Historically, recurrent miscarriage has been defined as three or more miscarriages, yet this definition has proven notoriously difficult to verify (e.g. chemical pregnancies may go undiagnosed), so ideally every woman should be evaluated on a case-by-case basis.
For example, if you have had just one miscarriage, but this occurred after 12 weeks gestation, then investigations would be warranted because miscarriages that occur after the first trimester are typically not related to chromosomal abnormalities.
In most cases, where a woman has had two miscarriages, she should request that a thorough investigation begins at that point, given the research indicates she would be at higher risk for a third miscarriage if no intervention is taken.
Chemical pregnancies (i.e. very early term losses) should be respected as much as a miscarriage at 6 weeks, especially if the woman believes she has had three or more of them. This would be described as a positive pregnancy test taken at the time the period was due, followed by the onset of menses a few days later.
Miscarriages are incredibly distressing for women and can take their toll emotionally as some may start to question why their body is 'failing' them. This is why it is so important to carry out investigations as soon as possible so that there is concrete information to work with, rather than advising women to 'just go off and try again'.
Why do I keep having miscarriages?
The causes of miscarriage are many and varied and may affect a woman regardless of her age.
Chromosomal abnormalities- While this is considered to be the most common cause of miscarriage, the likelihood of a woman experiencing two or more miscarriage due to chromosomal abnormalities is very slim. While aneuploidy of the egg follicles is often asserted as the main reason for a chromosomally abnormal embryo, the male fertility factor should not be excluded from this discussion. (see 'male factor fertility' below).
This type of miscarriage is most commonly experienced as a 'first time' miscarriage, so it could occur the first time you have ever been pregnant or you could experience this type of miscarriage after having had a couple of babies with no prior miscarriages up until that point.
Anatomical Issues-investigative methods such as hysteroscopy, laparoscopy, HSG (hystero-salpinogo-gram) or HyCoSy (hystero-salpingo-contrast-sonography) are likely to be recommended to you if anatomical issues are a suspected cause of your miscarriage(s).
- If you have had a D & C for a previous miscarriage this may result in the fomration of scar tissue or adhesions that may interfere with future pregnancies. In some women this is severe enough to be diagnosed as Asherman's Syndrome and specailised surgery may be required to correct the problem.
- Scarring from Endometriosis or from PID (pelvic inflammatory disease) due to a sexual infection would be other potential trigger of anatomical problems.
- Some women are born with a uterus that is an unusual shape,
e.g. unicornuate/bicornuate uterus and this can make it more difficult to retain a pregnancy.
- Uterine growths such as fibroids or polyps may affect proper implantation of the embryo and lead to early miscarriage.
While surgicial methods may be very effective at correcting anatomical problems, in the case of tissue growth e.g. endometriosis, fibroids etc.. it is important to avoid the tissue growing back again. Typically, cell proliferation is related to hormone imbalance that may be caused by past/current medication or diet and lifestyle so the aim of a fertility consultation would be to isolate any areas of your health that you can take control of so as to minimise the chances that your uterine anomalies will reoccur.
Male Factor Fertility- up until fairly recently miscarriages were thought to be a 'female' issue and the male factor went largely overlooked. It is now very clear that sperm quality or lack thereof, may be a contributing factor to the likelihood of a miscarriage occurring. Anomalies in the sperm are more likely to affect men over the age of 40, hence men have their own version of the 'biological clock' that most women are sick of hearing about.
Testing sperm health via a semen analysis may not be sufficient and a DNA fragmentation test and/or karyotyping may need to be considered. The sperm contributes 50% of the DNA, so equal importance should be placed on the health of the sperm as it is on the egg quality of the female.
Hormonal Imbalance-the endocrine system is complex and even subtle variations in hormone levels can have a far reaching impact. For women who have experienced miscarriages, problems with one or more endocrine organs is a common finding.
E.g. The Thyroid gland may be under-functioning with the TSH, T4 and T3 levels falling outside of the optimal range, there may be sub-clinical adrenal issues with DHEA and Cortisol levels fluctuating, Prolactin levels may be elevated or Progesterone levels may be border-line low. In these cases, hormone replacement with a synthetic version of the hormone may be recommended and this is effective therapy in acute cases. However, over the long-term it would be worth investigating what may be the underlying cause of these hormonal fluctuations so that there is the possibility to correct the problem. A woman's body is designed to produce all the hormones that she requires and in the right amounts. With the the right support and a specific protocol in place, there is no reason why most women shouldn't be able to regain this state of equilibrium.
Immune issues- auto-immune conditions are many and varied with known links to recurrent pregnancy loss. Crohns disease, hashimotos thyroiditis, rheumatoid arthritis, lupus, and secondary immune conditions such as endometriosis are a common finding in women who have had more than two miscarriages.
The thinking is that the immune cells within the uterus may be secondarily affected by a woman's immune condition leading to problems with implantation or rejection of the embryo. Treatments are contraversial and vary from the use of IVIG to Intralipids or steroid medications.
A natural approach to immune issues seeks to identify what triggers may be causing the immune cells to over react. These triggers could be extrinsic (e.g. diet, enviromental toxins) or intrinsic (e.g. inflammation within the gut/microbial imbalance, nutrient deficiencies). When the trigger is addressed, immune symptoms often dramtically improve and testing may confirm this improvement by demonstrating anti-bodies that are no longer elevated and have fallen back into the normal reference ranges.
Cardiovascular issues (i.e. Thrombophilia)
During the first trimester, the placenta develops and this requires many tiny capillaries to grow and ensure a steady blood supply to the embryo. If anything impedes this blood flow then a miscarriage may result. Screening for bio-markers that indicate a predisposition for 'sticky' blood could help prevent a further miscarriage occurring. In many cases these bio-markers are diet and lifestyle related and could be improved without resorting to blood thinning medications. Particularly in view of the latest research stating that the common blood thinning medication, Heparin makes no difference to the outcome of pregnancy and could in fact be detrimental in certain cases.
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"I first attended Jessica in July 2012. I had a miscarriage in September 2011 and was trying to conceive again but with no luck. I was beginning to lose hope.
Jessica immediately put a plan in place for myself and my partner - this involved acupuncture, diagnostic tests and lifestyle and nutritional changes. Following some test results Jessica advised that I use a natural progesterone support to help my cycle. My partner's semen analysis came back sub optimal but within 4 months following Jessica's advice this had returned to normal.
The structured plan gave us hope and by March 2013 I was pregnant. I am due in November and am very excited about welcoming our baby into the world. I know for a fact this happy result would not be possible without Jessica's help."
Update: This patient gave birth to a healthy baby girl who is now 6 months old and thriving.