarriage risks that apply to you (see page 181). So relax and enjoy your baby-making activities.
Testing After Miscarriage
“I just had my second miscarriage in a row. Should I get tested to figure out why this is happening?”
While a single loss isn’t usually worth investigating (because most of these are random, onetime events, most practitioners won’t work up a woman who has had 1 miscarriage), trying to get to the bottom of recurrent losses definitely makes sense before you try to conceive again. About 75 percent of the time that explanation can be found through testing, which usually involves simple blood tests. Once the cause or causes are uncovered, you can talk to your practitioner about treatment options—as well as how to best care for your next pregnancy (see page 181 for more).
Sometimes no definitive cause turns up. Even then, reducing risk as much as possible can lower the chances of a reoccurrence. No room for improvement? Just remember that the chances that you’ll achieve pregnancy success next time around are very good, even if nothing in your preconception profile changes.
Ectopic Pregnancy Repeat
“I had an ectopic pregnancy three months ago—does that put me at risk for a repeat?”
Your baby future is likely very bright. The vast majority of women who experience one ectopic (or tubal) pregnancy go on to have a completely normal pregnancy on their very next try. If you’ve had one ectopic, the repeat risk in your next pregnancy is somewhere between 7 and 15 percent (with the estimated risk on the lower end if you lost a tube, and the higher end if you have both tubes still intact after your ectopic). If you’ve already had one successful pregnancy after an ectopic, your chances of having another tubal pregnancy are the same as for the general pregnant population (with no increased risk at all). Women who have repeat ectopics (which are rare) usually have other tubal or underlying fertility issues—which means that if you have no fertility issues, your risk of a repeat is lower still.
As for your fertility, that will depend on how your ectopic was managed (medically or surgically). If both of your tubes were preserved, your fertility should be, too. More than half of all women who’ve had an ectopic go on to conceive a normal pregnancy within a year.
Preventing Pregnancy Loss
If you’ve had a miscarriage, you’re undoubtedly wondering what you can do next time around to prevent it from happening again. For most women, a miscarriage is a onetime event and the chances are excellent that the next pregnancy will end with a healthy baby, without any intervention at all—though it doesn’t hurt to increase those odds even more by minimizing, modifying, or eliminating any risk factors that apply. If you’ve had 2 or more miscarriages, trying to uncover the cause and then working to prevent repeats can help put a baby in your future a lot sooner. And luckily, with today’s technology and advanced treatments, there are more and more ways to figure out what caused prior miscarriages and how to prevent future ones.
Reducing Risk
“I’ve had one miscarriage and my doctor says it probably won’t happen again. Is there anything I can do now, before I start TTC again, to reduce the risk for next time?”
Your doctor’s right—it probably won’t happen again. Most single miscarriages are a chance occurrence, and the likelihood that you’ll have a second loss is very low—in fact, as low as it is for someone who hasn’t miscarried before. Still, it’s always smart to maximize your chances for a healthy pregnancy. You’re probably very familiar with this pro-pregnancy protocol—and you may already be following it carefully—but it doesn’t hurt to check it over to see if you’ve got any room for improvement in your preconception prep:
Your weight. Being significantly overweight or underweight can slightly increase the risk of miscarriage, but getting close to your ideal weight before you conceive can eliminate that risk.
Your diet. A well balanced diet is vital to a healthy pregnancy, so if there’s room for improvement in the way you eat, go for it. Deficiencies in certain nutrients (including folic acid and vitamin B12) have been linked to miscarriage risk. A prenatal vitamin (plus a good diet) can get your nutritional reserves up to par if they’re not already there, and help reduce the risk of miscarriage.
Your caffeine intake. Heavy caffeine intake early in pregnancy slightly increases the risk of miscarriage. Stick to no more than 200 mg of caffeine (about 12 ounces of brewed coffee or two shots of espresso) while you’re TTC and once you become pregnant.
A smoking habit. Don’t worry about smoking that’s in your past—but if you’re currently a smoker, quit as soon as possible to cross this risk off your profile. Try as best you can to steer clear of secondhand smoke as well (so if your spouse smokes, it’s time for him to call it quits, too).
A drinking habit. As you’ve most likely heard, alcohol and pregnancy don’t mix—and there’s growing evidence that too much alcohol can increase the risk for miscarriage. So if you do drink, cut out those cocktails (and beer and wine) once you start TTC.
Your general health. Untreated chronic conditions (such as diabetes, lupus, high blood pressure), untreated thyroid disorder, and untreated STDs can all increase miscarriage risk. Making sure your body is as healthy as possible before you conceive can help prevent miscarriage, again if there’s room for improvement.
Your stress level. Extremely high stress (not everyday stress, which isn’t harmful) has been linked to pregnancy loss. Reducing extreme stress in your life as best you can may help reduce the risk for future miscarriages.
Chromosomal Defect
“I’m 38 and I just had a second miscarriage. My doctor says there were problems with the baby’s chromosomes. Will I ever be able to have a healthy baby?”
It’s thought that more than half of all miscarriages are caused by a defect in the chromosomal makeup of the embryo or fetus—so your situation is definitely not unusual. It’s even less unusual among women in your age group. That’s because as you age, so do your eggs. And older eggs—and possibly your partner’s older sperm if he’s over 40—are more likely to contain chromosomal abnormalities than younger eggs.
You can’t change your age, of course, or the age of your eggs. And knowing that your older egg supply has likely been responsible for the chromosomal problems in your previous pregnancies can be discouraging. After all, won’t pregnancy losses keep on happening until the chance healthy egg and sperm meet up? The simple answer is yes—but happily, there is an excellent possibility that this perfect pairing will happen spontaneously with your next conception. That’s what happens most of the time in a case like yours.
But what happens if chromosomal problems keep preventing that happy outcome and that healthy embryo? For very few couples (particularly older ones), miscarriages due to chromosomal defects happen again and again. Unfortunately, it’s impossible to detect defective chromosomes in an embryo when conception occurs the natural way. But with today’s medical technology, physicians are able to screen embryos formed in vitro (in a test tube or petri dish) for chromosomal abnormalities and choose the healthiest embryos for implantation. This technology, called preimplantation genetic diagnosis (PGD), is basically an embryo biopsy that works in conjunction with in vitro fertilization (IVF). PGD enables your doctor to examine the DNA of one cell of each embryo and identify the healthy embryos. Once it is determined that an embryo is free from indentifiable chromosomal abnormalities, it can be transferred to your uterus with the hope that it implants and develops into a healthy pregnancy and healthy baby.
Of course, complicated procedures often come with complicated decisions. Before choosing PGD, you and your spouse will want to have a conversation with your doctor so that you’re clear about the pros and cons of the procedure, as well as the potential risks involved. You’ll also need to be comfortable with its implications (there might be embryos that show chromosomal anomalies, and you’ll need to think about what will be done with those). It’s also important to consider the added cost factor for the procedure (it’s not cheap, and IVF is already expensive) and to keep in mind that not all chromosomal defects can be detected by PGD. It’s also not yet clear whether PGD improves success rates or reduces miscarriage rates. Still, for many couples—especially ones who have been suffering from recurrent pregnancy losses—PGD can tip the healthy-pregnancy scales in their favor.
Keep in mind, too, that other factors may be contributing to your miscarriages. After all, just because the last baby had chromosomal problems, it’s impossible to conclude with certainty (unless tests were performed on the other fetus as well) that the same problem led to your previous pregnancy loss. So do make sure you’re screened for all other potential risk factors (including hormonal imbalances that are more common in women over 35) to increase your odds of a successful pregnancy next time around, no matter how you decide to conceive.
Hormonal Imbalance
“I have a luteal phase deficiency and I’m wondering if that has anything to do with the miscarriage I just had.”
It takes an intricate balance of hormones to deliver a pregnancy safely from conception to delivery. Most of the time, nature takes its hormonal course without incident, but sometimes an imbalance can result in a pregnancy loss. The most common hormonal imbalances associated with miscarriage are:
Luteal phase deficiency. When a woman has a luteal phase (the second half of a cycle) shorter than 10 to 12 days, her progesterone levels remain too low to sustain a pregnancy because there’s not enough time in the cycle for the levels to build. This progesterone shortage can lead to an inadequately prepared uterus (there’s not enough time for the endometrium to thicken sufficiently). A uterus without a thick lining can make it difficult for an embryo to implant or can result in an early miscarriage. A blood test and possibly a biopsy of your uterine wall can help confirm whether a luteal phase deficiency (LPD) was the cause of your miscarriage. If an LPD is found to be responsible, the right supplementation can reduce the risk of a repeat loss in future pregnancies. Supplemental natural progesterone taken as a vaginal suppository or as an oral tablet (called Prometrium)—and perhaps vitamin B6 supplementation as well—prior to conception may help remedy an LPD. In addition, continuing progesterone supplementation through the early stages of pregnancy may help sustain the pregnancy and avoid miscarriage.
Hyperprolactinemia. Higher-than- normal levels of prolactin (the hormone responsible for breast milk production) have been linked to an increased risk for miscarriage. Signs of hyperprolactinemia can be a milky discharge from your nipples or anovulation (when you have a period but don’t ovulate). Blood tests can reveal if you have excess prolactin. Luckily, once diagnosed, this imbalance can be easily treated with medication that decreases the levels of prolactin and increases the chances that the next pregnancy won’t end in miscarriage.
Thyroid condition. Thyroid, another important hormone, though not officially a member of the reproductive hormone team, can directly impact reproduction. Abnormal levels of thyroid hormone can not only reduce fertility, but they can make it less likely that a pregnancy will be sustained. Thyroid conditions, which affect about 15 to 20 percent of women of childbearing age, are easily detected through a blood test. Treating hyperthyroidism (too much thyroid hormone) and hypothyroidism (too little thyroid hormone) with medication can easily and dramatically reduce the risk for miscarriage in future pregnancies.
Polycystic ovarian syndrome (PCOS). Women with untreated PCOS are at greater risk of having irregular ovulation and periods because of higher-than-normal levels of testosterone and LH. In some cases, these abnormal hormone levels also increase the risk of miscarriage. Some women with untreated PCOS also have insulin resistance (insulin is a hormone, too), and it is thought that this type of hormonal imbalance can prevent the endometrial lining from maturing properly, making it harder for an embryo to implant properly.
Immune System Malfunction
“Is it true that some miscarriages are caused by the mom’s body attacking the baby? Is there anything that can be done to prevent that from happening?”
As implausible as it sounds, what you’ve heard is true. A very small percentage of miscarriages are thought to be triggered by antibodies in the mother’s body. These autoantibodies increase the risk of blood clots, affecting the blood flow to the developing fetus, and causing a miscarriage, usually after 10 weeks.
Autoimmune problems in general account for less than 5 percent of recurrent miscarriages. But if you have had multiple miscarriages, blood tests can reveal if you’re producing autoantibodies (called antiphospholipid antibodies). Once an immune system malfunction is confirmed, your practitioner may recommend one baby aspirin per day (about one-quarter of an adult aspirin) throughout your pregnancy and/or heparin (a stronger anticoagulant) injections given during the first half of your pregnancy, to help stop the formation of these fatal-to-the-fetus blood clots.
Anatomical Problems of the Uterus
“My doctor mentioned that I have an unusually shaped uterus. Could that be the cause of my miscarriage? Will that mean I’ll have another one?”
Possibly, but not necessarily. While experts believe that 10 to 15 percent of all miscarriages result from uterine malformations and other anatomical problems in the uterus and cervix, less than 5 percent of women with a uterine malformation have one that is bad enough to cause a miscarriage. That’s because only certain uterine shapes (such as a septate uterus, in which a wall of tissue separates the two sides of the uterus) interfere with the healthy implantation of an embryo or make women more prone to miscarriage. Other anatomical problems in the uterus, such as fibroids, may also interfere with implantation and/or the proper growth of a fetus. Tests such as hysterosalpingogram (HSG; an assessment of the uterus and fallopian tubes using X-ray imaging and dye), hysteroscopy (visualization of the uterus using a camera), sonohystogram (visualization using ultrasound), or an MRI can be used to diagnose a uterine problem.
If it turns out that the unusual shape of your uterus is serious enough to have caused your pregnancy loss and may threaten any future conceptions, surgery before you become pregnant again can be a quick and effective fix. If the issue is fibroids, those can be removed.
If it turns out that the shape of your uterus was not likely the cause of your miscarriage, chances are it was a random event that won’t repeat—in which case, your risk of miscarrying a second time is just as low as it is for the general pregnant population.
Infections
“I’ve heard that infections can cause pregnancy loss. Is it possible the cold I had right when I conceived caused my miscarriage?”
It takes a lot more than a cold to trigger a pregnancy loss. Though there is a small link between infection and miscarriage, it applies to far more serious (and less common) infections, such as mumps, measles, herpes, CMV, listeria, STDs (sexually transmitted diseases), and a host of others you’ve probably never even heard of. It does not apply to colds (even bad ones) or the flu, so it couldn’t have been responsible for your miscarriage.
So don’t worry about a bout with the sniffles when you’re next pregnant. But keep in mind that it’s always smart to avoid infections when you’re expecting (by getting plenty of rest and washing your hands often), and to have any infection that you do come down with treated promptly so it doesn’t impact your general health or your pregnancy.
Trying Again
If you’re like most hopeful parents-to-be, getting pregnant again is the best possible therapy after a pregnancy loss—and it’s something you’re likely aching to do as soon as you can. But it’s also likely you’ll approach trying to conceive again—like most hopeful parents who have suffered a miscarriage—with tempered enthusiasm. After all, you now know that a positive pregnancy test doesn’t necessarily come with the promise of a baby 9 months later. The loss of innocence that follows a pregnancy loss—and the trepidation it can bring when you contemplate conceiving again—is understandable, and so common. Just try to remind yourself—and it’s true!—that the vast majority of women who have had a miscarriage, or even multiple losses, go on to have healthy pregnancies. Chances are you’ll be on your way to starting—or adding to—your family again, just a little later than you originally thought.
When to Try Again
“I just had a miscarriage and I’m wondering when I can start trying to conceive again. I want to so badly.”
There’s no definitive answer to the question of when you can try to conceive again after a miscarriage, simply because there are no definitive rules. Even guidelines from different practitioners differ—and the same practitioner may recommend a different waiting period to two different women. Many practitioners give the go-head to start trying again as soon as you feel physically and emotionally up to it, whether your miscarriage was natural or you had a D & C after a miscarriage. In fact, some actually encourage a sooner-than-later approach. That’s because reproductive hormones may be at high levels following a miscarriage, so fertility could be at its peak for the 3 months after a loss—meaning that you’re possibly even more likely to conceive during this time. More encouraging news if you’re hoping to get an early start: There does not seem to be an increase in miscarriage rate for women who’ve conceived immediately after a pregnancy loss.
That said, some practitioners suggest waiting 2 to 3 months before trying to conceive again to allow your cycles to regulate, to give you time to beef up your nutritional reserve (if you hadn’t been taking prenatal vitamins before or if your iron stores were depleted due to heavy bleeding), or to give your body time to heal (if the miscarriage was a later one). Still other practitioners recommend waiting until you have your first normal period before actively trying for a baby. Their reasoning: so that the next pregnancy will be easier to date (though that’s usually less of an issue these days because early ultrasound can accurately pinpoint fetal age) and to ensure that all the hCG from the previous pregnancy has left your system completely and your hormone levels are back to normal. For most women, that first period will arrive pretty quickly, usually within 4 to 6 weeks after the miscarriage. Waiting until your cycle has resumed will also allow you to time your baby-making efforts effectively.
Finally, when you’ll be given the green light for TTC may also depend on whether or not tests need to be run to rule out conditions that may have caused the miscarriage, or if you have a chronic condition that needs to be better controlled. Either way, taking that extra time—and those extra precautions (if necessary and recommended by your practitioner)—can help ensure that any future conception will turn into a healthy pregnancy.
If your practitioner does give you the immediate go-ahead, go right ahead and begin your baby-making efforts. If he or she recommends waiting, use reliable contraception, preferably of the barrier type—condom, diaphragm—until the waiting time is up. Take advantage of this waiting period—spend it improving your diet and your health habits (if there’s any room for improvement) and generally getting your body into tip-top baby-making shape. That way, you’ll feel that you’re at least doing something constructive while you wait (plus, it’ll give you something else to focus on besides the waiting). If your practitioner recommends waiting, but you’re not sure why, ask—and if you’re super-anxious to start trying again right away, see if there’s any wiggle room in that recommendation.
Ready … or Not
“I just had a miscarriage and though my doctor told me I could start TTC again, I’m not sure I’m ready.”
For some couples, resuming TTC efforts as soon as possible after a pregnancy loss is just what the doctor ordered. For them, tracking cervical mucus changes, charting BBT, and actively trying for a baby again can help take their focus off their loss and shift it to something positive. It can also help a woman who’s suffered a pregnancy loss recover some of the control over her body that the miscarriage (an experience completely out of her control) took from her. For others, however, starting to TTC quickly may not feel right—whether because they’re fearful of another miscarriage or because they feel they need more time to grieve. Whichever category you fall into, remember that you need to do what feels right for you. Don’t let yourself feel pressured by anyone (your practitioner, your best friend, your mother-in-law) to pick up where you left off and start trying again right away. Maybe you are ready, maybe you’re not—but only you and your spouse can make that decision.
Just make sure that you do come to that decision together. Though it’s your body that has suffered the physical effects of the pregnancy loss, both of you have paid the emotional price. So talk about it. It may help, too, to talk to others who know exactly what you’re going through because they’re going through it, too—but who are objective in their feedback. In addition to helping you make (or feel better about) your decision, that support can help you heal. You’ll likely find such support on TTC or loss message boards, if you don’t have friends or family who can personally relate, or if you’d just like all the support you can get.
If you’re still on the fence about whether now’s the right time (and keeping in mind that there’s no time that’s right for everyone), you may want to take into account the physical facts. Since women may be more fertile in the 3 months following a miscarriage, beginning again sooner may bring you success sooner (though it’s definitely not a guarantee of success). But don’t discount—or second-guess—your emotions, either. If you feel you need to take a break, and take a breath, before you begin to TTC again, then that’s absolutely what you should do. Listen to—and follow—your heart, and you’ll make the decision that’s right for you.
A Return to a Normal Cycle
“When will I start ovulating and get my period again after my miscarriage?”
Your menstrual cycle can’t get up and running until your body realizes you’re no longer pregnant—and for that to happen, all of the hCG has to be out of your system. For the hCG to get out of your system, the developing placenta has to fully detach from the uterine wall (or be removed in a D & C). Once the hCG is completely gone (it takes about 10 days after the placenta detaches for hCG to hit zero), you can expect your period to return within 4 to 6 weeks (if your cycles were regular before conceiving), with ovulation occurring 2 to 4 weeks after your hCG reaches zero.
But don’t start counting those weeks from the first day you noticed spotting or bleeding. It could take a week or two (or even longer) from the beginning of the miscarriage until the placenta pulls away and that important hormonal shift takes place (you won’t notice these changes, you’ll only be aware of continuous bleeding). Which means that if you haven’t gotten your period again after 6 weeks from the first day you noticed miscarriage bleeding, there’s no need to worry. Wait another week or two before putting in a call to your practitioner. Your period might be just around the corner.
Something else to keep in mind: If your miscarriage occurred late in the first trimester or in the second trimester, you had a lot of hCG in your system (hCG rises as your pregnancy progresses)—and that means it’ll take longer to hit that zero mark and, consequently, your period may take a little longer to resume.
Another reason why your period may be late to return: Some women retain tiny fragments of placental tissue after a miscarriage (and more rarely, after a D & C). If that’s the case with you, you may have your bleeding taper off only to resume a few days (or even a week or two) later. This bleeding isn’t a period yet—it’s the continuation of your pregnancy loss. And that means you can’t expect to see a true period until at least 4 weeks after the miscarriage has truly completed (in other words, until 4 weeks after all the placental tissue has pulled away from the uterine wall). Though this scenario is normal (if uncommon), do put in a call to your practitioner just for peace of mind. If your hCG levels are at zero but you still continue spotting, your doctor may give you a shot of Provera or some other form of progesterone to trick your body into thinking it’s time for a period so your cycles can get back to normal. Of course, if at any time the bleeding becomes very heavy again, call your practitioner as soon as you can.
And though the return of your period may indicate that you’ve begun ovulating, it’s not a sure bet. That’s because there may be one (or more) anovulatory cycles (in which you get your period without ovulating) after a miscarriage. To figure out whether you’re back to ovulation business as usual, you’ll need to start up your cycle tracking again.
Lingering Pregnancy Symptoms
“I had a miscarriage and started TTC again right after. I’m still feeling pregnancy symptoms (tender breasts, bloating) and I’m wondering if that means I’m pregnant again or if they’re just residual symptoms from the pregnancy that I lost.”
That’s a tough call—in fact, it may be an impossible one to make at this point. The problem is, there are several explanations for your symptoms. One is that you’re experiencing PMS. As you probably discovered when you were TTC last time, PMS symptoms can be very difficult to distinguish from early pregnancy symptoms (especially those tender breasts and that bloating) and it might be tricky to figure out if those symptoms might be signaling the return of Aunt Flo or a new pregnancy—especially if you haven’t had a normal period since you miscarried. Also possible: Your body isn’t quite ready for the return of your period but is reacting to hormonal fluctuations—which can be substantial after a pregnancy loss.
Another less likely explanation is that what you’re feeling are residual pregnancy symptoms—but for that to be the case, you’d still have to have residual hCG in your system. This is possible if your miscarriage was very recent (the hCG is usually out of your system about 10 days after a miscarriage or D & C is complete) or took place later in the first trimester or in the second (in which case the hCG levels might take a little longer than that to hit zero). Until the hCG is completely gone, you can’t ovulate, you can’t get your period, and you can’t get pregnant. You can, however, possibly have a positive pregnancy test—which would further confuse the picture.
Still another explanation—and this is likely the one you’re hoping for—is that you might be pregnant again. It is possible to ovulate and conceive before you’ve had that first post-loss period, though diagnosing that pregnancy might be tricky initially (a home pregnancy test, again, might be responding to residual hCG in your system, rather than newly generated pregnancy hormone).
Sometimes, pregnancy symptoms after a loss can be triggered by emotional causes—you want to be pregnant still (or again), and so your psyche is clinging to the symptoms (which can feel very real even if they’re not physically plausible).
Check in with your doctor if you’re unsure of what to think—or if you’d like confirmation of whether or not you’re pregnant.